Every finding on record at Temple View Home Health and Hospice, LLC

Based on an abbreviated/complaint survey conducted from 07/12/2021 through 07/20/2021, it was determined that Temple View Home Health was found to be out of compliance with 42 Code of Federal Regulations for Home Health agencies. Deficient practice was cited in the following areas: 484.50 Patient Rights 484.55 Assessment of Patients 484.60 Care Planning 484.65 Quality assessments/performance improvement 484.80 Aide Services 484.105 Organization and Administration 484.110 Clinical records

Patient's or legal representative's signature CFR(s): 484.50(a)(2) Obtain the patient's or legal representative's signature confirming that he or she has received a copy of the notice of rights and responsibilities. This ELEMENT is not met as evidenced by: Based on interview and record review, it was determined the home health agency (HHA) could not provide evidence that a written notice of the patient's rights and responsibilities were provided to 2 of 5 sampled patients. (Patient identifiers: 2 and 3). Findings include: A review of patient 2 and 3's medical records was completed on 7/20/2021. There was no evidence available for review to indicate the HHA provided them a written copy of the patient's rights and responsibilities. On 7/14/2021 at 2:14 PM, an interview was conducted with Director of Clinical Services (DCS) related to written notification of patient rights. The DCS stated the admitting nurse was responsible for obtaining the patient signature that written notification of patient rights was given.

Comprehensive Assessment of Patients CFR(s): 484.55 Condition of participation: Comprehensive assessment of patients. Each patient must receive, and an HHA must provide, a patient-specific, comprehensive assessment. For Medicare beneficiaries, the HHA must verify the patient's eligibility for the Medicare home health benefit including homebound status, both at the time of the initial assessment visit and at the time of the comprehensive assessment. This CONDITION is not met as evidenced by: Based on interview and record review, it was determined that the home health agency (HHA) failed to ensure each patient received a complete patient specific comprehensive assessment. Findings include: 1. The HHA failed to ensure an initial assessment visit by a registered nurse was completed within 48 hours of the referral for home health services. (Refer to Tag G514) 2. The HHA failed to ensure that all patient medications had been reviewed. (Refer to Tag G536)

RN performs assessment CFR(s): 484.55(a)(1) A registered nurse must conduct an initial assessment visit to determine the immediate care and support needs of the patient; and, for Medicare patients, to determine eligibility for the Medicare home health benefit, including homebound status. The initial assessment visit must be held either within 48 hours of referral, or within 48 hours of the patient's return home, or on the physician or allowed practitioner - ordered start of care date. This ELEMENT is not met as evidenced by: Based on interview and record review, it was determined the home health agency (HHA) did not ensure a registered nurse (RN) conducted an initial assessment to determine the immediate care and support needs of the patient; and for Medicare patients, to determine eligibility for Medicare home health benefits, including home bound status. Additionally, the initial assessment visit was not conducted within 48 hours of referral, or within 48 hours of the patient's return home for 4 of 5 sampled patients. Specifically, an initial assessment was not completed within 48 hours of the referral for home health services, and a graduate from a nursing program, who was unlicensed, completed the initial and comprehensive assessments for patient's that were admitted to the HHA. (Patient identifiers: 1, 2, 4 and 5.) Findings include: 1. Patient 1 was admitted to the agency on 6/17/2021 with diagnoses which included venous insufficiency, diabetes mellitus type 2, peripheral vascular disease and status ulcer. A review of patient 1's medical record was completed on 7/19/2021. The initial nursing assessment was completed on 6/17/2021 by a graduate from a nursing program who had not obtained a licensed as a RN. The comprehensive nursing assessment was not completed until 6/22/2021 and had not been authenticated by a RN. 2. Patient 2 was admitted to the HHA on 3/30/2021 with diagnoses which included aftercare following a joint replacement surgery. A review of patient 2's medical record was completed on 7/19/2021. On 3/30/2021, patient 2's physician completed a referral to the HHA; however, patient 2 was not admitted to the agency until 4/9/2021 without documentation as to why. The comprehensive nursing assessment was not completed until 4/9/2021 and had not been authenticated by a RN. 3. Patient 4 was admitted to the HHA on 4/1/2021 with diagnoses including hypertensive heart and chronic kidney disease, chronic systolic and diastolic heart failure, and cardiomyopathy. A review of patient 4's medical record was completed on 7/19/2021. On 3/26/2021, patient 4's physician completed a referral to the HHA; however, patient 4 was not admitted to the agency until 4/1/2021 without documentation as to why. 4. Patient 5 was admitted to the agency on 5/4/2021 with diagnoses which included status post vein bypass on the right leg wound, hypertension and acute kidney failure. A review of patient 5's medical record was completed on 7/19/2021. On 4/29/2021, patient 5's physician completed a referral to the HHA; however patient 5 was not admitted to the agency until 5/4/2021 without documentation as to why. 5. An interview was conducted with the Director of Clinical Services (DCS) on 7/13/2021 at 1:42 PM. The DCS was asked about the unlicensed nursing graduate completing patient assessments. The DCS stated that he was "under the impression" that a graduate from a nursing program could work as a nurse pending her licensure. The DCS was asked how the HHA ensured that initial assessment were completed with 48 hours. The DCS was not aware that the initial assessment was to be completed within 48 hours of a referral being placed to the HHA.

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 interview and medical record review, it was determined that the agency did not ensure that all patient medications had been reviewed for 4 of 5 patients. (Patient identifiers: 1, 2, 3 and 5). Findings include: 1. Patient 1 was admitted to the agency on 6/17/2021 with diagnoses which included venous insufficiency and type 2 diabetes mellitus. A review of patient 1's medical record was completed on 7/19/2021. The admit Outcome and Assessment Information Set (OASIS) assessment indicated that patient 1 was on Toujeo 55 units in the morning. The Toujeo was not listed on the medication profile. An interview was conducted with Registered Nurse (RN) 1 on 7/13/2021 at 3:12 PM. RN 1 stated patient 1 self administered Toujeo 55-60 units in the morning. RN 1 stated the Toujeo was not on the initial paperwork and that she had "reached out" to patient 1's physician related to the Toujeo, but had not heard back from him. Additionally, RN 1 stated she was not sure what medications patient 1 was taking. An interview was conducted with patient 1 on 7/14/2021 at 10:18 AM. Patient 4 stated his blood sugar was "199 this morning" and that he injected Toujeo 66 units. 2. Patient 2 was admitted to the HHA on 3/30/2021 with diagnoses which included aftercare following a joint replacement surgery. A review of patient 2's medical record was completed on 7/19/2021. A review of the hospital history and physical indicated that patient 2 was on insulin, on an anticoagulant, and on other medications. The medication profile for patient 2 was blank. 3. Patient 3 was admitted to the HHA on 4/2/2021 with diagnoses which included Down's Syndrome, fracture of the upper and lower end of the right fibula and a nondisplaced comminute fracture of the shaft of the right tibia. A review of patient 3's medical record was completed on 7/19/2021. The medication profile for patient 3 was blank. 4. Patient 5 was admitted to the agency on 5/4/2021 with diagnoses which included status post vein bypass on the right leg wound, hypertension and acute kidney failure. A review of patient 5's medical record was completed on 7/19/2021. The rehabilitation center's discharge summary listed that patient 5 was medications including lasix, lisonopril, metoprolol, oxycodone, pantoprazole, spironolactone, xarelto as well as other medications. The medication profile created for patient 5 only included Lorazepam and Escitalopram that was started on 6/1/2021. 5. An interview was conducted with the Director of Clinical Service (DCS) on 7/19/2021 at 1:26 PM, related to the medication profiles. The DCS stated that medications, including medications at the time of discharge from other agencies, were to be reviewed with the patient at the time of admission. The DCS stated that any discrepancies were to be reported to the ordering physician for reconciliation.

Care planning, coordination, quality of care CFR(s): 484.60 Condition of participation: Care planning, coordination of services, and quality of care. Patients are accepted for treatment on the reasonable expectation that an HHA can meet the patient's medical, nursing, rehabilitative, and social needs in his or her place of residence. Each patient must receive an individualized written plan of care, including any revisions or additions. The individualized plan of care must specify the care and services necessary to meet the patient-specific needs as identified in the comprehensive assessment, including identification of the responsible discipline(s), and the measurable outcomes that the HHA anticipates will occur as a result of implementing and coordinating the plan of care. The individualized plan of care must also specify the patient and caregiver education and training. Services must be furnished in accordance with accepted standards of practice. This CONDITION is not met as evidenced by: Based on interview and record review, it was determined the home health agency (HHA) failed to provide care planning, coordination of services, and quality of care as required. Findings include: 1. The HHA failed to ensure the each patient had an individualized plan of care. (Refer to Tag G574) 2. The HHA failed to provide services only as ordered by a physician. (Refer to Tag G580)

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 interview and record review, it was determined the home health agency (HHA) did not ensure each patient's plan of care (POC) contained all the required elements for 5 of 5 sampled patients. (Patient identifiers: 1, 2, 3, 4 and 5.) Findings include: During an abbreviated/complaint survey 5 sampled patient records were reviewed. For 5 of 5 patients' their physician ordered individualized POC did not contain all the required elements. For 4 of 5 patients (1, 2, 3 and 5) the POC did not include an accurate and complete medication profile. For 1 of 5 patients (5) the POC did not include the durable medical equipment (DME) or supplies needed to care for the patient. For 2 of 5 patients (2 and 5) the POC did include the nutritional requirements. For 2 of 5 patients (2 and 5) the POC did not include allergies. For 1 of 5 patients (5) the POC did include the prognosis. For 3 of 5 patients (1, 3 and 5) the POC did not include orders for each discipline and treatment which identified the amount/frequency/duration. For 1 of 5 patients (1) the POC did not include orders for wound care. For 4 of 5 patients (2, 3, 4 and 5) the POC did not include identifiable psychosocial status documentation. For 3 of 5 patients (1, 2 and 5) the POC did not include measurable goals or interventions to achieve the goals. For 3 of 5 patients (1, 2 and 3) the POC was not signed by the nurse/therapist. For 5 of 5 patients (1, 2, 3, 4 and 5) the POC was not signed by a physician. 1. Patient 1 was admitted to the HHA on 6/17/2021 with diagnoses which included venous insufficiency, stasis ulcer, type 2 diabetes mellitus, muscle weakness and peripheral vascular disease. A review of patient 1's medical record was completed on 7/19/2021. The medication profile did not include that patient 1 was on Toujeo 55 units subcutaneously every morning. The duration for the skilled nurse (SN), home health aide or the physical therapist (PT) was not documented. There was no orders for treatment of the stasis ulcer on the right heel. Goals and interventions to achieve the goals developed were not completed. The POC was not signed by the nurse/PT or by the physician. 2. Patient 2 was admitted to the HHA on 3/30/2021 with diagnoses which included aftercare following a joint replacement surgery. A review of patient 2's medical record was completed on 7/19/2021. A medication profile was not completed, however; the hospital admission history and physical indicated that patient 2 was on insulin, an anticoagulant and other medications. The nutritional status and allergies were not documented; however, the hospital admission history and physical indicated that patient 2 was allergic to Vancomycin. There were no orders for each discipline and frequency, including duration. The POC was not authenticated or signed by a nurse or qualifying practitioner. 3. Patient 3 was admitted to the HHA on 4/2/2021 with diagnoses which included Down's Syndrome, fracture of the upper and lower end of the right fibula and a nondisplaced comminute fracture of the shaft of the right tibia. A review of patient 3's medical record was completed on 7/19/2021. The medication profile was not completed. There were no orders for each discipline which included the frequency and duration. The POC was not authenticated or signed by a nurse or qualifying practitioner. 4. Patient 4 was admitted to the HHA on 4/1/2021 with diagnoses which included hypertensive heart and chronic kidney disease, chronic combined systolic and diastolic heart failure, cardiomyopathy and anemia. A review of patient 4's medical record was completed on 7/19/2021. The POC was not authenticated by a qualifying practitioner. 5. Patient 5 was admitted to the HHA on 5/4/2021 with diagnoses which included status post vein bypass of the right leg and hypertensive chronic kidney disease. A view of patient 5's medical record was completed on 7/10/2021. The medication profile was not completed. The DME and supplies, nutritional requirements and allergies were left blank. There were no orders for each discipline which included the amount, frequency and duration. There were no goals or interventions. The POC was not authenticated by a qualifying practitioner. 6. The HHA policy and procedure related to the "Plan of Care" was reviewed. The following was documented: "...1. There is a written Plan of Care established based on the assessment of the patient, in consultation with the physician, Agency staff, the patient and members of the patient's family. The plan of care includes: Diagnoses (primary and relevant secondary), problems and needs. Patient's mental status. Types of interventions/services. Risk for emergency department visits and hospital re-admissions Identification of any services furnished by other provides. Coordination of care with other agencies. Frequency of visits and duration. Prognosis. Rehabilitation potential.. Functional limitations/homebound status. Activities permitted Nutritional requirements Medications and treatments Instructions for timely discharge or referral Expected goals or outcomes to be achieved Identify the continuing need for home care The physician's signature and date Food or drug allergies Education and Safety measures Treatment an disease management training Instructions for a timely discharge or referral The plan reflects the participation of the patient to the extend possible..." 7. An interview was conducted with the Director of Clinical Services (DCS) on 7/19/2021 at 1:26 PM related to the required elements of the POC. The DCS stated that the admitting personnel was responsible for developing all elements of the initial POC with the patients' input. The DCS stated that the POC was then to be sent to the ordering physician for review and signature. Additionally, the DCS stated the POC was to be updated when there was a change in the patient's status.

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 interview and record review, it was determined services and treatment were not administrated only as ordered by a physician for 2 of 5 sampled patients. Specifically, wound care was not provided as ordered by the physician. (Patient identifiers: 1 and 5) Findings include: 1. Patient 1 was admitted to the agency on 6/17/2021 with diagnoses which included venous insufficiency, stasis ulcer and type 2 diabetes mellitus. A review of patient 1's medical record was completed on 7/19/2021. Patient 1 was seen by the primary care physician (PCP) and assessed the Stage II (partial thickness) wound to right heel. The PCP documented that wound measured 1.5 cm (centimeters) X (by) 1.2 cm X 4 mm (millimeters). The wound had a small amount of serous drainage On 6/16/2021, patient 1's physician wrote admission orders to the agency which included: "Wound care R (right) heel: cleanse wound with saline or wound cleanser, apply optifoam or allevyn dressing, and apply 2 layer compression wrap to RLE (right lower extremity). change wrap and bandage 2x (twice) weekly. ..." The initial Plan of Care (POC) was reviewed and did not include the wound care order as a above. On 6/22/2021, patient 1's PCP documented the right heel wound measured 1.5 cm X 1.2 cm X 4 mm. There were no wound care orders documented. On 6/24/2021, there was no wound care provided. On 6/26/2021, a RN documented that venous stasis measured 1 cm X 1 cm and that there was sero-sanguineous drainage with granulating tissue. The RN cleansed the wound with Dakin's solution (a chemical agent used to debride a wound) and dried the wound with a 4X4. The RN applied an allevyn dressing and applied a 2nd layer compression wrap. [Note: There was not an order to change the dressing change to the use of Dakin's solution.] On 6/28/2021, patient 1's PCP documented the right heel wound measured 1.8 cm X 1.2 cm X 4 mm. There were no wound care orders documented. On 6/30/2021, a RN documented the venous stasis ulcer measures 1 cm X 1 cm and that there was sero-sanguineous drainage. The RN cleansed the wound with a Dakin's solution and dried the wound with a 4X4. The RN applied an allevyn dressing and applied a 2nd layer compression wrap. On 7/5/2021, patient 1's PCP documented the right heel wound measured 0.4 cm X 0.4 cm X 2 mm. On 7/2/2021, a RN documented the venous stasis ulcer measured 1 cm X 1 cm and that there was sero-sanguineous drainage with granulating tissue. The RN cleansed the wound with a Dakin's solution and dried the wound with a 4X4. The RN applied an allevyn dressing and applied a 2nd layer compression wrap. On 7/7/2021, a RN documented the venous stasis ulcer was closed but measures 1 cm X 1 cm. The wound had granulating tissue at the wound base. The RN cleansed the wound with a Dakin's solution and dried the wound with a 4X4. The RN applied an allevyn dressing and applied a 2nd layer compression wrap. An interview was conducted with RN 1 on 7/13/2021 at 3:12 PM. RN 1 was asked about the differing wound measurements as well as the dressing change orders. RN 1 was unable to give an answer as to why the wound care measurements did not change from start of care to 7/7/2021. Additionally, RN 1 was able to explain why she used Dakin's solution without an order. 2. Patient 5 was admitted to the HHA on 5/4/2021 with diagnoses which included status post vein bypass of the right leg and hypertensive chronic kidney disease. A view of patient 5's medical record was completed on 7/19/2021. Patient 5 was seen by the PCP on 5/4/2021. The PCP documented that patient 5 had two wounds to the left lower leg. Wound 1 measured 8.0 cm X 4.5 cm X 5 mm and had a moderate amount of purulent drainage with yellowish slough. Wound 2 measured 2.5 cm X 1.0 cm X 2 mm and had sero-sanguineous drainage. The PCP documented the left lower extremity wounds were to be cleansed with Dakin's solution 0.25%, apply calcium alginate, cover with adaptic and abd pad. Secure dressing with conforming gauze an apply tubigrip to lower leg. The dressings were to be changed twice a week on Wednesday and Friday. On 5/5/2021, an order was written to, "kecleanse (sic) wound with cleanser, apply calcium alginate, cover with adaptic, cover with abd and kerlix or gauze and then tubagrip (sic) 2 x week." Note: The order was not signed by the physician. There was no wound care provided during the week of 5/16/2021 through 5/22/2021. Additionally, there was only one SN visit instead of the ordered two and only two aide visits instead of the ordered three. There was only two aide visits made during the week of 5/23/2021 through 5/29/2021, instead of the ordered three. On 6/9/2021, an order was written to start Lorazepam 0.5 mg (milligrams) 1 tablet as needed and escitalopram oxalate 10 mg 1 tablet daily. The medications were to be started on 6/1/2021, eight days before the order was written. Note: The order was not signed by the physician. 6. An interview was conducted with the Clinical Manager (CM) on 7/14/21 at 2:14 PM related to the unsigned orders and missed visits. The CM stated, "I was aware some things were not being done right and that there is a lot that has to be fixed."

Quality assessment/performance improvement CFR(s): 484.65 Condition of participation: Quality assessment and performance improvement (QAPI). The HHA must develop, implement, evaluate, and maintain an effective, ongoing, HHA-wide, data-driven QAPI program. The HHA's governing body must ensure that the program reflects the complexity of its organization and services; involves all HHA services (including those services provided under contract or arrangement); focuses on indicators related to improved outcomes, including the use of emergent care services, hospital admissions and re-admissions; and takes actions that address the HHA's performance across the spectrum of care, including the prevention and reduction of medical errors. The HHA must maintain documentary evidence of its QAPI program and be able to demonstrate its operation to CMS. This CONDITION is not met as evidenced by: Based on interview and record review, it was determined the home health agency (HHA) failed to develop, implement, and maintain an effective, ongoing, hospice-wide data-driven quality assessment and performance improvement (QAPI) program. Specifically, the HHA and governing body did not maintain documentary evidence that could demonstrate operations of a functioning QAPI program that included: tracking, measuring, and analyzing quality indicators and adverse events, which could be implemented into performance improvement activities that would improve quality of care and patient safety. Findings include: On 7/12/2021, during entrance the agency's QAPI Plan, performance improvement projects (PIPs), evidence of QAPI meetings, adverse event log, and governing body minutes were requested. The surveyors reviewed all the information provided for the past 12 months, as follows: A documented titled, "Owners Meeting 3/9/21". The document contained the following headings: Billing Recap, Charting/Compliance, Training, Cash Flow, Payroll, [name of person] Compensation, CEO (chief executive officer)/Administrator, Contributions. Other than the headings, there was no other information in the document. A document titled, "Templeview Home Health & Hospice 11/25/2020 Owner Meeting". The document contained the following headings: Update on Accreditation; Current Condition/Temp of Operation; Personnel; Financial; and Medical. Four of the headings contained sub-headings. Other than the headings and sub-headings, there was no other information in the document. A monthly expense document was provided with no date. Everything else provided was from the first quarter of 2020 and was business or financial in nature and did not contain any QAPI information. Additionally, the above documents did not show a separation between HHA and there affiliated-hospice agency. The HHA did not provide evidence of adverse event tracking, a QAPI plan, or PIP's. An interview was conducted with the Administrator on 7/19/2021 at approximatelty 1:30 AM. The administrator stated that he did not have additional information to submit.

Home health aide assignments and duties CFR(s): 484.80(g)(1) Standard: Home health aide assignments and duties. Home health aides are assigned to a specific patient by a registered nurse or other appropriate skilled professional, with written patient care instructions for a home health aide prepared by that registered nurse or other appropriate skilled professional (that is, physical therapist, speech-language pathologist, or occupational therapist). This STANDARD is not met as evidenced by: Based on interview and record review, it was determined the home health aide care plan was not developed by a registered nurse or other appropriate skilled professional for 1 of 5 sampled patients. (Patient identifier: 5). Findings include: Patient 5 was admitted to the agency on 5/4/2021 with diagnoses which included status post vein bypass of the right leg and hypertensive chronic kidney disease. A view of patient 5's medical record was completed on 7/19/2021. On 5/10/2021, a home health aide care plan was developed by an unlicensed graduate nurse, not a registered nurse as required. An interview was conducted with the Director of Clinical Services (DCS) on 7/13/2021 at 1:42 PM. The DCS was asked about the unlicensed nursing graduate completing the home health aide care plan. The DCS stated that he was "under the impression" that a graduate from a nursing program could work as a nurse pending her licensure.

Organization and administration of services CFR(s): 484.105 Condition of participation: Organization and administration of services. The HHA must organize, manage, and administer its resources to attain and maintain the highest practicable functional capacity, including providing optimal care to achieve the goals and outcomes identified in the patient's plan of care, for each patient's medical, nursing, and rehabilitative needs. The HHA must assure that administrative and supervisory functions are not delegated to another agency or organization, and all services not furnished directly are monitored and controlled. The HHA must set forth, in writing, its organizational structure, including lines of authority, and services furnished. This CONDITION is not met as evidenced by: Based on interview and record review, it was determined the governing body (GB) failed to assume full legal authority and responsibility for the governance and operation of the facility. Findings include: 1. The GB failed to provide written notice of the patient's rights and responsibilities. (Refer to tag G418) 2. The GB failed to meet to provide a complete comprehensive assessment of patients. (Refer to tag G510) 3. The GB failed to provide care planning, coordination of services, and quality of care as required. (Refer to Tag G570) 4. The GB failed to develop, implement, and maintain an effective, ongoing, hospice-wide data-driven quality assessment and performance improvement program. (Refer to Tag G640) 5. The GB failed to ensure the home health aide care plan was developed by a registered nurse or other appropriate skilled professional. (Refer to Tag G940) 6. The GB failed to ensure a complete discharge summary was sent to the primary care practitioner within five business days of discharge or within two business days of a transfer occurring. (Refer to Tag G1022) 7. The GB failed to ensure nursing assessments were completed by a licensed professional, as required. (Refer to Tag G1072)

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 record review, it was determined the home health agency (HHA) did not complete a discharge summary that was sent to the primary care practitioner within five business days of discharge or within two business days of a transfer occurring, for 2 of 2 sampled discharged patients. (Patient identifiers: 4 and 5). Findings include: 1. Patient 4 was admitted to the HHA on 4/1/2021 with diagnoses which included hypertensive heart and chronic kidney disease, chronic combined systolic and diastolic heart failure, cardiomyopathy and anemia. A review of patient 4's medical record was completed on 7/19/2021. On 5/3/2021, an order was written to discharge the patient from home health related to patient 4 starting hospice services. The discharge summary in patient 4's medical record was blank. The OASIS (outcome and assessment information set) discharge assessment completed by the skilled nurse (SN), did not include the reason for admission to the HHA, types of services provided and the frequency of the services, laboratory date, medications that the patient was on at the time of discharge, discharge condition or the patient outcomes in meeting the goals in the plan of care. 2. Patient 5 was admitted to the agency on 5/4/2021 with diagnoses which included status post vein bypass on the right leg wound, hypertension and acute kidney failure. A review of patient 5's medical record was completed on 7/19/2021. Patient 5 was transferred to an inpatient facility. The OASIS transfer assessment completed by the SN, did not include the reason for admission to the HHA, types of services provided and the frequency of the services, laboratory date, medications that the patient was on at the time of transfer. An OASIS discharge assessment completed by the SN, did not include the reason for admission to the HHA, types of services provided and the frequency of the services, laboratory date, medications that the patient was on at the time of discharge, discharge condition or the patient outcomes in meeting the goals in the plan of care.

Registered Nurse CFR(s): 484.115(k) Standard: Registered nurse. A graduate of an approved school of professional nursing who is licensed in the state where practicing. This STANDARD is not met as evidenced by: Based on interview and record review, it was determined a newly graduated nurse who was unlicensed in the State of Utah, was completing nursing assessments for 2 of 5 sampled patients. (Patient identifiers: 1 and 5). Findings include: 1. Patient 1 was admitted to the agency on 6/17/2021 with diagnoses which included venous insufficiency, diabetes mellitus type 2, peripheral vascular disease and status ulcer. A review of patient 1's medical record was completed on 7/19/2021. The initial nursing assessment was completed on 6/17/2021 by a nursing graduate (NG) 1 who had not obtained a licensed as a registered nurse. 2. Patient 5 was admitted to the agency on 5/4/2021 with diagnoses which included status post vein bypass on the right leg wound, hypertension and acute kidney failure. A review of patient 5's medical record was completed on 7/19/2021. Ordered nursing visits were completed by NG 1 for twelve days between 5/10/2021 through 6/17/2021. 3. An interview was conducted with the Director of Clinical Services (DCS) on 7/13/2021 at 1:42 PM. The DCS was asked about the unlicensed nursing graduate completing patient assessments. The DCS stated that he was "under the impression" that a graduate from a nursing program could work as a nurse pending her licensure.