Every finding on record at Spoon River Home Health Services

The Emergency Preparedness requirements were evaluated, in conjunction with the recertification survey, on 9/26/2024. The Agency was in compliance with the Condition, 42 CFR 484.102, Establishment of the Emergency Program for this survey.

A recertification survey was conducted in conjunction with the evaluation of Emergency Preparedness requirements on 9/26/2024. The Agency was not in compliance with Standards for Home Health Agencies, 42 CFR 484 as evidenced by: Abbreviations: SOC= Start of Care SN= Skilled Nurse PT= Physical Therapist E= Employee

Discharge or Transfer Summary Content CFR(s): 484.58(b)(1) Standard: Discharge or transfer summary content. The HHA must send all necessary medical information pertaining to the patient's current course of illness and treatment, post-discharge goals of care, and treatment preferences, to the receiving facility or health care practitioner to ensure the safe and effective transition of care. This STANDARD is not met as evidenced by: Based on document review and interview, it was determined for 1 of 5 (Pt #12) patients, reviewed for discharge summaries, the agency failed to ensure there was a completed discharge summary. Findings include: 1. The policy titled "Discharge Criteria and Process Policy No. 4-045.1 (revised April 2018)" was reviewed on 9/25/24 at approximately 2:00 PM. The policy noted "...9. All discharge paperwork will be due in office within 72 hours of the discharge date. This will include...discharge summary..." 2. Pt #12 (Start of Care): 08/17/24 Diagnosis: Cellulitis of Right Foot. The record was reviewed on 09/25/24 at approximately 10:00 AM. The record noted a physician order dated 9/6/24 that included for discharge to be 09/08/24. The record lacked a discharge summary. 3. During an interview with the Director of Nursing (E#1) on 9/25/24 at approximately 2:00 PM, E#1 verbally confirmed the patient is discharged and a there had not been a discharge summary completed.

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 document review and interview, it was determined in 3 of 17 (Pt #2, Pt #7, Pt#8) patients' records reviewed, the Agency failed to ensure documentation was appropriately authenticated, dated, timed. Findings include: 1. Pt #2, SOC: 8/20/23 Diagnosis: Hemiplegia following cerebral infarct. Pt #2's record for dates 7/28/24 through 9/24/24, was reviewed on 9/24/2024 at approximately 3:00 PM. a. The physician’s order (dated 8/19/24), noted Skilled Nursing one time monthly for catheter care for 2 months. The Skilled Nursing visit on 9/9/24 lacked the associated date and time of the staff’s signature, as to when the documentation was signed. b. The physician’s order (dated 8/19/24),noted Physical Therapy one time per week for 5 weeks, subsequently extended for 4 weeks. Of the Physical Therapy notes, the visit note dated 9/24/24, lacked the associated date and time of the staff’s signature; four visit notes (dated 8/6/24, 8/12/24, 9/10/24, 9/18/24), lacked the staff’s associated title and signature date and time; and two visit notes (dated 8/26/24, 9/3/24)lacked the staff’s signature and associated title and date and time of signature. 2. Pt #7, SOC: 10/12/22 Diagnosis: Type 2 Diabetes Mellitus with foot ulcer. Pt #7's record for dates 7/28/24 through 9/25/24, was reviewed on 9/25/2024 at approximately 1:00 PM. The physician’s order (dated8/13/24), noted Skilled Nursing visits twice weekly for wound care for 9 weeks. The sixteen Skilled Nursing notes lacked the associated date and time of the staff’s signature, as to when the documentation was signed. 3. Pt#8, SOC: 5/12/24 Diagnosis: Encounter for change or removal of nonsurgical wound dressing. Pt #8’s record for dates 7/11/24 through 9/8/24 was reviewed on 9/24/24 at approximately 10:00 AM. a. The physician’s order (dated 7/30/24), noted Skilled Nursing visits three times per week for eight weeks. Of the Skilled Nursing visit notes, eleven notes (dated 7/31/24, 8/5/24, 8/7/24, 8/12/24, 8/16/24, 8/19/24, 8/23/24, 8/26/24, 8/28/24, 8/30/24, 9/11/24) lacked the associated date and time of the staff’s signature, as to when the documentation was signed; seven notes (dated 8/9/24, 8/14/24, 8/21/24, 9/16/24, 9/13/24, 9/9/24, 9/4/24), lacked the staff’s associated title and date and time of signature. b. The physician’s order (dated 7/30/24), noted Occupational Therapy visits once per week for 5 weeks. The Occupational Therapy visit notes (dated 7/23/24, 8/14/24), two signatures were illegible and lacking the associated date and time of the staff’s signature. 4. An interview with the Director of Nursing (E #1) was conducted on 9/26/24 at approximately 11:15 AM. E #1 verbally confirmed the lack of authentication related to missing staff signatures and associated titles, dates and times of the signature.

The Emergency Preparedness (EP) requirements were evaluated in conjunction with the recertification survey on 10/22/21. The Agency was in compliance with the Condition 42 CFR 484.22, Establishment of the Emergency Program.

A recertification survey was conducted in conjunction with an Emergency Preparedness survey on 10/19/21 through 10/22/21. The Agency was not in compliance with the Standards for Home Health Agencies, 42 CFR 484, as evidenced by: Abbreviations: APN – Advance Practice Nurse BID- Twice Daily CG- Caregiver Chemo – Chemotherapy EP- Emergency Preparedness Eval - Evaluation FNA - Fine Needle Aspiration Inst - Instruct LOTA- Left Open to the Air NS- Normal Saline po- By Mouth PT/INR- Prothrombin Time/International Normalized Ratio RLE- Right Lower Extremity RUE- Right Upper Extremity SN- Skilled Nurse SOC: Start of Care w- week w- with

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 document review and interview, it was determined for 3 of 9 (Pt #6, Pt #12, Pt #13) patients records reviewed, the Agency failed to ensure a Plan of Care was developed and documented within 5 days and/or received services per the Plan of Care. This has the potential to affect all patients who receive services by the Agency with a current census of 149 patients. Findings include: 1. The policy titled "Care Planning Process" (revised 1/2019) was reviewed on 10/21/2021. The policy noted "A written plan of care will be initiated within five (5) days of start of care... The patient plan of care will be developed or revised within five (5) working days of initiation of each service..." 2. Pt #6 Start of Care (SOC): 8/20/21 Diagnosis: Aftercare following surgery for Neoplasm. The record was reviewed on 10/20/21 at approximately 10:00 AM. The record lacked a Plan of Care as of 10/20/21. 3. Pt #12 SOC: 8/18/21 Diagnosis: Acute and Chronic Congestive Heart Failure. The record was reviewed on 10/20/21 at approximately 2:30 PM. The Plan of Care noted "Patient to weigh daily and record... SN (Skilled Nurse) to assess Patient/Cg (Caregiver) ability to perform blood glucose checks... recording readings... SN to instruct Patient/Cg regarding daily weights... Instruct to log daily weights..." 4 of 9 (8/20/21, 9/7/21, 9/28/21 and 9/30/21) SN visit notes lacked documentation blood glucose levels were assessed. 4 of 9 (8/20/21, 9/7/21, 9/28/21 and 9/30/21) SN visit notes lacked documentation daily weights were assessed and Pt #12 was admitted to the hospital on 9/13/21 through 9/24/21 for exacerbation of congestive Heart Failure. 4. Pt #13 SOC: 8/19/21 Diagnosis: Diabetes Mellitus. The record was reviewed on 10/21/21 at approximately 9:00 AM. The Plan of Care noted "SN to assess pt (patient) blood glucose level..." 5 of 9 (8/26/21, 8/30/21, 9/8/21, 9/27/21 and 10/5/21) SN visit notes lacked documentation blood glucose levels were assessed. 5. During an interview on 10/21/21 at approximately 3:00 PM, the Agency Supervisor (E#1) reviewed Pt #6's record and verbally agreed the record lacked a Plan of Care and one should have been completed. E#1 reviewed Pt #12 and Pt #13's record and verbally agreed the blood glucose levels and daily weights were not monitored as ordered in the Plan of Care and should have been documented.

All orders recorded in plan of care CFR(s): 484.60(a)(3) All patient care orders, including verbal orders, must be recorded in the plan of care. This ELEMENT is not met as evidenced by: Based on document review and interview, it was determined for 6 of 9 (Pt #6, Pt #7, Pt #9, Pt #11, Pt #12, Pt #13) patients records reviewed, the Agency failed to ensure orders and verbal orders were included in the Plan of Care. This has the potential to affect all patients who receive services by the Agency with a current census of 149 patients. Findings include: 1. The policy titled "Care Planning Process" (revised 1/2019) was reviewed on 10/21/21. The policy noted "The plan of care will be developed or revised within five (5) working days of initiation of each service or of the reassessment of the patient..." 2. Pt #6 Start of Care (SOC): 8/20/21 Diagnosis: Aftercare following surgery for Neoplasm. The record was reviewed on 10/20/21 at approximately 10:00 AM. The "Patient Recap from 8/20/21 through 8/20/21" noted under the Medication Reconciliation section Pt #6 was ordered Apixaban (anticoagulant) 2.5 mg (milligrams). The record lacked documentation Pt #6 had bleeding precautions initiated. The Plan of Care was not revised to include the following orders: a) 9/22/21, "Will need nursing assistance for daily dressing changes to graft site at RLE (Right Lower Extremity. Apply thin layer of bacitracin to entire wound bed, cover with telfa, then ace wrap. Scab over donor site can have vaseline applied daily." b) 9/26/21, "Resume home health services. SN (Skilled Nurse) 4w1 (week)(for 1 week)... SN/CG (Caregiver) to cleanse left leg graft site with NS (Normal Saline), apply bacitracin ointment, non stick pad, wrap with Kerlix and tape. change BID (twice daily). apply vaseline to left thigh donor site..." c) 10/1/21, "Wound measurements to be taken at least weekly... #1 intervention SN/CG to perform wound care to RUE (Right Upper Extremity) thigh area, apply vaseline to donor areas. RLE graft, apply xeroform, nonstick gauze, cover with ace wrap: Cleanse with NS, apply RUE vasoline and xerofrm to RLE graft, cover with RUE, Thigh donor area LOTA (left open to air) and RLE skin graft nonstick gauze until healed..." 3. Pt #7 SOC: 3/18/21 Diagnosis: Bilateral wrist fractures. The record was reviewed on 10/20/21 at approximately 12:10 PM. The Plan of care noted "15. Safety Precautions... Bleeding precautions w (with)/Coumadin (anticoagulant)..." The Plan of Care lacked Coumadin on the medication list. The Plan of Care was not revised to include the following orders: a) 4/2/21, "Patient to hold coumadin on 4/2/21 start coumadin 2 mg po (by mouth)daily on 4/3/21 and 4/4/21... 4/5/21 SN to perform venipuncture for PT/INR (Prothrombin Time/International Normalized Ratio)..." b) 4/5/21, "SN to perform venipuncture for PT/INR... Current dose of Coumadin 2mg po daily..." c) 4/9/21, "SN to perform venipuncture for PT/INR on 4/12/21, coumadin on hold starting 4/9/21..." d) 4/12/21, "SN to draw PT/INR on monday 4/19/21... Coumadin 1 mg daily started on 4/12/21..." 4. Pt #9 SOC: 4/20/21 Diagnosis: Nontoxic Goiter. The record was reviewed 10/20/21 to 10/21/21. An oncology physician history and physical noted “4/9/21… FNA (fine needle aspiration) thyroid… positive B-cell lymphoma.” On 5/14/21, a physician order stated to continue skilled nursing visits “for continued assessment and teaching after starting chemo (chemotherapy) and continued wound care.” The Plan of Cares dated 4/20/21 and 6/19/21 both lacked the lymphoma diagnosis. The POC (Plan of Care) was not updated to include assessment and teaching after starting chemo. 5. Pt #11 SOC: 11/2/18 Diagnosis: Fitting of Urinary Device. The record was reviewed on 10/20/21 at approximately 1:20 PM. The Plan of Care noted Aspirin 81 mg was ordered daily although lacked documentation bleeding precautions were implemented. 6. Pt #12 SOC: 8/18/21 Diagnosis: Congestive Heart Failure. The record was reviewed on 10/20/21 at approximately 2:30 PM. The Plan of Care noted Aspirin 81 mg was ordered daily although lacked documentation bleeding precautions were implemented. 7. Pt #13 SOC: 8/19/21 Diagnosis: Diabetes Mellitus. The record was reviewed on 10/21/21 at approximately 9:00 AM. The Plan of Care noted Pt#13 was ordered Plavix (anticoagulant) although lacked documentation bleeding precautions were implemented. 8. During an interview on 10/21/21 at approximately 2:00 PM, the Agency Supervisor (E#1) stated the Agency did not have a policy for bleeding precautions but anyone taking Aspirin, Coumadin or Plavix would be on bleeding precautions. E#1 stated the precautions would be at different levels for each medication. E#1 reviewed Pt #6, Pt #7, Pt #11, Pt #12 and Pt #13's records and verbally agreed the Agency failed to ensure orders and verbal orders for bleeding precautions were included in the Plan of Care and should have been. E#1 reviewed Pt #9’s record and verbally agreed the POCs lacked the lymphoma diagnosis and were not updated to include the assessment and teaching after starting chemo.

Conformance with physician orders CFR(s): 484.60(b) Standard: Conformance with physician or allowed practitioner orders. This STANDARD is not met as evidenced by: Based on document review and interview, it was determined for 2 of 13 (Pt #9, Pt #13) patients records reviewed, the Agency failed to ensure medications were administered per physicians order. This has the potential to affect all patients who receive care by the Home Health Agency with a current census of 149 patients. Findings include: 1. Pt #9 Start of Care (SOC): 4/20/21 Diagnosis: Nontoxic Goiter. Pt #9’s record was reviewed 10/20/21 to 10/21/21. On 5/14/21, a physician order stated to continue skilled nursing visits “for continued assessment and teaching after starting chemo (chemotherapy) and continued wound care.” There was no documentation of assessment and/or teaching related to chemotherapy during any of the subsequent visits. There was no documentation as to the patient starting, continuing, and/or completing chemotherapy. 2. Pt #13 SOC: 8/19/21 Diagnosis: Diabetes Mellitus. The record was reviewed on 10/21/21 at approximately 9:00 AM. The "Patient Recap from 9/2/2021 through 9/2/2021" noted "patient's hypoglycemic episode and glucagon administration reported to..." The Plan of Care lacked a physician's order for glucagon administration. 3. During an interview with the Agency Supervisor (E#1) on 10/21/21 at approximately 1:50 PM, E#1 reviewed Pt #9’s record and verbally agreed the record lacked documentation of an assessment and/or teaching related to chemotherapy. E#1 stated “I don’t see anything about the chemotherapy.” During an interview on 10/21/2021 at approximately 3:00 PM, E#1 reviewed Pt #13's record and verbally agreed the Plan of Care lacked a physician's order for glucagon and an order should have been obtained.

Communication with physicians CFR(s): 484.75(b)(7) Communication with all physicians involved in the plan of care and other health care practitioners (as appropriate) related to the current plan of care; This ELEMENT is not met as evidenced by: Based on document review and interview, it was determined for 1 of 13 (Pt #9) patients records reviewed, the Agency failed to ensure physician's involved in the Plan of Care were communicated with. This has the potential to affect all patients who receive services by the Home Health Agency with a current census of 149 patients. Findings include: 1. Pt #9 Start of Care (SOC): 4/20/21 Diagnosis: Nontoxic Goiter. The record was reviewed 10/20 to 10/21/21. The following are examples of the lack of SN (Skilled Nurse) follow up with the physician to obtain and/or clarify orders: On 4/27/21, the Skilled Nursing (SN) visit note noted “Continued – SN to instruct on home safety… Pt states (Pt #9) is agreeable to a therapy eval (evaluation)”. Subsequent nursing documentation intermittently noted “Continued – SN to instruct on home safety… Pt states (Pt #9) is agreeable to a therapy eval”. There was no documentation to indicate the doctor was contacted for a therapy evaluation.On 5/24/21, the SN visit note noted “Continued – SN inst (instruct) on an emergency response product… Pt did get 911 called before (Pt #9) passed out, but (Pt #9) doesn’t recall much else.” Subsequent nursing documentation intermittently noted the same information. There was no documentation to indicate the physician was notified and/or nursing follow up to obtain an emergency response product.On 6/2/21, the SN visit note noted “Continued – SN instrutct (misspelled in note) on new medications – investigate why patient on antibiotic only on weekends and the Normal Saline order for BID (twice a day) via nebulizer. Call into APN (Advance Practice Nurse).” Subsequent nursing documentation intermittently noted the same information. There was no documentation to indicate the physician was notified to order and/or clarify the order for the antibiotic and Normal Saline. 2. During an interview on 10/21/21 at approximately 1:50 PM, the Agency Supervisor (E#1) reviewed Pt #9’s record and stated “I don’t see anything (that says these were followed up on and/or clarified). It looks like they just chose the continued button which brings it forward.”