Every finding on record at Sioux Valley Memorial Hospital Association

A Recertification Survey was conducted by the Iowa Department of Inspections, Appeals & Licensing from 9/16/24 through 9/18/24 and the home health agency was found to be operating in compliance with the requirements of the Establishment of Emergency Preparedness.

The Iowa Department of Inspections, Appeals & Licensing conducted a Recertification Survey from 9/16/24 through 9/18/24. The recertification survey identified the home health agency was operating out of compliance with the following standard level home health regulations. The agency reported a current census of 58 patients at the time of the survey.

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 agency staff interviews, record reviews, and policy review, the home health agency failed to ensure the drug regimen review identified ineffective drug therapy, significant side effects, significant drug interactions, duplicate drug therapy, and noncompliance with drug therapy for 6 of 7 sampled patients (Patients #1, #2, #3, #5, #6 and #7) . Failure to ensure medications reviewed at the time of each drug regimen review are current and accurate and failure to identify actual/potential concerns increased the potential for unidentified medication interactions and side effect risks to the patient at the time of each comprehensive assessment. 4.Patient #2 had a start of care date of 3/9/23. Clinical record review revealed: a. Start of Care comprehensive assessment, dated 3/29/23, completed by Staff C, RN, included documentation a Drug Regimen Review (DRR) was completed. b. DRR identified duplicate drug therapy and non compliance with drug therapy but failed to address ineffective drug therapy, significant side effects and significant drug interactions. The RN failed to complete a drug regimen review that included 3 of 5 required components; ineffective drug therapy, significant side effects and significant drug interactions. 5.Patient #6 had a start of care date of 4/1/24 and a discharge date of 5/16/24 . Clinical record review revealed: a. Start of Care comprehensive assessment, dated 4/1/24, completed by Staff C, RN, included documentation a DRR was completed. b. DRR identified duplicate drug therapy and non compliance with drug therapy but failed to address ineffective drug therapy, significant side effects and significant drug interactions. c. Resumption of Care comprehensive assessment, dated 4/9/24, completed by Staff H, RN, included documentation a DRR was completed. d. DRR identified duplicate drug therapy and non compliance with drug therapy but failed to address ineffective drug therapy, significant side effects and significant drug interactions. e. Comprehensive assessment completed at discharge, dated 5/16/24, completed by Staff C, RN, included documentation a DRR was completed. f. DRR identified duplicate drug therapy and non compliance with drug therapy but failed to address ineffective drug therapy, significant side effects and significant drug interactions. The RN failed to complete a drug regimen review that included 3 of 5 required components; ineffective drug therapy, significant side effects and significant drug interactions. 6.Patient #7 had a start of care date of 3/6/24 and a discharge date of 3/24/24. Clinical record review revealed the following: a. Start of Care comprehensive assessment, dated 3/6/24, completed by Staff C, RN, included documentation a DRR was completed. b. DRR identified duplicate drug therapy and non compliance with drug therapy but failed to address ineffective drug therapy, significant side effects and significant drug interactions. c. Comprehensive assessment completed at discharge, dated 3/24/24, completed by Staff D, RN, included documentation a DRR was completed. d. DRR identified duplicate drug therapy and non compliance with drug therapy but failed to address ineffective drug therapy, significant side effects and significant drug interactions. The RN failed to complete a drug regimen review that included 3 of 5 required components; ineffective drug therapy, significant side effects and significant drug interactions. The above information was shared with the Administrator and Staff C, RN. 2. Patient #3 had a start of care date of 4/23/24. Clinical record review revealed: a. Start of Care comprehensive assessment, dated 4/23/23, included documentation the DRR completed for adverse side effects, drug interactions, duplicate therapy, ineffective drug and potential contradictions. The DRR identified "yes" and identified duplicate medications. The DRR failed to answer individual details for adverse side effects, drug interactions, ineffective drug therapy or potential contradiction. The RN failed to complete a drug regimen review that included 4 of 5 required components of ineffective drug therapy, significant side effects, potential drug interactions and non-compliance with therapy. 3. Patient #5 had a start of care date of 4/23/24. Clinical record review revealed: a. Start of Care comprehensive assessment, dated 4/23/24, included documentation the DRR completed for adverse side effects, drug interactions, duplicate therapy, ineffective drug and potential contradictions. The DRR identified "yes" and identified duplicate medications. The DRR failed to answer individual details for adverse side effects, drug interactions, ineffective drug therapy or potential contradiction. b. Resumption of Care comprehensive assessment, dated 9/4/24, included documentation the DRR completed for adverse side effects, drug interactions, duplicate therapy, ineffective drug and potential contradictions. The DRR identified "yes" and identified duplicate medications. The DRR failed to answer individual details for adverse side effects, drug interactions, ineffective drug therapy or potential contradiction. The RN failed to complete a drug regimen review that included 4 of 5 required components of ineffective drug therapy, significant side effects, potential drug interactions and non-compliance with therapy. According to the agency policy, titled Drug Regimen Review Home Health, dated December 2023, the Registered Nurse, (RN) will complete the drug regimen review contained in the EMR on admission, resumption of care, significant change in condition, recertification and discharge. During an interview with Staff B, Clinical Manager, on 9/17/24 at 9:00 AM, the Registered Nurse, (RN) completes the drug regimen review in the electronic medical record with admission, recertification, resumption of care, and discharge comprehensive assessments and when a new medication is added or a current medication is changed. The provider is given a copy of the drug regimen review which shows duplicate medications, potential or adverse reactions, any needed labs associated with the medications and any side effects noted with the patient. 1. Patient #1 had a start of care date of 8/16/2024. Clinical record review revealed: a. Start of Care comprehensive assessment, dated 08/16/24, included documentation of side effects and compliance, but lacked documentation of duplicate drug therapy, potential drug interactions, ineffective drug therapy, b. Resumption of Care comprehensive assessment, dated 9/10/24 included documentation of side effects and compliance, but lacked documentation of duplicate drug therapy, potential drug interactions, ineffective drug therapy, The RN failed to complete a drug regimen review that included the 5 required components of ineffective drug therapy, significant side effects, potential drug interactions, duplicate drug therapy and non-compliance with therapy.

HH aide supervision elements CFR(s): 484.80(h)(4)(i-vi) Home health aide supervision must ensure that aides furnish care in a safe and effective manner, including, but not limited to, the following elements: (i) Following the patient's plan of care for completion of tasks assigned to a home health aide by the registered nurse or other appropriate skilled professional; (ii) Maintaining an open communication process with the patient, representative (if any), caregivers, and family; (iii) Demonstrating competency with assigned tasks; (iv) Complying with infection prevention and control policies and procedures; (v) Reporting changes in the patient's condition; and (vi) Honoring patient rights. This ELEMENT is not met as evidenced by: Based on clinical record review, agency policy review and staff interview, the agency failed to ensure registered nurses supervising home health aides maintained documentation of a review of all required supervisory elements included following the patient plan of care, maintaining open communication with patient/caregiver, demonstrating competency of all assigned tasks, complying with infection prevention and control policies, reporting changes in the patient condition and honoring patient rights for 1 of 1 sampled pediatric patients receiving home health aide services (Patient #4). A total of 30 patients received home health aide services and the agency employed 4 home health aides at the time of the survey. Failure to ensure the supervision of home health aides by registered nurses maintained documentation of a review of all required supervisory elements increased the risk of agency staff not meeting the patients' personal care needs. Findings include: According to the agency's policy, titled Home Health Aide Services, dated 12/2023, the home health Registered Nurse (RN) will assume responsibility for supervision of the home health aide. The home health aide supervision must ensure that aides furnish care in a safe and effective manner including at least the following elements: maintaining an open communication process with the patient, representative, caregivers and family, the home health aide is following the patient's plan of care for completion of tasks assigned to a home health aide by the registered nurse or other appropriate skilled professional, the home health aide demonstrated competency with assigned tasks, complying with infection prevention and control policies and procedures, reports changes in the patient's condition appropriately and honoring of the patient's rights. During interview on 9/17/24 at 9:00 AM, the Clinical Manager stated the home health aide supervision documented in the skilled nurse visit report or can be documented in a journal note if a nursing visit not completed. Patient #4 had a start of care date of 3/24/22 and a pediatric patient. Clinical record review revealed the following: a. The Plans of Care, 7/11/24 to 9/8/24 and 9/9/24 to 11/4/24, included orders for skilled nursing and home health aide services. b. Skilled nursing visit notes, dated 7/15, 7/29 and 8/26/24, included documentation home health aide supervision was completed and the aide followed the care plan and demonstrated competency. The notes lacked documentation the nurse assessed the aide’s ability to meet the following required supervisory elements: maintaining open communication with patient/caregiver, complying with infection prevention and control policies, reporting changes in the patient condition and honoring patient rights. During an interview on 9/17/24 at 1:38 PM the Administrator stated pediatric patient supervision documented on the electronic medical record system. The program automatically pulls the shorter supervision form. She concurred the form did not include all of the supervisory components. The agency failed to supervise pediatric home health aide services to include all supervisory elements. The above findings were reviewed with the Administrator and Staff C, RN.

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 agency interviews, clinical record reviews and agency policy reviews, the home health agency failed to ensure all clinical documentation was completed in a timely manner for 4 of 7 sampled patients (Patients #3, #5, #6 and #7). Failure to ensure all clinical record documentation was completed in a timely manner increased the risk of ineffective communication between staff members providing services to its patients. Findings include: 3. Patient #3 had a start of care date of 4/23/24. Clinical record review revealed: a. The skilled nurse visit note, dated 7/16/24, signed completed 7/19/24 (1 day late) by Staff D, RN. Agency staff failed to complete documentation in a timely manner. 4. Patient #5 had a start of care date of 8/7/24. Clinical record review revealed: a. The skilled nurse visit note, dated 8/12/24, signed completed 8/15/24 (1 day late) by Staff C, RN. b. The physical therapy visit note, dated 8/16/24, signed completed 8/26/24 (8 days late) by Staff E, PT. c. The skilled nurse visit note, dated 9/9/24, signed completed 9/17/24 (6 days late) by Staff C, RN. Agency staff failed to complete documentation in a timely manner. The above findings shared with the Administrator and Staff C, RN. According to the agency policy titled Home Health and Hospice Clinical Record Documentation, dated 12/2023, all electronic documentation is expected to be completed, signed and submitted into the electronic medical record (EMR) as soon as possible but no later than 2 days for routine charting. During an interview on 8/17/24 at 9:00 AM, the Clinical Manager confirmed routine visit documentation is to be completed within 2 days of the visit. 1.Patient #6 had a start of care date of 4/1/24 and a discharge date of 5/16/24. Clinical record review revealed: a. The skilled nurse visit note, dated 4/13/24, signed completed 4/17/24 (2 days late) by Staff C, Registered Nurse (RN). b. The skilled nurse visit note, dated 4/18/24, signed completed 4/22/24 (2 days late) by Staff C, RN. 2.Patient #7 had a start of care date of 3/6/24 and a discharge date of 3/24/24. Clinical record review revealed: a. The skilled nurse visit note, dated 3/11/24, signed completed 3/15/24 (2 days late) by Staff C, RN. b. The physical therapy visit note, dated 3/12/24, signed completed 3/17/24 (3 days late) by Staff E, Physical Therapist (PT). c. The occupational therapy visit note, dated 3/13/24, signed completed 3/25/24 (10 days late) by Staff G, Occupational Therapist (OT). d. The skilled nurse visit note, dated 3/14/24, signed completed 3/18/24 (2 days late) by Staff C, RN. e. The physical therapy visit note, dated 3/15/24, signed completed 3/18/24 (1 day late) by Staff F, Physical Therapy Assistant (PTA). f. The skilled nurse visit note, dated 3/21/24, signed completed 3/25/24 (2 days late) by Staff C, RN. g. The physical therapy visit note, dated 3/22/24, signed completed 3/25/24 (1 day late) by Staff E, PT. The agency clinical record failed to include timely documentation.

A COVID-19 Focused Infection Control Survey was conducted by the Department of Inspections and Appeals in conjunction with a recertification survey from 10/25/21 through 10/27/21 . The survey found the agency operating in substantial compliance with the requirements of the Establishment of Emergency Preparedness.

A COVID-19 Focused Infection Control Survey was conducted by the Department of Inspections and Appeals in conjunction with with a recertification survey from 10/25/21 through 10/27/21 . The survey found the agency in substantial compliance with CMS and Centers for Disease Control and Prevention (CDC) recommended practices to prepare for infection control related to COVID-19. The recertification survey found the agency operating out of compliance with the following standard level regulatory requirements:

Last 5 days of every 60 days unless: CFR(s): 484.55(d)(1)(i,ii,iii) The last 5 days of every 60 days beginning with the start-of-care date, unless there is a- (i) Beneficiary elected transfer; (ii) Significant change in condition; or (iii) Discharge and return to the same HHA during the 60-day episode. This ELEMENT is not met as evidenced by: Based on clinical record review and agency policy review, the agency failed to ensure accurate completion of all required components of the recertification comprehensive assessments between day 56 and 60 of each 60 day certification period for 2 of 4 sampled patients requiring a recertification assessment (Patients #4 and #5) and failed to ensure accurate completion of all required components of the significant change in condition comprehensive assessment within 2 calendar days of the identification of the significant change for 1 of 1 sampled patients requiring a significant change in condition update (Patient #6). The agency reported a census of 69 patients at the time of the survey. The agency identified completing 1 significant change update in the previous 6 months. Failure to accurately and thoroughly complete recertification comprehensive assessments in a timely manner increased the potential that patients might not receive services in a manner to meet individualized patient needs. Findings include: According to the agency policy, titled Comprehensive Assessment Home Choice, a comprehensive assessment for recertification will be completed within the last five days of every 60 day episode (day 56 to 60), beginning with the start of care. Completion of a significant change in condition update will be completed within 2 calendar days of the identification of the change. 1. Patient #4 had a start of care date of 8/5/2020. Clinical record review revealed the following: a. The Plans of Care, dated 7/31/2021 to 9/28/2021 and 9/29/2021 to 11/27/2021, included physician orders for skilled nursing and physical therapy services. b. An update to the comprehensive assessment for recertification was initiated on 9/23/2021. Day 56 to 60 of the certification period included the dates of 9/24/2021 through 9/28/2021. The assessment was begun one day early, prior to the allowed recertification time frame by policy and regulation. 2. Patient #5 had a start of care date of 12/2/2020. Clinical record review revealed the following: a. The Plans of Care, dated 5/31/2021 to 7/29/2021 and 7/30/2021 to 9/27/2021, included physician orders for home health aide services without the provision of a skilled service. b. The update to the comprehensive assessment for recertification was initiated on 7/27/2021 but never electronically signed as complete. Documentation did not show the assessment was completed by the end of day 60 as required by agency policy and regulation. 3. Patient #6 had a start of care date of 5/21/2020 and was discharged to a higher level of care on 4/29/2021. Clinical record review revealed the following: a. The update to the comprehensive assessment of significant change in the patient's health status was initiated on 4/2/2021. The assessment was not electronically signed as completed until 4/5/2021, 3 calendar days after identification of the significant change, making the assessment one day late according to agency policy and regulation. The above stated findings for Patients #4, #5 and #6 were reviewed with the Administrator and the Clinical Manager. The agency provided no additional findings prior to the end of the survey.

Within 48 hours of the patient's return CFR(s): 484.55(d)(2) Within 48 hours of the patient's return to the home from a hospital admission of 24 hours or more for any reason other than diagnostic tests, or on physician or allowed practitioner - ordered resumption date; This ELEMENT is not met as evidenced by: Based on agency policy review and clinical record review, the agency failed to ensure completion of the update to the comprehensive assessment within 48 hours of the agency's knowledge of return home from an inpatient facility for 1 of 1 sampled patients requiring a resumption of care assessment (Patient #4). The agency reported a current census of 69 patients at the time of the survey. The agency reported completing 16 resumption of care assessments in the previous 6 months. Failure to complete resumption of care comprehensive assessment in a timely manner increased the potential that patients might not receive services in a manner to meet individualized patient needs. Findings include: According to the agency's policy, titled Resumption of Care OASIS and dated 9/2021, a patient specific comprehensive assessment must be performed within 48 hours of notification of the patient's return home from a 24 hour hospital inpatient admission unless the provider ordered otherwise. Patient #4 had a start of care date of 8/15/2020. Clinical record review revealed the following: The patient's clinical record included hospital discharge documentation, dated 7/12/2021 as received by the agency on 7/12/2021. The update to comprehensive assessment at the time of resumption of care was initiated on 7/12/2021. The assessment was electronically signed as complete on 7/15/2021, 72 hours after the agency received knowledge of the patient's return home from the inpatient facility, making the assessment 1 day late. The above stated findings for Patient #4 were reviewed with the Administrator and Clinical Manager. The agency provided no additional information prior to the end of the survey.

Plan of care must include the following CFR(s): 484.60(a)(2)(i-xvi) The individualized plan of care must include the following: (i) All pertinent diagnoses; (ii) The patient's mental, psychosocial, and cognitive status; (iii) The types of services, supplies, and equipment required; (iv) The frequency and duration of visits to be made; (v) Prognosis; (vi) Rehabilitation potential; (vii) Functional limitations; (viii) Activities permitted; (ix) Nutritional requirements; (x) All medications and treatments; (xi) Safety measures to protect against injury; (xii) A description of the patient's risk for emergency department visits and hospital re-admission, and all necessary interventions to address the underlying risk factors. (xiii) Patient and caregiver education and training to facilitate timely discharge; (xiv) Patient-specific interventions and education; measurable outcomes and goals identified by the HHA and the patient; (xv) Information related to any advanced directives; and (xvi) Any additional items the HHA or physician or allowed practitioner may choose to include. This ELEMENT is not met as evidenced by: Based on agency policy review, clinical record review, home visit observation, patient interview and agency staff interview, the agency failed to ensure the accurate completion of all components comprising the Plan of Care, including current physician orders, all supplies/equipment used by the patient to meet individualized needs and accurate, complete medication orders for 6 of 7 sampled patients (Patients #1, #2, #3, #4, #5 and #6). The agency reported a current census of 69 patients at the time of the survey. Failure to maintain complete and accurate Plans of Care with current orders placed the patients at risk to not receive services, medications and/or treatments according to assessed needs and physician orders. Findings include: 4. Patient #1 had a start of care date of 9/15/21. Clinical record review, home visit observation and accompanying interviews revealed the following: a. The Plan of Care, dated 9/15/21 to 11/13/21, included orders for Diclofenac Sodium and instructed to use four times per day for pain and apply to knees. b. The Patient Medication sheet, dated 10/25/21, included orders for Diclofenac Sodium and instructed to use four times per day for pain and apply to knees. During a home visit observation on 10/25/21 beginning at 3:15 PM, with Staff D, Registered Nurse (RN), the patient reported use of the Diclofenac Sodium topical gel for pain. The patient kept medications in a drawer in the kitchen. The tube of the medication included a strength of 1% and was last filled from the pharmacy on 10/1/21. The Plan of Care lacked the Diclofenac Sodium dosage used by the patient. c. The Plan of Care, dated 9/15/21 to 11/13/21, included orders for Tramadol Hcl 50 milligrams (mg) and instructed use every six hours as needed for moderate to severe pain. d. The Client Medication Report, dated 10/25/21, included orders for Tramadol Hcl 50 milligrams (mg) and instructed use every six hours as needed for moderate to severe pain. During the same home visit observation with Staff D, RN, the patient reported has never used Tramadol at home and did not ever fill prescription for the Tramadol due to feeling it would make the patient feel unsteady and crazy. The nurse further revealed the patient has never used since care with the agency. The Plan of Care identified the Tramadol as a medication the patient was using. e. The Plan of Care, dated 9/15/21 to 11/13/21, identified the following as medical equipment and supplies used by the patient: cane, bath bench, pill planner, incontinent briefs, incontinent pads, grab bars, scale, pill splitter, shower chair, thermometer, Lifeline, walker tray, walker, glucometer and testing supplies. During the same home visit observation with Staff D, RN, the surveyor observed the patient's bathroom. The shower in the bathroom included a hand held shower. The patient reported use of the hand held shower for bathing for a year "give or take". The Plan of Care lacked identification of the hand held shower as medical equipment/supplies used to meet the patient's needs. 5. Patient #2 had a start of care date of 9/21/21. Clinical record review, home visit observation and accompanying interviews revealed the following: The Plan of Care, dated 9/21/21 to 11/19/21, identified the following as medical equipment and supplies used by the patient: walker, shower chair, cane, grab bars, incontinent briefs, pill planner, commode, chair cushion, tegaderm foam dressing wound supplies. During a home visit observation on 10/26/21 beginning at 3:57 PM, with Staff E, Physical Therapy Assistant (PTA), the surveyor observed the patient's bathroom. The shower in the bathroom included a hand held shower. The patient reported use of the hand held shower for bathing for 2-3 months. The Plan of Care lacked identification of the hand held shower as medical equipment/supplies used to meet the patient's needs. 6. Patient #3 had a start of care date of 6/1/21. Clinical record review, home visit observation and accompanying interviews revealed the following: a. The Plan of Care, dated 9/29/21 to 11/27/21, included orders for medications used by the patient During a home visit observation on 10/27/21 beginning at 8:55 AM, with Staff , RN, the patient and nurse reported the pharmacy fills the patient's medications in blister packs and then the patient takes. The surveyor reviewed the pharmacy's list of current medications on the blister packs. The pharmacy was filling Doxycycline hyclate 100 mg twice daily. On 10/27/21 at 10:35 AM, interview with pharmacy staff revealed the Doxycycline was ordered by the physician on 10/7/21. The Plan of Care lacked identification of Doxycycline hyclate as medication ordered for the patient. b. The Plan of Care, dated 9/29/21 to 11/27/21, included orders for Levalbuterol Tartrate HFA every six hours as needed for shortness of breath. c. The Client Medication Report, dated 10/26/21, included orders for Levalbuterol Tartrate HFA every six hours as needed for shortness of breath. During the same home visit observation with Staff F, RN, the surveyor observed the patient's medications. The Levalbuterol Tartrate HFA was 45 micrograms per actuation. The Plan of Care lacked identification of the dosage of the Levalbuterol Tartrate HFA the patient was using. d. The Plan of Care, dated 9/29/21 to 11/27/21, included orders for Benadryl 50 mg daily for use one hour prior to the CT scan. e. The Client Medication Report, dated 10/26/21, included orders for Benadryl 50 mg daily for use one hour prior to the CT scan. During the same home visit observation with Staff F, RN, the patient revealed the Benadryl was a one time dosage and denied having any Benadryl in the home. The Plan of Care identified Benadryl as a medication the patient was using. f. The Plan of Care, dated 9/29/21 to 11/27/21, included orders for Aloe Vera 25 mg twice daily. g. The Client Medication Report, dated 10/26/21, included orders for Aloe Vera 25 mg twice daily . During the same home visit observation with Staff F, RN, the patient revealed the patient was using the Aloe Vera 25 mg twice daily until the supply ran out, but had not had the Aloe Vera for over a year ago. The Plan of Care identified the Aloe Vera as a medication the patient was using. h. The Plan of Care, dated 9/29/21 to 11/27/21, included orders for Psyllium 100 mg daily. i. The Client Medication Report, dated 10/26/21, included orders for Psyllium 100 mg daily . During the same home visit observation with Staff F, RN, the patient revealed the pharmacy filled the medication in the blister packs. On 10/27/21 at 10:35 AM, interview with pharmacy staff revealed the Psyllium 100 mg daily has never been on the patient's pharmacy profile list. The Plan of Care identified the Psyllium as a medication the patient was using. j. The Plan of Care, dated 9/29/21 to 11/27/21, identified the following as medical equipment and supplies used by the patient: pill planner, pill splitter, continous positive airway pressure device (CPAP), abdominal binder, wound vac machine, hypafix tape, 4x4's, and normal saline. During the same home visit observation with Staff F, RN, the surveyor reviewed with the patient's supplies and equipment in use. The patient denied use of a CPAP machine or abdominal binder. The patient further stated he/she did have a CPAP, but has not had for 3 years as it quit working and the patient refused to continue and did not receive another CPAP machine. The patient denies having an abdominal binder and stated that over a year ago a "copper fit" binder was purchased, but has not used in over a year. The Plan of Care identified a CPAP and abdominal binder as medical equipment/supplies used to meet the patient's needs. k. The Plan of Care, dated 9/29/21 to 11/27/21, included frequency orders dated 9/22/21 and 9/26/21 for skilled nursing visits one time per week for one week for an as needed visit to complete wound care. The Plan of Care included orders prior to the certification period beginning 9/29/21. The above findings for Patient #1, #2, #3, #4, #5, and #6 were reviewed with agency Administrator and Clinical Manager. Agency staff provided no further information prior to the end of the survey. According to the agency policy, titled Individualized Plan of Care for Home Health Patients and dated 9/2021, the Plan of Care must included: all pertinent diagnoses; the types of services, including planned frequency and duration for each; all equipment and supplies required by the patient;.... all medications and treatments needed by the patient;....and patient specific interventions for each discipline. 1. Patient #4 had a start of care date of 8/5/2020. Clinical record review revealed the following: The Plan of Care, dated 7/31/2021 to 9/28/2021, included the following discontinued orders: a. orders for skilled nursing visit, dated 9/17/2020, to reinitiate care following a hospitalization; b. orders for physical therapy, dated 9/17/2020, to reevaluate following hospitalization for a urinary tract infection with increased weakness; c. physical therapy frequency and duration, dated 9/21/2020, to add physical therapy to work on mobility, strength, balance and endurance; d. added frequency and duration for skilled nurse visits, dated 10/23/2020, 10/29/2020,12/23/2020, 3/1/2021; e. added physical therapy visit frequency and duration, dated 10/23/2020, 12/23/2020, 1/4/2021, 1/18/2021; f. added skilled nurse interventions to provide wound care twice weekly, dated 3/19/2021; g. added physical therapy services twice weekly, dated 3/19/2021, for functional strength and endurance training; h. added physical therapy visit frequency and duration, dated 4/1/2021, 4/27/2021, 5/18/2021, 5/31/2021, 6/4/2021, 6/29/2021,7/20/2021; i. added skilled nurse visit frequency and duration, dated 5/18/2021; j. resumption of care orders, dated 7/12/2021, following a hospitalization for wound infection; k. orders for an extra skilled nurse visit, dated 7/14/2021; and l. orders, dated 7/20/2021 for skilled nursing visits 3 times weekly for 1 week and 5 times weekly for 1 week to complete IV infusion and change the PICC line dressing weekly. All of the above stated orders were discontinued when the new Plan of Care was initiated on 7/31/2021 and should not have been included on the current Plan of Care. 2. Patient #5 had a start of care date of 12/2/2020 and received personal care only services from the agency. Clinical record review revealed the following: The Plan of Care, dated 7/30/2021 to 9/27/2021, included the following discontinued orders: a. orders for home health aide frequency and duration of service, dated 3/31/2021. b. orders for skilled nurse visit frequency and duration of service, dated 4/1/2021, 5/11/2021, 7/6/2021. c. orders for skilled nurse extra visit, dated 4/27/2021, to assess and obtain a blood draw for ordered labs. All of the above stated orders were discontinued when the new Plan of Care was initiated on 7/30/2021 and should not have been included on the current Plan of Care. The Plan of Care, dated 9/28/2021 to 11/26/2021, included the following discontinued orders: a. orders for home health aide frequency and duration of service, dated 3/31/2021. b. orders for skilled nurse visit frequency and duration of service, dated 4/1/2021, 5/11/2021, 7/6/2021, 8/3/2021, 9/13/2021, c. orders for skilled nurse extra visits, dated 4/27/2021 and 9/8/2021, to assess and obtain a blood draw for ordered labs. All of the above stated orders were discontinued when the new Plan of Care was initiated on 9/28/2021 and should not have been included on the current Plan of Care. 3. Patient #6 had a start of care date of 5/21/2020 and was discharged from agency services to a higher level of care on 4/29/2021. Clinical record review revealed the following: a. The Inpatient Discharge Records, dated 4/27/2021, documented the patient was transported by ambulance to the emergency room following a Lifeline contact. b. The Plan of Care, dated 3/17/2021 to 5/15/2021, did not include Lifeline or any emergency response system as equipment used to meet the patient's needs. During agency staff interview on 10/27/2021 at 2:00 PM, the Administrator and Clinical Manager both confirmed Patient #6 did use Lifeline, an emergency response system during the above stated Plan of Care period.

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 agency policy review and clinical record review, the agency failed to provide medications, treatments or services only as ordered by the physician for 1 of 4 sampled patients with wounds (Patient #2). The agency reported a current patient census of 69 patients. Failure to ensure staff obtain physician orders for administration of medications, treatments or services provided by agency staff placed agency patients at risk for inconsistent care/treatment and possible harm. Findings include: According to agency policy, titled Individualized Plan of Care for home health patient, dated 9/2021, All patient care orders, including verbal orders are part of the Plan of Care. The plan should be revised to reflect any verbal orders, medications, services, and treatments are administered only as ordered by the physician. Patient #2 had a start of care date of 9/21/21. Review of the clinical record and associated agency staff interviews revealed the following: a. The Plan of Care, dated 9/21/21 to 11/19/21, included orders for the skilled nurse to evaluate pressure sites and apply generous amounts of Calmoseptine to affected sits and measure wounds weekly. b. The initial comprehensive assessment for start of care, dated 9/21/21, included documentation of 3 wounds: wound 1 located on left forearm a trauma wound as a scabbed area measuring 2.5 cm (centimeters) in length by 1.5 cm in width with a depth of 0.1cm, wound 2 located on right forearm a trauma wound measuring 3 cm length by 1.5 cm width with a depth of 0.1 cm and filled with triple antibiotic ointment and a tegaderm foam dressing. c. The skilled nurse visit notes, dated 9/23/21 and 9/28/21, documented wound was cleansed with warm water and gentle soap, patted dry, triple antibiotic ointment applied, and the wound was covered with a tegaderm foam dressing. d. The interim physician order, dated as taken by the nurse on 10/5/21, included orders to begin treatment on 9/23/21 and discontinue on 10/1/21, for two skin tears to the left forearm as follows: clean twice weekly with gentle soap and water, pat dry, apply triple antibiotic ointment, and cover with Tegaderm foam dressing. The surveyor's attempt to contact the nurse for phone interview was unsuccessful The clinical record did not included any physician orders for the skin tear dressing changes until 10/5/21, 15 days after the treatment was initially provided by the nurse. The surveyor reviewed the above findings with agency Administrator and Clinical Manager. Agency staff provided no further information prior to the end of the survey.

Name/contact information of clinical manager CFR(s): 484.60(e)(5) Name and contact information of the HHA clinical manager. This ELEMENT is not met as evidenced by: Based on agency staff interview, home visit observation and admission packet review, the agency failed to provide agency patients with written contact information for the agency's clinical manager, including the clinical manager's name and contact information (telephone number and/or email address). The agency failed to provide this information for 2 of 2 sampled patients with home visits (Patients #1 and #2). The agency reported a census of 69 patients at the time of the survey. Failure to provide the contact information for the agency's clinical manager left the patients without the needed information to contact the agency clinical manager for any concerns about their services. Findings include: 1. Patient #1 had a start of care date of 9/15/21. On 10/25/21 beginning at at 3:15 PM, the surveyor accompanied Staff D, Registered Nurse, to the patient's home. During the home visit, the surveyor requested review of the agency's folder kept by the patient. During review of the folder, which included all paper work given to the patient by the agency, the surveyor found no documentation identifying the name and contact information of the clinical manager. The surveyor observed no documentation including the name and contact information of the clinical manager posted anywhere in the patient's home. The nurse confirmed the Clinical Manager contact information was not provided to agency patients. 2. Patient #2 had a start of care date of 9/21/21. On 10/26/21 beginning at at 3:57 PM, the surveyor accompanied Staff E, Physical Therapy Assistant, to the patient's home. During the home visit, the surveyor requested review of the agency's folder kept by the patient. During review of the folder, which included all paper work given to the patient by the agency, the surveyor found no documentation identifying the name and contact information of the clinical manager. The surveyor observed no documentation including the name and contact information of the clinical manager posted anywhere in the patient's home. The surveyor reviewed the above findings for Patients #1 and #2 with agency Administrator and Clinical Manager. Interview with agency Administrator on 10/26/21 at 8:52 AM revealed the patient's form was revised to contain the Clinical Manager information. and was being sent out to all patients on 10/26/21. No further information was provided prior to the end of the survey. Review of the agency's admission packet on 10/25/2021 at 2:30 PM found no documents identifying the clinical manager, including name and contact information. The surveyor reported the findings to the agency Administrator. During agency staff interview on 10/25/2021 at 3:00 PM, the Administrator reported she also reviewed the admission packet and found no documents identifying the clinical manager or contact information for the clinical manager. The Administrator reported a belief that the information had previously been included; however, concurred the information was currently missing from the packet.

Provide services in the plan of care CFR(s): 484.75(b)(3) Providing services that are ordered by the physician or allowed practitioner as indicated in the plan of care; This ELEMENT is not met as evidenced by: Based on clinical record review, agency policy review and agency staff interview, the agency failed to ensure skilled professionals provided care as ordered by the physician in the Plan of Care for 4 of 7 sampled patients (Patients #1, #2, #3 and #4). The agency reported a current census of 69 patients at the time of the survey. Failure to provide care in accordance with the physician ordered Plan of Care placed patients at risk to not receive safe, individualized and consistent care designed to meet each patients' health care needs. Findings include: 2. Patient #1 had a start of care date of 9/15/21. Clinical record review revealed the following: a. The Plan Of Care, dated 9/15/21 to 11/13/21, identified diagnoses of diabetes and multiple myeloma and included orders for the skilled nurse to assess the patient's weight. b. Skilled nurse visit notes, dated 9/16/21, 9/19/21, 9/30/21, and 10/4/21, lacked documentation of assessment of the patient's weight. 3. Patient #2 had a start of care date of 9/21/21. Clinical record review revealed the following: a. The Plan Of Care, dated 9/21/21 to 11/19/21, identified diagnoses of encounter for nonsurgical dressing changes and orthostatic hypotension and included orders for the skilled nurse to assess the patient's weight weekly. b. Skilled nurse visit note, dated 10/7/21, lacked documentation of assessment of the patient's weight. No further nursing visits were completed the week of 10/3/21, as a missed visit occurred on 10/5/21. 4. Patient #3 had a start of care date of 6/1/21. Clinical record review revealed the following: a. The Plans Of Care, dated 7/31/21 to 9/28/21 and 9/29/21 to 11/27/21, identified diagnoses of hypertension and encounter for nonsurgical dressing changes and included orders for the skilled nurse to assess multiple blood pressures orthostatic and vitals signs. b. Skilled nurse visit notes, dated 8/25/21, 9/1/21, 9/8/21, and 10/1/21, lacked documentation of assessment of orthostatic blood pressures. c. Skilled nurse visit note, dated 8/30/21, lacked documentation of assessment of the patient's temperature. The surveyors reviewed the above findings for Patients #1, #2, #3, and #4 with agency Administrator and Clinical Manager. Agency staff provided no further information prior to the end of the survey. According to the agency policy, titled Individualized Plan of Care for Home Health Patient and dated 9/2021, every home health patient must have an individualized Plan of Care established and periodically reviewed by the patient's physician to allow for coordinated, individualized care for the patient. The Plan of Care will included a planned frequency and duration of each service and specific interventions planned to meet the patient's needs. During agency staff interview on 10/25/2021 at 12:15 PM the Administrator reported if the Plan of Care established by the physician cannot be followed, the clinician should contact the patient's physician to report and complete an interim physician's order updating the Plan of Care as directed by the physician. 1. Patient #4 had a start of care date of 8/5/2020. Clinical record review revealed the following: a. The Plan of Care, dated 7/31/2021 to 9/28/2021, included physician orders for skilled nursing services only. b. The interim physician order, dated 8/6/2021, added physical therapy services twice weekly for 8 weeks. c. The Updated Plan of Care, dated 7/31/2021 to 9/28/2021 (effective 8/19/2021), included physician orders for physical therapy services twice weekly for 8 weeks (beginning 7/31/2021) included physician orders for physical therapy visits 0 times for one week; then twice weekly for 8 weeks for lower extremity strength and balance exercises. d. The clinical record lacked documentation of any physical therapy visits to work on strengthening and balance of the lower extremities during the weeks of 9/5-11/2021 and 9/12-18/2021. The clinical record lacked documentation of any communication with the physician reporting an inability to provide physical therapy services during the two above stated weeks of service. The clinical record lacked any physician interim orders changing the frequency of therapy services. e. The physician's interim order, dated 9/20/2021, discontinued physical therapy services. f. The physician's interim order, dated 9/21/2021, reinitiated physical therapy services twice weekly for one week and once weekly for one week, ending on 9/28/2021. g. The Plan of Care, dated 9/29/2021 to 11/27/2021, included physician orders for physical therapy services once weekly for one week and twice weekly for an additional 3 weeks. h. The clinical record included documentation of a physical therapy reevaluation on 9/21/2021 with continued services thereafter. The physical therapist did not follow the Plan of Care for Patient #4 as ordered by the physician. The clinician did not contact the physician to report concerns or inability to visit the patient between 9/5-18/2021. The patient's need for services did not change as evidenced by the continued therapy services.

Non-skilled direct observation every 60 days CFR(s): 484.80(h)(2) If home health aide services are provided to a patient who is not receiving skilled nursing care, physical or occupational therapy, or speech-language pathology services, the registered nurse must make an on-site visit to the location where the patient is receiving care no less frequently than every 60 days in order to observe and assess each aide while he or she is performing care. This ELEMENT is not met as evidenced by: Based on agency policy review, agency staff interview and clinical record review, the agency failed to ensure a registered nurse completed home health aide supervision at least every 60 days while observing the home health aide present and providing direct patient care for 1 of 1 sampled patients who received hands on personal care services with no skilled service provision. (Patient #5). The agency reported a current census of 69 patients, including 8 patients who received personal care assistance by a home health aide without any skilled service provision. Failure to supervise home health aide services, at least every 60 days while the aides provided direct patient care, increased the risk that patients received unsatisfactory or inappropriate care from home health aides. Findings include: According to the agency policy, titled Home Health Aide Services and dated 9/2021, a registered nurse must make a supervisory visit at least every 60 days to observe the home health aide while the aide is present in the home and providing direct patient care. Patient #5 had a start of care date of 12/2/2020. Clinical record review revealed the following: The Plans of Care, dated 5/31/2021 to 7/29/2021; 7/30/2021 to 9/27/2021 and 9/28/2021 to 11/26/2021, included physician orders for home health aide visits once weekly and completion of a comprehensive assessment and aide supervision every 60 days by a registered nurse. The clinical record included supervisory documentation by a registered nurse indicating direct observation of the aide providing care to Patient #5 on 5/28/2021. The update to the comprehensive assessment at the time of recertification, dated 7/27/2021, included indirect supervision of the aide by interviewing the patient/caregiver only. The update to the comprehensive assessment at the time of recertification, dated 9/23/2021, included indirect supervision of the aide by interviewing the patient/caregiver only. The patient's clinical record lacked documentation of any other supervisory visits between 5/28/2021 and the time of the survey. The findings for Patient #5 were reviewed with the Administrator and Clinical Manager. During agency staff interview on 10/27/2021 at 2:00 PM, the Administrator and the Clinical Manager reported a belief that all supervision of the aides was waived by CMS due to the pandemic. (The 14 day supervision of aide services in conjunction with a skilled service was the only supervision waived.) The agency provided no additional information prior to the end of the survey.

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 clinical record review and agency staff interview, the agency failed to maintain documentation showing transfer summaries were sent to the physician caring for the patient at the inpatient facility after transfer within 2 business days of the patient's transfer and/or failed to maintain documentation showing discharge summaries were sent to the physician and other health care professionals who would be providing care to the patient after discharge within 5 calendar days for 3 of 3 sampled patients with transfers/ discharges (Patients #4, #6, and #7). Failure to send the physician and other health care professionals a summary of the patient's care while receiving services from the agency in a timely manner may result in inadequate or inappropriate follow-up during inpatient care or after discharge. Findings include: During agency staff interview on 10/26/2021 at 2:02 PM, the Clinical Manager reported clinicians should document who the transfer and discharge summaries were sent and when sent either in the summary note itself or in a case communication note. 1. Patient #4 had a start of care date of 8/5/2020. Clinical record review revealed the following: a. The transfer assessment, dated 7/7/2021, documented the patient was hospitalized on 7/7/2021. The transfer summary was completed on 7/9/2021. The patient's clinical record did not document who the transfer summary was sent to or when. b. The transfer assessment, dated 7/15/2021, documented the patient was hospitalized on 7/15/2021. The transfer summary was completed on 7/14/2021. The patient's clinical record did not document who the transfer summary was sent to or when. 2. Patient #6 had a start of care date of 5/21/2020 and was discharged to a higher level of care on 4/29/2021. Clinical record review revealed the following: The transfer/discharge assessment, dated 4/29/2021, documented the patient was admitted to a nursing home on 4/29/2021. The transfer summary was completed on 4/29/2021. The patient's clinical record did not document who the transfer summary was sent to or when. 3. Patient #7 had a start of care date of 6/9/2021 and was discharged to an in-home hospice program on 6/29/2021. Clinical record review revealed the following: The discharge summary was completed on 629/2021 and documented the summary was sent to the primary care provider; however, failed to identify when the summary was sent. The above stated findings for Patients #4, #6 and #7 were reviewed with the Administrator and the Clinical Manager. The agency provided no additional information prior to the end of the survey.

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 agency policy review, clinical record review, review of agency staff lists and agency staff interview, the agency failed to ensure completion of documentation for routine visit notes were completed within the agency's administrative expectations and/or failed to ensure all documents were authenticated by the author by signature, credentials, date and time of signature for 7 of 7 sampled patients (Patients #1, #2, #3, #4, #5, #6 and #7). The agency reported a current census of 69 patients at the time of the survey. Failure to maintain appropriately authenticated clinical record documentation increased the risk that agency staff provided services without up to date information related to the patient's condition, and decreased the ability of agency staff to communicate effectively in order to coordinate patient care. Findings include: 5. Patient #1 had a start of care date of 9/15/21. Clinical record review revealed the following: a. The electronic routine physical therapy visit note, dated 10/1/2021, was not electronically created or signed as complete until 10/12/2021, making the completion of the document 4 days late according to the administration's expectation. b. The electronic routine home health aide visit notes, dated 9/17, 9/21, 9/24, 9/28, 10/1, 10/6, 10/8, 10/12, and 10/15/2021, included the electronic date and time of completion, but included the home health aide's name only and lacked inclusion of the credentials/title of the discipline completing the notes. 6. Patient #2 had a start of care date of 9/21/21. The surveyor began clinical record review on 10/26/21. Upon review of the record on 10/27/21, the surveyor noticed the agency had fixed the issue of authentication for current staff that were identified. Further clinic record review revealed the following: a. The initial comprehensive assessment completed at start of care, dated 9/21/21, included the electronic date and time of completion, and included the nurse's name, however, lacked inclusion of the credentials/title of the discipline completing the note. b. The electronic routine skilled nurse visit notes, dated 9/23, 9/28, 10/1, 10/5, and 10/7/21, included the electronic date and time of completion, and included the nurse's name, however, lacked inclusion of the credentials/title of the discipline completing the note initially when the surveyor reviewed the record on 10/26/21, however printed out with the credentials when documents were printed on 10/27/21. c. The electronic routine home health aide visit notes, dated 9/24, 9/28, 10/1, 10/5, 10/8, 10/12, and 10/15/2021, included the electronic date and time of completion, and included the aide's name, however, lacked inclusion of the credentials/title of the discipline completing the note initially when the surveyor reviewed the record on 10/26/21, however printed out with the credentials when documents were printed on 10/27/21. d. The electronic routine physical therapy aide visit note, dated,10/1/21, 10/8/21, and 10/12/21 included the electronic date and time of completion, and included the aide's name, however, lacked inclusion of the credentials/title of the discipline completing the note. 7. Patient #3 had a start of care date of 6/1/21. The surveyor began clinical record review on 10/27/21. Upon review of the record on 10/27/21, the surveyor noticed the agency had fixed the issue of authentication for current staff that were identified. Further clinic record review revealed the following: a. The update to the comprehensive assessment for recertification, dated 9/24/21, included the electronic date and time of completion, and included the nurse's name, however, lacked inclusion of the credentials/title of the discipline completing the note. b. The electronic routine skilled nurse visit notes, dated 9/5/21, 9/8/21, and 10/11/21, included the electronic date and time of completion, and included the nurse's name, however, lacked inclusion of the credentials/title of the discipline completing the note initially when the surveyor reviewed the record on 10/26/21, however printed out with the credentials when documents were printed on 10/27/21. c. The electronic routine skilled nurse visit notes, dated 9/18/2021, included the electronic date and time of completion, and included the nurse's name, however, lacked inclusion of the credentials/title of the discipline completing the note. The above findings for Patients #1, #2, #3, #4, #5, #6 and #7 were reviewed with agency Administrator and Clinical Manager. Agency staff provided no further information prior to the end of the survey. According to the agency policy, titled Home Health and Hospice Clinical Record Documentation, Correction of Errors and Additions and dated 9/2021, all electronic documentation should be completed as soon as possible but no later than 7 days for routine charting. During agency staff interview on 10/25/2021 at 12:30 PM, the agency Administrator reported all documentation should be completed no later than 7 days following a routine visit. During agency staff interview on 10/26/2021 at 2:34 PM, the surveyor discussed the inability of the surveyors to see the credentials for some of the staff. The Clinical Manager reported the issue was found during a hospice survey and may not have all gotten corrected at that time. During agency staff interview on 10/26/2021 at 3:00 PM, the Clinical Manager reported the electronic vendor added the discipline for staff in the audit trail section of the system after being cited for a deficiency during a hospice survey. The surveyor pointed out the audit trail included a discipline of "skilled nurse" for all nurses but did not identify the credentials of licensed practical nurse, registered nurse, advanced registered nurse practitioner. The surveyors noted on 10/27/2021 at 7:00 AM that previous electronic medical record documentation review on 10/26/2021 that was missing credentials for staff, were now corrected and included "RN" behind the electronic signature of the staff members. During agency staff interview on 10/27/2021 at 8:06 AM, the Administrator reported, after becoming aware of the missing credentials following the nurse electronic signature, she went into the system and added the credentials. The Administrator reported she believed the addition would affect only new documentation. She had not realized adding the discipline before printing documents requested by the surveyors for printing would alter the documents previously written by the staff members, to now include the credentials of nurses still employed by the agency. The Administrator reported there now is no way to print the documents as originally viewed by the surveyors. 1. Patient #4 had a start of care date of 8/5/2020 and received skilled nursing and physical therapy services. Clinical record review on 10/26/2021 at 2:00 PM revealed the following: a. The skilled nurse visit notes, dated 8/17, 8/19, 8/24, 8/26, 8/31, 9/2, 9/7, 9/9, 9/14, 9/16, 9/22, 9/28, 10/5, 10/7, 10/14 and 10/19/2021, included an electronic signature by Staff G. The audit trail identified Staff G as a "skilled nurse". The electronic signature failed to identify the credentials of Staff G. Review of the agency staff list identified Staff G was a registered nurse. b. The skilled nurse visit note, dated 9/30/2021, included an electronic signature by Staff H. The audit trail identified Staff H as a "skilled nurse". The electronic signature failed to identify the credentials of Staff H. Review of the agency staff list identified Staff H was a registered nurse. 2. Patient #5 had a start of care date of 12/2/2020 and received personal care only services from a home health aide without the provision of any skilled service. Clinical record review revealed the following: a. The home health aide visit notes, dated 8/17, 8/27, 9/2, 9/10, 9/16, 9/23, 9/28, 10/5 and 10/14/2021, were electronically signed by Staff J, Home Health Aide. The audit trails for each of the above stated home health aide visit notes documented Staff I, Home Health Aide, created, completed and electronically signed each of the documents. b. The skilled nurse visit notes, dated 9/9/2021 and 9/23/2021, included an electronic signature by Staff H. The audit trail identified Staff H as a "skilled nurse". The electronic signature failed to identify the credentials of Staff H. Review of the agency staff list identified Staff H was a registered nurse. The findings for Patient #5 were reviewed with the Administrator and Clinical Manager. Both reviewed the audit trails and the printed copies of the home health aide notes. During agency staff interview on 10/27/2021 at 2:00 PM, the Administrator and the Clinical Manager concurred the audit trail did not match the home health aide electronic signatures however did not know why. 3. Patient #6 had a start of care date of 5/21/2020 and was discharged from agency services to a higher level of care on 4/29/2021. Clinical record review on 10/26/2021 at 11:45 AM revealed the following: a. The skilled nurse visit notes, dated 3/1, 3/8, 3/10, 3/14, 3/22, 4/5, 4/12, 4/19 and 4/26/2021, included an electronic signature by Staff G. The audit trail identified Staff G as a "skilled nurse". The electronic signature failed to identify the credentials of Staff G. Review of the agency staff list identified Staff G was a registered nurse. b. The skilled nurse visit note, dated 3/29/2021, and the PRN Progress Note, dated 4/10/2021, included an electronic signature by Staff H. The audit trail identified Staff H as a "skilled nurse". The electronic signature failed to identify the credentials of Staff H. Review of the agency staff list identified Staff H was a registered nurse. c. The skilled nurse visit note, dated 3/19/2021, included an electronic signature by Staff K. The audit trail identified Staff K as a "skilled nurse". The electronic signature failed to identify the credentials of Staff K. Review of the agency staff list identified Staff K was a registered nurse. d. The PRN Progress Notes, dated 4/11/2021, included an electronic signature by Staff F. The audit trail identified Staff F as a "skilled nurse." The electronic signature failed to identify the credentials of Staff F. Review of the agency staff list identified Staff F was a registered nurse. 4. Patient #7 had a start of care date of 6/9/2021 and was discharged to an in-home hospice program on 6/29/2021. Clinical record review revealed the following: The Telephone Visit Progress Note, dated 6/21/2021, was electronically signed by Staff N. The audit trail identified Staff N as a "skilled nurse." The electronic signature failed to identify the credentials of Staff N. Review of the agency staff list identified Staff N was a registered nurse.