Every finding on record at Share Home Health LLC

The Oklahoma Department of Health conducted an unannounced Emergency Preparedness Program survey at the agency on 02/13/24 to 02/14/24. No deficiencies were cited as a result of the Emergency Preparedness Program survey.

The Oklahoma Department of Health conducted an unannounced Medicare re-certification survey at the agency on 02/13/24 to 02/14/24. An entrance conference was conducted with the Administrator and Quality Nurse. The survey process was explained. Questions were answered. The Administrator was identified as the contact person for administrative and clinical issues. Findings were discussed during an informal exit conference with the Administrator. Standard level deficiencies were cited as a result of the Medicare re-certification survey. Glossary: RN Registered Nurse SN Skilled Nurse POC Plan of Care SOC Start of Care EMR Electronic Medica Record

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 Agency failed to provide an individualized POC to include patient specific vital sign parameters based on the assessed needs of each patient for five (#2, #4 - #7) of seven (#1- #7) records reviewed. A review of the POCs for Patients #2, #4, #5, #6 and #7 each revealed Vital Sign Parameters with orders to contact physician if the following is outside of parameters: Weight: low value 125 to high value 250; Pain: low value 0.0 and high value 10.0; Fasting Blood sugar: low value 70.0 to high value 200.0; Random Blood sugar: low value 70.0 to high value 300.0; PT Result low value 11.0 to high value 13.0; INR result: low value 2.0 to high value 3.0 Further review of records #2, #4, #5, #6 and #7 failed to provide evidence of patient specific assessed needs to support the vital sign parameters for weight, pain, CBG results, PT or INR results. On 02/14/24 at 12:15 PM, the Administrator stated the Agency failed to revise default parameters provided within the Electronic Medical Record and failed to include patient specific vital sign parameters for Pts #2, #4, #5, #6 and #7.

Conformance with physician orders CFR(s): 484.60(b) Standard: Conformance with physician or allowed practitioner orders. This STANDARD is not met as evidenced by: Based on observations, record review and interview, the Skilled Nurse failed to monitor weights and CBG results as ordered on the POC for two (#4 and #6) of seven (#1 - #7) records reviewed. Patient #4 A review of the POC for Patient #4 for the re-certification period 01/11/24 to 03/10/24 revealed a primary diagnosis of Chronic Obstructive Pulmonary Disease and a secondary diagnosis Congestive Heart Failure. Review of the POC revealed orders for SN visits 1 time a week for eight weeks and vital sign parameters of "weight: low value 125 and high value 250" to be reported to the Physician. During a home observation visit conducted on 02/14/24 at 09:30 AM, the Caregiver demonstrated the home monitoring equipment and vital sign log which included daily weights and maintained by Pt. #4 to share with the physician as needed. Further review of SN Visit documentation indicated a weight of 155 pounds was obtained on 12/13/23 but failed to provide evidence weights were obtained or monitored for the following 8 weekly SN visits. Patient #6 A review of the POC for Patient #6 for the re-certification period 11/07/23 to 01/05/24 revealed a primary diagnosis of Type II Diabetes Mellitus and orders for SN visits every 14 days for the episode. Review of the POC revealed orders for "SN to assess diabetic status ...report significant changes to physician. SN may perform ... fingerstick blood glucose. SN instruct patient ... blood sugar monitoring...". Further review of SN Visit documentation failed to provide evidence blood glucose results were obtained or assessed as ordered for SN visits conducted 01/07/24, 01/10/24 or 11/24/24. On 02/14/24 at 12:15 PM, the Administrator stated the SN failed to monitor weights and CBGs results as ordered on the POC for Patient #4 and #6.

Preparing clinical notes CFR(s): 484.75(b)(6) Preparing clinical notes; This ELEMENT is not met as evidenced by: Based on record review and interview, the Skilled Nurse failed to prepare and submit timely the clinical visit notes for two (#1 and #4) of seven (#1 - #7) records reviewed. Patient #1 A review of the POC for Patient #1 for the re-certification period 01/24/24 to 03/23/24 revealed a primary diagnosis of Hemiplegia and secondary diagnosis of Dysphagia. Review of the POC revealed orders for SN visits 1 time a week for 9 weeks. Further review of SN Visit documentation revealed a SN visit note for 01/19/24 but failed to provide evidence of a SN Visit or clinical record documentation tor the following 3 weeks of 01/21/24, 01/28/24 and 02/04/24. Patient #4 A review of the POC for Patient #4 for the re-certification period 01/11/24 to 03/10/24 revealed a primary diagnosis of COPD and secondary diagnosis of Heart Failure. Review of the POC revealed orders for SN visits 1 time a week for 8 weeks. Further review of SN Visit documentation revealed a SN visit was conducted on 02/01/24 but failed to provide evidence of a SN Visit or clinical record documentation tor the following week of 02/04//24. On 02/14/24 at 12:15 PM, the Administrator stated the SN failed to complete and submit clinical note documentation timely for Patients #4 and #6.

Onsite supervisory visit every 14 days CFR(s): 484.80(h)(1)(i) If home health aide services are provided to a patient who is receiving skilled nursing, physical or occupational therapy, or speech-language pathology services, a registered nurse or other appropriate skilled professional who is familiar with the patient, the patient's plan of care, and the written patient care instructions described in §484.80(g), must make an onsite visit to the patient's home no less frequently than every 14 days. The home health aide does not have to be present during this visit. This ELEMENT is not met as evidenced by: Based on record review and interview, the RN failed to conduct onsite supervisory visits to the patient's home no less frequently than every 14 days for one (#2) of two (#2 and #5) records reviewed with orders for Home Health Aide services. Patient #2 Review of the POC for recertification periods 01/19/24 - 03/18/24 revealed a Primary Diagnosis of Paranoid Schizophrenia with orders for Home Health Aide services 2 times a week for 9 weeks. Further review of RN documentation for Supervisory Aide Visits indicated onsite visits were conducted on 01/17/24 and 02/29/24 (3 days late). On 02/14/24 at 12:15 PM, the Administrator stated the RN failed to conduct Supervisory Aide Visits at least every 14 days as required for Pt#2.

The Oklahoma State Department of Health conducted an unannounced Medicare Emergency Preparedness Program survey at the agency on 03/16/21 to 03/17/21. Standard level deficiencies were cited as a result of the Emergency Preparedness Program survey.

Plan Based on All Hazards Risk Assessment CFR(s): 484.102(a)(1)-(2) §403.748(a)(1)-(2), §416.54(a)(1)-(2), §418.113(a)(1)-(2), §441.184(a)(1)-(2), §460.84(a)(1)-(2), §482.15(a)(1)-(2), §483.73(a)(1)-(2), §483.475(a)(1)-(2), §484.102(a)(1)-(2), §485.68(a)(1)-(2), §485.625(a)(1)-(2), §485.727(a)(1)-(2), §485.920(a)(1)-(2), §486.360(a)(1)-(2), §491.12(a)(1)-(2), §494.62(a)(1)-(2) [(a) Emergency Plan. The [facility] must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least every 2 years. The plan must do the following:] (1) Be based on and include a documented, facility-based and community-based risk assessment, utilizing an all-hazards approach.* (2) Include strategies for addressing emergency events identified by the risk assessment. * [For Hospices at §418.113(a):] Emergency Plan. The Hospice must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least every 2 years. The plan must do the following: (1) Be based on and include a documented, facility-based and community-based risk assessment, utilizing an all-hazards approach. (2) Include strategies for addressing emergency events identified by the risk assessment, including the management of the consequences of power failures, natural disasters, and other emergencies that would affect the hospice's ability to provide care. *[For LTC facilities at §483.73(a):] Emergency Plan. The LTC facility must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least annually. The plan must do the following: (1) Be based on and include a documented, facility-based and community-based risk assessment, utilizing an all-hazards approach, including missing residents. (2) Include strategies for addressing emergency events identified by the risk assessment. *[For ICF/IIDs at §483.475(a):] Emergency Plan. The ICF/IID must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least every 2 years. The plan must do the following: (1) Be based on and include a documented, facility-based and community-based risk assessment, utilizing an all-hazards approach, including missing clients. (2) Include strategies for addressing emergency events identified by the risk assessment. This STANDARD is not met as evidenced by: Based on record review and interview, the agency failed to ensure an all hazard risk assessment: 1. identified the agency by name and; 2. was dated when completed effecting 107 patients and all staff members. Finding: A review of administrative records related to emergency preparedness showed no documentation of a current risk analysis for the agency. The risk analysis documentation did not identify the agency by name and showed no date the analysis was completed. On 03/17/21 at 9:25 a.m., Staff A stated the risk assessment: 1. did not identify the agency by name and; 2. showed no date the analysis was completed.

EP Testing Requirements CFR(s): 484.102(d)(2) §416.54(d)(2), §418.113(d)(2), §441.184(d)(2), §460.84(d)(2), §482.15(d)(2), §483.73(d)(2), §483.475(d)(2), §484.102(d)(2), §485.68(d)(2), §485.625(d)(2), §485.727(d)(2), §485.920(d)(2), §491.12(d)(2), §494.62(d)(2). *[For ASCs at §416.54, CORFs at §485.68, OPO, "Organizations" under §485.727, CMHCs at §485.920, RHCs/FQHCs at §491.12, and ESRD Facilities at §494.62]: (2) Testing. The [facility] must conduct exercises to test the emergency plan annually. The [facility] must do all of the following: (i) Participate in a full-scale exercise that is community-based every 2 years; or (A) When a community-based exercise is not accessible, conduct a facility-based functional exercise every 2 years; or (B) If the [facility] experiences an actual natural or man-made emergency that requires activation of the emergency plan, the [facility] is exempt from engaging in its next required community-based or individual, facility-based functional exercise following the onset of the actual event. (ii) Conduct an additional exercise at least every 2 years, opposite the year the full-scale or functional exercise under paragraph (d)(2)(i) of this section is conducted, that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or individual, facility-based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the [facility's] response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the [facility's] emergency plan, as needed. *[For Hospices at 418.113(d):] (2) Testing for hospices that provide care in the patient's home. The hospice must conduct exercises to test the emergency plan at least annually. The hospice must do the following: (i) Participate in a full-scale exercise that is community based every 2 years; or (A) When a community based exercise is not accessible, conduct an individual facility based functional exercise every 2 years; or (B) If the hospice experiences a natural or man-made emergency that requires activation of the emergency plan, the hospital is exempt from engaging in its next required full scale community-based exercise or individual facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional exercise every 2 years, opposite the year the full-scale or functional exercise under paragraph (d)(2)(i) of this section is conducted, that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or a facility based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (3) Testing for hospices that provide inpatient care directly. The hospice must conduct exercises to test the emergency plan twice per year. The hospice must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual facility-based functional exercise; or (B) If the hospice experiences a natural or man-made emergency that requires activation of the emergency plan, the hospice is exempt from engaging in its next required full-scale community based or facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional annual exercise that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or a facility based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop led by a facilitator that includes a group discussion using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the hospice's response to and maintain documentation of all drills, tabletop exercises, and emergency events and revise the hospice's emergency plan, as needed. *[For PRFTs at §441.184(d), Hospitals at §482.15(d), CAHs at §485.625(d):] (2) Testing. The [PRTF, Hospital, CAH] must conduct exercises to test the emergency plan twice per year. The [PRTF, Hospital, CAH] must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise; or (B) If the [PRTF, Hospital, CAH] experiences an actual natural or man-made emergency that requires activation of the emergency plan, the [facility] is exempt from engaging in its next required full-scale community based or individual, facility-based functional exercise following the onset of the emergency event. (ii) Conduct an [additional] annual exercise or and that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or individual, a facility-based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the [facility's] response to and maintain documentation of all drills, tabletop exercises, and emergency events and revise the [facility's] emergency plan, as needed. *[For PACE at §460.84(d):] (2) Testing. The PACE organization must conduct exercises to test the emergency plan at least annually. The PACE organization must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise; or (B) If the PACE experiences an actual natural or man-made emergency that requires activation of the emergency plan, the PACE is exempt from engaging in its next required full-scale community based or individual, facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional exercise every 2 years opposite the year the full-scale or functional exercise under paragraph (d)(2)(i) of this section is conducted that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or individual, a facility based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the PACE's response to and maintain documentation of all drills, tabletop exercises, and emergency events and revise the PACE's emergency plan, as needed. *[For LTC Facilities at §483.73(d):] (2) The [LTC facility] must conduct exercises to test the emergency plan at least twice per year, including unannounced staff drills using the emergency procedures. The [LTC facility, ICF/IID] must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise. (B) If the [LTC facility] facility experiences an actual natural or man-made emergency that requires activation of the emergency plan, the LTC facility is exempt from engaging its next required a full-scale community-based or individual, facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional annual exercise that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or an individual, facility based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the [LTC facility] facility's response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the [LTC facility] facility's emergency plan, as needed. *[For ICF/IIDs at §483.475(d)]: (2) Testing. The ICF/IID must conduct exercises to test the emergency plan at least twice per year. The ICF/IID must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise; or. (B) If the ICF/IID experiences an actual natural or man-made emergency that requires activation of the emergency plan, the ICF/IID is exempt from engaging in its next required full-scale community-based or individual, facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional annual exercise that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or an individual, facility-based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the ICF/IID's response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the ICF/IID's emergency plan, as needed. *[For HHAs at §484.102] (d)(2) Testing. The HHA must conduct exercises to test the emergency plan at least annually. The HHA must do the following: (i) Participate in a full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise every 2 years; or. (B) If the HHA experiences an actual natural or man-made emergency that requires activation of the emergency plan, the HHA is exempt from engaging in its next required full-scale community-based or individual, facility based functional exercise following the onset of the emergency event. (ii) Conduct an additional exercise every 2 years, opposite the year the full-scale or functional exercise under paragraph (d)(2)(i) of this section is conducted, that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or an individual, facility-based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the HHA's response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the HHA's emergency plan, as needed. *[For OPOs at §486.360] (d)(2) Testing. The OPO must conduct exercises to test the emergency plan. The OPO must do the following: (i) Conduct a paper-based, tabletop exercise or workshop at least annually. A tabletop exercise is led by a facilitator and includes a group discussion, using a narrated, clinically relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. If the OPO experiences an actual natural or man-made emergency that requires activation of the emergency plan, the OPO is exempt from engaging in its next required testing exercise following the onset of the emergency event. (ii) Analyze the OPO's response to and maintain documentation of all tabletop exercises, and emergency events, and revise the [RNHCI's and OPO's] emergency plan, as needed. *[ RNCHIs at §403.748]: (d)(2) Testing. The RNHCI must conduct exercises to test the emergency plan. The RNHCI must do the following: (i) Conduct a paper-based, tabletop exercise at least annually. A tabletop exercise is a group discussion led by a facilitator, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (ii) Analyze the RNHCI's response to and maintain documentation of all tabletop exercises, and emergency events, and revise the RNHCI's emergency plan, as needed. This STANDARD is not met as evidenced by: Based on record review and interview the agency failed to ensure emergency preparedness disaster table top exercises and drills conducted for fiscal years 2019 and 2020 documented agency staff participation effecting 107 patients and all staff members. Findings: A review of administrative records related to emergency preparedness showed no documentation of agency staff participation in disaster table top exercises and drills conducted for fiscal years 2019 and 2020. On 03/17/21 at 9:30 a.m., Staff A stated the agency had showed no agency staff participation in emergency preparedness disaster table top exercises and drills conducted for fiscal years 2019 and 2020.

The Oklahoma State Department of Health conducted an unannounced Medicare re-certification survey at the agency on 03/16/21 through 03/17/21. An entrance conference was conducted with Staff A. The survey process was explained. Questions were answered. Staff A was identified as the contact person for administrative and clinical issues. Findings were discussed during an informal exit conference with Staff A. Standard level deficiencies were cited as a result of the Medicare re-certification survey. Glossary: BS Blood Sugar DM II Diabetes Mellitus Type II SN Skilled Nurse/Skilled Nursing SOC Start of Care Pt's Patients PIP Performance Improvement Project QAPI Quality Assurance Performance Improvement

RN performs assessment CFR(s): 484.55(a)(1) A registered nurse must conduct an initial assessment visit to determine the immediate care and support needs of the patient; and, for Medicare patients, to determine eligibility for the Medicare home health benefit, including homebound status. The initial assessment visit must be held either within 48 hours of referral, or within 48 hours of the patient's return home, or on the physician or allowed practitioner - ordered start of care date. This ELEMENT is not met as evidenced by: Based on record review and interview, the agency failed to ensure a SOC assessment was conducted within 48 hours of referral for one (Patient #1) of seven patients. Findings: Patient #1 A review of the clinical record showed the agency received referral information on 01/04/21 and the SOC assessment occurred on 01/07/21 (72 hours later). Documentation showed no patient refusal of SOC assessment, no physician notification of a delay in SOC and no change in orders. On 03/17/21 at 12:30 p.m., Staff A stated the SOC assessment should have been conducted by 01/06/21.

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 agency failed to ensure medication embedded wound care supplies were included in the review of medications for potential/adverse effects, drug reactions, side effects, interactions and duplicate drug therapy for three (Pt's #1, 2 and #5) of seven patients. Findings: Patient #1 A review of the plan of care dated 01/07/21 to 03/07/21 documented a principal diagnosis of wound infection to right breast. A physician's order dated 01/29/21 ordered SN to perform wound site care using MaxOrb AG dressing (a medication embedded wound care supply material). A review of the medication profile showed the medicated dressing material was not added to the medication profile or reviewed for patient interactions, side effects, or allergies. Patient #2 A review of the plan of care dated 02/14/21 to 04/14/21 documented a principal diagnosis of DM II with gangrene right foot. A physician's order dated 02/14/21 ordered SN to perform wound site care using calcium alginate dressing (a medication embedded wound care supply material). A review of the medication profile showed the medicated dressing material was not added to the medication profile or reviewed for patient interactions, side effects, or allergies. Patient #5 A review of the plan of care dated 11/05/20 to 01/03/21 documented a principal diagnosis of DM II with wound infection to right foot. A physician's order dated 11/05/20 ordered SN to perform wound site care using Xeroform dressing (a medication embedded wound care supply material). A review of the medication profile showed the medicated dressing material was not added to the medication profile or reviewed for patient interactions, side effects, or allergies. On 03/17/21 at 12:50 p.m., Staff A stated the medication embedded wound care supplies ordered for wound care on Patients #1, 2 and #5 were not on the medication profiles and the Home Health Agency did not review medication embedded wound care supply materials for patient interactions, side effects, or allergies.

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 agency failed to ensure: 1. physician notification of SN wound care visits for one (Patient #1); and 2. physician notification of BS levels greater than the ordered reporting parameter of 225 for two (Pt's #2 and #5) of seven patients. Findings: Patient #1 A review of the POC dated 01/07021 to 03/07/21 documented a SN frequency of one time a week for one week then two times a week for eight weeks. Documentation showed during the week of 01/17/21 through 01/21/21 no SN visits were conducted (two missing SN visits.) Documentation showed no patient/caregiver refusal of visit, physician notification, or changes in orders. Patient #2 A review of the POC dated 02/14/21 to 04/14/21 showed orders for SN to report BS levels greater than 225. A review of clinical notes showed on 02/22/21 a BS level of 250; 02/24/21 BS level of 250; 02/26/21 BS level of 261. Documentation showed no physician notification of the BS levels. Patient #5 A review of the POC dated 11/05/20 to 01/03/21 showed orders for SN to report BS levels greater than 225. A review of clinical notes showed on 11/09/21 a BS level of 460; 11/12/20 BS level of 369; 11/13/20 BS level of 571; and on 11/18/20 BS level of 519. Documentation showed no physician notification of the BS levels. On 03/17/21 at 1:00 p.m., Staff A stated the physician should have been notified of: 1. missed SN visits on Patient #1 and; 2. BS levels greater than 225 for Pt's #2 and #5.

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 reviews and interview, the agency failed to ensure SN visits were conducted as ordered by the physician for one (Patient #1) of seven patients. Findings: Patient #1 A review of the POC dated 01/07/21 to 03/07/21 showed orders for SN to perform wound care one time a day for two days, two times a week for two weeks, then one time a week for three weeks. An additional physician order dated 02/22/21 ordered SN to continue wound care one time a week for one week, then two times a week for one week. A review of clinical documentation showed one additional visit made during the weeks of 01/24/21 through 01/30/21 and 02/21/21 through 02/27/21. Documentation showed no additional SN visits needed, no physician notification, no request by patient/family/caregiver and no change in orders. On 03/17/21 at 12:20 p.m., Staff A stated SN visit frequency for Patient #1 should have been conducted as ordered by the physician.

Performance improvement projects CFR(s): 484.65(d)(1)(2) Standard: Performance improvement projects. Beginning July 13, 2018 HHAs must conduct performance improvement projects. (1) The number and scope of distinct improvement projects conducted annually must reflect the scope, complexity, and past performance of the HHA's services and operations. (2) The HHA must document the quality improvement projects undertaken, the reasons for conducting these projects, and the measurable progress achieved on these projects. This STANDARD is not met as evidenced by: Based on record review and interview, the agency failed to ensure the initiation and review of a PIP through their QAPI Program for 107 patients and all employees. Findings: A review of 2019 and 2020 QAPI and administrative records showed no initiation, review, data analysis, or status of PIPs. On 03/16/21 at 1:00 p.m., Staff A stated the agency had no available PIP data for 2019 and 2020.

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 record review and interview, the agency failed to ensure their Infection Control Program: 1. was included in QAPI activities and; 2. included comprehensive infection control surveillance activities and interventions to reduce future infections and promote learning and preventative measures throughout the agency for 107 patients and all employees. Findings: A review of administrative records showed no infection control surveillance data for the agency for calendar year's 2019 and 2020. On 03/17/21 at 10:00 a.m., Staff A stated the agency should have: 1. included infection control data as part of a comprehensive QAPI program and 2. had infection control surveillance and follow up activities in place.

Discharge and transfer summaries CFR(s): 484.110(a)(6)(i-iii) (i) A completed discharge summary that is sent to the primary care practitioner or other health care professional who will be responsible for providing care and services to the patient after discharge from the HHA (if any) within 5 business days of the patient's discharge; or (ii) A completed transfer summary that is sent within 2 business days of a planned transfer, if the patient's care will be immediately continued in a health care facility; or (iii) A completed transfer summary that is sent within 2 business days of becoming aware of an unplanned transfer, if the patient is still receiving care in a health care facility at the time when the HHA becomes aware of the transfer. This ELEMENT is not met as evidenced by: Based on record reviews and interview the agency failed to ensure completed transfer/discharge summaries were provided for three (Pt's #5, 6 and #7) of seven patients. Findings: Patient #5 A review of the clinical record showed the patient was discharged from the agency on 12/28/20 to in-patient hospital care services. Documentation showed no transfer/discharge summary was provided to the in-patient hospital care service provider. Patient #6 A review of the clinical record showed the patient was transferred to and later discharged from the agency on 12/17/20 to in-patient hospital care services. Documentation showed no transfer/discharge summary was provided to the in-patient hospital care service provider. Patient #7 A review of the clinical record showed the patient was discharged from the agency on 12/22/20 to hospice care services. Documentation showed no discharge summary was provided to the hospice service provider. On 03/17/21 at 1:00 p.m., Staff A stated: 1. no transfer/discharge summaries were sent to the hospital service providers for Pt's #5 and #6 and; 2. no discharge summary was sent to the hospice service provider for Patient #7.

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 agency failed to ensure clinical records were complete for one (Patient #4) of seven patients. Findings: Patient #4 A review of the clinical record showed incomplete documentation (a blank visit note) of a SN visit conducted on 03/13/21. On 03/13/21 at 12:30 p.m., Staff A stated the SN visit note dated 03/13/21 should have been completed after the SN visit was conducted.