Every finding on record at The Evangelical Lutheran Good Samaritan Society

The Department of Inspections and Appeals conducted a recertification survey on 12/12/2022 through 12/14/22 and found the agency to be in compliance with emergency preparedness regulations.

The recertification survey conducted on 12/12/22 through 12/14/22 by the Department of Inspections and Appeals found the agency operating in compliance with the Conditions of Participation for home health, however found the agency operating out of compliance with the following standard level deficiencies. The agency reported a current census of 54 patients at the time 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 #6). 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. According to the agency policy, titled OASIS (Outcome and Assessment Information Set), dated 3/8/22, at resumption of care time point, the comprehensive assessment must be completed within 48 hours of returning home after discharge from an inpatient facility or on physician ordered resumption of care. Patient #6 had a start of care date of 3/11/21 and a discharge date of 9/23/22. Clinical record review revealed the update to the comprehensive assessment at the time of resumption of care, dated 4/4/22, documented the patient was discharged from the hospital on 4/1/22 with a physician ordered resumption of care date of 4/4/22. The nurse initiated the assessment on 4/4/22 but did not complete the assessment until 4/7/22, 3 days after the patient's physician ordered resumption of care date. The assessment was completed 1 day late as required by regulation and the agency's own policy. The above stated findings were reviewed with the Administrator/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 and patient/patient caregiver interviews, the agency failed to ensure the accurate completion of all components comprising the Plan of Care, including all supplies/equipment and medications used by the patient for 2 of 3 sampled patients with surveyor home visit observation(Patients #1 and #3). 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: According to agency policy, titled Plan of Care-Home Health Therapy and Rehab, dated 2/8/22, ...all clinical services are implemented in accordance with a Plan of Care (POC) and established by physician/non-physician practitioner written orders.... Each client must receive home health services that are written in an individualized POC and identifies client specific measurable goals.... 1. Patient #1 had a start of care date of 10/22/2021. The patient received home care aide services only with 60 day supervision visits completed by the skilled nurse. Clinical record review, home visit observation and accompanying interviews revealed the following: a. The Plans of Care, dated 6/17/22 to 8/17/22, 8/18 to 10/16/22, and 10/17 to 12/15/22, included orders for Omeprazole 40 milligrams (mg) daily. b. The Client Medication Report, dated 6/7/21, included orders for Omeprazole 40 milligrams (mg) daily. During a home visit observation on 12/12/22 at 1:30 PM, with Staff B, Registered Nurse (RN), the nurse revealed the patient's caregiver sets up the patients medications. The surveyor reviewed all medications with the patient's caregiver. The survyeor observed a bottle of Pantoprazole 40 mg to be taken twice daily. The patient caregiver revealed the patient was given this in place of the Omeprazole. The bottle had an original refill date of 6/22/22. The Plans of Care identified the Omeprazole as medication used by the patient and lacked identification of the Pantoprazole used by the patient. c. The Plans of Care, dated 6/17/22 to 8/17/22, 8/18 to 10/16/22, and 10/17 to 12/15/22, identified the following equipment and supplies as equipment needed to meet the patient's needs: wheeled walker, manual wheelchair, incontience supplies, lift chair, bed rails, medication planner, shower chair, toilet riser, commode, exterior ramp, and nebulizer machine and supplies. During the same home visit observation on 12/12/22 at 1:30 PM, with Staff B,RN, the surveyor observed a hand held shower in the patient's bathroom. The patient's caregiver reported the patient has had the hand held shower since the patient caregiver moved in with the patient in 2016. The Plans of Care lacked identification of the hand held shower as equipment/supplies needed to meet the patient's needs. 2. Patient #3 had a start of care date of 9/21/2018. The patient received skilled nurse weekly and home care aide services 2-3 times per week. Clinical record review, home visit observation and accompanying interviews revealed the following: a. The Plans of Care, dated 7/2/22 to 8/30/22, 8/31 to 10/29/22, and 10/30 to 12/28/22, identified the following equipment and supplies as needed to meet the patient's needs: medication planner, diabetic supplies, quad cane, high rise stool, ted hose, telehealth monitor, bath bench, hand held shower, grab bars, straight cane, incontinence supplies, and 4 wheeled walker. During a home visit observation on 12/14/22 at 11:00AM, with Staff D, RN, the surveyor observed the patient sitting in a lift chair. The patient reported having the lift chair for a short time and got a new one as the previous lift chair had broken and that the patient had another lift chair before that one as well. The Plans of Care lacked identification of the lift chair as medical equipment/supplies needed to meet the patient's needs. During the same home visit observation with Staff D, RN, the surveyor discussed with patient use of ted hose. The patient reported still having ted hose and use of the ted hose when legs swell up and informed the surveyor 3-4 months ago the patient received a sock aide so is now independent with putting on the ted hose. b. The Plans of Care lacked identification of the sock aide as medical equipment/supplies needed to meet the patient's needs. The above findings were reviewed with the agency Administrator/Clinical Manager. The agency provided no additional information prior to the end of the survey.

Competency evaluation CFR(s): 484.80(c)(1)(2)(3) Standard: Competency evaluation. An individual may furnish home health services on behalf of an HHA only after that individual has successfully completed a competency evaluation program as described in this section. (1) The competency evaluation must address each of the subjects listed in paragraph (b)(3) of this section. Subject areas specified under paragraphs (b)(3)(i), (iii), (ix), (x), and (xi) of this section must be evaluated by observing an aide's performance of the task with a patient or pseudo-patient. The remaining subject areas may be evaluated through written examination, oral examination, or after observation of a home health aide with a patient, or with a pseudo-patient as part of a simulation. (2) A home health aide competency evaluation program may be offered by any organization, except as specified in paragraph (f) of this section. (3) The competency evaluation must be performed by a registered nurse in consultation with other skilled professionals, as appropriate. This STANDARD is not met as evidenced by: Based on personnel file review and review of the agency's home health aide job description, the agency failed to ensure a registered nurse, or other appropriate skilled professionals in consultation with a registered nurse as appropriate, performed direct observation of a home health aide's performance of all required health aide skills assigned beyond the basics on a home health patient to determine satisfactory competency prior to allowing the home health aide to provide care independently to agency patients for 1 of 2 sampled home health aides assigned to complete skills beyond the basic skills. At the time of the survey, the agency employed 4 home health aides and provided home health aide services to 28 patients. Failure to ensure home health aides successfully complete a competency evaluation in all basic home health aide skills on a patient and were competent in any assigned extra skills which exceed the level of basic home health aide skills placed agency patients at risk to receive inadequate or unsafe home health aide services. Findings include: The Medicare Conditions of Participation for home health agencies to ensure all home health aides are competent in all of the basis home health aide skills by successfully demonstrating competency in the performance of all the hands on basic home health aide skills with a home health patient, exactly as these tasks will be performed with and actual home health patient, in the presence of a qualified Registered Nurse before being assigned to provide any patient care independently. The list of "hands on" basic home health aide tasks are: communication skills, reading and recording temperature, pulse, respirations, bed bath, sponge bath, tub bath and shower bath, shampoo in a sink, tube and bed, skin care, oral care, nail care, toileting and elimination, transfers/ambulation, positioning, nutrition and fluid intake and range of motion. An individual may furnish home health services on behalf of the agency only after that individual has successfully competed a competency evaluation. According to agency policy, titled Home Health Aide Services, dated 3/29/22,...The aide will be trained and competency tested according to state and federal regulations. According to agency policy, titled Home Health Aide Supervision and Delegation of Duties, dated 3/30/22, ...all new skills performed by the aide will be under the direct supervision of the Registered Nurse/Case Manager.... Patient #3 had a start of care date of 9/21/18 and received home care aide services by Staff C, Home Care Aide (HCA). The aide was assigned the following tasks: shower every visit, remind patient to take medications, assist the patient with applying lidocaine patch every visit to lower back or legs, after drying patient assist patient with applying Clindamycin phosphate 1% to scalp, shoulders, chest, and back, then minerin anti-itch cream, and shampoo with hibiclens, then apply chlorhexidine to red areas on scalp, apply ted hose per patient request, and assist with transfers of stand by assist with walker every visit. Staff C, HCA, had a hire date of 7/30/14. Staff C's personnel file included core competency testing and additional testing. The aide file lacked competency testing for the aide to apply medicated ointments, creams, shampoos, and also to assist with application of the lidocaine patch. Interview with agency Administrator/Clinical Manager on 12/15/22 at 8:35 AM reported the aide competency testing is completed by the nurse in the home and documented in the supervision section of the chart for every aide. The Administrator/Clinical Manager would look for the requested documentation of proof of aides being competency tested. Agency staff provided no additional information prior to the end of the survey.

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 agency policy review, clinical record review and staff interview, the agency failed to ensure home health aides provided care to agency patients only as ordered by the physician, permitted under state law and/or as directed by the skilled professional assigning the home health aide to the patient for 2 of 3 sampled patients receiving home health aide services (Patients #1 and #3). The agency reported 28 patients received care provided by a home health aide. Failure to ensure that home health aide services are provided only as ordered by the physician, permitted under state law and/or as directed by the skilled professional assigning the home health aide to the patient and according to the home health aide care plan increased the risk that patients' personal care needs were not adequately met. Findings including: According to agency policy, titled Home Health Aide Services, dated 3/29/22, ...the aide is assigned to a specific patient by the Case Manager or RN. An aide provided services that are ordered by a physician or non-physician practitioner, are included in the Plan of Care, permitted to be performed under state law and are consistent with aide training. Interview with the agency Administrator/Clinical Manager on 12/12/22 at 2:04 PM reported if the aide is unable to complete a task, the aide would document refusal by writing in or checking box on the aide form. 1. Patient #1 had a start of care date of 10/22/21. The Plans of Care, dated 8/8/22 to 10/16/22 and 10/17/22 to12/15/22, included physician orders for home health aide services 2 times per week to assist with personal cares and skilled nursing visits every 60 days for supervisory visits. Clinical record review revealed: a. The Aide Care Plan dated as developed on 6/14/22 and reviewed on 8/16/22, and 10/13/22 included direction to the aide to perform bathing of shower every visit, partial or complete sponge bath per patient request, shampoo and dry hair per patient request, apply lotion to back arms, legs and feet each visit, provide nondiabetic foot care every Tuesday, assist the patient with grooming of selecting patient's clothes, assist with dressing and brushing and combing hair each visit, and provide ambulation assistance of chair bound each visit with pivot transfers. b. Home health aide visit notes, dated 10/18, 11/1,11/22 and 12/6/22, documented completion of a shower, documented partial/complete sponge bath as refused, lacked documentation of completion of nondiabetic foot care or why the task was not completed and documented the patient refused the task of walked with walker which was not assigned. c. Home health aide visit notes, dated 10/25/22, documented completion of a shower, documented partial/complete sponge bath as refused, lacked documentation of completion of nondiabetic foot care or why the task was not completed and documented the patient the task of walked with walker was completed which was not assigned. The home health aide failed to provide services that are ordered by the physician, included in the plan of care, permitted under state law, and consistent with home health aide training. 2. Patient #3 had a start of care date of 9/21/18. The Plans of Care, dated 8/31/22 to 10/29/22 and 10/30/22 to12/28/22, included physician orders for weekly skilled nurse visits and health aide services 3 times per week to assist with personal cares. Clinical record review revealed: a. The Aide Care Plan dated as developed on 5/2/22 and reviewed on 6/27/22, 8/29/22, and 10/26/22 included direction to the aide to perform bathing of shower every visit, shampoo with hibiclens, then apply chlorhexidine to red areas on scalp each visit, provide skin care as clindamycin to lesions on head, back, shoulders after shower, then minerin cream and anti-itch cream every visit, assist the patient with grooming of selecting patient's clothes, assist with dressing each visit, apply ted hose per patient request, provide medication reminder each visit, walk patient with walker every visit and apply lidocaine patch to lower back or legs each visit. b. Home health aide visit notes, dated 10/10, 10/12, 10/14, 10/17, 10/19, 10/21, 10/24, 10/26, 10/28, 10/31, 11/2, 11/4, 11/7, 11/9, 11/11, 11/14, 11/16, 11/18, and 11/21/22, documented completion of a shower, documented shampoo and Clindamycin/Phosphate was completed, documented lotion was applied, lotion not tasked to patient, and identified Eucerin and hydrocortisone cream was applied, documented refusal of the task of walking with cane which was not assigned and lacked document of application of the lidocaine patch. Interview with Staff C, Home Care Aide on 12/13/22 at 4:07 PM reported she charts med reminder as the aide reminds the patient to take the patient's medications. The aide documents N/A if the aide does not complete assigned tasks on the care plan. The aide does help the patient with application of lidocaine patches by guiding the patient's hand where to put it. The aide does not document this. j The home health aide failed to provide services that are ordered by the physician, included in the plan of care, permitted under state law, and consistent with home health aide training. The above findings were reviewed with the agency Administrator/Clinical Manager. Agency staff 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 clinical record review and agency staff interview, the agency failed to ensure completion of documentation for routine visit notes were completed within the agency's administrative expectations for 4 of 7 sampled patients (Patients #2, #3, #4, and #7). 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: Interview on 12/13/22 at 1:55 PM with the Administrator reported she spoke with her consultant and routine charting is to be completed within 24 hours and anything else within 48 hours. The consultant is looking for a policy. 3. Patient #2 had a start of care date of 11/25/22. Clinical record review revealed skilled nurse visit note, dated 12/7/22, included nurse's electronic signature, dated as completed 12/12/22, 5 days after the visit date and 4 days late per agency expectation. 4. Patient #7 had a start of care date of 5/6/22 and a discharge date of 6/20/22. Clinical record review revealed: a. skilled nurse visit note, dated 5/9/22, included nurse's electronic signature, dated as completed 5/11/22, 2 days after the visit date and 1 day late per agency expectation. b. skilled nurse visit note, dated 5/13/22, included nurse's electronic signature, dated as completed 5/16/22, 3 days after the visit date and 2 days late per agency expectation. c. skilled nurse visit note, dated 6/7/22, included nurse's electronic signature, dated as completed 6/9/22, 2 days after the visit date and 1 day late per agency expectation. The above stated findings were reviewed with the Administrator/Clinical Manager. The agency provided no additional information prior to the end of the survey. 1. Patient #4 had a start of care date of 10/6/22. Clinical record review revealed: a. A skilled nurse visit note , dated 10/20/22, included the nurse's electronic signature, dated as completed on 10/24/22, 4 days after the visit date and 3 days late per agency expectation. b. A skilled nurse visit note , dated 11/17/22, included the nurse's electronic signature, dated as completed on 11/21/22, 4 days after the visit date and 3 days late per agency expectation. c. A skilled nurse visit note , dated 12/1/22, included the nurse's electronic signature, dated as completed on 12/5/22, 4 days after the visit date and 3 days late per agency expectation. 2. Patient #3 had a start of care date of 9/21/18. Clinical record review revealed: a. A skilled nurse visit note , dated 11/3/22, included the nurse's electronic signature, dated as completed on 11/7/22, 4 days after the visit date and 3 days late per agency expectation. b. A skilled nurse visit note , dated 12/8/22, included the nurse's electronic signature, dated as completed on 12/12/22, 4 days after the visit date and 3 days late per agency expectation.