Every finding on record at Siloe Home Health & Infusion, LLC

Siloe Home Health & Infusion LLC Initial Comments Purpose of Visit - To conduct 1 Complaint Investigation. Entrance Date/Time - 08/03/21 at 08:58 a.m. Census: 102 Licensed and Certified: 102 Intake # 228982 was an ACT's Complaint and was found to be Substantiated and Cited. Agency was also Cited for unrealted deficiencies. An exit conference was conducted on 08/06/2021 at 11:53 p.m. with the Administrator, the Chief Operating Officer and the Alternate Administrator / Director of Nursing. The preliminary findings were discussed with agency staff. The agency was afforded the opportunity to provide additional information. Written instructions were provided for submitting a plan of correction within 10 days of the receipt of the Statement of Deficiencies. Administrator - Adm Chief Operating Officer - COO Alternate Administrator/Director of Nursing- AA/DON Previous Alternate Director of Nursing - P-ADON EX - Alternate Director of Nursing - EX-ADON Registered Nurse - RN Licensed Vocational Nurse - LVN EX-Licensed Vocational Nurse - EX-LVN

Participate in care CFR(s): 484.50(c)(4)(i,ii,iii,iv,v,vi,vii,viii) Participate in, be informed about, and consent or refuse care in advance of and during treatment, where appropriate, with respect to-- (i) Completion of all assessments; (ii) The care to be furnished, based on the comprehensive assessment; (iii) Establishing and revising the plan of care; (iv) The disciplines that will furnish the care; (v) The frequency of visits; (vi) Expected outcomes of care, including patient-identified goals, and anticipated risks and benefits; (vii) Any factors that could impact treatment effectiveness; and (viii) Any changes in the care to be furnished. This ELEMENT is not met as evidenced by: Based on clinical record review and interview, the Agency failed to respect the patient rights to be informed of changes in frequency of Physical Therapy Care as was established on the individualized Plan of Care (POC) for 1 of 6 discharged Agency Patients (#1) whose clinical records were reviewed. This failure violates patients right to have their physical needs treated and hinders a detailed approach to care customized to an individual patient needs. The Findings included: At the entrance conference on 08/03/21 at 08:57 a.m. with the AA/DON, the Surveyor requested and received a list of discharged patients that corresponded to the dates of the six complaints the Surveyor was there to investigate. Review of the list revealed the name of Patient #1, who was mentioned in two of the complaints. Review of active Patient #1's electronic clinical record included a form titled "Home Health Certification and Plan of Care" (POC) for the period of 07/15/20 thru 08/27/20 with diagnoses of Hemiplegia (paralysis of one side of the body) of the Left Side and Atrial Fibrillation (irregular heart rate) The POC included a skilled nurse (SN) visit frequency of one time a week for nine weeks and a PT visit frequency of two times a week for four weeks. Review of the visit frequency for PT showed that for the first four weeks of the Certification period that only four PT visits were made. The dates were 07/17/20 (This was a documented Missed Visit [MV]) 07/22/20, 07/29/20 and 08/05/20. Review of the 485 (POC), dated 07/10/20 revealed the order for PT frequency as two times a week for 4 weeks. The POC was signed by the Physician A and by the AA/DON. Review of the Recertification dated 07/10/20 and signed by the AA/DON read in part: "Patient is making slow steady progress with ongoing PT. Ongoing PT needed to continue progress. Patient has a paid caregiver that assist with all ADL's (Activities of Daily Living [Bathing, Dressing, Functional Transfers, Ambulation, Memory Care]) and IADL's (Instrumental Activities of Daily Living [examples - Telephone, Shopping, Preparing meals, Medications, Finances and Transportation]). It is determined that the patient would benefit greatly from ongoing skilled services. The last time PT was discharged the patient regressed to the point she could only take 2 steps and was maximum assistance to stand." Review of Patient #1's electronic clinical record revealed an Agency Communication Note dated 07/22/20. It was signed by the COO, it read in part: "Physician's order received for increased in PT. She is receiving PT at this time on a weekly basis due to her positive progress. The Patient does not met [sic] criteria for an increase in physical therapy at this time. It may be more beneficial for the patient to attend outpatient therapy for more intense treatments." Review of a Skilled Nurse (SN) visit note dated 07/20/20 and signed by EX-LVN B read in part: "Patient is confined because of illness, needs the aid of supportive devices such as crutches, canes, wheelchairs and walkers; the use of special transportation; or the assistance of another person in order to leave her place of residence. Patient #1 has a condition such that leaving her home is medically contraindicated. Patient #1 has a normal inability to leave home and leaving home requires a considerable and taxing effort for the patient." The above SN visit note was dated 2 days before the Agency Communication Note. Review of all of the Communication Notes in Patient #1's electronic clinical record failed to contain documentation that one that was faxed to Physician A notifying him of the PT frequency change made by the COO and the AA/DON. Continued review of Patient #1's electronic clinical record revealed that there was no Physician order that changed the PT frequency to one time a week for four weeks from the two times a week for 4 weeks that was ordered on the POC. Further review of the 3 SN visits that were made (07/22/20, 07/29/20 and 08/05/20), failed to include documentation that Patient #1 had been informed of the change in Physical Therapy care. Further review of the Communication Notes in Patient #1's electronic clinical record failed to contain documentation that Patient #1 had been notified of the change in Physical Therapy care. In an interview and concurrent record review conducted on 08/05/21 at 02:10 p.m. with the AA/DON, the Surveyor reviewed Patient #1's POC with the AA/DON, and asked if the POC had an order for PT 2 times per week for 4 weeks, the AA/DON stated "Yes, okay." The Surveyor pointed out the PT frequency for the reviewed certification period and asked if the POC had been followed for PT Frequency, the AA/DON stated "No, okay." The Surveyor reviewed the SN visit notes with the AA/DON and asked if there was documentation that Patient #1 had been notified of the PT change. After reviewing the AA/DON stated "No, okay." The Surveyor review the Communication Notes and asked if there was documentation that Patient #1 had been notified of the change in Physical Therapy care. The AA/DON stated "No." and acknowledged that Patient #1 had not been notified of any changes in the PT care to be furnished. Review of the Agency's Policy and Procedure manual revealed a policy titled "Patient Bill of Rights and Responsibilities: Rights of the Elderly". It was numbered RI.1 and had a revision date of 01/13/18. It read in part: "The patient has the right to be informed in advance of expected outcomes, barriers to treatment and any changes in the care to be furnished. The Agency must ensure the patient understands the type of care and services that may be provided by the Agency." Continued review of the Patient Bill of Rights and Responsibilities: Rights of the Elderly policy read in part: "P. The patient has the right to participate in the planning of the care or treatment and in planning changes in the care or treatment. 1. Agency must advise or consult with the patient in advance of any changes in the Plan of Care." Continued review of the Agency's Policy and Procedure manual revealed a policy titled "Plan of Care." It was numbered TX.6 and had a revision date of 01/13/18. I read in part: "V. Each patient must receive the home health services that are written in an individualized plan of care." Further review of the Plan of Care policy read in part: "B. 1. Any revision to the plan of care due to a change must be communicated to the patient/caregiver and all physicians issuing orders for the Agency plan of care.

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 clinical record review and interview, the Supervising Nurse failed to ensure the patients Plans of Care (POC) were executed as written for 1 of 6 discharged patients (#1) whose records were reviewed. The AA/DON and COO failed to execute Physical Therapy (PT) orders as written on the Plan of Care (POC) for Patient #1 and Ex-LVN A, EX-LVN B and the AA/DON did not instruct Patient #1 and/or caregiver as ordered. The Failure of the Agency's skilled nurses to follow the plan of care places the Agency's 102 active Licensed and Certified patients at risk of receiving inadequate care and services which could ultimately cause negative patient outcomes. The Findings Included: Review of active Patient #1's electronic clinical record included a form titled "Home Health Certification and Plan of Care" (POC) for the period of 07/15/20 thru 08/27/20 with diagnoses of Hemiplegia (paralysis of one side of the body) of the Left Side and Atrial Fibrillation (irregular heart rate) The POC included a skilled nurse (SN) visit frequency of one time a week for nine weeks and a PT visit frequency of two times a week for four weeks Review of the visit frequency for PT showed that for the first four weeks of the Certification period that only four PT visits were made. The dates were 07/17/20 (This was a documented Missed Visit [MV]) 07/22/20, 07/29/20 and 08/05/20. Review of the 485 (POC), dated 07/10/20 revealed the order for PT frequency as two times a week for 4 weeks. The POC was signed by the Physician A and by the AA/DON. Review of the Recertification dated 07/10/20 and signed by the AA/DON read in part: "Patient is making slow steady progress with ongoing PT. Ongoing PT needed to continue progress. Patient has a paid caregiver that assist with all ADL's (Activities of Daily Living [Bathing, Dressing, Functional Transfers, Ambulation, Memory Care]) and IADL's (Instrumental Activities of Daily Living [examples - Telephone, Shopping, Preparing meals, Medications, Finances and Transportation]). It is determined that the patient would benefit greatly from ongoing skilled services. The last time PT was discharged the patient regressed to the point she could only take 2 steps and was maximum assistance to stand." Review of Client #1's electronic clinical record revealed an Agency Communication Note dated 07/22/20. It was signed by the COO, it read in part: "Physician's order received for increased in PT. She is receiving PT at this time on a weekly basis due to her positive progress. The patient does not met [sic] criteria for an increase in physical therapy at this time. It may be more beneficial for the patient to attend outpatient therapy for more intense treatments." Review of a Skilled Nurse (SN) visit note dated 07/20/20 and signed by EX-LVN B read in part: "Client is confined because of illness, needs the aid of supportive devices such as crutches, canes, wheelchairs and walkers; the use of special transportation; or the assistance of another person in order to leave her place of residence. Patient #1 has a condition such that leaving her home is medically contraindicated. Patient #1 has a normal inability to leave home and leaving home requires a considerable and taxing effort for the client." The above SN visit note was dated 2 days before the Agency Communication Note. Review of all of the Communication Notes in Patient #1's electronic clinical record failed to contain one that was faxed to Physician A notifying him of the PT frequency change made by the COO and the AA/DON. Continued review of Patient #1's electronic clinical record revealed that there was no Physician order that changed the PT frequency to one time a week for four weeks from the two times a week for 4 weeks that was ordered on the POC. Continued review of the POC included orders for the Skilled Nurse (SN) to teach and /or instruct on the following topics: Signs and Symptoms of a Heart Attack, Signs and Symptoms of a UTI (Urinary Tract Infection), A Heart Healthy Diet, Proper Footwear, Proper Use of Assistive Device, Change Position Slowly, to Report Falls and Cardiac Dysfunction Further review of Patient #1's electronic clinical record failed to reveal any documentation for SN visits dated Further review of Patient #1's electronic record revealed 7 SN visits signed by LVN A, LVN B and the AA/DON. The Skilled Nurse visits signed by EX- LVN B were dated 07/15/20, 07/20/20. The SN visits signed by the AA/DON were dated 07/29/20 and 08/04/20 and the SN visits signed by EX-LVN A were dated 08/12/20, 08/19/20 and 0825/20. All the SN Visit Notes failed to contain documentation that EX-LVN B, the AA/DON and EX-LVN A instructed Patient #1 and/or the caregiver on Signs and Symptoms of a Heart Attack, Signs and Symptoms of a UTI (Urinary Tract Infection), A Heart Healthy Diet, Proper Footwear, Proper Use of Assistive Device, Change Position Slowly, to Report Falls and Cardiac Dysfunction In an interview and concurrent record review conducted on 08/05/21 at 02:10 p.m. with the AA/DON, the Surveyor reviewed Patient #1's POC with the AA/DON, and asked if the POC had an order for PT 2 times per week for 4 weeks, the AA/DON stated "Yes, okay." The Surveyor pointed out the PT frequency for the reviewed certification period and asked if the POC had been followed for PT Frequency, the AA/DON stated "No, okay." The Surveyor then pointed out the teachings, the Surveyor asked the AA/DON , if EX- LVN B, the AA/DON and EX-LVN A had taught Patient #1 and/or caregiver Signs and Symptoms of a Heart Attack, Signs and Symptoms of a UTI (Urinary Tract Infection), A Heart Healthy Diet, Proper Footwear, Proper Use of Assistive Device, Change Position Slowly, to Report Falls and Cardiac Dysfunction. After review of the SN visits the AA/DON stated "Okay" and acknowledged that the teachings had not been done. Review of the Agency's Policy and Procedure Manual revealed a policy titled "Responsibilities of the Supervising Nurse", it was numbered LD.7 and had a revision date of 01/13/18. It read in part: "The responsibilities of the Supervising Nurse include: H. Ensuring that a patients Plan of Care is executed as written."

Infection control education CFR(s): 484.70(c) Standard: Education. The HHA must provide infection control education to staff, patients, and caregiver(s). This STANDARD is not met as evidenced by: Based on record review and interview, the agency failed to ensure compliance with the Occupational Safety and Health Administration (OSHA) 29 CFR Part 1910.1030 and Appendix A relating to Bloodborne Pathogens training for 6 of 7 agency employees (Adm, AA/DON, EX-ADON, RN A, EX-LVN A and EX-LVN B whose personnel records were reviewed. Failure to enforce requirements for training related to Bloodborne pathogens could place staff and the Agency's 102 active patients at risk for exposure to communicable and/or infectious diseases. The Findings Included: During the Entrance Conference conducted on 08/03/21 at 08:58 a.m. with the AA, the Surveyor asked if the annual in-services were done on the employee hire date or if the agency conducted them monthly for all employees. The AA, "The in-services were conducted initially on hire and then monthly for all employees, usually in March of each year." 1. Review of the Adm's personnel record revealed a hire date of 05/11/16. Continued review of the Adm's personnel record revealed an Agency form titled "Inservice sign in List", it was signed by the Administrator and showed that he had completed Bloodborne Pathogen training on 03/14/19. Further review of the Adm's personnel record failed to contain documentation of annual Bloodborne Pathogen training for 2020 and 2021. 2. Review of the AA/DON's personnel record revealed a hire date of 01/27/20. Continued review of the AA/DON's personnel record revealed an Agency form titled "Orientation Checklist." The checklist was dated 01/27/20 and listed all topics discussed at orientation for the AA/DON. Review of the Checklist showed that the only Infection Control training conducted was "Hand Hygiene." Further review of the AA/DON's personnel record failed to contain documentation of initial Bloodborne Pathogen training and documentation of the annual Bloodborne Pathogen training for 2021 which was due in March. 3. Review of RN A's personnel record revealed a hire date of 03/02/21. Continued review of RN A's personnel record revealed an Agency form titled "Orientation Checklist." The checklist was dated 03/02/21 and was signed by RN A, it listed all training topics discussed at orientation. Review of the Checklist showed that the only Infection Control training conducted was "Hand Hygiene." Further review of the RN A's personnel record failed to contain documentation of initial Bloodborne Pathogen training. 4. Review of EX-LVN A's personnel record revealed a hire date of 02/08/19 and a last working day of 02/20/20. Continued review of EX-LVN A's personnel record revealed an Agency form titled "Orientation Checklist." The checklist was dated 02/08/19 and was signed by EX-LVN A, it listed all training topics discussed at orientation. Review of the Checklist showed that the only Infection Control training conducted was "Hand Hygiene." Further review of the EX-LVN A's personnel record failed to contain documentation of initial Bloodborne Pathogen training. 5. Review of EX-LVN B's personnel record revealed a hire date of 01/14/19 and a last working day of 01/15/20. Continued review of EX-LVN B's personnel record revealed an Agency form titled "Orientation Checklist." The checklist was dated 01/08/19 and was signed by EX-LVN B, it listed all training topics discussed at orientation. Review of the Checklist showed that the only Infection Control training conducted was "Hand Hygiene." Further review of the EX-LVN B's personnel record failed to contain documentation of initial Bloodborne Pathogen training. 6. Review of P-ADON's personnel record revealed an initial hire date of 01/23/17 and a last working day in June of 2019. However, shortly after the entrance conference the AA/DON told the Surveyor that the P-ADON was the current ADON. Review of the P-ADON's personnel record failed to contain any required personnel documentation dated after June of 2019. Continued review of the P-ADON's personnel record failed to contain documentation of annual Bloodborne Pathogen training for 2019, 2020 and 2021. During an interview on 08/04/20 at 2:30 p.m. with the AA, the Surveyor presented the above findings and asked if there was documentation that the annual Bloodborne Pathogen Trainings had been completed for the above listed employees. After review of each of the 6 personnel records, the AA stated, "Okay, no it wasn't done." Review of the Agency's Policy and Procedure Manual revealed a policy titled "Infection Control", it was numbered IC.1 and had a revision date of 01/13/18. It read in part: "Upon hire and annually thereafter, all Agency employees will be educated regarding: c. Bloodborne/Airborne/HIV Pathogen Program."

Responsible for all day-to-day operations CFR(s): 484.105(b)(1)(ii) (ii) Be responsible for all day-to-day operations of the HHA; This ELEMENT is not met as evidenced by: Based on record review and interview, the Administrator failed to manage the daily operations of the agency in that: 1. The Administrator failed to ensure compliance with the Occupational Safety and Health Administration (OSHA) 29 CFR Part 1910.1030 and Appendix A relating to Bloodborne Pathogens training for 6 of 7 agency employees (Adm, AA/DON, EX-ADON, RN A, EX-LVN A and EX-LVN B whose personnel records were reviewed. 2. The Administrator failed to respect the patient rights to be informed of changes in frequency of Physical Therapy Care as was established on the individualized Plan of Care (POC) for 1 of 6 discharged Agency Patients (#1) whose clinical records were reviewed. 3. The Administrator failed to designate in writing, a qualified alternate to serve as supervising nurse in the absence of the supervising nurse, in that there was no acting Alternate Director of Nursing since February 28, 2021. These failures could place the Agency's clients at risk of receiving substandard care, inadequate or incomplete care/treatment and lack of coordination of services that could result in negative outcomes. The Findings Included: 1. During the Entrance Conference conducted on 08/03/21 at 08:58 a.m. with the AA, the Surveyor asked if the annual in-services were done on the employee hire date or if the agency conducted them monthly for all employees. The AA, "The in-services were conducted initially on hire and then monthly for all employees, usually in March of each year." -Review of the Adm's personnel record revealed a hire date of 05/11/16. Continued review of the Adm's personnel record revealed an Agency form titled "Inservice sign in List", it was signed by the Administrator and showed that he had completed Bloodborne Pathogen training on 03/14/19. Further review of the Adm's personnel record failed to contain documentation of annual Bloodborne Pathogen training for 2020 and 2021. -Review of the AA/DON's personnel record revealed a hire date of 01/27/20. Continued review of the AA/DON's personnel record revealed an Agency form titled "Orientation Checklist." The checklist was dated 01/27/20 and listed all topics discussed at orientation for the AA/DON. Review of the Checklist showed that the only Infection Control training conducted was "Hand Hygiene." Further review of the AA/DON's personnel record failed to contain documentation of initial Bloodborne Pathogen training and documentation of the annual Bloodborne Pathogen training for 2021 which was due in March. -Review of RN A's personnel record revealed a hire date of 03/02/21. Continued review of RN A's personnel record revealed an Agency form titled "Orientation Checklist." The checklist was dated 03/02/21 and was signed by RN A, it listed all training topics discussed at orientation. Review of the Checklist showed that the only Infection Control training conducted was "Hand Hygiene." Further review of the RN A's personnel record failed to contain documentation of initial Bloodborne Pathogen training. -Review of EX-LVN A's personnel record revealed a hire date of 02/08/19 and a last working day of 02/20/20. Continued review of EX-LVN A's personnel record revealed an Agency form titled "Orientation Checklist." The checklist was dated 02/08/19 and was signed by EX-LVN A, it listed all training topics discussed at orientation. Review of the Checklist showed that the only Infection Control training conducted was "Hand Hygiene." Further review of the EX-LVN A's personnel record failed to contain documentation of initial Bloodborne Pathogen training. - Review of EX-LVN B's personnel record revealed a hire date of 01/14/19 and a last working day of 01/15/20. Continued review of EX-LVN B's personnel record revealed an Agency form titled "Orientation Checklist." The checklist was dated 01/08/19 and was signed by EX-LVN B, it listed all training topics discussed at orientation. Review of the Checklist showed that the only Infection Control training conducted was "Hand Hygiene." Further review of the EX-LVN B's personnel record failed to contain documentation of initial Bloodborne Pathogen training. -Review of P-ADON's personnel record revealed an initial hire date of 01/23/17 and a last working day in June of 2019. However, shortly after the entrance conference the AA/DON told the Surveyor that the P-ADON was the current ADON. Review of the P-ADON's personnel record failed to contain any required personnel documentation dated after June of 2019. Continued review of the P-ADON's personnel record failed to contain documentation of annual Bloodborne Pathogen training for 2019, 2020 and 2021. During an interview on 08/04/20 at 2:30 p.m. with the AA, the Surveyor presented the above findings and asked if there was documentation that the annual Bloodborne Pathogen Trainings had been completed for the above listed employees. After review of each of the 6 personnel records, the AA stated, "Okay, no it wasn't done." Review of the Agency's Policy and Procedure Manual revealed a policy titled "Infection Control", it was numbered IC.1 and had a revision date of 01/13/18. It read in part: "Upon hire and annually thereafter, all Agency employees will be educated regarding: c. Bloodborne/Airborne/HIV Pathogen Program." 2. At the entrance conference on 08/03/21 at 08:57 a.m. with the AA/DON, the Surveyor requested and received a list of discharged patients that corresponded to the dates of the six complaints the Surveyor was there to investigate. Review of the list revealed the name of Patient #1, who was mentioned in two of the complaints. Review of active Patient #1's electronic clinical record included a form titled "Home Health Certification and Plan of Care" (POC) for the period of 07/15/20 thru 08/27/20 with diagnoses of Hemiplegia (paralysis of one side of the body) of the Left Side and Atrial Fibrillation (irregular heart rate) The POC included a skilled nurse (SN) visit frequency of one time a week for nine weeks and a PT visit frequency of two times a week for four weeks. Review of the visit frequency for PT showed that for the first four weeks of the Certification period that only four PT visits were made. The dates were 07/17/20 (This was a documented Missed Visit [MV]) 07/22/20, 07/29/20 and 08/05/20. Review of the 485 (POC), dated 07/10/20 revealed the order for PT frequency as two times a week for 4 weeks. The POC was signed by the Physician A and by the AA/DON. Review of the Recertification dated 07/10/20 and signed by the AA/DON read in part: "Patient is making slow steady progress with ongoing PT. Ongoing PT needed to continue progress. Patient has a paid caregiver that assist with all ADL's (Activities of Daily Living [Bathing, Dressing, Functional Transfers, Ambulation, Memory Care]) and IADL's (Instrumental Activities of Daily Living [examples - Telephone, Shopping, Preparing meals, Medications, Finances and Transportation]). It is determined that the patient would benefit greatly from ongoing skilled services. The last time PT was discharged the patient regressed to the point she could only take 2 steps and was maximum assistance to stand." Review of Patient #1's electronic clinical record revealed an Agency Communication Note dated 07/22/20. It was signed by the COO, it read in part: "Physician's order received for increased in PT. She is receiving PT at this time on a weekly basis due to her positive progress. The Patient does not met [sic] criteria for an increase in physical therapy at this time. It may be more beneficial for the patient to attend outpatient therapy for more intense treatments." Review of a Skilled Nurse (SN) visit note dated 07/20/20 and signed by EX-LVN B read in part: "Patient is confined because of illness, needs the aid of supportive devices such as crutches, canes, wheelchairs and walkers; the use of special transportation; or the assistance of another person in order to leave her place of residence. Patient #1 has a condition such that leaving her home is medically contraindicated. Patient #1 has a normal inability to leave home and leaving home requires a considerable and taxing effort for the patient." The above SN visit note was dated 2 days before the Agency Communication Note. Review of all of the Communication Notes in Patient #1's electronic clinical record failed to contain documentation that one that was faxed to Physician A notifying him of the PT frequency change made by the COO and the AA/DON. Continued review of Patient #1's electronic clinical record revealed that there was no Physician order that changed the PT frequency to one time a week for four weeks from the two times a week for 4 weeks that was ordered on the POC. Further review of the 3 SN visits that were made (07/22/20, 07/29/20 and 08/05/20), failed to include documentation that Patient #1 had been informed of the change in Physical Therapy care. Further review of the Communication Notes in Patient #1's electronic clinical record failed to contain documentation that Patient #1 had been notified of the change in Physical Therapy care. In an interview and concurrent record review conducted on 08/05/21 at 02:10 p.m. with the AA/DON, the Surveyor reviewed Pateint #1's POC with the AA/DON, and asked if the POC had an order for PT 2 times per week for 4 weeks, the AA/DON stated "Yes, okay." The Surveyor pointed out the PT frequency for the reviewed certification period and asked if the POC had been followed for PT Frequency, the AA/DON stated "No, okay." The Surveyor reviewed the SN visit notes with the AA/DON and asked if there was documentation that Patient #1 had been notified of the PT change. After reviewing the AA/DON stated "No, okay." The Surveyor review the Communication Notes and asked if there was documentation that Patient #1 had been notified of the change in Physical Therapy care. The AA/DON stated "No." and acknowledged that Patient #1 had not been notified of any changes in the PT care to be furnished. Review of the Agency's Policy and Procedure manual revealed a policy titled "Patient Bill of Rights and Responsibilities: Rights of the Elderly". It was numbered RI.1 and had a revision date of 01/13/18. It read in part: "The patient has the right to be informed in advance of expected outcomes, barriers to treatment and any changes in the care to be furnished. The Agency must ensure the patient understands the type of care and services that may be provided by the Agency." Continued review of the Patient Bill of Rights and Responsibilities: Rights of the Elderly policy read in part: "P. The patient has the right to participate in the planning of the care or treatment and in planning changes in the care or treatment. 1. Agency must advise or consult with the patient in advance of any changes in the Plan of Care." Continued review of the Agency's Policy and Procedure manual revealed a policy titled "Plan of Care." It was numbered TX.6 and had a revision date of 01/13/18. I read in part: "V. Each patient must receive the home health services that are written in an individualized plan of care." Further review of the Plan of Care policy read in part: "B. 1. Any revision to the plan of care due to a change must be communicated to the patient/caregiver and all physicians issuing orders for the Agency plan of care. 3. On 08/02/21 at 9:00 a.m., a Pre -Survey review of TULIP (Texas Unified Licensure Information Portal), the Texas Health and Human Services Commission main database, revealed the name of the previous Alternate Director of Nursing (EX-ADON) for the Agency. During the Entrance Conference on 08/03/21 at 08:58 a.m., the Surveyor asked the AA/DON to verify the names and titles of the Agency's Administrator, Alternate Administrator, Director of Nursing and the Alternate Director of Nursing. The name and titles for the ADON position that was listed in TULIP was incorrect according to the AA/DON. The AA/DON stated that RN A was the current ADON. The Surveyor requested the State form "2021" for proof of notification of the change. On 08/03/21 at 09:30 a.m. the AA/DON informed the Surveyor that she had spoken with the Administrator and that the EX-ADON was still the current ADON. During Pre-Survey the Surveyor spoke with the EX-ADON and was informed by her that she no longer worked at the Agency in any capacity. The EX-ADON's hire date with the Agency was 01/13/19 and her last working day was 09/07/20. The Surveyor asked the AA/DON if the Agency had an ADON. The AA/DON stated that she would find out. On 08/03/21 at approximately 11:40 a.m. the AA/DON informed the Surveyor that the P-ADON was the current ADON. The Surveyor requested his personnel record. Review of P-ADON's personnel record revealed an initial hire date of 01/23/17 and a last working day in June of 2019. Review of the P-ADON's personnel record failed to reveal any documentation dated after June of 2019. In an interview conducted on 08/04/21 at 12:35 p.m. with the Administrator the Surveyor presented the P-ADON's personnel record and asked for up to date documentation for the P-ADON's current position and requested the State form "2021" for proof of notification of the change. On 08/05/21 at 08:50 a.m. the Administrator brought the surveyor a printout of a worklog which revealed that the P-ADON had worked 16 days since June of 2019. The dates are as follows: 11/27/20, 12/13/20, 12/19/20, 12/23/20, 01/02/21, 01/05/21, 01/22/21, 01/25/21, 01/26/21, 01/28/21, 01/30/21, 02/11/21, 02/15/21, 02/16/21, 02/17/21 and 02/18/21. In an interview conducted on 08/05/21 at 01:35 p.m. with the Adm, the Surveyor presented the above findings and asked if the P-ADON was a full-time employee. the Adm stated "No." The Surveyor reviewed the P-ADON's personnel record with the Adm and asked again if there was up to date documentation for the P-ADON's current position. The Adm stated "No, this is all we have." The Surveyor asked if there was a 2021 form showing the P-ADON as the current ADON. The Adm stated "I have this one, but I just did it, it is dated 08/03/21." The Surveyor asked if they have a qualified alternate to serve as supervising nurse in the absence of the supervising nurse. The Adm stated, "I could call him if I needed him, but no, there is no full time ADON right now." Review of the Agency's policy and procedure manual revealed a policy titled "Responsibilities of the Supervising Nurse". It was numbered LD.7 and had a revision date of 01/13/18. It read in part: "IV. The Administrator will designate, in writing a similarly qualified alternate to serve as the Supervising Nurse in the absence of the Supervising Nurse."

Ensure clinical manager is available CFR(s): 484.105(b)(1)(iii) (iii) Ensure that a clinical manager as described in paragraph (c) of this section is available during all operating hours; This ELEMENT is not met as evidenced by: Based on interview and record review, the agency failed to designate in writing, a qualified alternate to serve as supervising nurse in the absence of the supervising nurse, in that there was no acting Alternate Director of Nursing since February 28, 2021. This failure could lead to a lack of critical guidance for Agency nurses in the event of the Director of Nurses absence. The Findings Included: On 08/02/21 at 9:00 a.m., a Pre -Survey review of TULIP (Texas Unified Licensure Information Portal), the Texas Health and Human Services Commission main database, revealed the name of the previous Alternate Director of Nursing (EX-ADON) for the Agency. During the Entrance Conference on 08/03/21 at 08:58 a.m., the Surveyor asked the AA/DON to verify the names and titles of the Agency's Administrator, Alternate Administrator, Director of Nursing and the Alternate Director of Nursing. The name and titles for the ADON position that was listed in TULIP was incorrect according to the AA/DON. The AA/DON stated that RN A was the current ADON. The Surveyor requested the State form "2021" for proof of notification of the change. On 08/03/21 at 09:30 a.m. the AA/DON informed the Surveyor that she had spoken with the Administrator and that the EX-ADON was still the current ADON. During Pre-Survey the Surveyor spoke with the EX-ADON and was informed by her that she no longer worked at the Agency in any capacity. The EX-ADON's hire date with the Agency was 01/13/19 and her last working day was 09/07/20. The Surveyor asked the AA/DON if the Agency had an ADON. The AA/DON stated that she would find out. On 08/03/21 at approximately 11:40 a.m. the AA/DON informed the Surveyor that the P-ADON was the current ADON. The Surveyor requested his personnel record. Review of P-ADON's personnel record revealed an initial hire date of 01/23/17 and a last working day in June of 2019. Review of the P-ADON's personnel record failed to reveal any documentation dated after June of 2019. In an interview conducted on 08/04/21 at 12:35 p.m. with the Administrator the Surveyor presented the P-ADON's personnel record and asked for up to date documentation for the P-ADON's current position and requested the State form "2021" for proof of notification of the change. On 08/05/21 at 08:50 a.m. the Administrator brought the surveyor a printout of a worklog which revealed that the P-ADON had worked 16 days since June of 2019. The dates are as follows: 11/27/20, 12/13/20, 12/19/20, 12/23/20, 01/02/21, 01/05/21, 01/22/21, 01/25/21, 01/26/21, 01/28/21, 01/30/21, 02/11/21, 02/15/21, 02/16/21, 02/17/21 and 02/18/21. In an interview conducted on 08/05/21 at 01:35 p.m. with the Adm, the Surveyor presented the above findings and asked if the P-ADON was a full-time employee. the Adm stated "No." The Surveyor reviewed the P-ADON's personnel record with the Adm and asked again if there was up to date documentation for the P-ADON's current position. The Adm stated "No, this is all we have." The Surveyor asked if there was a 2021 form showing the P-ADON as the current ADON. The Adm stated "I have this one, but I just did it, it is dated 08/03/21." The Surveyor asked if they have a qualified alternate to serve as supervising nurse in the absence of the supervising nurse. The Adm stated, "I could call him if I needed him, but no, there is no full time ADON right now." Review of the Agency's policy and procedure manual revealed a policy titled "Responsibilities of the Supervising Nurse". It was numbered LD.7 and had a revision date of 01/13/18. It read in part: "IV. The Administrator will designate, in writing a similarly qualified alternate to serve as the Supervising Nurse in the absence of the Supervising Nurse."