Every finding on record at St Rita Home Health Care, Inc

The Emergency Preparedness requirements were evaluated, in conjunction with the recertification survey, on 09/13/24. 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 09/13/24. Standard level deficiencies cited. Abbreviations: % = Percentage BP = Blood Pressure Dept.= Department HHA= Home Health Aide HR = Heart rate lbs.= pounds MSW = Medical Social Worker POC = Plan of Care PsOC=Plans of Care Pt./ Pts. = Patient/Patients RN = Registered Nurse SN = Skilled Nurse SOC = Start of care OASIS = Outcome and Assessment Information Set

Encoding and transmitting OASIS CFR(s): 484.45(a) Standard: An HHA must encode and electronically transmit each completed OASIS assessment to the CMS system, regarding each beneficiary with respect to which information is required to be transmitted (as determined by the Secretary), within 30 days of completing the assessment of the beneficiary. This STANDARD is not met as evidenced by: Based on the review of the OASIS Error Summary report and Staff interview, it was determined in 2 of 39 reports submitted for the last 12 months, the Agency failed to submit all timely reports, resulting in a warning. Finding include: 1. The OASIS Error Summary report for 10/01/23 - 09/08/24, was reviewed on 09/10/24 at 11:30 AM. The report included error # -3330 for 2 of 39 submissions, 5.13 % of the reports submitted were more than 30 days after the M0090. 2.During an interview with the Administrator, on 09/11/24 at 11:50 AM, the Administrator confirmed that the error occurred.

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 staff interview, it was determined that in 3 of 7 (Pts. #1, 2 and 4) the Agency failed to ensure that services were provided, according to the POC. 2. Pt. #2 was admitted to the Home Health Services on 04/11/24 with the diagnoses of: Hypertensive Heart Disease and Type 2 Diabetes Mellitus without complications. The clinical record was reviewed on 09/10/24. The clinical record contained a POC dated 06/10/24 and 08/09/24, that required diabetic supplies and the SN to assess the patient, 1 time a week for 9 weeks. A home visit interview was conducted with Pt. #2, on 09/10/24 at 2:00 PM. Patient #2 stated he did not have a sharp container (diabetic supply) and was disposing his sharps into his garbage. 3. Pt. #4 was admitted to the Home Health Services on 08/16/24 with the diagnoses of: Polyosteoarthritis Unspecified and Type 2 Diabetes Mellitus without complications. The clinical record was reviewed on 09/10/24. The clinical record contained a POC dated 08/16/24, that required diabetic supplies and the SN to assess the patient’s weight, 1 time a week for 9 weeks. The SN visit notes dated 08/19/24, 08/27/24 and 09/03/24 lacked the patient’s weight and the sharp container (diabetic supply) for disposing the patient’s sharps. 4. Pt. #6 was admitted to the Home Health Services on 05/08/24 with the diagnosis of: Hemiplegia following Cerebral Infarction. The clinical record was reviewed on 09/11/24. The clinical record contained a POC dated 05/08/24, that included a verbal order dated 05/10/24 for MSW services. As of 09/12/24, the MSW visit was not conducted. 5. The findings were confirmed, during the interview with the Administrator and Assistant Director of Nursing, on 09/11/24 between 2:00 PM – 3:00 PM. Findings include: 1. Pt. #1 was admitted to Home Health Services on 04/03/24 with the diagnosis of: Epilepsy and Hypertensive Heart and Chronic Kidney Disease with Heart Failure. The clinical record was reviewed on 09/10/24. The PsOC effective 06/02/24 and 08/01/24, required 2 SN visits, every 1 week for 9 weeks. The SN visit notes documented 1 SN visit from 07/17/24 to 09/06/24. The PsOC effective 06/02/24 and 08/01/24, required Aide visit, 5 hours/day, 6 days/week for 9 weeks. The Aide visit notes documented 5 visits from 07/29/24 to 08/09/24 and from 08/26/24 to 08/31/24. The clinical record lacked documentation that the SN and Aide provided services, as ordered. There was no modification in Physician orders. The POC effective 06/02/24, required: “…. Notify physician if weight gain x 5 or loss x 1 week.” The following SN assessments documented a weight of 252.30 lbs. on 07/17/24, 245.70 lbs. (6 lbs. weight difference) on 07/23/24 and 250.90 lbs. (5.2 lbs. weight difference) on 7/31/24. The clinical record lacked documentation that the Physician was notified of the weight change.

Services provided by HH aide CFR(s): 484.80(g)(2) A home health aide provides services that are: (i) Ordered by the physician or allowed practitioner; (ii) Included in the plan of care; (iii) Permitted to be performed under state law; and (iv) Consistent with the home health aide training. This ELEMENT is not met as evidenced by: Based on clinical record review and Staff interview, it was determined that in 2 of 3 (Pts. #1 and 3) clinical records reviewed wherein the Pt. received Home Health Aide services, the Agency failed to ensure that Aide provided services, as directed on the Home Health Aide Care Plan. Findings include: 1. Pt. #1 was admitted to Home Health Services on 04/03/24 with the diagnosis of Epilepsy. The clinical record was reviewed on 09/10/24. The “HHA Care Plan”, effective 06/02/24 and completed by the RN, required the Aide to provide/assist with bath. The Aide visits from 07/15/24 to 07/20/24, lacked documentation that the Aide provided/assisted with bath during those visits. The “HHA Care Plan, effective 08/01/24 and completed by the RN, required Aide to assist with bath and “…. check and record BP, HR, weigh daily….” The Aide visits from 08/02/24 to 08/06/24 and from 09/04/24 to 09/07/24, lacked documentation that the Aide provided/assisted with bath and assessed BP, HR and weight during those visits. 2. Pt. #3 was admitted to Home Health Services on 08/19/24 with the diagnosis of Ataxia following Cerebral Infarction. The clinical record was reviewed on 09/10/24. The “HHA Care Plan” effective 08/19/24 and completed by the RN, required the Aide to provide shower or bed bath as needed if not able to shower. The following Aide notes dated 08/30/24, 09/04/24 and 09/06/24, lacked documentation that the Aide provided shower or bed bath during those visits. 3. During an interview with the Administrator and Assistant Director of Nursing on 09/11/24 at 2:30 PM, both confirmed the above findings.

Plan Based on All Hazards Risk Assessment CFR(s): 484.102(a)(1)-(2) [(a) Emergency Plan. The [facility] must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least every 2 years. The plan must do the following:] (1) Be based on and include a documented, facility-based and community-based risk assessment, utilizing an all-hazards approach.* (2) Include strategies for addressing emergency events identified by the risk assessment. *[For LTC facilities at §483.73(a)(1):] Emergency Plan. The LTC facility must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least annually. The plan must do the following: (1) Be based on and include a documented, facility-based and community-based risk assessment, utilizing an all-hazards approach, including missing residents. (2) Include strategies for addressing emergency events identified by the risk assessment. *[For ICF/IIDs at §483.475(a)(1):] Emergency Plan. The ICF/IID must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least every 2 years. The plan must do the following: (1) Be based on and include a documented, facility-based and community-based risk assessment, utilizing an all-hazards approach, including missing clients. (2) Include strategies for addressing emergency events identified by the risk assessment. * [For Hospices at §418.113(a)(2):] Emergency Plan. The Hospice must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least every 2 years. The plan must do the following: (1) Be based on and include a documented, facility-based and community-based risk assessment, utilizing an all-hazards approach. (2) Include strategies for addressing emergency events identified by the risk assessment, including the management of the consequences of power failures, natural disasters, and other emergencies that would affect the hospice's ability to provide care. This STANDARD is not met as evidenced by: . A. Based on review of the Agency's Emergency plan, Agency policy review, and staff interview, it was determined the Agency failed to ensure its Emergency Plan and Facility-Based and Community-Based Risk Assessment was reviewed and updated as per their policy. This has the potential to affect all Pts. receiving services from the Agency. Findings include: 1. The Agency's Emergency Plan (last updated 11/30/17) was reviewed on 8/16/21 at 1:10 PM. The plan included a "Risk Assessment," last updated 11/30/17. 2. The Agency policy titled "Emergency Management Plan" was reviewed on 8/16/21 at 1:25 PM. The policy required: "...Hazard Vulnerability Analysis will be conducted and evaluated annually..." 3. The Agency policy titled "Emergency Preparedness Plan" was reviewed on 8/16/21 at 1:45 PM. The policy required: "...The Administrator, Director of Nursing, and other individuals designated by the Administrator will review the plan at least annually, and after each emergency response, to evaluate its effectiveness and to update the plan as needed..." 4. During an interview on 8/18/21 at 1:50 PM with the Administrator, Assistant Director of Nursing, and Accounts Receivable/Biller, the Administrator confirmed the above findings.

Recertification Survey conducted. Standard level deficiencies cited. Abbreviations: Pt./Pts. = Patient/Patients SOC = Start of Care AM = Morning PM = Evening, Night SN = Skilled Nurse OT = Occupational Therapist/Occupational Therapy. COVID-19 = Coronavirus 2019

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: . A. Based on clinical record review and staff interview, it was determined the Agency failed to complete discharge summaries and send these summaries to the Physician within 5 business days of the Patient's discharge. This was found 2 of 2 (Pt. #1 and 6) records reviewed wherein the Pt. had been discharged from professional Agency services. Findings include: 1. Pt. #1. SOC 4/21/21. Primary Diagnosis: Pressure Ulcer of Left Heel. The clinical record was reviewed on 8/17/21 at 1:00 PM. The record contained documentation the OT provided service on 6/26/21, 6/30/21, 7/3/21, 7/8/21, 7/10/21, and 7/15/21. The record also included a Physician's order dated 7/17/21 to discontinue OT services. The record lacked documentation the OT completed a discharge summary and sent it to the Physician. 2. Pt. #6. SOC 5/4/21. Primary Diagnosis: Aftercare following Surgery. The clinical record was reviewed on 8/18/21 at 9:25 AM. The record included weekly SN visit notes from 5/4/21 to 6/24/21, which documented the SN provided service. The record contained documentation the Pt. was discharged from the Agency on 7/1/21. The record lacked documentation the SN completed a discharge summary and sent it to the Physician. 3. During an interview on 8/18/21 at 1:50 PM with the Administrator, Assistant Director of Nursing, and Accounts Receivable/Biller, the Administrator stated all professional disciplines must complete a discharge summary at the end of their services, and confirmed the above discharge summaries were never completed and sent to the Patient's Physicians.

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: 4. Pt. #1. SOC 4/21/21. Primary Diagnosis: Pressure Ulcer of Left Heel. The clinical record was reviewed on 8/17/21 at 1:00 PM. The record contained a document titled "Authorization for Release of Medical Record Information," signed by the Pt., but not dated. The sections including name of provider, patient's written name, date of birth, and dates of treatment were left blank. 5. Pt. #5. SOC 7/29/21. Primary Diagnosis: Acute Respiratory Failure. The clinical record was reviewed on 8/16/21 at 2:30 PM. The record contained a document titled "Authorization for Release of Medical Record Information," signed by the Pt., and dated 7/29/21. The sections including name of provider, Patient's written name, and dates of treatment were left blank. 6. Pt. #6. SOC 5/4/21. Primary Diagnosis: Aftercare following Surgery. The clinical record was reviewed on 8/18/21 at 9:25 AM. The record contained a document titled "Authorization for Release of Medical Record Information," signed by the Pt., and dated 5/4/21. The sections including name of provider, patient's written name, date of birth, and dates of treatment were left blank. The record also included a document titled "Notice of Medicare Non-Coverage," which was signed by the Pt. on 5/4/21, but lacked the Patient's written name. 7. Pt. #7. SOC 4/5/21. Primary Diagnosis: Paroxysmal Atrial Fibrillation. The clinical record was reviewed on 8/17/21 at 3:00 PM. The record contained a document titled "Authorization for Release of Medical Record Information," signed by the Pt., and dated 4/5/21. The sections including name of provider, Patient's written name, date of birth, and dates of treatment were left blank. The record also included a document titled "Notice of Medicare Non-Coverage," which was signed by the Pt. on 4/5/21, but lacked the effective date skilled Nursing services would end. 8. During interviews on 8/18/21 at 1:15 PM and 1:50 PM with the Administrator, Assistant Director of Nursing, and Accounts Receivable/Biller, the Administrator confirmed the above documents were not completely filled out. . A. Based on clinical record review and staff interview, it was determined the Agency failed to ensure medical record documents were complete. This was found in 7 of 7 (Pts. #2, 3, 4, 1, 5, 6, and 7) records reviewed. Findings include: 1. Pt. #2. SOC 5/3/21. Primary Diagnosis: Paroxysmal Atrial Fibrillation. The clinical record was reviewed on 8/16/21 at 3:00 PM. The record contained a document titled "Authorization for Release of Medical Record Information," signed by the Pt., but not dated. The sections including name of provider, Patient's written name, date of birth, and dates of treatment were left blank. 2. Pt. #3. SOC 8/4/21. Primary Diagnosis: Pressure Ulcer of the Right Buttock. The clinical record was reviewed on 8/17/21 at 2:00 PM. The record contained a document titled "Authorization for Release of Medical Record Information," signed by the Pt., but not dated. The sections including name of provider, Patient's written name, date of birth, and dates of treatment were left blank. 3. Pt. #4. SOC 12/3/20. Primary Diagnosis: Hypertensive And Chronic Kidney Disease with Heart Failure. The clinical record was reviewed on 8/17/21 at 4:00 PM. The record contained a document titled "Authorization for Release of Medical Record Information," signed by the Pt., but not dated. The sections including name of provider name, Patient's written name, date of birth, and dates of treatment were left blank.