Every finding on record at Rest Haven Illiana Christian Convalescent Home

Revised plan of care CFR(s): 484.60(c)(2) A revised plan of care must reflect current information from the patient's updated comprehensive assessment, and contain information concerning the patient's progress toward the measurable outcomes and goals identified by the HHA and patient in the plan of care. This ELEMENT is not met as evidenced by: Based on record review and interview, the home health agency failed to ensure the plan of care was revised to disclose current, accurate patient information for 1 of 1 patient with a resumption of care (ROC), from a total of 5 active clinical records reviewed. (#2) The findings include: Record review of an agency policy titled “Physician Participation in Plan of Care” revised December 2015, stated “Policy … The attending physician will certify that medical, skilled, rehabilitation, and social services provided by the organization are medically required for the patient … Procedure 1. Physician (or other authorized licensed independent practitioner) orders will be individualized, based on patient’s needs, and include: … B. Treatments and/or procedures needed, including type, frequency, duration, and goals … C. Medications to be administered and/or monitored … 7. Orders will be reviewed and revised by the patient’s physician (or other authorized licensed independent practitioner) based on: A. Changes in diagnosis or treatment, including procedures, medications and equipment … E. Changes in diagnoses or treatment, including procedures, medications, and equipment ….” Record review of an agency policy titled "Contents of the Clinical Record" revised December 2015, stated "Purpose To outline the requirements for and components of a clinical record … Policy … The clinical record will contain sufficient information to identify the patient, describe the patient’s problems and needs, justify care, accurately document care provided and results in detail, and facilitate continuity of care among organization and contract personnel … Procedure 1. The following information will be available in the clinical record, as applicable to care and services provided: … R. Care planning activity based on patient’s problem and needs … CC. Current medication profile, including prescription and nonprescription medications, herbal products and home remedies, dose, frequency, route of administration, and new, changed, or discontinued medications ….” Record review of an agency policy titled “Reassessments/Recertification” reviewed in April 2020, stated “Purpose To outline the requirements for ongoing updates to the comprehensive assessment (reassessments) and recertification … Policy … The total plan of care must be renewed at least every 60 days, or more often as warranted by the condition of the patient. Any assessment findings that suggest a need to alter the plan of care will be reported to the patient’s physician … Procedure … 4. Each patient will be reassessed using a comprehensive OASIS [Outcome and Assessment Information Set] assessment tool for the review and revision of the plan of care when: … A. The patient returns home after an inpatient admission lasting 24 hours or longer for any purpose other than diagnostic testing … 8. The updated Home Health Certification and Plan of Care will be prepared and sent to the physician for review and signature in a timely manner ….” Record review of an agency policy titled "Contents of the Clinical Record" revised December 2015, stated "Purpose To outline the requirements for and components of a clinical record … Policy A clinical record will be maintained for each patient receiving care. The clinical record will contain sufficient information to identify the patient, describe the patient’s problems and needs, justify care, accurately document care provided and results in detail, and facilitate continuity of care among organization and contract personnel … Procedure 1. The following information will be available in the clinical record, as applicable to care and services provided: … Q. Statement of any changes in the patient’s condition related to care and service … BB. Documentation of the assessment data collected, actions and interventions performed, and patient response to care provided ….” Clinical record review on 3/11/2022, for patient #2, start of care 2/9/2022, evidenced an agency document titled “Home Health Care Certification and Plan of Care” for certification period 2/9/2022 – 4/9/2022, diagnoses include but were not limited to a surgical wound, chronic obstructive pulmonary disease [COPD], and pulmonary fibrosis. This document was signed by the physician on 2/22/2022 and had an area subtitled “Medications” which stated “… ascorbic acid [vitamin C] 500 mg [milligrams] oral capsule; Take 1 cap(s) [capsule(s)] orally once a day for supplement … Oxycodone Hydrocholoride [opioid pain medication] 15 mg oral tablet; Take 1 tab(s) [tablet(s)] oral every 4 hours as needed for pain ….” This document was indicated to be the current plan of care by clinical manager A on 3/9/2022. Record review evidenced an agency document titled “Verbal Order” from 2/23/2022, and signed by the physician on 3/3/2022. This document stated “1: Resume HHC [home health care] services. Patient discharged from [Entity A] on 2/22/22 … 2: ROC 2/23/22 Patient was hospitalized at [Entity A] from 2/16/22 – 2/22/22 for new onset atrial fibrillation with rapid ventricular response [irregular, rapid heartbeat] … Plan of care and medications to continue as previously ordered with the addition of Digoxin [medication used to treat heart failure and heart rhythm problems] 125 mcg [micrograms] orally daily ….” Record review evidenced an agency document titled “Verbal Order” which was signed by RN F on 2/23/2022. This document stated “1: Digox [digoxin] 125 mcg (0.125 mg) oral tablet; Take 1 tab(s) orally once a day for chf [congestive heart failure], af [atrial fibrillation] … Start Date: 2/23/2022 … 2: Aide / 2 wk 3 wk [twice a week for 3 weeks]; 1 wk 4 wk [once a week for 4 weeks]; - read back and confirmed … Start Date: 2/23/2022 … 4. Discontinue: effective 2/23/2022 – ascorbic acid 500 mg oral capsule … 5. Discontinue: effective 2/23/2022 – oxycodone Hydrochloride 15 mg oral capsule ….” This document was signed by the physician on 3/1/2022. Record review of the plan of care evidenced ascorbic acid 500 mg capsule and oxycodone Hydrochloride 15 mg listed as an active medication. Review failed to evidence Digox was added to the active medication list. Review of the plan of care failed to evidence the patient had a history of atrial fibrillation. Record review failed to evidence the current plan of care was a current and accurate description of the patient’s pertinent diagnoses and medications. During an interview on 3/7/2022, at 10:02 AM, clinical manager A stated the agency considers the “485” (Home Health Care Certification and Plan of Care) to follow as the plan of care. During an interview on 3/11/2022, at 10:42 AM, clinical manager A indicated the process to update the plan of care after orders are added or discontinued would include making corrections to the plan of care and then send to the physician for a signature.

Other pertinent instructions CFR(s): 484.60(e)(4) Any other pertinent instruction related to the patient's care and treatments that the HHA will provide, specific to the patient's care needs. This ELEMENT is not met as evidenced by: Based on observation, record review and interview, the home health agency failed to ensure detailed instructions pertinent to the patient’s care were provided for 1 of 1 patient with home health aide services, from a total sample of 5 active clinical records reviewed. (#2) The findings include: Record review of an agency policy titled “Rights/Responsibilities” reviewed February 2022, stated “Purpose To encourage awareness of patient rights and responsibilities, to provide guidelines to assist patients making decisions regarding care, and to support active participation in care planning … Policy Each patient will be an active, informed participant in care planning … Procedure 1. The patient will be informed upon admission and, as needed, of: … B. The goals of care, the interventions that support these goals and the identification of staff providing service … D. The right to be informed of his/her condition, participate in all aspects of care , and the right to refuse al or part of his/her care to the extent permitted by law ….” Review of an agency policy titled “Home Health Aide Plan of Care” reviewed April 2020, stated “Purpose To define the process for the development and use of the home health aide [HHA] plan of care … Policy Each patient receiving home health aide services will have an individualized plan developed and utilized to direct care performed by the assigned aide … Procedure … 2. The home health aide plan of care will be individualized to the specific patient and will include at least: A. Type of services/procedures to be provided … H. Specific procedure(s) to be performed, including amount, frequency, and duration … 6. The home health aide plan of care will be reviewed with the patient to ensure understanding of the aide’s role in the home ….” An observation of a home visit was conducted on 3/9/2022, at 4:00 PM, for patient #2, start of care 2/9/2022, with Registered Nurse (RN) F. At the beginning of the visit, RN F indicated she placed a plan of care in the patient’s home folder. At 4:27 PM, the patient’s home folder was reviewed to ensure all pertinent information for accurate delivery of services, including but not limited to a home health aide (HHA) care plan. Review of the home folder failed to evidence a HHA care plan to include specific tasks that were provided by the agency. Observation failed to evidence all pertinent information was provided to the patient. Clinical record review on 3/11/2022, for patient #2, primary diagnosis of an abdominal surgical wound, evidenced an agency document titled “Home Health Care Certification and Plan of Care” for certification period 2/9/2022 – 4/9/2022, and signed by the physician on 2/22/2022. This document had an area subtitled “Orders/Treatments” which stated, “Discipline Orders … Aide; 1 wk 1 wk [once a week for one week]; 2 wk 4 wk [twice a week for 4 weeks]; 1 wk 4 wk [once a week for 4 weeks] … Interventions … Aide: Elimination: Incontinent Care … Aide: Hygiene: Bath: Bed … Aide: Hygiene: Skin care ….” This document was indicated to be the HHA care plan on 3/9/2022, by clinical manager A. Review failed to evidence pertinent details for incontinent care to include but not limited to frequency and specific details for cleaning the perineal area [pertaining to the area between the thighs, bounded by the anus and either scrotum for males or the vagina for females]. Review failed to evidence pertinent details of a bath to include but not limited to frequency, and specific tasks such as shampoo hair and/or shave. Review of this document failed to evidence pertinent information to include but not limited to frequency of skin care and specific tasks such as apply lotion and/or frequent turns. During an interview on 3/8/2022, at 10:02 AM, clinical manager A indicated clinicians would document directly to the patient care plans with their tablet via the electronic medical record (EMR). During an interview on 3/11/2022, at 10:41 AM, clinical manager A was queried how clinicians would know which tasks to perform if the EMR was down or unable to access in a patient’s home. She indicated the plan of care should be in every patient’s home.

This visit was a recertification, re-licensure, and emergency preparedness survey. The survey visit took place from 1/13/2022 to 1/25/2022. Facility ID: 003435 At this Emergency Preparedness survey, Providence at Home Inc. was found to be in compliance with 42 CFR 484.102 Emergency Preparedness Requirements for Medicare Participating Providers and Suppliers for Home Health Agencies.

This visit was a recertification, re-licensure, and emergency preparedness survey. The survey visit took place from 1/13/2022 to 1/25/2022. Facility ID: 003435 These deficiencies reflect State Findings cited in accordance with 410 IAC 17. Refer to state form for additional state findings. Providence At Home Inc., is precluded from providing its own home health aide training and competency evaluation for a period of two years from 1/25/2022 - 1/24/2024, due to being found out of compliance with Conditions of Participation 42 CFR 484.60 Care Planning, Coordination of Care and Quality of Care. Quality Review Completed 02/09/2022

Accuracy of encoded OASIS data CFR(s): 484.45(b) Standard: The encoded OASIS data must accurately reflect the patient's status at the time of assessment. This STANDARD is not met as evidenced by: Based on record review and interview, the home health agency failed to ensure OASIS data accurately reflected the patient's status at the time of assessment in 1 of 7 patient records reviewed with a home visit. (#7) The findings include: Review of an agency policy, with an agency revised date of January 2015, and received 1/25/2022, titled, "OASIS Data Transmission," stated, "Purpose: To outline the OASIS data transmission requirements. Procedure: ... The encoded OASIS data must accurately reflect the patient's status at the time of assessment...." Clinical record review on 1/18/2022 for patient #7, start of care 1/6/2022, for certification period 1/6/2022 to 3/6/2022, evidenced an agency document titled "SOC [Start of Care] OASIS [Outcomes and Assessment Information Set] D-1 (ver 21.2) (SOC)" dated 1/6/2022 and electronically signed by RN [registered nurse] R. This document had a subsection titled "Management of Injectable Medications, " which stated, "...NA - No injectable medications prescribed...." This document failed to have the patient's correct medication listed. Clinical record review evidenced an agency document titled "Home Health Certification and Plan of Care," electronically signed by RN M on 1/12/2022. This document had a subsection titled "Medication," which included but was not limited to, "...cyanocobalamin [used to treat vitamin B12 deficiency] 1000 mcg/mL [micrograms/milliliter] injectable solution; Inject 1000 microgram(s) intramuscularly [into the muscle] once a month; Vitamin Start Date: 01/06/2022...." During an interview on 1/24/2022 at 11:18 a.m., employee B (Quality Director) indicated the error was a mistake and mistakes are hard to catch.

Written notice for non-covered care CFR(s): 484.50(c)(8) Receive proper written notice, in advance of a specific service being furnished, if the HHA believes that the service may be non-covered care; or in advance of the HHA reducing or terminating on-going care. The HHA must also comply with the requirements of 42 CFR 405.1200 through 405.1204. This ELEMENT is not met as evidenced by: Based on record review and interview, the home health agency failed to provide the patient with a written notice of termination of service in 1 of 5 discharged patient records reviewed. (#13) The findings include: Review of an agency policy, with an agency reviewed date of 4/2020, and obtained 1/25/2022, titled, "Patient Notification of Changes in Care," stated, "Purpose: To define organization requirements for patient notification of changes in care. Policy: The patient will be notified within 24 hours of any significant changes in the agreed-upon schedule or plan of care...." Review of an agency policy, with an agency reviewed date of 4/2020, and obtained 1/25/2022, titled, "Discharge Planning," stated, "... Patients will not be discharged without appropriate preparation. The patient's continuing care needs will be assessed on an ongoing basis, as well as at discharge. Information will be provided to assist the patient in planning his/her discharge, including referral and transfer. ... Clinicians will assist patients regarding their discharge by: A. Consulting with the patient and family/caregiver regarding plans for discharge from the organization, B. Serving as a referral source for the patient/caregiver in obtaining follow-up support services ... All communication and information regarding discharge planning will be documented in the clinical record...." Clinical record review on 1/21/2022 for patient #13, start of care 11/23/2021, certification period 11/23/2021 to 1/21/2022, failed to evidence documentation the agency provided written notice prior to termination of services. Clinical record review evidenced an agency document titled, "Administrative Communication" with two entries dated 12/29/2021 and created by RN [registered nurse] M. The first entry, timed at 2:05:27 p.m., stated, "Spoke with NP [nurse practitioner] ... office to notify that insurance has suspended authorization and will not give further auth. There is an issue with the SOC date for their auth and when services were actually started and the insurance has not corrected the date. This writer stated we have discharged as of 12/16/21." The second entry, timed at 2:27:59 p.m., stated, "Contacted daughter of patient ... to notify her of the insurance auth issues. Patient is discharged from agency services as of 12/16/21." Clinical record review evidenced an agency document titled, "Speech Therapy Visit Note," dated 12/16/2021, which stated, "...No Visit Made, Reason Visit Not Made: Other: Insurance denied visits Actions Taken by Clinician No further actions needed, Narrative Notes: ST [Speech Therapy] DC [Discharge]: Insurance denied coverage. Goals met/partially met...." Clinical record review evidenced an agency document titled, "Skilled Nursing Visit Note," dated 12/16/2021, which stated, "...Visit Plan - No Visit Made ... Narrative Notes: 12/16/21 No insurance authorization to make SN visit today...." Clinical record review evidenced an agency document titled, "Discharge OASIS-D1 (ver21.2) (Discharge)," dated 12/16/2021 and completed by physical therapist O. This document indicated the patient was discharged from physical therapy services on 12/16/2021. During an interview on 1/25/2022 at 9:42 a.m., when queried as to how many days between denial of insurance and discharge of services, the clinical supervisor indicated the agency asked the insurance company for more visits on 12/16/2021 but was denied, so the agency kept the patient without services until 12/29/2021 for billing purposes only.

Provide contact info other services CFR(s): 484.50(d)(5)(iii) (iii) Provide the patient and representative (if any), with contact information for other agencies or providers who may be able to provide care; and This ELEMENT is not met as evidenced by: Based on record review and interview, the home health agency failed to provide the patient and caregivers with information for other agencies or resources who may be able to provide care in 1 of 5 discharged patient records reviewed. (#13) The findings include: Review of an agency policy, with an agency reviewed date of 4/2020, and obtained 1/25/2022, titled, "Discharge Planning," stated, "... Patients will not be discharged without appropriate preparation. The patient's continuing care needs will be assessed on an ongoing basis, as well as at discharge. Information will be provided to assist the patient in planning his/her discharge, including referral and transfer. ... Clinicians will assist patients regarding their discharge by: A. Consulting with the patient and family/caregiver regarding plans for discharge from the organization, B. Serving as a referral source for the patient/caregiver in obtaining follow-up support services ... All communication and information regarding discharge planning will be documented in the clinical record...." Clinical record review on 1/21/2022 for patient #13, start of care 11/23/2021, certification period 11/23/2021 to 1/21/2022, failed to evidence documentation the agency gave the patient/caregiver information for other agencies/providers or community resources that may have been able to provide services to the patient upon discharge. During an interview on 1/25/2022 at 9:42 a.m., when queried if the agency provided assistance to the patient or caregiver in finding another agency, the clinical supervisor indicated that the agency does not provide that assistance.

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 and interview, the home health agency failed to review all medications the patient was currently taking in 1 of 7 patient records reviewed with a home visit. (#6) The findings include: Review of an agency policy, with an agency revised date of 6/2021, and obtained 1/25/2022, titled "Medication Profile," stated, "... Patients receiving medications will have a current, accurate medication profile in the clinical record. Medication profiles will be updated for each change to reflect current medications and new and/or discontinued medications...." Clinical record review on 1/13/2022 for patient #6, start of care 10/22/2021, certification period 12/21/2021 to 2/18/2022, evidenced an agency document titled, "Medication Profile," dated 1/18/2022. This document stated, "...10/28/2021 - 11/3/2021 [start date - end date] Tramadol Hydrochloride (a narcotic medication used to treat moderate to severe pain) 50 mg oral tablet; Take 1 tab(s) oral every 6 hours for 7 day(s) as needed for pain, narcotic analgesics [classification of drug], Active [status]...." During an interview on 1/24/2022 at 11:04 a.m., clinical supervisor A indicated medications should not be shown as active in the medication profile once they are completed. 17-14-1(a)(1)(B)

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 and interview, the home health agency failed to ensure: the plan of care was individualized to meet the patient needs (see tag G0570), the plan of care was followed (see tag G0572), the individualized plan of care included all services, safety measures, medications and treatments (see tag G0574), services and treatments only as ordered by a physician were provided (see tag G0580), the physician was promptly alerted to changes in the patient's condition (see tag G0590), and care was coordinated with other entities providing care for the patient (see tag G0608). The cumulative effect of these systemic problems has resulted in the home health agency's inability to ensure provision of quality health care in a safe environment for the condition of participation 42CFR 484.60 Care Planning, Coordination, Quality of Care. A deficient practice citation was also evidenced at this standard as follows: Based on record review and interview, the agency failed to provide services to meet the patient's medical, nursing, and rehabilitative needs in 8 of 17 clinical records reviewed (#2, #6, #9, #11, #12, #13, #15, #17). The findings include: 1. Review of an agency policy, with an agency reviewed date of 06/2014, and received 1/25/2022, titled, "Rights/Responsibilities," stated, "Purpose: To encourage awareness of patient rights and responsibilities, to provide guidelines to assist patients making decisions regarding care, and to support active participation in care planning. ... The patient will be informed upon admission and, as needed, of: A. The organization's mission and care/services provided directly or through contractual arrangements ... D. The right to be informed of his/her condition, participate in all aspects of care, and the right to refuse all or part of his/her care to the extent permitted by law...." 2. Review of an agency policy, with an agency reviewed date of 04/2020, and received 1/25/2022, titled, “Care Decisions,” stated, “Purpose: To ensure that the integrity of clinical decision-making is not compromised. Policy: Clinical decisions are based on identified patient health care needs. Decisions are not based solely on compensation or financial risk … Procedure: … Initial and ongoing patient assessment data will identify patient health care needs … all home health services will be delivered under a physician’s (or other authorized licensed independent practitioner's) orders….” 3. Review of an agency policy, with an agency reviewed date of 4/2020, and received 1/25/2022, titled, "Uniform Quality of Care," stated, “Purpose: To ensure uniform quality of patient care and service throughout the organization and to ensure that patients have access to the home health resources they need to meet their health care needs … Procedure: … The care and resources each patient receive [sic] … will be based on the standards of care and practices … as well as on the patient’s health care needs….” 4. Review of an agency policy, with an agency reviewed date of 12/2015, and received 1/25/2022, titled, "Care Planning Process," stated, "...The plan of care will be based upon the physician's (or other authorized licensed independent practitioner's) orders and will encompass the equipment, supplies, and services required to meet the patient's needs...." 5. Review of an agency policy, with an agency reviewed date of 4/2020, and received 1/25/2022, titled, "Missed Visits Policy," stated, "...A missed visit modifies the frequency of visits ordered by the physician. If the visits cannot be rescheduled within the week it was missed, it is considered a missed visit. If the agency can reschedule the visit during the same week in which it was missed, the physician-ordered frequency of visits is maintained, and there is no missed visit. ... Visit schedules are created based on patient clinical need. ... All reasonable attempts will be made to re-schedule and make up missed visits within 24 hours...." 6. Clinical record review on 1/13/2022 for patient #6, start of care 10/22/2021, for certification period 12/21/2021 to 2/18/2022, evidenced an agency document titled "Home Health Care Certification and Plan of Care" electronically signed by RN [registered nurse] M. This document had an area subtitled "Orders/Treatments," which stated, "...Skilled Nursing; 2 wk 1 wk [twice a week for one week]; 3 wk 8 wk [three times a week for 8 weeks]; Start Date: 12/21/2021 - End Date: 2/18/2022...." Clinical record review evidenced two agency documents titled, "Skilled Nursing Visit Note." The document dated 12/24/2021, stated, "...Visit Plan - No Visit Made: ... Reason Visit Not Made: Patient Unavailable / Unable to Contact Patient ... Narrative Notes: Patient refusing visit due to holiday weekend...." The document dated 12/31/2021 stated, "...Visit Plan - No Visit Made: ... Reason Visit Not Made: Schedule conflicts between Clinician and Patient ... Narrative Notes: Scheduling conflict...." There failed to be evidence in the patient's record these visits were rescheduled. The home health agency failed to meet the patient’s skilled nursing needs as ordered by the primary physician. 7. Clinical record review on 1/20/2022 for patient #11, start of care 12/10/2021, for certification period 12/10/2021 to 2/7/2022, evidenced an agency document titled "Home Health Care Certification and Plan of Care" electronically signed by RN M. This document had an area subtitled "Orders/Treatments," which stated, "...Physical Therapy to Assess and Evaluate 12/10/2021 through 12/17/2021, Physical Therapy; 2 wk 5 wk [twice a week for five weeks]; Beginning during week of 12/13/2021 - Ending on 1/15/2022...." Clinical record review evidenced an agency document titled, "Verbal Order," signed 12/22/2021 by nurse practitioner D. This document stated, "1: Aide; 1 wk 2 wk [once a week for two weeks]; 2 wk 1 wk [twice a week for one week]; 1 wk 1 wk [once a week for one week]; For assistance with bathing and personal care. ; Start Date: 12/21/2021 -- End Date: 1/15/2022; Total number of visits: 5...." Clinical record review evidenced an agency document titled, "Aide Visit Note," dated 12/24/2021, which stated, "...Visit Plan - No Visit Made ... Narrative Notes: Pt [patient] already bathe [sic] ...." There failed to be evidence in the patient's record this visit was rescheduled. The home health agency failed to meet the patient’s home health aide needs as ordered by the primary physician. Clinical record review evidenced an agency document titled, "Physical Therapy Visit Note," dated 12/25/2021, which stated, "...Visit Plan - No Visit Made ... Narrative Notes: 12/25/21 patient called and cancelled today due to holiday...." There failed to be evidence in the patient's record this visit was rescheduled. The home health agency failed to meet the patient’s physical therapy needs as ordered by the primary physician. 8. Clinical record review on 1/20/2022 for patient #12, start of care 8/27/2021, for certification period 12/25/2021 to 2/22/2022, evidenced an agency document titled "Home Health Care Certification and Plan of Care" electronically signed by RN M. This document had an area subtitled "Orders/Treatments," which stated, "...Skilled Nursing; 2 wk 8 wk [twice a week for eight weeks]; Beginning during week of 12/27/2021 - Ending on 2/19/2022...." Clinical record review evidenced four agency documents titled, "Skilled Nursing Visit Note." The document dated 12/29/2021, stated, "...Visit Plan - No Visit Made ... Narrative Notes: SN [skilled nurse] MV [missed visit] 12/29/21 Patient is out of town. Pt is receiving hemodialysis [process of purifying the blood of a person whose kidneys are not working normally] while out of town...." The document dated 12/31/2021 stated, "...Visit Plan - No Visit Made ... Narrative Notes: SN MV 12/31/21 Pt still out of town for the holidays. Will return on Monday, January 3, 2022...." The document dated 1/5/2022 stated, "...Visit Plan - No Visit Made ... Narrative Notes: SN MV 1/5/22 Pt has court this morning. Patient says she will contact SN [skilled nurse] when she returns home. By end of day, patient did not contact SN...." The document dated 1/7/2022 stated, "...Visit Plan - No Visit Made ... Narrative Notes: SN MV 1/7/22 Patient has dialysis today. Dialysis days changed to Monday, Wednesday, Friday...." There failed to be evidence in the patient's record these visits were rescheduled. The home health agency failed to meet the patient’s skilled nursing needs as ordered by the primary physician. 9. Clinical record review on 1/21/2022 for patient #13, start of care 11/23/2021, for certification period 11/23/2021 to 1/21/2022, evidenced an agency document titled "Home Health Care Certification and Plan of Care" electronically signed by RN M. This document had an area subtitled "Orders/Treatments," which stated, "...Skilled Nursing to Assess and Evaluate 11/23/2021 through 11/30/2021, Skilled Nursing; 1 wk 1 wk [once a week for one week]; 2 wk 4 wk [twice a week for 4 weeks]; 1 wk 4 wk [once a week for four weeks] Beginning during week of 11/24/2021 - Ending on 1/21/2022, Physical Therapy to Assess and evaluate 11/23/2021 through 11/30/2021, Physical Therapy; 2 wk 4 wk [twice a week for four weeks]; Beginning during week of 11/30/2021 - Ending on 12/25/2021, Speech Therapy to Assess and Evaluate 11/23/2021 through 11/30/2021, Occupational Therapy to Assess and Evaluate 11/23/2021 through 11/30/2021, Occupational Therapy; 2 wk 3 wk [twice a week for three weeks]; 1 wk 1 wk [once a week for one week; Beginning during week of 11/28/2021 - Ending on 12/25/2021...." Clinical record review evidenced an agency document titled, "Physical Therapy Visit Note," dated 12/11/2021, which stated, "...Visit Plan - No Visit Made ... Narrative Notes: 12/11/21 patient's daughter returned call and said her mother not feeling too good today...." There failed to be evidence in the patient's record this visit was rescheduled. The home health agency failed to meet the patient’s physical therapy needs as ordered by the primary physician. Clinical record review evidenced two agency documents titled, "Skilled Nursing Visit Note." The document dated 12/6/2021, stated, "...Visit Plan - No Visit Made ... Narrative Notes: SN [skilled nurse] MV [missed visit] 12/6/21 Pt [patient] has appointment with podiatrist today...." The document dated 12/16/2021 stated, "...Visit Plan - No Visit Made ... Narrative Notes: 12/16/21 No insurance authorization to make SN visit today...." There failed to be evidence in the patient's record these visits were rescheduled. The home health agency failed to meet the patient’s skilled nursing needs as ordered by the primary physician. 10. Clinical record review on 1/20/2022 for patient #17, start of care 9/5/2021, for certification period 11/4/2021 to 1/2/2022, evidenced an agency document titled "Home Health Care Certification and Plan of Care" electronically signed by RN M. This document had an area subtitled "Orders/Treatments," which stated, "...Skilled Nursing; 1 wk 1 wk [once a week for one week]; 2 wk 4 wk [twice a week for four weeks]; 1 wk 4 wk [once a week for four weeks]; Beginning during week of 11/5/2021 - Ending on 1/1/2022...." Clinical record review evidenced two agency documents titled, "Skilled Nursing Visit Note." The document dated 11/22/2021, stated, "...Visit Plan - No Visit Made ... Narrative Notes: SN missed visit 11/22/21, patient was not feeling well and wanted SN to come on next scheduled day...." The document dated 11/24/2021 stated, "...Visit Plan - No Visit Made ... Narrative Notes: SN missed visit 11/24/21, patient reported she is still 'not feeling well.' SN informed importance of patient going to ER since patient has been feeling sick recently. Patient refused and stated, 'no I'm not going, I am going back to bed.' Asked patient what symptoms she was experiencing, patient reported, 'it's my heart, it's irregular.' Patient was unsure what she meant when SN asked. Patient does not have a hx [history] of A-Fib [atrial fibrillation -irregular and often very rapid heart rhythm that can lead to blood clots in the heart]. Will contact patient next week to attempt to schedule a visit...." There failed to be evidence in the patient's record these visits were rescheduled. The home health agency failed to meet the patient’s skilled nursing needs as ordered by the primary physician. 11. Clinical record review on 1/18/2022, for patient #2, start of care 6/6/2020, certification period 11/28/2021 to 1/26/2022, primary diagnosis of venous insufficiency (improper functioning of the vein valves in the leg, causing swelling and skin changes), evidenced an agency document titled, “Home Health Care Certification and Plan of Care”, signed by the physician on 1/10/2022. The plan of care had a subsection titled, “Orders / Treatments”, which stated,” … Skilled Nursing; 3 wk 8 wk [three times a week for eight weeks]; 2 wk 1 wk [two times a week for 8 weeks]; Beginning during week of 11/29/2021 – Ending on 1/26/2022….” Clinical record review evidenced a group of agency documents titled, “Skilled Nursing Visit Note”. A visit note dated 12/15/2021, signed by LPN [licensed practical nurse] E stated, “ … No Visit Made … Reason Visit Not Made: Patient Unavailable / Unable to Contact Patient…”. Clinical record review failed to evidence the visit was rescheduled. A visit note dated 12/24/2021, signed by RN [registered nurse] I, stated, “ … No Visit Made … Reason Visit Not Made: Schedule conflicts between Clinician and Patient….”. Clinical record review failed to evidence the visit was rescheduled. A visit note dated 1/4/2022, signed by RN I stated, “ … No Visit Made … Reason Visit Not Made: Other: Seen by SN [skilled nurse] yesterday….”. Clinical record review failed to evidence the visit was rescheduled. Clinical record review evidenced the agency failed to provide 3 skilled nursing visits per week for 8 weeks. During an interview on 1/24/2022, at 10:36 a.m., the clinical supervisor indicated the frequency of patient visits was based on what the patient needs. The clinical supervisor indicated clinicians should attempt to reschedule visits that are missed. 12. Clinical record review on 1/20/2022, for patient #9, start of care 12/9/2021, certification period 12/9/2021 to 2/6/2022, primary diagnosis of Osteomyelitis (infection in a bone) of the ankle and foot, evidenced an agency document titled, “Home Health Care Certification and Plan of Care”, signed by the physician on 12/28/2021. The plan of care had a subsection titled, “Orders / Treatments”, which stated, “ … Skilled Nursing; 2 wk 8 wk [two times a week for 8 weeks]; Beginning during week of 12/13/2021 – Ending on 2/5/2022. Clinical record review evidenced an agency document titled, “Skilled Nursing Visit Note”, dated 12/30/2021, signed by RN [registered nurse] H stated, “ … No Visit Made … Reason Visit Not Made: Other Schedule Conflicts ….”. Clinical record review failed to evidence the visit was rescheduled. During an interview on 1/24/2022, at 10:36 a.m., the clinical supervisor indicated the frequency of patient visits was based on what the patient needs. The clinical supervisor indicated clinicians should attempt to reschedule visits that are missed. 13. Clinical record review on 1/21/2022, for patient #15, start of care 2/12/2021, certification period 2/12/2021 to 4/12/2021, primary diagnosis of Primary generalized osteoarthritis (the breakdown of cartilage in the joint causing pain and limited movement), evidenced an agency document titled, “SOC [start of care] OASIS [Outcome and Assessment Information Set] [the patient-specific, standardized assessment used in Medicare home health care]-D1”, dated 2/12/2021, and signed by RN N. The assessment had a subsection titled, “REVIEW OF SYSTEMS – INTEGUMENTARY [related to the skin] STATUS”, which stated, “ …. CLINICAL FINDINGS – INTEGUMENTARY Skin tear Location(s) – Rt [right] upper arm….” Clinical record review evidenced an agency document titled, “Home Health Care Certification and Plan of Care”, signed by the physician on 2/28/2021. Review of the plan of care failed to evidence skilled nursing care. Review of the plan of care failed to evidence wound care instructions. Review of all visit notes, orders, and communication notes failed to evidence assessment or treatment of the patient’s wound. The home health agency failed to ensure the skilled nurse completed a comprehensive assessment to include a complete wound assessment and failed to notify the primary physician of the patient’s medical needs. During an interview on 1/25/2022, at 10:12 a.m., the clinical supervisor indicated if a wound was found at start of care, skilled nursing care should be ordered for the patient. The clinical supervisor indicated the nurse should measure the wound and call the physician for wound care orders. When queried, the clinical supervisor indicated the agency failed to document a full wound assessment, inform the physician of the wound, obtain wound care orders, and re-assess the wound at subsequent visits. 17-13-1(a)

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 and interview, the home health agency failed to ensure the plan of care was followed in 8 of 17 patient records reviewed (#2, #4, #7, #8, #9, #10, #12, #13). The findings include: 1. Record review on 1/25/2022, evidenced an agency policy titled, “CARE PLANNING PROCESS”, revised 5/2014, which stated, “PURPOSE to provide clinical direction to clinicians providing direct patient care … The care planning decisions will be reflected in the specific services that will be provided and the associated actions planned and implemented to meet individualized patient problems and goals ... The plan of care will be based upon the physician's (or other authorized licensed independent practitioner's) orders and will encompass the equipment, supplies, and services required to meet the patient's needs...." 2. Clinical record review on 1/18/2022, for patient #2, start of care 6/6/2020, certification period 11/28/2021 to 1/26/2022, primary diagnosis of venous insufficiency (improper functioning of the vein valves in the leg, causing swelling and skin changes), evidenced an agency document titled, “Home Health Care Certification and Plan of Care”, signed by the physician on 1/10/2022. The plan of care had a subsection titled, “Orders / Treatments”, which stated, “ … Interventions … SN [skilled nurse]: Assess lab values; PT / INR every other week. Results to [physician A]…." Clinical record review evidenced an agency document titled, “INR [international normalized ratio] / PT [prothrombin time] / PTT [partial thromboplastin time] [3 different blood tests that measure the time for the blood to clot] FLOWSHEET”. The flowsheet failed to evidence any PT/INR results from 11/25/2021 to 1/4/2022. The flowsheet indicated a PT/INR was performed on 1/5/2022. Clinical record review evidenced an agency document titled, “Skilled Nursing Visit Note”, dated 1/5/2022, signed by RN (registered nurse) I, which failed to evidence informing the physician of the PT/INR result. Review of all communication notes for the certification period 11/28/2021 to 1/26/2022, failed to evidence physician notification of any PT/INR results. During an interview on 1/24/2022, at 10:51 a.m., the clinical supervisor indicated the clinical record failed to evidence any PT/INR was performed from 11/25/2021 to 1/4/2022. The clinical supervisor indicated the clinical record failed to evidence physician notification of the PT/INR result performed on 1/5/2022. Clinical record review on 1/18/2022, for patient #2, start of care 6/6/2020, certification period 11/28/2021 to 1/26/2022, evidenced an agency document titled, “Home Health Care Certification and Plan of Care”, signed by the physician on 1/10/2022. The plan of care had a subsection titled, “Medication:”, which stated, “ … warfarin [a blood thinning medication] 1 mg [milligram] oral tablet; Take 1 tab(s) orally once a day for anticoagulant [blood thinner] … **High Risk. Monitor for abnormal bleeding **….”. The plan of care had a subsection titled, “Safety Measures:”, which stated, “Safe transfers; Transfer Precautions; Fall precautions….” Clinical record review evidenced a group of agency documents titled, “Skilled Nursing Visit Note”. Nurse’s notes with the following dates failed to evidence monitoring for bleeding: 11/29/2021, 12/1/2021, 12/3/2021, 12/6/2021, 12/8/2021, 12/11/2021, 12/13/2021, 12/17/2021, 12/21/2021, 12/23/2021, 12/30/2021, 1/3/2022, 1/5/2022, 1/7/2022, 1/10/2022, 1/12/2022, and 1/14/2022. Nurse’s notes with the following dates failed to evidence assessments of, or interventions for safe transfers and fall precautions: 11/29/2021, 12/1/2021, 12/3/2021, 12/6/2021, 12/8/2021, 12/13/2021, 12/17/2021, 12/21/2021, 12/23/2021, 12/30/2021, 1/3/2022, 1/5/2022, 1/7/2022, 1/10/2022, 1/12/2022, and 1/14/2022. During an interview on 1/24/2022, at 11:56 a.m., the clinical supervisor indicated safety should be addressed by all clinicians at each visit and documented in the visit notes. When queried, the clinical supervisor indicated the visit notes failed to evidence the safety precautions ordered in the plan of care. 3. Clinical record review on 1/20/2022, for patient #9, start of care 12/9/2021, certification period 12/9/2021 to 2/6/2022, primary diagnosis of Osteomyelitis (infection in a bone) of the ankle and foot, evidenced an agency document titled, “Home Health Care Certification and Plan of Care”, signed by the physician on 12/28/2021. The plan of care had a subsection titled, “Orders / Treatments”, which stated, “ … PICC [peripherally inserted central catheter][an IV inserted for long-term use] line Care – Change PICC Line dressing once a week and PRN [as needed] if soiled or loose using sterile technique - Change caps to each lumen [opening] once a week using sterile technique – Measure the PICC line arm circumference around once a week – Measure the PICC line catheter length from the insertion site to the end of the catheter, once a week….” Clinical record review evidenced an agency document titled, “SOC [start of care] OASIS [the Outcome and Assessment Information Set][the patient-specific, standardized assessment used in Medicare home health care], dated 12/9/2021, signed by RN (registered nurse) H. This assessment failed to evidence a measurement of the PICC line catheter length. Clinical record review evidenced a group of agency documents titled, “Skilled Nursing Visit Notes”, dated 12/16/2021, 12/20/2021, 12/23/2021, 1/3/2022, 1/10/2022, and 1/17/2022. Review of each of the nurse’s notes failed to evidence the nurse changed the caps on each lumen. Review of each of the nurse’s notes failed to evidence the nurse measured the arm circumference and measurement of the PICC line catheter length. During an interview on 1/24/2022, at 1:52 p.m., the clinical supervisor indicated all tasks performed by a clinician should be documented in a visit note. The clinical supervisor indicated the skilled nurse’s notes failed to evidence the nurse changed the caps, measured the patient’s arm circumference, and measured the PICC line catheter length. 4. Clinical record review on 1/20/2022, for patient #4, start of care 12/22/2021, certification period 12/22/2021 to 2/19/2022, primary diagnosis of Hemiplegia (muscle weakness or partial paralysis on one side of the body) following cerebral infarction (a stroke), evidenced an agency document titled, “Home Health Care Certification and Plan of Care”, signed by the physician on 1/7/2022. The plan of care had a subsection titled, “Safety Measures:”, which stated, “Fall Precautions … Bleeding Precautions….” Clinical record review evidenced an agency document titled, “Skilled Nursing Visit Note”, dated 12/30/2021. Review of the nurse’s note failed to evidence assessments of, or interventions for Bleeding Precautions. Clinical record review evidenced a group of agency documents titled, “Physical Therapy Visit Note”. Review of the physical therapy notes dated 12/28/2021, and 1/4/2022, failed to evidence assessments of, or interventions for Bleeding Precautions and Fall Precautions. During an interview on 1/24/2022, at 11:56 a.m., the clinical supervisor indicated safety should be addressed by all clinicians at each visit and documented in the visit notes. When queried, the clinical supervisor indicated the visit notes failed to evidence the safety precautions ordered in the plan of care. 5. Review of an agency policy, with an agency reviewed date of12/2015, and obtained 1/25/2022, titled "Care Planning Process," stated, "... The plan of care will be based upon the physician's (or other authorized licensed independent practitioner's) orders and will encompass the equipment, supplies, and services required to meet the patient's needs...." Clinical record review on 1/20/2022 for patient #12, start of care 8/27/2021, certification period 12/25/2021 to 2/22/2022, evidenced an agency document titled "Home Health Care Certification and Plan of Care," which had a subsection titled "Orders/Treatments." In this subsection it stated, "... Vital ranges: Notify MD with B/P [blood pressure] greater than 160/90 or less than 100/50, Apical greater than 100 or less than 50, Respirations greater than 30 or less than 12, temperature greater than 100.5, pulse oximetry reading less than 88%...." 6. Clinical record review on 1/18/2022 for patient #7, start of care 1/6/2022, certification period 1/6/2022 to 3/6/2022, evidenced an agency document titled "Home Health Care Certification and Plan of Care," which had a subsection titled "Orders/Treatments." In this subsection it stated, "... Vital ranges: Notify MD with B/P [blood pressure] greater than 160/90 or less than 100/50, Apical greater than 100 or less than 50, Respirations greater than 30 or less than 12, temperature greater than 100.5, pulse oximetry reading less than 88%...." Clinical record review on 1/18/2022 for patient #7 evidenced an agency document titled "Vital Signs." Entries dated 1/6/2022, 1/11/2022, and 1/13/2022 did not evidence patient temperature and respiratory rate. 7. Clinical record review on 1/18/2022 for patient #8, start of care 1/8/2022, certification period 1/8/2022 to 3/8/2022, evidenced an agency document titled "Home Health Care Certification and Plan of Care," which had a subsection titled "Orders/Treatments." In this subsection it stated, "... Vital ranges: Notify MD with B/P [blood pressure] greater than 160/90 or less than 100/50, Apical greater than 100 or less than 50, Respirations greater than 30 or less than 12, temperature greater than 100.5, pulse oximetry reading less than 88%...." Clinical record review on 1/18/2022 for patient #8 evidenced an agency document titled "Vital Signs." Entries dated 1/10/2022, 1/11/2022, 1/12/2022, and 1/13/2022 did not evidence patient temperature and respiratory rate. 8. Clinical record review on 1/18/2022 for patient #10, start of care 1/13/2022, certification period 1/13/2022 to 3/13/2022, evidenced an agency document titled "Home Health Care Certification and Plan of Care," which had a subsection titled "Orders/Treatments." In this subsection it stated, "... Vital ranges: Notify MD with B/P [blood pressure] greater than 160/90 or less than 100/50, Apical greater than 100 or less than 50, Respirations greater than 30 or less than 12, temperature greater than 100.5, pulse oximetry reading less than 88%...." Clinical record review on 1/18/2022 for patient #10 evidenced an agency document titled "Vital Signs." Entries dated 1/14/2022 and 1/18/2022 did not evidence patient temperature and respiratory rate. 9. Clinical record review on 1/21/2022 for patient #13, start of care 11/23/2021, certification period 11/23/2021 to 1/21/2022, evidenced an agency document titled "Home Health Care Certification and Plan of Care," which had a subsection titled "Orders/Treatments." In this subsection it stated, "... Vital ranges: Notify MD with B/P [blood pressure] greater than 160/90 or less than 100/50, Apical greater than 100 or less than 50, Respirations greater than 30 or less than 12, temperature greater than 100.5, pulse oximetry reading less than 88%...." Clinical record review on 1/21/2022 for patient #13 evidenced an agency document titled "Vital Signs." Entries dated 11/24/2022, 12/1/2021, 12/3/2021, and 12/6/2021 did not evidence patient temperature and respiratory rate.

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 record review and interview, the agency failed to ensure the individualized plan of care included all services, safety measures, medications and treatments in 3 of 12 active patient records reviewed (#1, #2, #9). The findings include: 1. Record review on 1/25/2022, evidenced an agency policy titled, “CARE PLANNING PROCESS”, revised 5/2014, which stated, “ … Definitions 1. Plan of Care: The clinical plan of care includes pertinent diagnoses, mental status, types of services / equipment, frequency of visits, goals and interventions appropriate to each discipline, prognosis, rehabilitation potential, functional limitations, precautions, activities, nutritional requirements, food / drug allergies, medications, treatments, safety measures, instructions, discharge plan. Documents include plan of treatment (485) and plans of care (all disciplines)….” 2. Clinical record review on 1/18/2022, for patient #1, start of care 12/12/2021, certification period 12/12/2021 to 2/9/2022, primary diagnosis of Type 2 diabetes (an impairment in the way the body regulates and uses sugar as a fuel) with diabetic peripheral angiopathy [problems with circulation caused by diabetes], evidenced an agency document titled, “MEDICATION PROFILE”, dated 12/22/2021, which stated, “ … clopidogrel [a blood thinner] … Take 1 tab(s) orally once a day for anticoagulant [blood thinner]; *high risk* Watch for signs and symptoms of bleeding … glimepiride [a medication used to lower blood sugar] … *high risk* Watch for signs and symptoms of hypoglycemia [low blood sugar] … levothyroxine [a thyroid medication] … Take 1 tab(s) orally once a day … losartan [a blood pressure medication] … Take 1 tab(s) orally once a day … metformin [a medication used to lower blood sugar] … Take 1 tab(s) orally 2 times a day … *high risk* Watch for signs or symptoms of hypoglycemia….” Clinical record review evidenced an agency document titled, “Home Health Care Certification and Plan of Care”, signed by the physician on 12/23/2021. The plan of care had a subsection titled, “Medications”, which failed to evidence any patient medications. Review of the plan of care failed to evidence bleeding precautions. During an interview on 1/24/2022, at 10:22 a.m., the clinical supervisor indicated the plan of care should include all medication orders and safety precautions for the patient. 3. Clinical record review on 1/18/2022, for patient #2, start of care 6/6/2020, certification period 11/28/2021 to 1/26/2022, primary diagnosis of venous insufficiency (improper functioning of the vein valves in the leg, causing swelling and skin changes), evidenced an agency document titled, “Home Health Care Certification and Plan of Care”, signed by the physician on 1/10/2022. The plan of care had a subsection titled, “Medications”, which stated, “ … HumaLOG [a type of insulin] … Patient takes 14 units with meal plus sliding scale for adjustment….”. Review of the plan of care failed to evidence a sliding scale for Humalog. On 1/24/2022, at 11:00 a.m., when informed of the findings, the clinical supervisor reviewed the patient record and indicated the plan of care failed to evidence a sliding scale for Humalog. 4. Clinical record review on 1/20/2022, for patient #9, start of care 12/9/2021, certification period 12/9/2021 to 2/6/2022, primary diagnosis of Osteomyelitis (infection in a bone) of the ankle and foot, evidenced an agency document titled, “Home Health Care Certification and Plan of Care”, signed by the physician on 12/28/2021. The plan of care had a subsection titled, “Orders / Treatments”, which stated, “ … Flush the PICC [peripherally inserted central catheter][an IV placed for long-term use] line with 5 cc’s Heparin [a medication used to prevent blood clots] after normal saline flush, after antibiotic is completed….” The plan of care had a subsection titled, “Medications”, which stated, “ … cefepime [an intravenous antibiotic] 2 gm [grams] … Inject 2 gm(s) intravenously every 12 hours … heparin flush … Inject 5 units intravenously every 24 hours….” During an interview on 1/24/2022 at 2:06 p.m., employee B (Quality Director) indicated the plan of care failed to include clear instruction on frequency of the heparin flush. Employee B stated, “I would like it to be clearer … It shouldn’t look like that.” 17-13-1(a)(1)(D)(ix)

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 and interview, the agency failed to provide services and treatments only as ordered by a physician in 2 of 12 records reviewed receiving physical therapy (#4, #16). The findings include: 1. Record review on 1/25/2022, evidenced an agency policy titled, “CARE PLANNING PROCESS”, revised 5/2014, which stated, “PURPOSE to provide clinical direction to clinicians providing direct patient care … The care planning decisions will be reflected in the specific services that will be provided and the associated actions planned and implemented to meet individualized patient problems and goals….” 2. Clinical record review on 1/20/2022, for patient #4, start of care 12/22/2021, certification period 12/22/2021 to 2/19/2022, primary diagnosis of Hemiplegia (muscle weakness or partial paralysis on one side of the body) following cerebral infarction (a stroke), evidenced an agency document titled, “Skilled Nursing Visit Note”, dated 1/6/2022, and signed by RN (registered nurse) H. The note had a subsection titled, “NARRATIVE NOTES”, which stated, “ … Patient fell out of moving vehicle onto pavement on 1/5/22, resulting in ER visit. Patient has a laceration [a deep cut in the flesh] to proximal [situated nearest the center of the body] left side of head resulting in 7 sutures placed, a laceration to right thumb, resulting in 5 sutures placed, and abrasions [scrapes] to bilateral [left and right] knees. Abrasions to knees were cleansed with NS [normal saline], bacitracin [an antibiotic ointment] applied, and covered with optifoam [ an advanced wound dressing designed for wounds with heavy drainage]. Thumb was unable to be assesses [sic] due to non removable dressing in place. Head was assessed ... Cleansed with NS, wrapped with kerlix [rolled gauze] ... SN [skilled nurse] will contact for wound care orders...." A nurse's visit note dated 1/13/2021, signed by RN H, had a narrative note that stated, " ... Wound care provided to bilateral knees, head, and thumb. Cleansed with NS, applied bacitracin, and left OTA [open to air]...." Review of all physician's orders for patient #4 failed to evidence any wound care orders. During an interview on 1/21/2022, at 3:05 p.m., the clinical supervisor indicated if a clinician finds a new wound on a patient during a visit, they should measure it, and call the physician to get wound care orders. When queried, the clinical supervisor indicated the nurse performed wound care without a physician order. 3. Clinical record review on 1/21/2022, for patient #16, start of care 7/25/2021, certification period 7/25/2021 to 9/22/2021, primary diagnosis of Hypertensive heart and chronic kidney disease (when the heart is not pumping well, resulting in long-term kidney problems), evidenced an agency document titled, "Home Health Care Certification and Plan of Care", signed by the physician on 7/30/2021. The plan of care had a subsection titled, "Orders / Treatments: ... SN [skilled nurse]: Perform wound care / dressing change: Cleanse with NS [normal saline], pat dry, apply alginate [an absorbing wound dressing] to right calf wound, cover with ABD [an absorbent dressing pad], wrap with kerlix [rolled gauze] then wrap with Coban [a stretchy bandage wrap that sticks to itself] twice a week...." Clinical record review evidenced an agency document titled, "Skilled Nursing Visit Note", dated 8/2/2021, signed by RN (registered nurse) R. The visit note had a subsection titled, "NARRATIVE NOTES", which stated, " ... Skin tear to Rt [right] leg scabbed over, left OTA [open to air] .... ". Review of the visit note failed to evidence any wound care performed. Clinical record review of all physician orders failed to evidence discontinuing wound care. During an interview on 1/25/2022, at 10:33 a.m., the clinical supervisor indicated RN R changed the care for the wound to assessment only because the wound had healed. When queried, the clinical supervisor indicated the clinical record failed to evidence a physician order to discontinue wound care or change to assessment only. 17-13-1(a)

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 record review and interview, the agency failed to promptly alert the physician to changes in the patient's condition in 1 of 7 records reviewed with a home visit (#4). The findings include: Record review on 1/25/2022, evidenced an agency policy titled, “CARE PLANNING PROCESS”, revised 5/2014, which stated, “PURPOSE to provide clinical direction to clinicians providing direct patient care ... All clinicians will consider the conclusions of initial and ongoing assessments in their care planning process, including, but not limited to: ... Changes in patient's condition … The care planning decisions will be reflected in the specific services that will be provided and the associated actions planned and implemented to meet individualized patient problems and goals….” Record review on 1/25/2022, evidenced an agency policy titled, "PHYSICIAN PARTICIPATION IN PLAN OF CARE", revised 12/2015, which stated, " ... Orders will be reviewed and revised by the patient's physician ... based on: A. Changes in the care or service being provided B. Changes in the patient's physical and / or psychosocial condition C. The patient's response to care D. The patient's outcome related to treatment care or services E. Changes in diagnoses or treatment, including procedures, medications and equipment...." Record review evidenced an agency policy titled, "MONITORING PATIENT'S RESPONSE / REPORTING TO PHYSICIAN", revised 2/2020, which stated, "The patient's physician will be contacted on the same day when any of the following occur: A. Changes in the patient's condition B. Changes in the patient's psychosocial status, family / caregiver support, home environment C. Inability to achieve goals within the specified time frame D. Changes in the patient's expected response to treatment or medications E. Changes that have occurred regarding diagnoses, prognosis, or treatment (including procedures, medications, precautions, and limitations) F. When there is any problem implementing the plan of care...." Clinical record review on 1/20/2022, for patient #4, start of care 12/22/2021, certification period 12/22/2021 to 2/19/2022, primary diagnosis of Hemiplegia (muscle weakness or partial paralysis on one side of the body) following cerebral infarction (a stroke), evidenced an agency document titled, "Home Health Care Certification and Plan of Care", signed by the physician on 1/7/2022. The plan of care had a subsection titled, "Orders / Treatments:", which stated, " ... Physical Therapy; 2 wk 6 wk [two times per week for 6 weeks]; 1 wk 2 wk [one time per week for 2 weeks]; Beginning during week of 12/26/2021 - Ending on 2/19/2022...." Clinical record review evidenced an agency document titled, "Physical Therapy Visit Note", dated 1/6/2022, and signed by PT (physical therapist) Q, which stated, " ... No Visit Made Reason Visit Not Made; Patient Refused Home Health Services ... narrative notes Patient without authorization....". Clinical record review of all communication notes and all physician's orders failed to evidence they physician was made aware of the patient not receiving physical therapy as ordered. During an interview on 1/19/2022, at 9:15 a.m., patient #4 indicated they hadn't been receiving physical therapy, "because of insurance". During an interview on 1/24/2022, at 11:25 a.m., the clinical supervisor indicated patient #4 was not currently receiving physical therapy because they were waiting on insurance approval. When queried, the clinical supervisor indicated the clinical record failed to evidence physician notification of the patient not receiving physical therapy as ordered. 17-13-1(a)(2)

Coordinate care delivery CFR(s): 484.60(d)(4) Coordinate care delivery to meet the patient's needs, and involve the patient, representative (if any), and caregiver(s), as appropriate, in the coordination of care activities. This ELEMENT is not met as evidenced by: Based on observation, record review, and interview, the agency failed to coordinate care in 2 of 3 records reviewed receiving care from other entities (#5, #9) The findings include: 1. Record review on 1/25/2022, evidenced an agency policy titled, "CARE COORDINATION", dated 12/2010, which stated, "PURPOSE To ensure the coordination of services for each patient and to minimize the potential for missed, conflicting, or duplicated services ... Written evidence of care coordination will be recorded during the case conference and repeated in skilled nursing visit reports in the patient's clinical records ... Care coordination will include, but not be limited to: ... Clearly outlining each clinician's responsibilities to avoid duplication of services ... Developing complementary actions and goals ... Written evidence of care coordination may be found in the plan of care, case conference summary forms, or clinical notes in the patient's records...." 2. Observation of a home visit for patient #5 was conducted on 1/19/2022, at 3:50 p.m. Upon entering the patient's home, caregiver B from home care agency C was observed doing light housekeeping and getting a drink for the patient. At 3:53 p.m., caregiver B informed RN (registered nurse) I they found a blister on the patient's right heel during their bath. Clinical record review on 1/20/2022, for patient #5, start of care 1/6/2022, certification period 1/6/2022 to 3/6/2022, primary diagnosis of Chronic obstructive pulmonary disease (a lung disease that blocks airflow and makes it difficult to breathe), evidenced a group of agency documents titled, "Prep Notes Communication", identified by the clinical supervisor as all communication notes from patient #5's clinical record. Review of all communication notes failed to evidence coordination of care with agency C. Clinical record review failed to evidence an agency coordination of care form. Review of the patient's electronic medical record (MatrixCare) failed to evidence coordination of care with agency C. During an interview on 1/19/2022, at 3:50 p.m., caregiver B indicated they had been providing care for patient #5 since May 2021. During an interview on 1/21/2022, at 3:06 p.m., the clinical supervisor indicated coordination of care should be documented in the communication notes and on an agency coordination of care form. When informed of the findings, the clinical supervisor indicated they did not know patient #5 was receiving services from agency C. 3. Clinical record review on 1/20/2022, for patient #9, start of care 12/9/2021, certification period 12/9/2021 to 2/6/2022, primary diagnosis of Osteomyelitis (infection in a bone) of the ankle and foot, evidenced an agency document titled, “Home Health Care Certification and Plan of Care”, signed by the physician on 12/28/2021. The plan of care had a subsection titled, "Orders / Treatments;" which stated, " ... Patient goes to wound clinic once a week on Tuesdays...." Clinical record review evidenced a group of agency documents titled, "Prep Notes Communication". Review of all communication notes failed to evidence coordination of care with a wound clinic. Clinical record review failed to evidence an agency coordination of care form. Review of the patient's electronic medical record (MatrixCare) failed to evidence coordination of care with a wound clinic. During an interview on 1/21/2022, at 3:06 p.m., the clinical supervisor indicated coordination of care should be documented in the communication notes and on an agency coordination of care form. During an interview on 1/24/2022, at 2:08 p.m., the clinical supervisor indicated patient #9 was receiving wound clinic services. When queried, the clinical supervisor indicated the agency failed to document coordination of care with the wound clinic. 17-14-1(a)(1)(F)

Track adverse patient events CFR(s): 484.65(c)(2) Performance improvement activities must track adverse patient events, analyze their causes, and implement preventive actions. This STANDARD is not met as evidenced by: Based on record review and interview, the agency failed to track adverse patient events in 4 of 5 patients with falls (#1, #3, #4, #7). The findings include: 6. Clinical record review on 1/18/2022, for patient #7, start of care 1/6/2022, certification period 1/6/2022 to 3/6/2022, evidenced an agency document titled, “Occupational Therapy Visit Note”, dated 1/13/2022, and signed by OT (occupational therapist) F. The document had a subsection titled, “Narrative Notes”, which stated, “ … Treatment addressed challenge standing tolerance with pt [patient] improving with second stand, initiated training with Pursed lip breathing and exercise with Pt's [patient's] sats [oxygen saturation] improving with breathing technique, assessing adaptive equipment needs with hospital bed recommendation due to current bed situation and commode due to increase of fall exiting bathroom....” During an interview on 1/24/2022 at 11:15 a.m., when queried as to where patient #7's falls would be documented, the clinical supervisor indicated the home health agency only documents witnessed falls in the incident log. 17-12-2(a) 1. Record review on 1/25/2021, evidenced an agency policy titled, “INCIDENT REPORTING”, revised 6/2020, which stated, “ … The organization will maintain a process for generating incident reports and follow up corrective action, if applicable. The five (5) purposes of the incident report are: 1. To facilitate the early detection or compensable events 2. To establish a foundation for early investigation of all potentially serious events 3. To develop a database for long-range problem detection analysis and correction 4. To enable cross-reference with other risk detection systems 5. To investigate and respond to sentinel events [a patient safety event that results in death, permanent harm, or severe temporary harm, in accordance with accrediting bodies standards]. All events or occurrences listed in “Examples of Specific Events or Occurrences that Must Be Reported” (see Addendum 4-017 A) must be reported….” 2. Record review evidenced an undated agency policy titled, “ADDENDUM 4-017.A EXAMPLES OF SPECIFIC EVENTS OR OCCURRENCES THAT MUST BE REPORTED”, which stated, “ … 1. Attended / Unattended Fall … The patient and family / caregiver reports a fall sustained by the patient during the course of his / her time on service…." 3. Clinical record review on 1/18/2022, for patient #1, start of care 12/12/2021, certification period 12/12/2021 to 2/9/2022, primary diagnosis of Type 2 diabetes (an impairment in the way the body regulates and uses sugar as a fuel) with diabetic peripheral angiopathy (problems with circulation caused by diabetes), evidenced an agency document titled, “Physical Therapy Visit Note”, dated 1/11/2022, and signed by PT (physical therapist) G. The note had a subsection titled, “NARRATIVE NOTES”, which stated, “ … Patient seen for re-assessment visit, reports feeling okay but tired and weak and … had fallen last Saturday while in the bathroom….” Review on 1/21/2022, of what was identified by the clinical supervisor as the incident log in its entirety from 1/1/2021 to 1/21/2022, failed to evidence any documented falls for patient #1. During an interview on 1/21/2022, at 1:44 p.m., employee B (Quality Director) indicated tracking patient falls was part of the agency’s QAPI (quality assurance and performance improvement). During an interview on 1/21/2022, at 2:36 p.m., the clinical supervisor indicated the agency was focusing on witnessed patient falls, and that incident reports were not always completed for falls reported by family or caregivers. 4. Clinical record review on 1/20/2022, for patient #3, start of care 12/26/2021, certification period 12/26/2021 to 2/23/2022, primary diagnosis of Femur (thigh bone) fracture, evidenced an agency document titled, “Skilled Nursing Visit Note”, dated 1/3/2022, and signed by RN (registered nurse) P. The note had a subsection titled, “NARRATIVE NOTES”, which stated, “ … Patient states … is feeling quite anxious today … had a fall yesterday in the garage. Patient was taken to ER [emergency room] and evaluated with CT [computed tomography] [ a medical imaging technique used in radiology to obtain detailed internal images of the body] of the head performed. Bruising noted to left side of face in addition to swelling….” Review on 1/21/2022, of what was identified by the clinical supervisor as the incident log in its entirety from 1/1/2021 to 1/21/2022, failed to evidence any documented falls for patient #3. During an interview on 1/21/2022, at 1:44 p.m., employee B (Quality Director) indicated tracking patient falls was part of the agency’s QAPI (quality assurance and performance improvement). During an interview on 1/21/2022, at 2:36 p.m., the clinical supervisor indicated the agency was focusing on witnessed patient falls, and that incident reports were not always completed for falls reported by family or caregivers. 5. Clinical record review on 1/20/2022, for patient #4, start of care 12/22/2021, certification period 12/22/2021 to 2/19/2022, primary diagnosis of Hemiplegia (muscle weakness or partial paralysis on one side of the body) following cerebral infarction (a stroke), evidenced an agency document titled, “Skilled Nursing Visit Note”, dated 1/6/2022, and signed by RN (registered nurse) H. The note had a subsection titled, “NARRATIVE NOTES”, which stated, “ … Patient fell out of moving vehicle onto pavement on 1/5/22, resulting in ER visit. Patient has a laceration [a deep cut in the flesh] to proximal [situated nearest the center of the body] left side of head resulting in 7 sutures placed, a laceration to right thumb, resulting in 5 sutures placed, and abrasions [scrapes] to bilateral [left and right] knees….” A skilled nurse visit note dated 1/19/2022, signed by RN H, had a narrative note that stated, “ … Patient reported having an unwitnessed fall on Monday 1/17/22. Patient … slid out of bed….” During an interview on 1/19/2022, at 9:07 a.m., patient #4 indicated they fell out of their vehicle 1/17/2022, when they could not fasten their seatbelt or close the car door completely due to weakness after a stroke. Review on 1/21/2022, of what was identified by the clinical supervisor as the incident log in its entirety from 1/1/2021 to 1/21/2022, failed to evidence any documented incidents for patient #4. During an interview on 1/21/2022, at 1:44 p.m., employee B (Quality Director) indicated tracking patient falls was part of the agency’s QAPI (quality assurance and performance improvement). During an interview on 1/21/2022, at 2:36 p.m., the clinical supervisor indicated the agency was focusing on witnessed patient falls, and that incident reports were not always completed for falls reported by family or caregivers.

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, record review and interview, the home health agency failed to ensure all employees practiced universal precautions in 2 of 7 home visits observed (#5, #7). The findings include: 5. Observation of a home visit for patient #5 took place on 1/19/2022, at 3:50 p.m. At 3:55 p.m., RN (registered nurse) I removed an automatic blood pressure cuff from the patient’s left arm and placed it on a barrier next to their bag. RN I then removed their gloves and placed them in the right pocket of their uniform shirt. At 3:57 p.m., RN I was observed removing a stethoscope from their bag. RN I failed to dispose of dirty gloves properly, and failed to perform hand hygiene before entering their bag. During an interview on 1/21/2022, at 2:40 p.m., the clinical supervisor indicated after removing gloves, the clinician should dispose the gloves, and perform hand hygiene. The clinical supervisor indicated only clean hands should enter a clinician’s bag. 17-12-1(m) 1. Review of an agency policy, with an agency reviewed date of 4/2020, and obtained 1/25/2022, titled, "Standard Precautions" stated, "...Hand hygiene will be performed to prevent cross-contamination between the patient and personnel. ... Gloves are to be worn when: 1. There is actual or potential contact with blood or other potentially infectious materials ... 3. Touching contaminated items or surfaces 4. Performing invasive procedures ... 8. Obtaining laboratory specimens ... Gloves are to be changed: 1. Between tasks and procedures on the same patient...." 2. Review of an agency policy, with an agency reviewed date of 4/2020, and obtained 1/25/2022, titled, "Hand Hygiene," stated, "Purpose: To prevent cross-contamination and home-health acquired infections. ... Hand decontamination using an alcohol-based hand rub should be performed: A. Before having direct contact with patients, B. Before donning sterile gloves when performing sterile procedures; before inserting indwelling urinary catheters, peripheral vascular catheters, or other invasive devices, C. After contact with a patient's skin ... D. After contact with body fluids or excretions, mucous membranes, non-intact skin... G. After removing gloves...." 3. Review of an agency policy, with an agency reviewed date of 4/2020, and obtained 1/25/2022, titled, "Bag Technique," stated, "Purpose: To describe the procedure for maintaining a clean patient care supply bag and preventing cross contamination. ... Bag Technique: ... When the visit is completed, reusable equipment will be cleaned using an acceptable approved disinfectant of agency's choice as appropriate, hands will be washed, and equipment and supplies will be returned to the bag. ... Hands will be decontaminated prior to returning clean equipment to bag...." 4. During a home visit on 1/14/2022 at 8:33 a.m., RN [registered nurse] N was observed providing care to patient #7. While providing care, RN N performed hand hygiene with alcohol-based hand rub, donned gloves, and inserted a needle into the patient's arm for a blood draw. The blood flow was inadequate for the specimen, so RN N removed the needle, placed it into a sharps container inside the dirty section of the RN's bag, and then removed their gloves. Without performing hand hygiene, RN N then reached into their bag to retrieve a baggie of new blood draw needles. The RN then performed hand hygiene with alcohol-based hand rub, placed a new needle on top of the patient, performed hand hygiene again and donned gloves. RN N then made a second attempt at a blood draw, obtained blood samples in tubes, removed the needle from the patient and placed the needle into the sharps container inside the dirty section the the RN's bag. The RN then removed their gloves, performed hand hygiene with alcohol-based hand rub, went inside their bag to retrieve a band-aid and placed it on the blood draw site without gloves on. RN N then labeled the blood tubes without gloves on and placed the blood tubes in a biohazard baggie. The RN then placed the baggie containing the tubes of blood into the dirty section of the RN bag without gloves on, then picked up previously cleaned items (blood pressure cuff, stethoscope, pulse oximeter) and placed them into the clean section of the RN bag without performing hand hygiene first. During an interview on 1/21/2022 at 2:41 p.m., the clinical manager indicated that gloves should be worn when handling and labelling vials of blood and hand hygiene should be performed any time gloves are removed.

Responsibilities of skilled professionals CFR(s): 484.75(b) Standard: Responsibilities of skilled professionals. Skilled professionals must assume responsibility for, but not be restricted to, the following: This STANDARD is not met as evidenced by: Based on observation, record review, and interview, the agency failed to ensure the clinician performed and documented full patient assessments during visits in 7 of 12 records reviewed receiving physical therapy (#1, #3, #4, #5, #14, #15, #16). The findings include: 1. Record review on 1/25/2022, evidenced an agency policy titled, “STANDARDS OF CARE AND PRACTICE”, dated 12/2010, which stated, “ … PURPOSE … To provide guidelines for developing and implementing standards of care and practice … Use of standards of care and practice will be evident in the documentation of visits and assessments, as well as in the care planning process.” 2. Record review evidenced an agency policy titled, “Documentation”, revised 2/1999, which stated, “ … PURPOSE To provide accurate and adequate written information on the patient and services provided. This is done to insure [sic] quality and continuity of care, inform staff / team members of the patient’s condition, the plan of care, and skilled and supportive care provided … Entries should be accurate in time, amounts and descriptions….” 3. Record review evidenced an agency policy titled, “ENTRIES INTO THE CLINICAL RECORD”, revised 5/2013, which stated, “ … Documentation in the clinical record will be timely, detailed, accurate, and reflect the care or services provided….” 4. Record review evidenced an agency policy titled, “ONGOING ASSESSMENTS”, dated 12/2010, which stated, “ … PROCEDURE 1. During each home visit, the clinician or other discipline will re-evaluate the patient … 2. Using the standards of care identified by the organization, the clinician will reassess the patient (as appropriate) for: A. Blood pressure, pulse, respirations, temperature….” 5. Clinical record review on 1/18/2022, for patient #1, start of care 12/12/2021, certification period 12/12/2021 to 2/9/2022, primary diagnosis of Type 2 diabetes (an impairment in the way the body regulates and uses sugar as a fuel) with diabetic peripheral angiopathy (problems with circulation caused by diabetes), evidenced an agency document titled, “VITAL SIGNS”. Entries dated 12/13/2021, 12/15/2021, 12/17/2021, 12/21/2021, 12/23/2021, 12/27/2021, and 1/4/2022, failed to evidence patient temperature and respiratory rate. An entry dated 1/11/2022, failed to evidence a respiratory rate. During an interview on 11/24/2022, at 11:09 a.m., the clinical supervisor indicated all clinicians should record the patient’s pulse, respiratory rate, blood pressure, and temperature at each visit. 6. Observation of a home visit for patient #3 took place on 1/19/2022, at 12:30 p.m. The surveyor entered the patient’s home with OT [occupational therapist] F, observed the entire visit, and exited with OT F. Observation of the home visit failed to evidence OT F taking patient #3’s temperature. Clinical record review on 1/20/2022, for patient #3, start of care 12/26/2021, certification period 12/26/2021 to 2/23/2022, primary diagnosis of Femur (thigh bone) fracture, evidenced an agency document titled, “VITAL SIGNS”. Entries dated 12/28/2021, 1/4/2022, 1/6/2022, 1/10/2022, 1/14/2022, and 1/18/2022, failed to evidence patient temperature and respiratory rate. During an interview on 11/24/2022, at 11:09 a.m., the clinical supervisor indicated all clinicians should record the patient’s pulse, respiratory rate, blood pressure, and temperature at each visit. 7. Clinical record review on 1/20/2022, for patient #4, start of care 12/22/2021, certification period 12/22/2021 to 2/19/2022, primary diagnosis of Hemiplegia (muscle weakness or partial paralysis on one side of the body) following cerebral infarction (a stroke), evidenced an agency document titled, “VITAL SIGNS”. Entries dated 12/23/2021, 12/28/2021, 12/30/2021, 1/4/20022, 1/11/2022, and 1/14/2022, failed to evidence patient temperature and respiratory rate. During an interview on 11/24/2022, at 11:09 a.m., the clinical supervisor indicated all clinicians should record the patient’s pulse, respiratory rate, blood pressure, and temperature at each visit. 8. Clinical record review on 1/20/2022, for patient #5, start of care 1/6/2022, certification period 1/6/2022 to 3/6/2022, primary diagnosis of Chronic obstructive pulmonary disease (a lung disease that blocks airflow and makes it difficult to breathe), evidenced an agency document titled, “VITAL SIGNS”. Entries dated 1/6/2022, 1/7/2022, 1/12/2022, and 1/18/2022, failed to evidence patient temperature and respiratory rate. During an interview on 11/24/2022, at 11:09 a.m., the clinical supervisor indicated all clinicians should record the patient’s pulse, respiratory rate, blood pressure, and temperature at each visit. 9. Clinical record review on 1/21/2022, for patient #14, start of care 1/7/2022, certification period 1/7/2021 to 3/7/2022, primary diagnosis of Aftercare following joint replacement surgery, evidenced an agency document titled, “VITAL SIGNS”. Entries dated 1/7/2022, 1/11/2022, 1/14/2022, 1/17/2022, and 1/20/2022, failed to evidence patient temperature and respiratory rate. During an interview on 11/24/2022, at 11:09 a.m., the clinical supervisor indicated all clinicians should record the patient’s pulse, respiratory rate, blood pressure, and temperature at each visit. 10. Clinical record review on 1/21/2022, for patient #15, start of care 2/12/2021, certification period 2/12/2021 to 4/12/2021, primary diagnosis of Primary generalized osteoarthritis (the breakdown of cartilage in the joint causing pain and limited movement), evidenced an agency document titled, “VITAL SIGNS”. Entries dated 2/12/2021, 2/15/2021, 2/18/2021, 2/23/2021, 2/24/2021, 2/26/2021, 3/2/2021, 3/4/2021, 3/6/2021, 3/8/2021, 3/9/2021, and 3/12/2021, failed to evidence patient temperature and respiratory rate. During an interview on 11/24/2022, at 11:09 a.m., the clinical supervisor indicated all clinicians should record the patient’s pulse, respiratory rate, blood pressure, and temperature at each visit. 11. Clinical record review on 1/21/2022, for patient #16, start of care 7/25/2021, certification period 7/25/2021 to 9/22/2021, primary diagnosis of Hypertensive heart and chronic kidney disease (when the heart is not pumping well, resulting in long-term kidney problems), evidenced an agency document titled, “VITAL SIGNS”. Entries dated 7/29/2021, 8/3/2021, and 8/5/2021, failed to evidence patient temperature and respiratory rate. An entry dated 7/27/2021 failed to evidence a respiratory rate. During an interview on 11/24/2022, at 11:09 a.m., the clinical supervisor indicated all clinicians should record the patient’s pulse, respiratory rate, blood pressure, and temperature at each visit.

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 home health agency failed to ensure all entries in the clinical record were complete and appropriately authenticated in 2 of 5 records reviewed receiving only skilled nursing (#2, #9). The findings include: 1. Record review on 1/25/2022, evidenced an agency policy titled, “STANDARDS OF CARE AND PRACTICE”, dated 12/2010, which stated, “ … PURPOSE … To provide guidelines for developing and implementing standards of care and practice … Use of standards of care and practice will be evident in the documentation of visits and assessments, as well as in the care planning process.” 2. Record review evidenced an agency policy titled, “Documentation”, revised 2/1999, which stated, “ … PURPOSE To provide accurate and adequate written information on the patient and services provided. This is done to insure [sic] quality and continuity of care, inform staff / team members of the patient’s condition, the plan of care, and skilled and supportive care provided … Entries should be accurate in time, amounts and descriptions….” 3. Record review evidenced an agency policy titled, “ENTRIES INTO THE CLINICAL RECORD”, revised 5/2013, which stated, “ … Documentation in the clinical record will be timely, detailed, accurate, and reflect the care or services provided….” 4. Clinical record review on 1/18/2022, for patient #2, start of care 6/6/2020, certification period 11/28/2021 to 1/26/2022, primary diagnosis of venous insufficiency [improper functioning of the vein valves in the leg, causing swelling and skin changes], evidenced an agency document titled, “Recert [recertification] OASIS [Outcome and Assessment Information Set] [the patient-specific, standardized assessment used in Medicare home health care]-D1, dated 11/30/2021, and signed by RN [registered nurse] I. This assessment had a subsection titled, “REVIEW OF SYSTEMS – MUSKULOSKELETAL [having to do with the muscles and bones] STATUS”, which stated, “ … AMPUTATION Location RLE [right lower extremity] [right leg] BKA [below-the-knee amputation]….” Clinical record review evidenced an agency document titled, “Skilled Nursing Visit Note”, dated 12/17/2021, and signed by LPN [licensed practical nurse] E, which stated, “ … Pt [patient] has a L [left] BKA. Pt has stasis ulcers [a wound that develops due to poor circulation] to left lower leg….” During an interview on 1/24/2022, at 10:44 a.m., the clinical supervisor indicated the patient only had a right below-the-knee amputation and had wounds to the left lower leg. The clinical supervisor indicated LPN E’s documentation was erroneous. 5. Clinical record review on 1/20/2022, for patient #9, start of care 12/9/2021, certification period 12/9/2021 to 2/6/2022, primary diagnosis of Osteomyelitis [infection in a bone] of the ankle and foot, evidenced a group of agency documents titled, “Skilled Nursing Visit Note”, signed by RN [registered nurse] H. Each of the nurse’s notes had a subsection titled, “NARRATIVE NOTES”. A narrative in a note dated 12/9/2021 stated, “ … RUA [right upper arm] PICC [peripherally inserted central catheter] [an IV inserted for long-term intravenous medication therapy]….” A narrative note dated 12/13/2021 stated, “ … LUA [left upper arm] PICC line dressing changed….”. A narrative note dated 12/16/2021, stated, “ … RUA PICC line dressing intact….”. A narrative note dated 12/20/2021 stated, “ … LUA PICC line dressing changed….”. A narrative note dated 12/23/2021 stated, “ … RUA PICC line dressing intact….”. A narrative note dated 12/27/2021 stated, “ … LUA PICC line dressing changed….”. A narrative note dated 1/3/2022 stated, “ … RUA PICC line dressing changed….”. Clinical record review failed to evidence the patient received a new or changed PICC line from 12/9/2021 to 1/20/2022. During an interview on 1/24/2022, at 2:00 p.m., the clinical supervisor indicated the patient only had one PICC line from 12/9/2021 to 1/20/2022. The clinical supervisor indicated the findings were errors in RN H’s documentation. 17-15-1(a)(7)