Every finding on record at Serenity Home Health LLC

On behalf of the Centers for Medicare & Medicaid Services (CMS), an unannounced on-site Recertification Survey ASPEN #QZW711, at the above-named Home Health Agency from 05/25/21 to 06/01/21 resulted in a finding of no deficiency citations respective to the Emergency Preparedness Program Condition of Participation under 42 CFR 484.22.

On behalf of the Centers for Medicare & Medicaid Services (CMS), an unannounced on-site Recertification Survey ASPEN #I51Y11, at the above-named Home Health Agency from 05/25/21 to 06/01/21 resulted in a finding of substantial compliance respective to applicable COP under 42 CFR 484, Subpart A through C, with the following standard deficiencies.

Patients receive education and training CFR(s): 484.60(d)(5) Ensure that each patient, and his or her caregiver(s) where applicable, receive ongoing education and training provided by the HHA, as appropriate, regarding the care and services identified in the plan of care. The HHA must provide training, as necessary, to ensure a timely discharge. This ELEMENT is not met as evidenced by: Based on document review, policy review and interview, the agency failed to ensure each patient and his or her caregiver(s) received ongoing education and training provided by the agency regarding care and services identified in the plan of care for five of seventeen patients (Patients 1, 4, 8, 12 and 13). The agency's failure to ensure documented, ongoing patient medication education and training, including patient and caregiver response, may result in failure to ensure timely patient discharges. Findings Include: Review of a policy titled, "Care/Service Coordination Policy No. 1-004, Revised date 12/2018," showed care coordination would include ensuring that each patient, and their caregiver(s), where applicable, receive ongoing education and training provided by the organization regarding the are and services identified in the plan of care. The organization shall provide training, as necessary, to ensure a timely discharge. Review of a policy titled, "Care Planning Process, Policy No. 1-007, Revised date 12/2018," showed all clinicians will consider the conclusions of initial and ongoing assessments in their care planning process, including but not limited to Patient and caregiver education and training that the organization will provide specific to the patient's care needs. Based on assessment and conclusions, the plan of care will include specific interventions and education; patient and caregiver education and training to facilitate a timely discharge. Each patient will be monitored for his/her response to care or services provided against established patient goals and patient outcomes to determine if goals have been met. Care decisions and services to be provided will be made as a result of the care planning process, analysis of initial and ongoing assessments, and the analysis of patient response to care against goals and outcomes. Review of a policy titled, "Patient Education Process, Policy No. 2-030, Revised date 12/2018," showed Patient and family/caregivers will receive education in verbal, visual, and written format, as appropriate. Unless otherwise ordered by the physician, the patient and family/caregiver will receive verbal and, as appropriate, written instructions that included, the medial regimen, medication management and administration, food and drug interactions, prescribed treatment and pain management. Documentation of patient and family/caregiver education will consist of describing what was taught to the patient (if using preprinted materials, document the name of the handout);describing the patients response to the teaching, including the level of understanding and the ability to repeat or demonstrate what was taught; describing any additional learning needs not currently met and describing teaching planned for subsequent visits. Patient and family/caregiver education will be interdisciplinary, as appropriate to the plan of care. 1. Patient 1 Review of Patient 1's medical record showed the patient was a 76-year-old female, living at home alone, admitted for service on 03/31/21 with a primary diagnosis of Type 2 diabetes mellitus with foot ulcer. Review of Patient 1's "Plan of Care, for the Certification Period of 03/31/21-05/29/21," showed Skilled Nursing Services provided one time a week for one week, then two times a week for eight weeks, then one time a week for one week, then three times a week for six weeks for SN (Skilled Nurse) Medication Management Interventions that included; assess medication compliance, instruct Pt/Pcg (Patient/Patient care giver): Medication actions, uses, frequency, dose, side effects, interactions of all new/change meds, Perform/Instruct Pt/Pcg: Medication management, pill box, calendar, reminders. Review of Patient 1's "Medication Profile," dated 03/31/21 showed Staff J, Skilled Nurse, did not complete the Date Teaching Performed section and Indication section of the profile to confirm dates of agency instruction on each medication ordered for the patient on admission. Staff J documented on the profile, "Medications reconciled at SOC." Review of Patient 1's "Adult Assessment," dated 03/31/21 showed Staff J, Skilled Nurse, documented that patient needs assistance with taking medications and "Pt (Patient) is non- compliant with her medications and takes them how she feels and not how they are prescribed." Review of Patient 1's Skilled Nurse Visit Note for the date of 04/07/21 showed that Staff L, Skilled Nurse documented patient as having a new medication. Staff L did not specify teaching performed, did not document interdisciplinary patient or family/caregiver education on medication management and administration that included; written material utilized, level of understanding, learning needs not met, and teaching planned for subsequent visits as required by policy. Review of Patient 1's Skilled Nurse Visit Note for the date of 04/12/21 showed that Staff L, Skilled Nurse did not document interdisciplinary patient or family/caregiver education on medication management and administration that included; written material utilized, level of understanding, learning needs not met, and teaching planned for subsequent visits as required by policy. Review of Patient 1's Skilled Nurse Visit Note for the date of 04/14/21 showed Staff M, Skilled Nurse did not document interdisciplinary patient or family/caregiver education on medication management and administration that included; written material utilized, patient's response to the teaching, level of understanding, learning needs not met, and teaching planned for subsequent visits as required by policy. Review of Patient 1's Skilled Nurse Visit Note for the date of 04/16/21 showed Staff N, Skilled Nurse did not document interdisciplinary patient or family/caregiver education on medication management and administration that included; written material utilized, patient's response to the teaching, level of understanding, learning needs not met, and teaching planned for subsequent visits as required by policy. Review of Patient 1's Skilled Nurse Visit Note for the date of 04/19/21 showed Staff L, Skilled Nurse documented that SN Medication Management Goal: Pt/Pcg will verbalize/demonstrate knowledge of and compliance with medication management: dose, route and schedule/actions, interactions and contraindication/administration and compliance with prefilled medications/adherence to diet impacting medications/safe preparation and storage of medications/side effects and symptoms to report by: Achieve by Date: 05/28/21. Start Effective Date: 03/31/21. Progress Toward Goal: 50%. Staff L did not document how progress was measured/determined, did not document interdisciplinary patient or family/caregiver education on medication management and administration that included: written material utilized, patient's response to the teaching, level of understanding, learning needs not met, and teaching planned for subsequent visits as required by policy. Review of Patient 1's Skilled Nurse Visit Note for the date of 04/21/21 showed Staff K, Skilled Nurse did not document interdisciplinary patient or family/caregiver education on medication management and administration that included; written material utilized, patient's response to the teaching, level of understanding, learning needs not met, and teaching planned for subsequent visits as required by policy. Review of Patient 1's Skilled Nurse Visit Note for the date of 05/05/21 showed Staff O, Skilled Nurse did not document interdisciplinary patient or family/caregiver education on medication management and administration that included: written material utilized, learning needs not met, and teaching planned for subsequent visits as required by policy. The surveyor requested and reviewed Patient 1's agency home folder documentation. There was no documentation provided to support the agency ensured the patient and/or his caregiver received ongoing education and training by the agency related to individual medications and medication management. 2. Patient 4 Review of Patient 4's medical record showed the patient was a 93- year-old male, living in an assisted living facility, admitted for service on 04/27/21 with a primary diagnosis of encounter for fitting and adjustment of urinary device. Review of Patient 4's, "Plan of Care, for the Certification Period of 04/27/21-06/25/21," showed Skilled Nursing frequency of one time a week every two weeks for eight weeks to include Medication Management Interventions that included; Instruct Pt/Pcg (Patient/Patient care giver): Medication actions, uses, frequency, dose, side effects, interactions of all new/change meds. SN (Skilled Nursing) Medication Management Goals: Pt/Pcg will verbalize/demonstrate knowledge of and compliance with medication management: dose, route and schedule/actions, interactions and contraindication/administration and compliance with prefilled medications/adherence to diet impacting medications/safe preparation and storage of medications/side effects and symptoms to report. Review of Patient 4's "Medication Profile," dated 04/26/21, showed that Staff P, Skilled Nurse did not complete the Date Teaching Performed or Indication section of the profile to confirm dates of agency instruction on each medication ordered for the patient on admission. Review of Patient 4's medical record visit notes dated 04/26/21-05/20/21 did not show documentation of interdisciplinary patient or family/caregiver (staff) education on medication management and administration that included; written material utilized, patient's or caregiver's response to the teaching, level of understanding, learning needs not met, and teaching planned for subsequent visits as required by policy. The surveyor requested and reviewed Patient 4's agency home folder documentation. There was no documentation provided to support the agency ensured the patient and/or his caregiver received ongoing education and training by the agency related to individual medications and medication management. 3. Patient 8 Review of Patient 8's medical record showed the patient was an 85-year-old male, living in a memory care unit, admitted for service on 05/27/21 with a primary diagnosis of Atherosclerotic heart disease of the native coronary artery (hardening of arteries that bring oxygen rich blood to the heart) w/o angina pectoris (without chest pain). Review of Patient 8's " Plan of Care, for the Certification Period of 04/27/21 - 06/25/21," showed Physical Therapy services 1 time a week for one week, two times a week for two weeks then 1 time a week for two weeks for education on edema and compression, gait training, transfer training and therapeutic exercise. Review of Patient 8's "Medication Profile," dated 04/27/21, showed Staff C, physical therapist did not complete the Date Teaching Performed section of the profile to confirm dates of agency instruction on each medication ordered by the patient on admission. Review of Patient 8's "Physical Therapy Visit Note, "from the date of 05/30/21 through 05/24/21 showed Staff D, Physical Therapist did not document interdisciplinary patient or family/caregiver (staff) education on medication management and administration that included; written material utilized, patient's response to the teaching, level of understanding, learning needs not met, and teaching planned for subsequent visits as required by policy. The surveyor requested and reviewed Patient 8's agency home folder documentation. There was no documentation provided to support the agency ensured the patient and/or his caregiver received ongoing education and training by the agency related to individual medications and medication management. 4. Patient 12 Review of Patient 12's medical record showed the patient was an 83-year-old male, living alone in his home, admitted for service on 05/01/21 with a primary diagnosis of Encounter for orthopedic aftercare. Review of Patient 12's, " Plan of Care, for the Certification Period of 05/11/21 - 07/09/21," showed Physical Therapy services 1 time a week for one week, two times a week for four weeks then 1 time a week for three weeks and for Occupational Therapy services 1 time a week for one week, two times a week for one week then 1 time a week for four weeks for therapy services. Review of Patient 12's "Medication Profile," dated 05/11/21, showed the Staff E, physical therapist did not complete the Date Teaching Performed section of the profile to confirm dates of agency instruction on each medication ordered by the patient on admission Review of Patient 12's "Physical Therapy Visit Note, " from the dates of 05/11/21 through 05/25/21 showed Staff E, Physical Therapist did not document interdisciplinary patient or family/caregiver (staff) education on medication management and administration that included; written material utilized, patient's response to the teaching, level of understanding, learning needs not met, and teaching planned for subsequent visits as required by policy. Review of Patient 12's "Occupational Therapy Evaluation and Care Plan," dated 05/13/21 showed Staff G, Certified Occupational Therapy Assistant did not document interdisciplinary patient or family/caregiver (staff) education on medication management and administration that included; written material utilized, patient's response to the teaching, level of understanding, learning needs not met, and teaching planned for subsequent visits as required by policy. Review of Patient 12's "Occupational Therapy Visit Note, " from the dates of 05/21/21 through 05/25/21 showed Staff G, Certified Occupational Therapy Assistant did not document interdisciplinary patient or family/caregiver (staff) education on medication management and administration that included; written material utilized, patient's response to the teaching, level of understanding, learning needs not met, and teaching planned for subsequent visits as required by policy. The surveyor requested and reviewed Patient 12's agency home folder documentation. There was no documentation provided to support the agency ensured the patient and/or his caregiver received ongoing education and training by the agency related to individual medications and medication management. 5. Patient 13 Review of Patient 13's medical record showed the patient was an 82- year-old female, living at home with family, admitted for service on 12/09/20 with a primary diagnosis of COVID-19. Review of Patient 13's, " Plan of Care, for the Certification Period of 12/09/20 - 02/06/21," showed Skilled Nursing Services provided two times a week for one week then 1 time a week for seven weeks for SN (Skilled Nurse) Medication Management Interventions that included; assess medication compliance, Pt/Pcg (Patient/Patient caregiver) will verbalize/demonstrate knowledge of and compliance with medication management: does, route and schedule/actions, interactions and contraindication/administration and compliance with prefilled medication/adherence to diet impacting medications/safe preparation and storage of medications/side effects and symptoms to report. Review of Patient 13's "Medication Profile," dated 12/09/20, showed Staff H, Skilled Nurse, did not complete the Date Teaching Performed section of the profile to confirm dates of agency instruction on each medication ordered by the patient on admission. Staff H documented on the profile, All med in home, needs generalized medication information. Review of Patient 13's Skilled Nurse Visit Notes for the dates of 12/15/20 through 12/23/20 showed Staff I, Skilled Nurse did not document interdisciplinary patient or family/caregiver (staff) education on medication management and administration that included; written material utilized, patient's response to the teaching, level of understanding, learning needs not met, and teaching planned for subsequent visits as required by policy. The surveyor requested and reviewed Patient 13's agency home folder documentation. There was no documentation provided to support the agency ensured the patient and/or his caregiver received ongoing education and training by the agency related to individual medications and medication management. During an interview on 05/27/21 at 8:45 AM, Staff A, Administrator, confirmed agency staff should be documenting medication education and response to teaching on the Medication Profile and within the visit note for the discipline at each visit. Staff A confirmed documentation of education may be documented on written materials in the patient's home folder.

Infection control CFR(s): 484.70(b)(1)(2) Standard: Control. The HHA must maintain a coordinated agency-wide program for the surveillance, identification, prevention, control, and investigation of infectious and communicable diseases that is an integral part of the HHA's quality assessment and performance improvement (QAPI) program. The infection control program must include: (1) A method for identifying infectious and communicable disease problems; and (2) A plan for the appropriate actions that are expected to result in improvement and disease prevention. This STANDARD is not met as evidenced by: Based on observations, policy review, and interview, the Home Health Agency (HHA) failed to maintain a coordinated agency-wide program for the identification of infectious and communicable diseases, that included methods for COVID-19 symptom screening of patients and caregivers, prior to services provided in the home each visit. The agency's failure to maintain processes to ensure staff implement screening of symptoms prior to home visits may result in failure to identify potential infections for investigation and intervention by agency staff on behalf of patients and caregivers. Findings Include: Review of a document titled "COVID-19 Screening Tool Questionnaire and COVID-19 Report," dated 03/17/20 and contained within the Policy section of the COVID-19 manual, showed DeVero (the agency EMR, electronic medical record for documentation of patient services) has added a COVID-19 screening tool questionnaire to the forms page for each discipline. The first question asks, "Patient was screened according to CDC guidelines?" Yes or No. In order to answer this question, you will ask the patient the following questions (Taken from CMS Memo March 10, 2020). Staff B, Director listed four questions for staff to ask patients. The document showed If the answer is yes to an of these questions, both patient and staff should only proceed having a mask place on the patient and the staffing donning all PPE including gown mask, gloves, shoe covers, goggles or glasses. The second question asked "Family or Visitors were screened according to CDC guidelines." Yes or No. In order to answer this question, you will ask the patient the following questions (Taken from the CMS Memo Match 10, 2020) Staff B, Director listed four questions for staff to ask patients. The document showed if the answer was yes family members should leave the area during patient care. Attached documentation from Staff B, Director showed In order to track COVID-19 screenings, we have added a new form to all Fields Staff user menus; "COVID-19 Screening Tool Questionnaire". As of today, the form has been added to all Field Staff menus on your Site (EMR). Review of a document titled "Updates to COVID-19 Screening Tool Questionnaire and COVID-19 Report," dated 03/19/20 and contained within the Policy section of the COVID-19 manual, showed Staff A, Administrator confirmed anyone who completed a start of care with new admits tomorrow, Friday, March 20, 2020, would add this form to your start of care forms. It is available for all disciplines to add. The document included electronic medical record information for staff to access the COVID-19 Screening Tool and Report. Review of a document within the COVID book, titled, "Incident Command Center Initiated in response to the COVID-19 Pandemic," dated February 2020 through June 2020," showed "March" COVID screening implemented for all team members at start of shift. Questionnaire at patient visit implemented, using CDC recommended questions. Review of a document titled, " Process Change in Response to COVID-19, dated 07/08/20, showed All clinicians conduct a screening at admission and immediately before each visit. COVID-19 Screening Tool added to the admission packet in the electronic health record. The document showed Screening Questions in the home Clients/Other People in Home for COVID like Illness that listed four questions to ask the patient in the home. There was no documentation to support patient COVID-19 screening was completed by all team members at the start of shift nor the implementation of the agency questionnaire completed prior to patient visits, following the admission visit, using CDC recommended questions in compliance with the February 2020 Incident Command Center Directive. During an interview on 05/27/21 at 12:45 PM, Staff A, Administrator, confirmed agency staff were expected to complete the COVID-19 screening processes according to agency directives, following CDC guidelines for COVID-19.