Every finding on record at Renaissance Home Health Care

Extended Substantial Allegation Survey Substantial Allegation Numbers 111676 and 112036 The following deficiencies are based upon substantial allegations 111676 and 112036 completed on 01/13/25. Renaissance Home Health Care, 368498, is not in compliance with the requirements found at 42 CFR Part 484, Subpart B, C, for Home Health Agency. Renaissance Home Health Care is precluded from providing its own home health aide training and competency testing or competency evaluation program for a period of two years from the date of the receipt of the deficiency report (2567) for this survey.

A review of all current medications CFR(s): 484.55(c)(5) A review of all medications the patient is currently using in order to identify any potential adverse effects and drug reactions, including ineffective drug therapy, significant side effects, significant drug interactions, duplicate drug therapy, and noncompliance with drug therapy. This ELEMENT is not met as evidenced by: Based on record review, staff interview, and policy review, the agency failed to ensure every patient had an updated medication profile. This affected three (Patients #3, #4 and #6) out of five patients reviewed. The census was 145. 1. Review of the medical record for Patient #3 revealed start of care was 03/08/22. Patient #3 did not have a medication profile. Interview on 01/09/25 at 10:33 AM Staff G confirmed there was no medication profile in the medical record. On 01/09/25 at 10:48 AM Staff G provided a medication list dated 07/19/24 and stated it was the last updated medication list from the physician's office, from six months ago. Staff G stated the registered nurse (RN) did not go out to Patient #3's home. 2. Review of the medical record for Patient #4 revealed a start of care date 02/16/24. The last medication profile was dated 02/16/24. 3. Review of the medical record for Patient #6 revealed a start of care 10/17/24. There was no medication profile. Review of the policy titled “Medication Profile,” revised 05/2024, revealed the comprehensive assessment (OASIS) performed at time of admission includes a review of all medications the patient is currently using in order to identify any potential adverse effects and drug reactions, including ineffective drug therapy, significant side effects, significant drug interactions, duplicative drug therapy and noncompliance with drug therapy. The medication profile will be reviewed every home visit and updated as changes occur. Interview on 01/09/25 at 12:41 PM Staff C confirmed this finding.

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: Based on record review, policy review, and staff interview, the agency failed to ensure all patients had a physician’s plan of care. (G572) The agency failed to ensure there were signed physician orders for all services provided. (G580) The agency failed to ensure the physician signed the plan of care orders within the 60 days certification period. (G588)

Plan of care CFR(s): 484.60(a)(1) Each patient must receive the home health services that are written in an individualized plan of care that identifies patient-specific measurable outcomes and goals, and which is established, periodically reviewed, and signed by a doctor of medicine, osteopathy, or podiatry acting within the scope of his or her state license, certification, or registration. If a physician or allowed practitioner refers a patient under a plan of care that cannot be completed until after an evaluation visit, the physician or allowed practitioner is consulted to approve additions or modifications to the original plan. This STANDARD is not met as evidenced by: Based on record review, policy review, and staff interview, the agency failed to ensure all patients had a physician’s plan of care. This affected two (#3 and #4) out of five patients reviewed. The census was 145. 1. Review of the medical record for Patient #3 revealed a start of care date of 03/08/2022. The medical record did not reveal a physician's plan of care. Interview on 01/08/25 at 11:32 AM the Office Manager stated Patient #3 does not have a physician's plan of care or physician's orders for the home health aide (HHA) to provide care. The Office Manager stated the HHA provides care 15 hours per week Patient #3. Interview on 01/09/25 at 10:09 AM, Staff G confirmed the physician’s plan of care was not updated since 03/08/22. 2. Review of the medical record for Patient #4 revealed no physician’s plan of care after 04/15/24. Review of the home health aide (HHA) time sheets revealed the HHA provided service to Patient #4 from 04/16/24 through 05/02/24. Review of the agency policy titled “Plan of Care – CMS #485 and Physician’s Orders,” revised 05/2024, revealed each patient must receive an individualized written plan or care. 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 disciplines and the measurable outcomes that the Agency anticipates wi1l 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. Recertification of the Plan of Care is required at least every 60 days when there is a need for continuous home health care after an initial 60-day episode. Interview on 01/13/25 at 10:20 AM, Staff D confirmed this finding.

Only as ordered by a physician CFR(s): 484.60(b)(1) Drugs, services, and treatments are administered only as ordered by a physician or allowed practitioner. This ELEMENT is not met as evidenced by: Based on record review, policy review, timecard review, and staff interview, the agency failed to ensure there were signed physicians’ orders for all services provided. This affected three (#3, #4 and #5) out of three patients reviewed. The census was 145. 1. Review of the medical record for Patient #3 revealed a start of care date of 03/08/2022. The medical record did not reveal signed physician’s orders for the home health aide (HHA). Review of the HHA time sheets from 11/25/24 to 12/22/24 revealed the HHA worked three hours a day for 15 hours per week. 2. Review of the medical record for Patient #4 and physician’s plan of care dated 02/16/24 to 04/15/24 did not reveal signed physician’s orders for the HHA. Review of the HHA time sheets from 02/19/24 to 04/18/24 revealed the HHA worked 28 hours per week 3. Review of the medical record for Patient #5 and physician’s plan of care dated 09/29/24 to 11/27/24 did not reveal signed physician’s orders for the HHA. Review of the HHA time sheets from 09/30/24 to 11/27/24 revealed the HHA worked 14 hours per week. Review of the agency policy titled “Plan of Care – CMS #485 and Physician’s Orders,” revised 05/2024, revealed all clinical services are implemented only in accordance with a Plan of Care established by a physician's written order. Interview on 01/09/25 at 10:09 AM, Staff G confirmed there were no signed physician’s orders for the HHA visits made.

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 policy review, record review, and staff interview, the agency failed to ensure the physician signed the plan of care orders within the 60 days certification period. This affected three (#4, #5 and #6) out of three patient records reviewed. The census was 145. 1. Review of the medical record for Patient #4 and physician’s plan of care dated 02/16/24 to 04/15/24 revealed no physician signature. Interview on 01/13/25 at 12:04 PM, Staff C confirmed this was the last physician’s plan of care done. Staff C stated the registered nurse left. 2. Review of the medical record for Patient #5 and physician’s plan of care dated 09/29/24 to 11/27/24 revealed no physician’s signature. 3. Review of the medical record for Patient #6 and physician’s plan of care dated 10/17/24 to 12/15/24 revealed no physician’s signature. Review of the agency policy titled “Plan of Care – CMS #485 and Physician’s Orders,” revised 05/2024, revealed the total Plan of Care will be reviewed and signed by the attending physician at least once every 60 days. Interview on 01/09/25 at 12:48 PM Staff C confirmed these findings.

Home health aide services CFR(s): 484.80 Condition of participation: Home health aide services. All home health aide services must be provided by individuals who meet the personnel requirements specified in paragraph (a) of this section. This CONDITION is not met as evidenced by: Based on policy and record review, the agency failed to ensure the home health aide (HHA) plan of care was updated every 60 days. (G798) The agency failed to ensure the home health aides (HHA) followed the HHA Plan of Care. (800) The agency failed to ensure the registered nurse did a home visit to supervise the home health aide every 60 days. (814)

Home health aide assignments and duties CFR(s): 484.80(g)(1) Standard: Home health aide assignments and duties. Home health aides are assigned to a specific patient by a registered nurse or other appropriate skilled professional, with written patient care instructions for a home health aide prepared by that registered nurse or other appropriate skilled professional (that is, physical therapist, speech-language pathologist, or occupational therapist). This STANDARD is not met as evidenced by: Based on record review and staff interview, the agency failed to ensure the home health aide (HHA) plan of care was updated every 60 days. This affected three (#3, #4, and #5) out of three patients reviewed. The census was 145. 1. Review of the medical record for Patient #3 revealed the only home health aide (HHA) Care Plan was dated 03/08/22. Interview on 01/09/25 at 10:09 AM, Staff C confirmed the HHA care plan for Patient #3 was not updated since admission on 03/08/22. 2. Review of the medical record for Patient #4 revealed the last updated HHA Care Plan was dated 02/16/24. 3. Review of the medical record for Patient #5 revealed the last updated HHA Care Plan was 10/05/23. Interview on 01/09/25 at 1:54 PM Staff C confirmed these findings.

Services provided by HH aide CFR(s): 484.80(g)(2) A home health aide provides services that are: (i) Ordered by the physician or allowed practitioner; (ii) Included in the plan of care; (iii) Permitted to be performed under state law; and (iv) Consistent with the home health aide training. This ELEMENT is not met as evidenced by: Based on record review, time sheet review, and staff interview, the agency failed to ensure the home health aides (HHA) followed the HHA Plan of Care. This affected two (#6 and #7) out of two patients reviewed. The census was 145. 1. Review of the medical record for Patient #6 and the HHA Care Plan dated 12/16/24, revealed the HHA was to provide a bath, shampoo, perineal care, skin, hair and foot care and oral hygiene at every visit. Review of the HHA time sheets from 10/21/24 to 11/22/24 revealed Patient #6 did not receive a bath, shampoo, perineal care, skin, hair and foot care or oral hygiene at every visit. 2. Review of the medical record for Patient #7 and the HHA Care Plan last HHA Care Plan dated 10/19/23, revealed the HHA was to provide a bath, shampoo, skin care, hair care and oral hygiene at every visit. Review of the HHA time sheets from 09/30/24 to 11/22/24 revealed Patient #7 did not receive a bath, shampoo, skin, hair care or oral hygiene at every visit. Interview on 01/09/25 at 12:541 PM with Staff C confirmed these findings.

Non-skilled direct observation every 60 days CFR(s): 484.80(h)(2) If home health aide services are provided to a patient who is not receiving skilled nursing care, physical or occupational therapy, or speech-language pathology services, — (A) The registered nurse must make an onsite, in person visit every 60 days to assess the quality of care and services provided by the home health aide and to ensure that services meet the patient's needs; and (B) The home health aide does not need to be present during this visit. (ii) Semi-annually the registered nurse must make an on-site visit to the location where each patient is receiving care in order to observe and assess each home health aide while he or she is performing non-skilled care This ELEMENT is not met as evidenced by: Based on policy review, record review, time sheet review, and staff interview, the agency failed to ensure the registered nurse (RN) did a home visit to supervise the home health aide (HHA) every 60 days. This affected two (#3 and #4) out of three patients reviewed. The census was 145. 1. Review of the medical record for Patient #3 revealed the last RN visit and last supervisory visit of the HHA was 07/05/23. Interview on 01/09/25 at 10:49 AM, Staff G confirmed the last RN visit was 07/05/23 and confirmed the RN had not visited Patient #3 for one year and six months. Staff G stated the insurance company stopped payment on the RN visits. 2. Review of the medical record for Patient #4 revealed no supervisory visit was made after admission 02/16/24. Review of the HHA time sheets for Patient #4, from 02/19/24 through 05/02/24, revealed the HHA provided assistance with personal care. Review of the agency’s policy titled “Home Health Aide Supervision,” revised 05/2024, revealed if Home Health Aide services are provided to a patient who is not receiving skilled nursing care, physical or occupational therapy, or speech-language pathology services, the registered nurse will make an on-site visit to the location where the patient is receiving care, no less frequently than every 60 day in order to assess the quality of care and services provided by the home health aide and to ensure the services meet the patient's needs. Interview on 01/13/25 at 11:16 AM, Staff G confirmed the supervisory visits for the patients with HHA service only were not done every 60 days. v

Extended Substantial Allegation Survey Substantial Allegation 100304 An entrance conference was conducted on 07/31/23 at 9:15 AM with the Director of Nursing, and an exit conference was conducted on 08/01/23 at 4:06 PM with administrative staff. The following deficiencies are based upon substantial allegations 100304 completed on 08/01/23. Renaissance Home Health Care 368498, is not in compliance with the requirements at 42 CFR Part 484, Subpart B, C for Home Health Agencies. Renaissance Home Health Care is precluded from offering its own aide training and/or competency evaluation program for a period of two years from the exit date of this survey.

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: Based on interview, policy review, and medical record review, the agency failed to ensure the physical therapist conducted a timely initial assessment visit to determine the immediate care and support needs (G516). The agency failed to ensure a registered nurse conducted comprehensive assessments (G522). The agency failed to ensure that a re-assessment was completed 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 (G548). The cumulative effect of these systemic problems resulted in the facility's inability to ensure the provision of quality health care in a safe setting.

Skilled professional performs assessment CFR(s): 484.55(a)(2) When rehabilitation therapy service (speech language pathology, physical therapy, or occupational therapy) is the only service ordered by the physician or allowed practitioner, who is responsible for the home health plan of care, and if the need for that service establishes program eligibility, the initial assessment visit may be made by the appropriate rehabilitation skilled professional. This ELEMENT is not met as evidenced by: Based on interview, policy review, and medical record review, the agency failed to ensure the physical therapist conducted a timely initial assessment visit to determine the immediate care and support needs for one of one patient reviewed who was receiving physical therapy services only (Patient #2). The total sample was four patients. This deficient practice had the potential to negatively affect any patient the agency provided care for. The agency census was 233. Findings include: Review of the agency policy titled, Assessments/Comprehensive Assessments, revised 2018, Initial Assessment and Time Frame: A registered nurse (RN), physical therapist (PT) or speech language pathologist (SLP) must conduct the initial assessment visit within 48 hours of referral, within 48 hours of the patient’s return home or on the physician-ordered start of care date. The initial assessment visit is conducted to determine the immediate care and support needs of the patient. In the absence of a physician-specified start of care date, the initial assessment visit is conducted within 48 hours of the referral. If the physician specified a start of care date, this supersedes the 48-hour time frame. For Medicare patients, if the initial assessment indicates that the patient is not eligible for the Medicare home health care benefit, e.g., the patient is not homebound, has no skilled need, etc. and the Agency does not admit the patient, then there is no indication for the Agency to conduct a comprehensive assessment or to collect, encode or transmit OASIS data to the State. Review of the medical record for Patient #2 revealed the patient had a start of care date of 05/25/23. The agency documentation revealed the patient had been hospitalized on 05/12/23 for a hypertensive crisis. Additionally, Patient #2 had diagnoses which included hypertension, end stage renal disease with dialysis treatment, alcoholic cirrhosis, and diabetes mellitus. The patient was discharged from the hospital on 05/18/23. The agency documentation revealed the agency had received a referral from the hospital for physical therapy and occupational therapy evaluations and treatment for Patient #2 on 05/16/23 with a requested start of care date of 05/19/23. Review of the medical record revealed Physical Therapy Staff E conducted the initial start of care comprehensive assessment on 05/25/23, or seven days after the requested start of care date. Interview with Administrative staff B on 08/01/23 at 3:01 PM confirmed the agency failed to conduct the initial assessment on the physician ordered start of care date for Patient #2.

Eligibility for Medicare home health benefit CFR(s): 484.55(b)(2) Except as provided in paragraph (b)(3) of this section, a registered nurse must complete the comprehensive assessment and for Medicare patients, determine eligibility for the Medicare home health benefit, including homebound status. This ELEMENT is not met as evidenced by: Based on interview, policy review, and medical record review, the agency failed to ensure a registered nurse conducted comprehensive assessments for two of four patients’ medical records reviewed (Patient #1 and Patient #4). This deficient practice had the potential to negatively affect any patient the agency provided care for. The agency census was 233. Findings include: Review of the agency policy titled, Assessments/Comprehensive Assessments, revised 2018, revealed each patient admitted by the Agency will have appropriate initial assessments performed and documented. Each patient admitted will receive a comprehensive assessment. The assessment will reflect the patient’s current health status and include information to demonstrate the patient’s progress toward achievement of desired outcomes. The comprehensive assessment will identify the patient’s need for home care and meet the patient’s need for medical, rehabilitative, nursing, social, discharge planning. For Medicare patients, Agency must verify the patient’s eligibility for home health benefit, including homebound status. The Agency’s comprehensive assessment includes the use of the Outcome and Assessment Information Set (OASIS) items for all patients except patients under the age of 18, patients receiving pre- or post-partum services, patients receiving only housekeeping or chore services, private insurance patients. 1. Review of Patient #1's medical record revealed the patient was admitted to the agency on 11/04/13 with diagnoses which included congestive heart failure, hypertension, chronic obstructive pulmonary disease, and diabetes. The agency was unable to provide evidence of an initial comprehensive assessment, or any subsequent comprehensive assessments completed by a Registered Nurse for Patient #1. 2. Review of Patient #4's medical record revealed the patient was admitted to the agency on 02/23/23. The agency was unable to provide evidence of an initial comprehensive assessment, or any subsequent comprehensive assessments completed by a Registered Nurse for Patient #4. Interview on 08/01/23 at 11:04 AM with Administrative Staff B confirmed the agency failed to conduct comprehensive assessments on all their patients. Staff B stated, "we didn’t know all patients had to have comprehensive or updated assessments."

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 medical record review, agency policy and procedure review, and staff interview, the agency failed to complete a re-assessment of a patient following hospitalization for one of four patients reviewed (Patient #1). This deficient practice had the potential to negatively affect any patient the agency provided care for. The agency census was 233. Findings include: Review of the agency’s policy titled, Re-assessment and Update of the Assessment, with a revision date of 2018, directed that minimally, the comprehensive assessment must be updated and revised: Resumption of Care: 48 hours of the patient’s return home from a hospital admission of 24 hours or more for any reason other than diagnostic tests, or on physician-ordered resumption of care. Review of the medical record for Patient #1 revealed the patient was admitted to the hospital on 07/10/23 for nausea and vomiting. The patient was discharged to home on the afternoon of 07/12/23. The documentation revealed the agency had received a referral for home care services the morning of 07/12/23. The agency was unable to provide documentation a re-assessment was completed after the patient returned from the hospital to determine home health needs. Review of the home health aide Visitation Report revealed the agency had provided home health aide services from 07/12/23 through the current survey date of 07/31/23. Interview with Administrative Staff B on 08/01/23 at 11:04 AM confirmed the agency had failed to have a nurse re-assess a patient following a hospital stay. Staff B stated the agency did not assess or re-assess any unskilled patients. This deficiency represents non-compliance investigated under Substantial Allegation 100304.

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: Based on medical record review, policy review, and interview, the agency failed to ensure each patient received home health services that were written and reviewed by a physician in an individualized plan of care (G572). The facility failed to promptly alert the relevant physician(s) or allowed practitioner(s) to any changes in the patient's condition or needs that suggest that outcomes are not being achieved and/or that the plan of care should be altered (G590). The cumulative effect of these systemic problems resulted in the facility's inability to ensure the provision of quality health care in a safe setting.

Plan of care CFR(s): 484.60(a)(1) Each patient must receive the home health services that are written in an individualized plan of care that identifies patient-specific measurable outcomes and goals, and which is established, periodically reviewed, and signed by a doctor of medicine, osteopathy, or podiatry acting within the scope of his or her state license, certification, or registration. If a physician or allowed practitioner refers a patient under a plan of care that cannot be completed until after an evaluation visit, the physician or allowed practitioner is consulted to approve additions or modifications to the original plan. This STANDARD is not met as evidenced by: Based on medical record review, policy review, and interview, the agency failed to ensure each patient received home health services that were written and reviewed by a physician in an individualized plan of care for three of four patients reviewed for plan of care (Patient #1, #2, and #4). The agency census was 233. Findings include: 1. Review of the medical record for Patient #1 revealed the patient’s start of care with the agency was 11/04/13. Patient #1 was admitted with diagnoses which included congestive heart failure, hypertension, diabetes mellitus and chronic obstructive pulmonary disease. The agency was unable to provide a physician ordered plan of care for Patient #1 that was reviewed by the physician. Review of the home health Visit Notes revealed the agency had provided 49 hours of home health aide services consistently to the patient from the review dates of 05/08/23 through current date of 07/31/23. Observations during a home visit on 07/31/23 beginning at 1:55 PM revealed the patient had medications, durable medical equipment, diabetic needs but no monitoring equipment. There was no plan of care that directed the patient’s needs related to these concerns. 2. Review of the medical record for Patient #2 revealed the patient was admitted to the agency on 05/25/23 with diagnoses which included hypertensive crises, congestive heart failure, end stage renal disease requiring dialysis, and diabetes mellitus. The patient had been discharged from the hospital on 05/18/23. The agency documentation revealed the agency had received a referral from the hospital for physical therapy and occupational therapy evaluations and treatment. The Medicare certification period reviewed was 05/25/23 through 07/23/23. Patient #2 had a physician order for physical therapy services once per week for one week and twice per week for four weeks thereafter. Review of the medical record revealed the therapist provided services on 05/25/23, 05/30/23 and 06/01/23. The agency was unable to provide documentation therapy had provided any further services or that the patient was discharged. The medical record lacked documentation of an evaluation by the agency’s occupational therapist. Interview with Administrative Staff B and C on 08/01/23 at 3:15 PM revealed the agency was unable to provide documentation the patient received an occupational therapy evaluation and the missed physical therapy visits. 3. Review of the medical record for Patient #4 revealed a start of care date of 02/13/23. The agency was unable to provide a plan of care for Patient #4 that was reviewed by the physician. Review of the home health aide Visit Notes revealed the agency had provided 12 hours of home health aide services from 06/02/23 through current date of 07/31/23. Interview with Staff A on 08/01/23 at 11:04 AM revealed the agency could not provide plans of care for patients who only received home health aide services that were provided under non-Medicare payor sources. Staff B stated that no plans of care existed for these patients, “we didn’t know they needed them or that they needed reviewed by the physician. We don’t do them.”

Promptly alert relevant physician of changes CFR(s): 484.60(c)(1) The HHA must promptly alert the relevant physician(s) or allowed practitioner(s) to any changes in the patient's condition or needs that suggest that outcomes are not being achieved and/or that the plan of care should be altered. This ELEMENT is not met as evidenced by: Based on medical record review, agency policy review, and staff interview, the agency failed to notify the physician of a change in the patient's condition for one of four patients reviewed (Patient #2). This had the potential to negatively affect any patient who the agency provided care for. The agency census was 233. Findings include: Review of the agency’s policy titled, Care Planning Process, with a revision date of 2018, directed that the individualized plan of care must be reviewed and revised by the physician who is responsible for the home health plan of care and the Agency 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. The Agency must promptly alert the relevant physician(s) to any changes in the patient’s condition or needs that suggest that outcomes are not being achieved and/or that the plan of care should be altered. Review of the medical record for Patient #2 revealed therapy Staff E had conducted a home visit on 06/01/23. The visit note revealed the patient had suffered a fall the previous day (05/31/23) and refused to participate in any treatment during that visit. There was no documentation the agency notified the physician of Patient #2's fall. Interview on 08/01/23 at 3:15 PM with Administrative Staff B and Staff C confirmed the agency was unable to provide documentation the agency notified the physician of Patient #2’s fall.

Home health aide services CFR(s): 484.80 Condition of participation: Home health aide services. All home health aide services must be provided by individuals who meet the personnel requirements specified in paragraph (a) of this section. This CONDITION is not met as evidenced by: Based on observation during home visitation, medical record review, agency policy review, and staff interview, the agency failed to ensure aide staff reported changes in condition to the registered nurse (G800). The cumulative effect of these systemic practices resulted in the agency's inability to ensure that the patients' nursing needs would met.

Aides are members of interdisciplinary team CFR(s): 484.80(g)(4) Home health aides must be members of the interdisciplinary team, must report changes in the patient's condition to a registered nurse or other appropriate skilled professional, and must complete appropriate records in compliance with the HHA's policies and procedures. This ELEMENT is not met as evidenced by: Based on observation during home visitation, medical record review, agency policy review, and staff interview, the agency failed to ensure aide staff reported changes in condition to the registered nurse for one of four patients reviewed (Patient #1). Findings include: Review of the agency’s policy titled, Home Health Aide Documentation, with a revision date of 2018, directed that the agency will ensure accurate documentation of home health aide services. The home health aide will be responsible for reporting any changes in the patient’s condition and/or other pertinent observations to the supervising RN/Therapist. Review of Patient #1's medical record revealed the patient was admitted to the agency on 11/04/13 with diagnoses which included congestive heart failure, hypertension, chronic obstructive pulmonary disease, and diabetes. The agency was unable to provide a physician ordered plan of care for Patient #1 that was reviewed by the physician. However, the home health Visit Notes revealed the agency had provided 49 hours of home health aide services consistently to the patient from the review dates of 05/08/23 through current date of 07/31/23. Further review of Patient #1's medical record revealed the patient was admitted to the hospital on 07/10/23 for nausea and vomiting. The patient was discharged to home on the afternoon of 07/12/23. Observations were made during a home visit to Patient #1’s home along with the agency’s nursing Staff D on 07/31/23 beginning at 1:30 PM. The patient was observed seated in his wheelchair; Staff D completed a head-to-toe assessment. The patient’s bilateral legs had open vascular wounds with the presence of slight serosanguinous drainage to the anterior portion of the patient’s legs on the shin bone. There were pervasive foul odors which included the odor of stool, old urine, and unidentifiable environmental odors. There were multiple sightings of cockroaches observed on or near the patient. The roaches were observed to crawl across the patient’s toes, on the floor, on the patient’s chair and on or near the bedside commode. The patient was unable to feel his feet due to the level of diabetic neuropathy. Review of the nurse’s note dated 07/31/23 revealed the presence of six wounds on the patient which included wounds to his bilateral legs, wounds to his bilateral feet and toes, as well as penile and scrotal wounds. The nurse’s note revealed the patient was with peripheral neuropathy secondary to diabetes, both feet wet and patient unable to feel. The documentation further revealed the patient was diabetic but had no machine to check his blood sugar for a couple weeks. Further documentation revealed that skilled nursing was provided by another agency. Concerns for neglect, wound care, and roaches were documented. Additionally, it was documented that a call to the state was made, and the nurse was awaiting further orders. Interview with Staff D on 07/31/23 at 1:55 PM revealed the wounds were new and the aide had failed to notify the agency of the wounds or the infestation of roaches. This deficiency represents non-compliance investigated under Substantial Allegation 100304.