Every finding on record at The Community Group Home Health LLC

This entity is in compliance with federal emergency preparedness requirements.

Recertification A COVID-19 Focused Infection Control Survey was conducted on 12/15/2021. The facility was found to be in compliance with 42 CFR §483.80 infection control regulations and has implemented the CMS and Centers for Disease Control and Prevention (CDC) recommended practices to prepare for COVID-19. Unduplicated Admissions: 52 Total Census: 42

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 record review and interview, the agency failed to ensure the patient's written individualized POC (plan of care) was followed as evidenced by the SN (Skilled Nurse) administering medications that were not on the patient’s plan of care for 1 (patient #5) out of 7 sampled patients. (#5) Patient #5. Review of the patient’s clinical records revealed the start of care date was 5/1/2018. The patient’s diagnoses included Diffuse TBI (Traumatic Brain Injury) With Loss of Consciousness of Unspecified Duration, Hypertension, Epilepsy, Presence of Cerebrospinal Fluid Drainage Device and Encounter for Attention to Gastrostomy. The certification periods reviewed were 10/2/2021 to 11/30/2021 and 12/1/2021 to 1/29/2022. Review of the skilled nursing progress notes for the certification period 10/2/2021 to 11/30/21 revealed that the skilled nurse administered Hydrocodone/Acetaminophen (narcotic pain medication) on 10/4/21. Further review of the notes revealed that the skilled nurse administered Zofran 4mg (a medication for nausea and vomiting) on 11/1/21 and Lactulose (a laxative) on 11/2/21, 11/15/21, 11/15/21, and 11/29/21. Review of the Medication Administration Record (MAR) dated 10/31/21 to 11/13/21 revealed that the skilled nurse administered Hydrocodone/Acetaminophen on 11/8/21. Review of the POC for the certification period 10/2/21 to 11/30/21 revealed that there were no physician orders for the medications administered. Review of the Medication Administration Record (MAR) for the certification period for 12/1/21 to 1/29/22 revealed that the skilled nurse administered Lactulose on 12/6/21 and Hydrocodone/Acetaminophen on 12/11/21. Review of the POC for the certification period 12/1/21 to 1/29/2022 revealed that there were no physician orders for the medications administered. On 12/14/21 @ 12:35 PM, S1DON (Director of Nurses) stated that a patient’s current medications should be on their plan of care. He confirmed that the patient’s POC for the certification periods 10/2/21 to 11/30/21 did not contain medication orders for Hydrocodone/Acetaminophen, Zofran and Lactulose. He also confirmed that the patient’s POC for the certification period 12/1/21 to 1/29/22 did not contain medication orders for Hydrocodone/Acetaminophen and Lactulose.

Promptly alert relevant physician of changes CFR(s): 484.60(c)(1) The HHA must promptly alert the relevant physician(s) or allowed practitioner(s) to any changes in the patient's condition or needs that suggest that outcomes are not being achieved and/or that the plan of care should be altered. This ELEMENT is not met as evidenced by: Based on record review and interview, the agency failed to ensure Patient #7's physician was promptly alerted of a seven pound weight gain in one week that was noted by the skilled nurse during the skilled nurse visit made on 6/3/2021 for 1 (#7) out of 7 sampled patients. Patient #7. Review of the patient's clinical record revealed the start of care date was 3/13/2021. The patient's diagnoses included Fracture of Right Acetabulum, Diabetes, and Hypertension. The certification period reviewed was 5/12/2021 to 7/5/2021. Review of the patient's POC (Plan of Care) for certification period 5/12/2021 to 7/5/2021 revealed the following order; SN 1w10 (skilled nurse visit one time a week for ten weeks). Further of the POC revealed, “… Notify physician immediately of any potential problems that impede completion of patient recovery and desired goals… SN to assess cardiovascular status, identify any signs and symptoms of impaired cardiovascular function…” Review of the patient's SN Visit Note dated 5/28/2021 revealed that the patient’s weight was 153 pounds. Review of the patient’s SN Visit Note dated 6/3/2021 revealed that the patient’s weight was 160 pounds, which was a seven pound weight gain in one week. There was no evidence that the SN notified the physician of the patient’s 7 pound weight gain in one week. On 12/14/2021 at 12:15 pm, an interview was conducted with S1DON (Director of Nurses) and after a review of the patient's clinical record, S1DON verified that there was no evidence that the physician was notified of the patient’s seven pound weight gain in one week. Also, S1DON stated that the seven pound weight gain should have been reported to the physician.