Every finding on record at The Evangelical Lutheran Good Samaritan Society

On behalf of the Centers for Medicare & Medicaid Services (CMS), an unannounced on-site Complaint survey (61FF3-H1) conducted at the above-named Home Health Agency (HHA) on 01/23/24 resulted in substantial compliance respective to applicable Condition of Participation (CoP) under 42 CFR 484, Subpart A through C.

Advise the patient of discharge for cause CFR(s): 484.50(d)(5)(i) (i) Advise the patient, representative (if any), the physician(s) or allowed practitioner(s), issuing orders for the home health plan of care, and the patient's 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) that a discharge for cause is being considered; This ELEMENT is not met as evidenced by: Based on clinical record review, agency document review, policy review, and staff interview, the Home Health Agency (HHA) failed to notify the patient and physician of their desire to discontinue services for cause prior to discharging the patient for 2 (Patient 1 & 3) of 10 discharged records reviewed. This failed practice of not notifying the patient and physician of the discharge prior to discontinuing services placed the patients at risk of unmet needs and adverse outcomes. Findings Include: Review of agency policy titled, "Discharge and Transfer", contained bullet points under a Section titled, "Procedure", which indicated "A discharge or transfer may occur for the following reasons: ...Advise the patient/representative, the provider issuing the orders, and the patient's primary practitioner, or other health care professional who will be responsible for providing care after discharge from the agency, that a discharge for cause is being considered..." Patient 1 Review of agency document titled, "Home Health Suggestion, Complaint/Concern or Grievance" dated 07/05/23, indicated that the patient had filed a complaint regarding a nurse messing up her medications. The document also indicated that the patient had called in the complaint and had been loud and rude during the call. The indicated resolution to the complaint was documented as, the Skilled Nurse (SN) reached out to the patient and informed her due to her refusal to allow multiple staff into her home and due to her noncompliance with her medications she was being discharged from the agency. The above document contained a statement which indicated, "This form is NOT part of the Medical Record". Review of the clinical record for the episode dates beginning 06/07/23 through the date of discharge, 07/05/23, revealed no documented noncompliance by the patient or of any agency staff informing the patient of an upcoming discharge due to noncompliance. Patient 3 Review of agency document titled, "Home Health Suggestion, Complaint/Concern or Grievance" dated 11/03/23, indicated that the patient had filed a complaint regarding not receiving the wound care supplies she preferred and of the nurses' missing visits. The complainant also indicated that she would be filing a complaint with the Kansas state board of nursing. The indicated resolution to the complaint was documented as, the Skilled Nurse (SN) and supervising nurse reached out to the patient to discuss her complaint and informed her due to her not being happy with the services provided that she should look for another agency. The patient was informed that she was being discharged from the agency. The supervising nurse also called the physician's office and informed the nurse of the patient's discharge. The above document contained a statement which indicated, "This form is NOT part of the Medical Record". Review of the clinical record for the episode dates beginning 10/06/23 through the date of discharge, 11/03/23, revealed no documented noncompliance by the patient or of any agency staff informing the patient of an upcoming discharge due to noncompliance. During an interview on 01/23/24 at 8:40 AM, Staff A, Administrator confirmed the above finding of discharging patients prior to notifying the patient and physician of the discharge prior to discontinuing services.

Make efforts to resolve the problem(s) CFR(s): 484.50(d)(5)(ii) (ii) Make efforts to resolve the problem(s) presented by the patient's behavior, the behavior of other persons in the patient's home, or situation; This ELEMENT is not met as evidenced by: Based on clinical record review, agency document review, policy review, and staff interview, the Home Health Agency (HHA) failed to make efforts to resolve patient problems, behaviors and complaints prior to discharging the patient for 2 (Patient 1 & 3) of 10 discharged records reviewed. This failed practice of not making efforts to resolve patient problems and complaints prior to discontinuing services placed the patients at risk of unmet needs and adverse outcomes. Findings Include: Review of agency policy titled, "Discharge and Transfer", contained bullet points under a Section titled, "Procedure", which indicated "...Make efforts to resolve the problems, behaviors, or situations. Document all efforts made to resolve the problem, the assessment of the situation, all communication with agency management and the provider responsible for the POC (Plan of Care)." Patient 1 Review of agency document titled, "Home Health Suggestion, Complaint/Concern or Grievance" dated 07/05/23, indicated that the patient had filed a complaint regarding a nurse messing up her medications. The document also indicated that the patient had called in the complaint and had been loud and rude during the call. The indicated resolution to the complaint was documented as, the Skilled Nurse (SN) reached out to the patient and informed her due to her refusal to allow multiple staff into her home and due to her noncompliance with her medications she was being discharged from the agency. The above document contained a statement which indicated, "This form is NOT part of the Medical Record". Review of the clinical record for the episode dates beginning 06/07/23 through the date of discharge, 07/05/23, revealed no documented noncompliance by the patient or of any agency staff taking any actions to teach the patient what would occur due to the problem of noncompliance. Patient 3 Review of agency document titled, "Home Health Suggestion, Complaint/Concern or Grievance" dated 11/03/23, indicated that the patient had filed a complaint regarding not receiving the wound care supplies she preferred and of the nurses' missing visits. The complainant also indicated that she would be filing a complaint with the Kansas state board of nursing. The indicated resolution to the complaint was documented as, the Skilled Nurse (SN) and supervising nurse reached out to the patient to discuss her complaint and informed her due to her not being happy with the services provided that she should look for another agency. The patient was informed that she was being discharged from the agency. The supervising nurse also called the physician's office and informed the nurse of the patient's discharge. The above document contained a statement which indicated, "This form is NOT part of the Medical Record". Review of the clinical record for the episode dates beginning 10/06/23 through the date of discharge, 11/03/23, revealed no documented noncompliance by the patient or of any agency staff taking any actions to teach the patient what would occur due to the problem of noncompliance. During an interview on 01/23/24 at 8:40 AM, the agency Administrator, Staff A, confirmed the above finding of not documenting any efforts to resolve patient problems or concerns prior to discontinuing services.

Provide contact info other services CFR(s): 484.50(d)(5)(iii) (iii) Provide the patient and representative (if any), with contact information for other agencies or providers who may be able to provide care; and This ELEMENT is not met as evidenced by: Based on record review, policy review, and staff interview, the agency failed to provide the patient with contact number and name of other home health agency that might be able to provide services to the patient after discharge for 2 (Patient 1 & 3) of 10 discharged patients. This failed practice of not providing the patient with contact information of other agencies that might provide home health services to the patient prior to discontinuing services placed the patients at risk of unmet needs and adverse outcomes. Findings Include: Review of agency policy titled, "Discharge and Transfer", contained bullet points under a Section titled, "Procedure", which indicated "…Provide the patient/representative with contact information for other agencies/providers who may be able to provide appropriate care”. Patient 1 Review of agency document titled, "Home Health Suggestion, Complaint/Concern or Grievance" dated 07/05/23, indicated that the patient had filed a complaint regarding a nurse messing up her medications. The document also indicated that the patient had called in the complaint and had been loud and rude during the call. The indicated resolution to the complaint was documented as, the Skilled Nurse (SN) reached out to the patient and informed her due to her refusal to allow multiple staff into her home and due to her noncompliance with her medications she was being discharged from the agency. The above document contained a statement which indicated, "This form is NOT part of the Medical Record". Review of the clinical record for the episode dates beginning 06/07/23 through the date of discharge, 07/05/23, revealed that the agency did not document providing the patient with contact information of other agencies that might provide home health services to the patient after discharge. Patient 3 Review of agency document titled, "Home Health Suggestion, Complaint/Concern or Grievance" dated 11/03/23, indicated that the patient had filed a complaint regarding not receiving the wound care supplies she preferred and of the nurses' missing visits. The complainant also indicated that she would be filing a complaint with the Kansas state board of nursing. The indicated resolution to the complaint was documented as, the Skilled Nurse (SN) and supervising nurse reached out to the patient to discuss her complaint and informed her due to her not being happy with the services provided that she should look for another agency. The patient was informed that she was being discharged from the agency. The supervising nurse also called the physician's office and informed the nurse of the patient's discharge. The above document contained a statement which indicated, "This form is NOT part of the Medical Record". Review of the clinical record for the episode dates beginning 10/06/23 through the date of discharge, 11/03/23, revealed that the agency did not document providing the patient with contact information of other agencies that might provide home health services to the patient after discharge. During an interview on 01/23/24 at 8:40 AM, the agency Administrator, Staff A, confirmed the above finding of not providing the patient with contact information of other agencies that might provide home health services to the patient after discharge.

Document efforts to resolve problems CFR(s): 484.50(d)(5)(iv) (iv) Document the problem(s) and efforts made to resolve the problem(s), and enter this documentation into its clinical records; This ELEMENT is not met as evidenced by: Based on clinical record review, agency document review, policy review, and staff interview, the Home Health Agency (HHA) failed to document efforts made to resolve patient problems, behaviors and complaints in the patient record for 2 (Patient 1 & 3) of 10 records reviewed. This failed practice of not documenting making efforts to resolve patient problems and complaints in the patient record placed the patients at risk of unmet needs and adverse outcomes. Findings Include: Review of agency policy titled, "Discharge and Transfer", contained bullet points under a Section titled, "Procedure", which indicated "A discharge or transfer may occur for the following reasons: ...Document all efforts made to resolve the problem... Patient 1 Review of agency document titled, "Home Health Suggestion, Complaint/Concern or Grievance" dated 07/05/23, indicated that the patient had filed a complaint regarding a nurse messing up her medications. The document also indicated that the patient had called in the complaint and had been loud and rude during the call. The indicated resolution to the complaint was documented as, the Skilled Nurse (SN) reached out to the patient and informed her due to her refusal to allow multiple staff into her home and due to her noncompliance with her medications she was being discharged from the agency. The above document contained a statement which indicated, "This form is NOT part of the Medical Record". Review of the clinical record for the episode dates beginning 06/07/23 through the date of discharge, 07/05/23, revealed no documented noncompliance by the patient or of any agency staff taking any actions to teach the patient what would occur due to the problem of noncompliance. They agency did not document the patient concerns, complaints in the clinical record, or or efforts to resolve the problems. Patient 3 Review of agency document titled, "Home Health Suggestion, Complaint/Concern or Grievance" dated 11/03/23, indicated that the patient had filed a complaint regarding not receiving the wound care supplies she preferred and of the nurses' missing visits. The complainant also indicated that she would be filing a complaint with the Kansas state board of nursing. The indicated resolution to the complaint was documented as, the Skilled Nurse (SN) and supervising nurse reached out to the patient to discuss her complaint and informed her due to her not being happy with the services provided that she should look for another agency. The patient was informed that she is being discharged from the agency. The supervising nurse also called the physician's office and informed the nurse of the patient's discharge. The above document contained a statement which indicated, "This form is NOT part of the Medical Record". Review of the clinical record for the episode dates beginning 10/06/23 through the date of discharge, 11/03/23, revealed no documented noncompliance by the patient or of any agency staff taking any actions to teach the patient what would occur due to the problem of noncompliance. The agency did not document the patient concerns, complaints in the clinical record, or efforts to resolve the problems. During an interview on 01/23/24 at 8:40 AM, the agency Administrator, Staff A, confirmed the above finding of not documenting any efforts to resolve patient problems or concerns in the patient record.

On behalf of the Centers for Medicare & Medicaid Services (CMS), an unannounced on-site Recertification Survey (4F3E6-H1) at the above-named Home Health Agency (HHA) from 08/19/22 to 08/24/22 resulted in a finding of no deficiency citations respective to the Emergency Preparedness Program Condition of Participation under 42 CFR 484.22.

On behalf of the Centers for Medicare & Medicaid Services (CMS), an unannounced on-site Recertification survey (4F3E6-H1) conducted at the above-named Home Health Agency (HHA) from 08/19/22 to 08/24/22 resulted in a finding of substantial compliance respective to applicable Condition of Participation (CoP) under 42 CFR 484, Subpart A through C, with the following standard-level deficiencies cited.

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 interviews and record review, it was determined the home health agency (HHA) failed to ensure patients' plans of care (POCs - individualized and comprehensive plans that include diagnoses, medications, and interventions that guide the staff in providing patient care) included all pertinent diagnoses for 3 (Patients 2, 4, and 5) of 13 patients whose POCs were reviewed. This failure had the potential to cause Patients 2, 4, and 5 not to receive education and services related to management of their health issues. Findings Include: During the survey, the facility's policy regarding care plans was requested from the Administrator (Admin). The facility did not provide a policy. 1. Review of a "Home Health Certification and Plan of Care (POC)," dated 08/23/22, showed the HHA admitted Patient 2 on 06/23/22 with diagnoses that included lymphedema (a condition that causes swelling of the leg or arms) and heart failure. Further review showed that Patient 2 was taking pantoprazole (a medication used to treat digestive issues) one time per day. The POC did not include any diagnoses related to digestive issues. 2. Review of a "POC," dated 08/21/22, showed the HHA admitted Patient 4 on 04/19/21 with diagnoses that included amyotrophic lateral sclerosis (ALS - a progressive neurological disorder which results in weakened muscles and deformity) and diabetes. Further review showed that Patient 4 was taking lisinopril (a medication used to treat high blood pressure and heart issues) one time per day. The POC did not include any diagnoses related to high blood pressure or heart issues. Review of a, "Veterans Health Administration (VHA) Medical Documentation," form, dated 04/16/21, showed that Patient 4 was referred to the HHA on 04/16/21 and was taking lisinopril one time per day for heart or high blood pressure issues. 3. Review of a "POC," dated 07/19/22, showed the HHA admitted Patient 5 on 03/09/22 with diagnoses that included diabetes and chronic kidney failure. Further review showed that Patient 5 was taking baclofen (a medication used to treat muscle spasms) as needed, pantoprazole one time per day, and Synthroid (a medication used to treat thyroid issues) one time per day. The POC did not include any diagnoses related to muscle spasms, digestive issues, or thyroid issues. Review of a, "Physician's Orders/Plan of Care" form, dated 03/22/22, showed that earlier in Patient 5's admission, the patient was taking baclofen as needed for muscle spasms and had a diagnosis of hypothyroidism (thyroid issue). These diagnoses were not carried forward to the current plan of care. During an interview conducted on 08/24/22 at 11:06 AM, the Nursing Supervisor (NS) stated that the agency reviewed each patient's face-to-face (an in-person assessment of the patient by a physician) and referral documents to determine which diagnoses should be included on a patient's POC. During an interview conducted on 08/24/22 at 4:23 PM, the Administrator stated if a medication was included on a patient's POC, the agency should also include the diagnosis that "ties in" with that medication on the patient's POC.

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 interviews, record review, and agency policy review, it was determined the home health agency (HHA) failed to provide services as ordered by a physician. Specifically, the facility failed to: - Ensure skilled nursing visits were provided as ordered on the patients' Plans of Care (POCs -individualized and comprehensive plans that include diagnoses, medications, and interventions that guide the staff in providing patient care) for 6 (Patients 1, 3, 6, 7, 12, and 13) of 13 sampled patients whose POCs were reviewed. - Ensure a speech therapy (ST) evaluation was provided as ordered on the patient's POC for 1 (Patient 10) of 2 sampled patients who had orders for an ST evaluation (Patient 10). - Ensure vital signs were assessed as ordered on the patient's POCs for 1 (Patient 1) of 13 sampled patients whose clinical records were reviewed. These failures had the potential to cause these patients not to receive the necessary assessments, interventions, and services. Findings Include: Review of an agency policy titled, "Provider Orders and Notification, Home Health-Enterprise," revised 03/08/22, showed the HHA should provide services that conform to provider orders. 1. Review of a, "Home Health Certification and Plan of Care (POC)," dated 07/15/22, showed that the agency admitted Patient 1 on 06/30/22 with a diagnosis of pressure ulcers (ulcers which occur on the skin surface due to prolonged pressure) on the left and right buttocks. Review of Patient 1's "Laboratory Orders," dated 06/28/22, showed that the agency received a referral order for a skilled nurse to assess Patient 1 and to perform wound care for the pressure ulcer on Patient 1's right buttock every two to three days. Further review of Patient 1's, "POC," dated 07/15/22, showed that the agency completed the skilled nursing assessment as ordered and developed Patient 1's POC on 6/30/22. The POC indicated that the agency was to provide one skilled nurse visit during the week of 06/30/22. The agency was unable to provide evidence that a skilled nursing visit was provided to Patient 1 during the week of 6/30/22 as ordered on Patient 1's POC or that Patient 1 had refused the visit. 2. A review of Patient 3's, "POC," dated 07/13/22, showed that the agency admitted Patient 3 on 06/29/22, with diagnoses that included hypomagnesemia (low level of magnesium in the blood), atrial fibrillation (irregular, rapid heart rate), and high blood pressure. A review of an untitled document in Patient 3's clinical record, dated 06/28/22, showed that the agency received a referral order for a skilled nurse to assess Patient 3. Further review of Patient 3's, "POC," dated 07/13/22, showed that the agency completed the skilled nursing assessment as ordered and developed Patient 3's POC on 06/29/22. The POC indicated that the agency was to provide two skilled nursing visits during the week of 06/29/22. The agency was unable to provide evidence that the agency provided two skilled nursing visits to Patient 3 during the week of 06/29/22, as ordered on Patient 3's POC or that Patient 3 had refused a visit. 3. Review of Patient 6's, "POC," dated 07/29/22, showed that the agency admitted Patient 6 on 07/27/22, with diagnoses that included displaced bimalleolar fracture of the left lower leg (ankle fracture) and chronic kidney disease. Review of an untitled document in Patient 6's clinical record, dated 07/26/22, showed that the agency received a referral order for a skilled nurse to assess Patient 6. Further review of Patient 6's "POC," dated 07/29/22, showed that the agency completed the skilled nursing assessment as ordered and developed Patient 6's POC on 07/27/22. The POC indicated that the agency was to provide one skilled nurse visit during the week of 07/27/22. The agency was unable to provide evidence that a skilled nursing visit was provided to Patient 6 during the week of 07/27/22, as ordered on Patient 6's POC or that Patient 6 had refused the visit. 4. Review of Patient 7's "POC," dated 07/25/22, showed that the agency admitted Patient 7 on 07/25/22, with diagnoses that included pyogenic arthritis (an infection in a joint) and a complete rotator cuff tear (a tear in the muscles or tendons surrounding the shoulder joint) of the right shoulder. Review of an untitled document in Patient 7's clinical record, dated 07/22/22, showed that the agency received a referral order for a skilled nurse to assess Patient 7. Further review of Patient 7's "POC," dated 07/15/22, showed that the agency completed the skilled nursing assessment as ordered and developed Patient 7's POC on 07/25/22. The POC indicated that the agency was to provide two skilled nurse visits during the week of 07/25/22. The agency was unable to provide evidence that two skilled nursing visits were provided to Patient 7 during the week of 07/25/22, as ordered on Patient 7's POC or that Patient 7 had refused the visit. 5. A review of Patient 12's "POC," dated 08/30/21, showed that the agency admitted Patient 12 on 08/20/21, with diagnoses that included an open wound on the left arm, diabetes, and chronic kidney failure. A review of Patient 12's, "Home Health Physician Orders," dated 08/18/21, showed that the agency received a referral order for a skilled nurse to assess Patient 12. Further review of Patient 12's, "POC," dated 08/30/21, showed that the agency completed the skilled nursing assessment as ordered and developed Patient 12's POC on 08/20/21. The POC indicated that the agency was to provide two skilled nursing visits during the week of 08/20/21. The agency was unable to provide evidence that the agency provided two skilled nursing visits to Patient 12 during the week of 08/20/21, as ordered on Patient 12's POC or that Patient 12 had refused the visit. 6. Review of Patient 13's "POC," dated 06/02/21, showed that the agency admitted Patient 13 on 06/02/21, with diagnoses that included dysphagia (difficulty swallowing), anxiety and depression. Review of a, "Fax Communication to Physician," dated 06/01/21, showed that the agency requested and received a referral order for a skilled nurse to assess Patient 13. Further review of Patient 13's "POC," dated 06/02/21, showed that the agency completed the skilled nursing assessment as ordered and developed Patient 13's POC on 06/02/21. The POC indicated the agency was to provide two skilled nursing visits during the week of 06/02/21. The agency was unable to provide evidence that the agency provided two skilled nursing visits to Patient 13 during the week of 06/02/21, as ordered on Patient 13's POC or that Patient 13 had refused the visit. 7. Review of Patient 10's "POC," dated 06/24/21, showed that the agency admitted Patient 10 on 06/15/21, with diagnoses that included chronic obstructive pulmonary disease (COPD - a chronic inflammatory lung disease that causes obstructed airflow in the lungs) and high blood pressure. Further review showed that the agency was to provide Patient 10 with a speech therapy evaluation. A review of Patient 10's entire clinical record showed no evidence the agency provided Patient 10's speech therapy evaluation. The agency was unable to provide evidence that the agency provided Patient 10's speech therapy evaluation, as ordered on the POC or that Patient 10 had refused the evaluation. During an interview conducted on 08/24/22 at 12:14 PM, the Nursing Supervisor (NS) stated that the agency's expectation was that all visits would be completed as ordered by the patient's physician, unless the patient refused the visit, and that agency staff should document patient refusals of service. During an interview conducted on 08/24/22 at 4:23 PM, the Administrator (Admin) stated that the agency delivered the nursing visits as ordered on Patients 1's, 3's, 12's and 13's POCs, as the agency included the initial assessment visits in the visit count orders on the patients' POCs. The Admin stated that the agency needed to include the completed assessment visits in the visit frequencies on the POCs due to a requirement of the agency's software program. The Admin confirmed that Patient 10's speech therapy evaluation had not been completed as ordered and acknowledged that the agency was not following its policy. 8. Review of Patient 1's "POC," dated 07/15/22, showed that the agency admitted Patient 1 on 06/30/22 with a diagnosis of pressure ulcers on the left and right buttocks. Further review indicated that staff were to monitor Patient 1's vital signs at each nursing visit. During a concurrent record review and interview conducted on 08/24/22 at 11:06 AM, the NS confirmed that the nursing visit documentation completed on 09/05/21, 09/07/21, and 09/10/21 did not include all of Patient 1's vital signs readings. The NS stated that the agency's expectation was that clinicians would provide services as ordered by the provider in the POC and acknowledged that the agency was not following its policy.

Interdisciplinary assessment of the patient CFR(s): 484.75(b)(1) Ongoing interdisciplinary assessment of the patient; This ELEMENT is not met as evidenced by: Based on observation, interviews, record review, and agency policy review, it was determined that the home health agency (HHA) failed to assess the patient's medication regimen for 1 (Patient 6) of 5 patients with whom home visits were attended by the surveyor. This failure had the potential to result in the HHA being unaware of any potential changes to the medication regimen, which could result in failure to provide necessary education and monitoring for the patient. Findings Include: Review of an agency policy titled, "Medication Management-Home Health," revised 03/07/22, showed that staff were to complete ongoing assessment of patient medication regimens during visits. Review of Patient 6's, "Home Health Certification and Plan of Care (POC)," dated 07/29/22, showed that the agency admitted Patient 6 on 07/29/22 with diagnoses that included displaced bimalleolar fracture of the left lower leg (ankle fracture), chronic kidney disease, and anxiety. During an observation conducted on 08/22/22 at 1:05 PM in Patient 6's living room, Staff A, a Physical Therapy Assistant (PTA), did not ask Patient 6 if there were any changes or updates to the patient's medication regimen. During an interview conducted on 08/22/22 at 2:08 PM, Staff A, PTA, confirmed he did not ask Patient 6 any questions about possible changes to the medication regimen during the visit. Staff A stated he did not have information about Patient 6's medication regimen and did not ask patients about changes to medications unless the patients mentioned any changes. During an interview conducted on 08/22/22 at 2:40 PM, the Nursing Supervisor (NS) stated that all therapy staff, including PTAs, were expected to assess changes to patients' medication regimens at each visit and report any changes to the patients' case managers. Review of Patient 6's, "PT [Physical Therapy] for Therapy Assistant Visit Summary," dated 08/22/22, did not show that Staff A, PTA had assessed Patient 6 for changes to the medication regimen. During an interview conducted on 08/24/22 at 4:14 PM, the Administrator (Admin) acknowledged that the agency was not following agency policy when Staff A, PTA did not assess Patient 6 for medication regimen changes.

Provide services in the plan of care CFR(s): 484.75(b)(3) Providing services that are ordered by the physician or allowed practitioner as indicated in the plan of care; This ELEMENT is not met as evidenced by: Based on interviews, record review, and agency policy review, it was determined that the home health agency (HHA) failed to assess vital signs (clinical measurements of pulse, temperature, respiratory rate, and blood pressure) as ordered on the patients' Plans of Care (POCs) for 1 (Patient 1) of 13 sampled patients whose clinical records were reviewed. This failure had the potential for Patient 1 to experience health issues and not receive necessary interventions or services. Findings Include: A review of an agency policy titled, "Provider Orders and Notification, Home Health-Enterprise," revised 03/08/22, showed that the agency should provide services that conform to provider orders. Review of Patient 1's, "Home Health Certification and Plan of Care (POC)," dated 07/15/22, showed that the agency admitted Patient 1 on 06/30/22, with a diagnosis of pressure ulcers (ulcers which occur on the skin surface due to prolonged pressure) on the left and right buttocks. Further review indicated that staff were to monitor Patient 1's vital signs at each nursing visit. During a concurrent record review and interview conducted on 08/24/22 at 11:06 AM, the Nursing Supervisor (NS) confirmed that the nursing visit documentation completed on 09/05/21, 09/07/21, and 09/10/21 did not contain all of Patient 1's vital signs readings. The NS stated the nurse should have obtained Patient 1's vital signs. The NS also indicated the agency's expectation was that clinicians would provide services as ordered by provider in the POC and acknowledged that the agency was not following its policy.