Every finding on record at Shine Home Healthcare LLC

At the time of the emergency preparedness survey completed on 01/06/22, Shine Home Healthcare is in compliance with the provisions of 42 CFR Part 484.22, Conditions of Participation for Home Health Agencies.

The following deficiencies are based on the partial extended recertification survey completed 01/06/22. Shine Home Healthcare is not in compliance with the requirements found at 42 CFR Part 484, Subpart B, C, Home Health Agencies.

At discharge CFR(s): 484.55(d)(3) At discharge. This ELEMENT is not met as evidenced by: Based on medical record review and staff interview the agency failed to complete an updated comprehensive assessment at discharge for two (Patients #4 and #5) of four medical records reviewed for discharge services. The agency census was three. 1.Review of the medical record for Patient #4 revealed the patient was admitted to the agency on 02/07/20 with the primary diagnosis of internal derangement of right knee. Review of the certification period dated 02/07/20 through 04/06/20 revealed the patient was to receive SN serviced once a week and HHA services 13 hours per week for nine weeks. Review of Patient #4 medical record revealed the patient was discharged from the agency on 04/06/20 with no documented evidence a discharge oasis assessment was completed. Interview with Staff A on 01/04/22 at 9:37 AM confirmed the agency had not completed a discharge oasis assessment. 2. Review of the medical record for Patient #5 revealed the patient was admitted to the agency on 12/23/19 with the primary diagnosis of hypertension. Review of the certification period dated 12/23/19 through 03/20/20 revealed the patient was to receive SN services twice a week for nine weeks. Review of Patient #5 medical record revealed the patient was discharged from the agency on 02/03/20 with no documented evidence a discharge oasis assessment was completed. Interview with Staff A on 01/05/22 at 9:40 AM confirmed the agency had not completed a discharge oasis assessment.

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 medical record review, staff interview, and policy review the agency failed to ensure skilled nurse (SN) and home health aide (HHA) services were administered only as ordered by a physician or allowed practitioner. This affected four (Patient #1, #3, #4, and #5) of seven active and discharge medical records reviewed. The facility census was 3. Findings include: 1. Review of the medical record for Patient #1 revealed the patient was admitted to the agency on 12/01/20 with the primary diagnosis of osteoporosis. Review of the certification period dated 11/26/21 through 01/24/22 revealed the patient was to receive SN services every 60 days. Review of Patient #1's medical record revealed the patient received 35 hours of HHA services the week of 11/29/21, 34 hours the week of 12/06/21, 30 hours the week of 12/13/21, 35 hours the week of 12/20/21, and 33 hours the week of 12/27/21. Review of the medical record revealed no documented evidence of a physician's order for HHA services. Interview with Staff A on 01/04/22 at 10:57 AM confirmed there was no physician’s order for HHA services. 2. Review of the medical record for Patient #3 revealed the patient was admitted to the agency on 01/19/19 with the primary diagnosis of Encephalopathy. Review of the certification period dated 11/04/21 through 01/02/22 revealed the patient was to receive SN services one hour bi-weekly for nine weeks and HHA services eight hours a day, seven days a week, for nine weeks. Review of Patient #3's SN notes revealed the patient was seen by the nurse on 11/05/21, 11/12/21, 11/18/21, 11/26/21 12/06/21, 12/17/21, 12/23/21, and 12/31/21 which was not every other week as ordered by the physician. Review of Patient #3's HHA timesheets revealed from 11/04/21 through 11/25/21 the patient received six hours of HHA services per day, no HHA services on 11/26/21, and five hours of HHA services per day from 11/27/21 through 01/02/22 as ordered by the physician. The medical record failed to have documented evidence the physician was notified of missed visits. Interview with Staff A on 01/04/21 at 12:00 PM confirmed the SN was not performed SN services every other week and the HHA had not performed eight hours of HHA services per day as ordered by the physician. 3. Review of the medical record for Patient #4 revealed the patient was admitted to the agency on 02/07/20 with the primary diagnosis of internal derangement of right knee. Review of the certification period dated 02/07/20 through 04/06/20 revealed the patient was to receive SN serviced once a week and HHA services 13 hours per week for nine weeks. Review of Patient #4's medical record revealed no documented evidence of SN services being provided except for the start of care oasis assessment completed on 02/07/20 with no physician notification of missed visit. Review of Patient #4's HHA timesheets revealed the patient received one hour of HHA services the week of 02/10/20, four hours the week of 02/17/20, nine hours the week of 03/02/20, four hours the week of 03/09/20, and no hours the week of 03/16/20, 03/23/20, and 03/30/20 with no physician notification of missed visits. Interview with Staff A on 01/04/22 at 9:37 AM confirmed the SN and HHA had not provided services as ordered by the physician. 4. Review of the medical record for Patient #5 revealed the patient was admitted to the agency on 12/23/19 with the primary diagnosis of hypertension. Review of the certification period dated 12/23/19 through 03/20/20 revealed the patient was to receive SN services twice a week for nine weeks. Review of Patient #5's SN notes revealed the nurse provided services on 12/24/19, 12/27/19, 01/03/20, 01/24/20, and 01/31/19 which was not per physician orders for twice a week. There was also no evidence of physician notification of missed visits. Interview with Staff A on 01/05/22 at 9:40 AM confirmed the SN had not performed services per the physician orders. Review of policy and procedure for Certified Nursing Aide/Home Health Aide (undated) revealed the HHA provides services that are ordered by the physician and included in the plan of care. Review of Policy and Procedure for Registered Nurse (undated) revealed the nurse would administer medications and treatments as prescribed by the patient’s physician or podiatrist.