Every finding on record at Uc Home Health Care Inc

A complaint survey prompted by #CO110393 was completed on 11/21/24. Nine deficiencies were cited.

Condition of Participation: Patient rights. CFR(s): 484.50 Condition of participation: Patient rights. The patient and representative (if any), have the right to be informed of the patient's rights in a language and manner the individual understands. The HHA must protect and promote the exercise of these rights. This CONDITION is not met as evidenced by: Based on the manner and degree of the standard level deficiencies referenced to the Condition, it was determined the Condition of Participation 484.50, Patient Rights was out of compliance. A total of 10 clinical records were reviewed for compliance with the Condition and Standards for Patient Rights. Record review revealed a pattern of failures in regard to patient neglect, patient transfers and discharges, and the home health complaint process. These failures had the potential to affect all patients served by the home health agency. G430- Based on interviews and record reviews the agency failed to protect patient rights specifically; to provide goods and/or services necessary to avoid physical harm, mental anguish or mental illness for 1 of 2 patients. (Patient #1) G464- Based on interviews and record reviews the agency failed to protect patient rights specifically; Transfer and discharge for 2 of 2 patients. (Patients #1 and #2) G478- Based on interviews and record reviews the agency failed to protect patient rights specifically; Investigation of complaints for 1 of 2 patients. (Patient #1) G484- Based on interviews and record reviews the agency failed to protect patient rights specifically; Documentation of both the existence of the complaint, and the resolution of complaints for 1 of 2 patients. (Patient #1)

Be free from abuse CFR(s): 484.50(c)(2) Be free from verbal, mental, sexual, and physical abuse, including injuries of unknown source, neglect and misappropriation of property; This ELEMENT is not met as evidenced by: Based on interviews and record reviews the agency failed to protect patient rights specifically; to provide goods and/or services necessary to avoid physical harm, mental anguish or mental illness for 1 of 2 patients. (Patient #1) Findings Include: AGENCY POLICY According to the policy titled, "Patient Rights," dated 2/2002 (in part): "The agency protects and promotes the rights of each individual in its care." 1. The clinical record for Patient #1 was reviewed on 11/18/24. Plan of care orders for the certification period dated 8/5/24 to 10/3/24 revealed a start of care date of 6/6/24; diagnoses included epilepsy, attention deficit hyperactivity disorder (ADHD), chronic insomnia, depression and a history of asthma attacks. Plan of care orders included home health aide services twice a day for 60 days, for activities of daily living, and skilled nursing services twice a day for 60 days for medication administration, and to assess for signs and symptoms of depression at each visit. a. The agency failed to provide goods and/or services necessary to avoid physical harm, mental anguish or mental illness. A review of Patient #1’s record revealed the Director of Nursing (DON, Employee # 1) discontinued skilled nursing services on 9/16/24, the patient was ordered to receive skilled nursing services twice a day for 60 days for medication administration, and to assess for signs and symptoms of depression at each visit. The DON had documented the patient had been refusing medication and had experienced behavioral problems during skilled nursing visits to the case manager and in a patient document. A review of the clinical documentation from the Registered Nurse (RN, Employee #5), Licensed Practical Nurse (LPN, Employee #2), and the nurse aide (Employee #3) showed no evidence of the patient refusing medications or having behavioral problems. On 11/19/24 at 9:30 a.m., an interview with the LPN (Employee #2) about Patient #1's care revealed that he never had an issue with Patient #1 refusing medications but the patient would sometimes have behavioral issues that were not directed at the nurse or any staff just about medications related to his diagnosis of ADHD. He went on to say that he did not document the behavioral issues in the medical record or alert the physician because he called the agency’s clinical manager (Employee #7) to alert them with patient concerns. On 11/19/24 at 10:44 a.m., an interview with the nurse aide (Employee #3) about Patient #1’s care confirmed there were some behavioral issues that were not directed at the nurse or any staff just about medications related to his diagnosis of ADHD. She went on to say that she did not document the behavioral issues or any concerns in the medical record but she alerted the agency’s clinical manager (Employee #7). A record review from 9/16/24 revealed that the agency had emailed Patient #1's case manager, reporting that the patient refused medications on 9/14/24 and 9/15/24. The agency also stated that, beginning 9/17/24, skilled nursing services would be suspended until a new provider appointment and treatment plan were established, although nurse aide services would continue. However, further review of the records indicated that skilled nursing care was actually stopped on 9/16/24, and only the nurse aide (Employee #3) visited the patient thereafter. On 11/19/24 at 11:17 a.m., an interview with RN (Employee #5), revealed that she was asked to take over care of Patient #1 because he was not happy with the current skilled nursing services. She stated that she provided patient care on 9/14/24 and 9/15/24, she stated she had a hard time getting into the patient's home to provide care and she had documented no concerns. She confirmed that both days Patient #1 took all prescribed medications and had no behavioral issues during her visits. She was unclear why the agency notified the case manager of medication refusal. An interview conducted on 11/19/24 at 3:40 p.m. with the administrator and Director of Nursing (DON) revealed their lack of experience with home health processes and regulations. They admitted to being unaware that medication refusal and behavioral issues reported to Patient #1's case manager was not documented in the medical record by the clinical staff. They acknowledged that the agency failed to review Patient #1's record to ensure these concerns were properly recorded.They acknowledged the agency failed to communicate any concerns with the patient to the medical provider. Additionally, they confirmed that from 9/16/24 to 9/29/24, Patient #1 did not receive the required skilled nursing services twice a day for 60 days, which included medication administration and assessments for signs and symptoms of depression during each visit. Furthermore, they did not recognize that leaving the patient without necessary medication assistance or wellness checks for 14 days constituted neglect, even though the nurse aide was still providing patient care.

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 interviews and record reviews the agency failed to protect patient rights specifically; Transfer and discharge for 2 of 2 patients. (Patients #1 and #2) Findings Include: AGENCY POLICY According to agency policy titled, Transfer/Discharge Criteria, dated 2/2022 (read in pertinent parts): "Discharge for cause: behavior of the patient or caregiver interferes with the Agency’s ability to provide care. If the Agency has determined that the patient or caregiver or others have behavior that is a barrier to the patient’s success, or the safety of the staff and discharge may be considered: The Agency must document all efforts to resolve any issues. The Agency must provide the patient and or authorized representative with verbal and written information that discharge is being considered and how the issues may be resolved. The Agency must contact the physician, or allowed practitioner issuing orders for the home health plan of care, and the patients primary care practitioner or other health care professionals who will be responsible for providing care and services to the patient after discharge that discharge is being considered. The Agency must provide the patient or representative with contact information of other agencies that may be able to provide care. The Agency must be aware and follow any state regulations regarding a discharge for cause or immediate discharge. In the event of an emergent discharge the Agency will notify the health department, the case manager (if applicable), the MD within 48 hours of the need for an emergent discharge." 1. The clinical record for Patient #1 was reviewed on 11/18/24. Plan of care orders for the certification period dated 8/5/24 to 10/3/24 revealed a start of care date of 6/6/24; diagnoses included epilepsy, attention deficit hyperactivity disorder (ADHD), chronic insomnia, depression and a history of asthma attacks. Plan of care orders included home health aide services twice a day for 60 days, for activities of daily living, and skilled nursing services twice a day for 60 days for medication administration, and to assess for signs and symptoms of depression at each visit. a. The agency failed to advise the patient, the representative, the physician(s) or allowed practitioners(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. (Patient #1) Further review of Patient #1's record revealed the Director of Nursing (DON, Employee #1), had discontinued skilled nursing services on 9/16/24 for skilled nursing visits twice a day for 60 days for medication administration, and to assess for signs and symptoms of depression at each visit. The DON had documented the patient had been refusing medication and was having behavioral problems during skilled nursing visits. A review of the clinical documentation showed no evidence of the patient medication refusals or behavioral problems experienced with the clinical staff. A record review from 9/16/24 revealed that the agency had emailed Patient #1's case manager, reporting that the patient refused medications on 9/14/24 and 9/15/24. The agency had documented, beginning 9/17/24, skilled nursing services would be suspended until a new provider appointment and treatment plan were established, although nurse aide services would continue. However, further review of the records indicated that skilled nursing care was actually stopped on 9/16/24, and only the nurse aide (Employee #3) visited the patient thereafter. There was no evidence a physician was alerted to the care suspension until 11/20/24, during the survey. On 9/29/24, documentation for Patient #1 showed the agency discharged the patient from the agency. There was no evidence a physician was alerted to the discharge until 10/13/24. An interview conducted on 11/19/24 at 3:35 p.m., with the administrator and Director of Nursing (DON), revealed that they had used the nurse aide (Employee #3) to verbalize the impending discharge to Patient #1 but they had forgotten to document this discharge communication from the aide to the patient. They also thought that if the case manager were aware of the impending patient discharges, the case manager would alert the patient's physician offices. They acknowledged Patient #1 had severe memory problems and needed skilled nursing and the agency did not follow their policy or regulations regarding discharging patients and it was not a safe discharge. 2. A clinical record for Patient #2 was reviewed on 11/19/24. Patient #2's start of care was 5/29/24 and the certification period was 7/30/24 to 9/27/24. Diagnoses include type 2 diabetes mellitus with hyperglycemia, type 2 diabetes mellitus with diabetic nephropathy, type 2 diabetes mellitus with polyneuropathy, depression, anxiety disorder, and chronic obstructive pulmonary disease (COPD). Plan of care (POC) orders include skilled nursing (SN) visits two times a day for 60 days for medication management, medication teaching, medication administration of insulin. A. The agency failed to advise the patient, the representative, the physician(s) or allowed practitioners(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 home health agency that a discharge for cause is being considered. (Patient #2) Further record review of Patient #2 showed the DON had discharged the patient on 9/16/24 due to unsafe home conditions but did not alert the physician until 10/13/24. An interview conducted on 11/19/24 at 3:40 p.m. with the administrator and Director of Nursing (DON) revealed their lack of experience with home health processes and regulations. They admitted to not alerting the physician or allow practitioner because they believed that it was the case manager's responsibility to alert the physician of the agency discharging the patient. They acknowledged the agency did not follow their policies and procedures as it relates to patient discharges and transfers.

Investigate complaints made by patient CFR(s): 484.50(e)(1)(i) The HHA must— (i) Investigate complaints made by a patient, the patient's representative (if any), and the patient's caregivers and family, including, but not limited to, the following topics: (A) Treatment or care that is (or fails to be) furnished, is furnished inconsistently, or is furnished inappropriately; (B) Mistreatment, neglect, or verbal, mental, sexual, and physical abuse, including injuries of unknown source, and/or misappropriation of patient property by anyone furnishing services on behalf of the HHA. This ELEMENT is not met as evidenced by: Based on interviews and record reviews the agency failed to protect patient rights specifically; Investigation of complaints for 1 of 2 patients.(Patient #1) indings Include: AGENCY POLICY According to the policy titled, "Complaint Processing," dated 2/2002 (in part): "The Administrator and/or Clinical Manager will document the existence, the investigation, and the resolution of the complaint. The Administrator and/or Clinical Manager shall notify the complainant of the results of the investigation and the Agency’s plan to resolve any issue identified within five (5) business days of receiving the grievance/complaint/concern." 1. The clinical record for Patient #1 was reviewed on 11/18/24. Plan of care orders for the certification period dated 8/5/24 to 10/3/24 revealed a start of care date of 6/6/24; diagnoses included epilepsy, attention deficit hyperactivity disorder (ADHD), chronic insomnia, depression and a history of asthma attacks. Plan of care orders included home health aide services twice a day for 60 days, for activities of daily living, and skilled nursing services twice a day for 60 days for medication administration, and to assess for signs and symptoms of depression at each visit. a. The agency failed to investigate a complaint about skilled nurse services. (Patient #1) On 11/18/24 at 1:24 p.m., the administrator was asked for the complaint log, she stated that the agency did not have a complaint log but the agency documented complaints in the medical record. She then submitted an agency complaint document for Patient #1. A review of the complaint document dated 7/21/24 revealed a general complaint regarding skilled nursing services, but it lacked specific details. Additionally, there was no evidence that the agency had conducted an investigation into the skilled nursing services that Patient #1 was supposed to receive. A review of agency emails from 9/13/24, related to Patient #1, revealed that the case manager had submitted a complaint to the agency regarding several missed visits and concerns about questionable practices by the Licensed Practical Nurse (LPN, Employee #2). There was no evidence to indicate that this was part of the agency's investigation. During an interview with the Director of Nursing (DON, Employee #1), on 11/18/24 at 2:00 p.m., she verbally acknowledged aspects of the complaint but did not provide specific details regarding the complaint investigation itself. During the same interview, the DON admitted she was unaware the agency was required to provide evidence of an investigation when a complaint was received. She also acknowledged failing to follow agency policy when addressing patient complaints. The DON further stated that Employee #6, a consultant, was responsible for managing the agency's complaints. When asked about the last time complaints were reviewed, she mentioned it occurred sometime in February 2024. In this conversation, the DON also confessed to lacking knowledge of home health regulations and agency policies regarding the handling of patient complaints, noting that she relied heavily on Employee #6 for guidance in these matters. In an interview conducted on 11/19/24 at 3:40 p.m. with the administrator and Director of Nursing (DON), the administrator acknowledged that the agency had failed to address Patient #1's complaint per the agency policy. She admitted to a lack of knowledge regarding home health rules and regulations, but stated that with the assistance of Employee #6, the consultant, they were committed to ensuring these issues would be addressed and prevented in the future.

Document complaint and resolution CFR(s): 484.50(e)(1)(ii) (ii) Document both the existence of the complaint and the resolution of the complaint; and This ELEMENT is not met as evidenced by: Based on interviews and record reviews the agency failed to protect patient rights specifically; Documentation of both the existence of the complaint, and the resolution of complaints for 1 of 2 patients. Findings Include: AGENCY POLICY According to the policy titled, "Complaint Processing," dated 2/2002 (in part): "The Administrator and/or Clinical Manager will document the existence, the investigation, and the resolution of the complaint. The Administrator and/or Clinical Manager shall notify the complainant of the results of the investigation and the Agency’s plan to resolve any issue identified within five (5) business days of receiving the grievance/complaint/concern." 1. The clinical record for Patient #1 was reviewed on 11/18/24. Plan of care orders for the certification period dated 8/5/24 to 10/3/24 revealed a start of care date of 6/6/24; diagnoses included epilepsy, attention deficit hyperactivity disorder (ADHD), chronic insomnia, depression and a history of asthma attacks. Plan of care orders included home health aide services twice a day for 60 days, for activities of daily living, and skilled nursing services twice a day for 60 days for medication administration, and to assess for signs and symptoms of depression at each visit. a. The agency failed to track complaints from receipt through resolution. (Patient #1) On 11/18/24 at 1:24 p.m., when asked for the complaint log, the administrator explained that the agency did not maintain a separate complaint log and instead documented complaints in the medical record. She then provided an agency complaint document for Patient #1. During the same conversation, a binder labeled "Complaints" was noticed and reviewed, revealing that it contained documentation intended to track complaints, but the log was empty. A review of the agency complaint document dated 7/31/24 revealed the Director of Nursing (DON, Employee #1) had documented a general complaint stating skilled nursing services and a generalized resolution, but it lacked specific details of the complaint and the resolution from the tracked complaint. Additionally, there was no evidence that the agency had documented the existence of the complaint to the resolution and tracking the results in the agency quality meetings. A review of agency emails from 9/13/24, related to Patient #1, revealed that the case manager had submitted a complaint to the agency regarding several missed visits and concerns about questionable practices by the Licensed Practical Nurse (LPN, Employee #2). There was no evidence to indicate that this was part of the agency's investigation. During an interview with the DON (Employee #1), on 11/18/24 at 2:00 p.m., she verbally acknowledged aspects of the complaint but did not provide specific details regarding the complaint investigation itself. During the same interview, the DON admitted she was unaware the agency was required to provide evidence of an investigation when a complaint was received. She also acknowledged failing to follow agency policy when addressing patient complaints. The DON further stated that Employee #6, a consultant, was responsible for managing the agency's complaints. When asked about the last time complaints were reviewed, she mentioned it occurred sometime in February 2024. In this conversation, the DON also confessed to lacking knowledge of home health regulations and agency policies regarding the handling of patient complaints, noting that she relied heavily on Employee #6 for guidance in these matters. In an interview conducted on 11/19/24 at 3:40 p.m. with the administrator and Director of Nursing (DON), the administrator acknowledged that the agency had failed to address Patient #1's complaint per the agency policy. She admitted to a lack of knowledge regarding home health rules and regulations, but stated that with the assistance of Employee #6, the consultant, they were committed to ensuring these issues would be addressed and prevented in the future.

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 the manner and degree of the standard level deficiencies referenced to the Condition, it was determined the Condition of Participation 484.60, Care Planning, Coordination of Services, and Quality of Care was out of compliance. A total of 10 clinical records were reviewed for compliance with the Condition and Standards for Care Planning, Coordination and Quality of Care Condition. Record review revealed a pattern of failures in regard to patient plan of care, communication to the physician, and discharge planning revisions. These failures had the potential to affect all patients served by the home health agency. G572- Plan of care G590- Alert Physician with changes in condition G598- Revision's of patient discharge

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 interviews and record reviews, the agency failed to follow the plan of care, specifically by not alerting the patient's physician or authorized practitioner when a treatment or service was missed for 2 of 2 patients. (Patient #1 and #2) Findings Include: AGENCY POLICY According to the policy titled, "Visit Schedule/Missed Visits," dated 2/2002 (read in pertinent parts): "The patient shall be informed about scheduled visits during the initial visit and development of the plan of care, and at the time of updates to the plan of care, as appropriate. Documentation shall be maintained in the patient record and alterations in the schedule shall be provided to the patient as soon as practical. ● In the event of employee illness, vacation, holidays and unexpected voluntary or involuntary termination of employment, the Agency will provide alternate, qualified personal care worker(s) to complete the required visits. ● If the patient does not respond to let staff in the home for the scheduled visit, the Agency’s attempts to ensure the safety of the patient and the outcome of each attempt shall be documented. ● If there is a missed visit, services shall be provided as agreed upon by the patient and the Agency. o The Agency will coordinate with the patient or patient’s authorized representative to reschedule a missed visit whenever possible. o Family or caregiver is available, able and willing to participate in the patient’s care when conditions warrant." 1. The clinical record for Patient #1 was reviewed on 11/18/24. Plan of care orders for the certification period dated 8/5/24 to 10/3/24 revealed a start of care date of 6/6/24; diagnoses included epilepsy, attention deficit hyperactivity disorder (ADHD), chronic insomnia, depression and a history of asthma attacks. Plan of care orders included home health aide services twice a day for 60 days, for activities of daily living, and skilled nursing services twice a day for 60 days for medication administration, and to assess for signs and symptoms of depression at each visit. a. The agency failed to follow the plan of care, specifically by not alerting the patient's physician or authorized practitioner when a treatment or service was missed. (Patient #1) Record review for Patient #1 revealed the Licensed Practical Nurse (LPN, Employee #2) had missed visits on 9/6/24, 9/7/24, 9/10/24, 9/13/24, and 9/14/24, where he was supposed to administer medications and assess for depression. There was no evidence of the LPN #2, or the agency ensured Patient #1 received care according to the plan of care. A review of agency emails from 9/13/24, related to Patient #1, revealed that the case manager had submitted a complaint to the agency regarding several missed visits and concerns about questionable nursing practices by the Licensed Practical Nurse (LPN, Employee #2). A review of Patient #1’s record revealed the Director of Nursing (DON, Employee #1) had discontinued skilled nursing services on 9/16/24, stating the patient refused to take medication despite the lack of evidence to support that statement. Further review showed no evidence of ever notifying the patient, or the physician until 11/20/24, at the time of the survey. On 9/29/24, the DON had created a verbal order to discharge the patient from the home health agency effective on 9/29/24 but showed no evidence of the physician being notified until 10/13/24 or how Patient #1 had received services according to the care plan from 9/16/24 to 10/13/24. On 10/10/24, the agency contacted Patient #1’s case manager stating they needed advice on discharging Patient #1 from the agency because he was refusing nurse visits, verbally disrespecting the nurse aide, insurance issues, and refusal of doctor visits. On 11/19/24 at 9:30 a.m., an interview with the LPN (Employee #2) about Patient #1's care revealed that he never had an issue with Patient #1 refusing medications but the patient would sometimes have behavioral issues that were not directed at the nurse or any staff just about medications related to his diagnosis of ADHD. He said that he had difficulties getting access to the Patient #1's home which would sometimes result in multiple trips. He went on to say that he did not document the behavioral issues in the medical record or alert the physician because he called the agency’s clinical manager (Employee #7) to alert them with patient concerns. In this same conversation, the LPN acknowledged he had missed visits for Patient #1 but was unaware that he had to alert the physician. He went on to say that often times he would just call the patient to see if he needed anything instead of visiting the patient but he had forgotten to document this patient communication in the record because he was a new nurse. An interview conducted on 11/19/24 at 3:40 p.m. with the administrator and DON revealed they felt the patients needs were met because the nurse aide was able to care for the patient.They could not explain why they did not utilize the nurse aide visits to get the LPN #2 visits completed. They acknowledged the agency failed to communicate with the medical provider about the missed skilled nurse visits. She went on to say the agency tried to reschedule missed visits but that depends on the staff's availability but she believed the patient was refusing skilled nurse visits. The DON could not explain why the clinical record failed to show the patient had been refusing medication. The administrator stated the agency was new to the electronic medical record's fax to physician procedures and admitted to the physician not getting notified of patients' missed visits per the home health regulations or agency policy. 2. A clinical record for Patient #2 was reviewed on 11/19/24. Patient #2's start of care was 5/29/24 and the certification period was 7/30/24 to 9/27/24. Diagnoses include type 2 diabetes mellitus with hyperglycemia, type 2 diabetes mellitus with diabetic nephropathy, type 2 diabetes mellitus with polyneuropathy, depression, anxiety disorder, and chronic obstructive pulmonary disease (COPD). Plan of care orders include skilled nursing visits twice a day for 60 days for medication management, medication teaching, medication administration of insulin. a. The agency failed to follow the plan of care, specifically by not alerting the patient's physician or authorized practitioner when a treatment or service was missed. (Patient #2) Record review revealed that Patient #2 missed visits on 8/23/24, 8/28/24, 9/3/24, 9/5/24, 9/8/24, 9/9/24, and 9/12/24. Documentation from the DON stated that the reason for the missed visits was an unsafe environment. There was no evidence in the record showing how Patient #2's needs were met on those dates. On 9/15/24 the DON placed skilled nurse visits for medication administration on hold and had not notified the physician of Patient #2's missed visits or environmental concerns until 10/13/24. On 9/27/24 the DON created a discharge order in Patient #2's record and did not notify the patient's physician until 10/13/24. An interview conducted on 11/19/24 at 5:11 p.m., with the administrator and DON revealed their lack of experience with home health care processes and regulations. The DON stated the patient's home was unsafe for staff so they educated the patient on medication administration until her home was deemed safe to resume care. She thought because the agency was working with the case manager, she did not have to notify the physician for not following the plan of care. She acknowledged the physician was not notified about the patient issues in a timely manner. The administrator stated the agency was new to the electronic medical record's fax to physician procedures and admitted to the physician not getting notified of patients missed visits or any other patient concerns per the home health regulations or agency policy. She followed up with the agency plans to get all staff retrained on electronic health record documentation right away.

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 interviews and record reviews the agency failed to alert the patient's physician or allowed practitioner to any changes in a patient's condition or needs that suggest that outcomes are not being achieved or the plan of care should be altered for 2 of 2 patients. (Patients #1 and #2). Findings Include: AGENCY POLICY According to the policy titled, "Coordination of Patient Care," dated 2/2002 (read in pertinent parts): "- The Agency coordinates care by ● Coordinating care delivery to meet the patient’s needs, involve the patient, representative (if any), and caregiver ● Ensuring communications with ALL physicians involved in the plan of care. ● Integrating orders from all physicians involved in the plan of care to ensure the coordination of all services and interventions provided to the patient - Staff provides the Administrator, Clinical Manager and/or Supervisor with patient information on an as-needed basis regarding: ● Current condition and changes in condition. ● Outcomes of care and service. ● Changes in the environment and/or caregiver support." 1. The clinical record for Patient #1 was reviewed on 11/18/24. Plan of care orders for the certification period dated 8/5/24 to 10/3/24 revealed a start of care date of 6/6/24; diagnoses included epilepsy, attention deficit hyperactivity disorder (ADHD), chronic insomnia, depression and a history of asthma attacks. Plan of care orders included home health aide services twice a day for 60 days, for activities of daily living, and skilled nursing services twice a day for 60 days for medication administration, and to assess for signs and symptoms of depression at each visit. a. The agency failed to promptly alert the physician or allowed practitioner with any changes in the patient's condition. (Patient #1) On 9/13/24 at 2:03 p.m., the agency emailed Patient #1's case manager, stating that they had observed behaviors suggesting a significant deterioration in the patient's condition, which interfered with care. A review of Patient #1's record showed no evidence the agency or the Director of Nursing, (DON, Employee #1) had notified the patient's physician about the significant deterioration noted in the email to the case manager on 9/13/24. On 11/19/24 at 9:30 a.m., an interview with the licensed practical nurse (LPN, Employee #2) about Patient #1's care revealed that he never had an issue with Patient #1 refusing medications but the patient would sometimes have behavioral issues that were not directed at the nurse or any staff just about medications related to his diagnosis of ADHD. He went on to say that he did not document the behavioral issues in the medical record or alert the physician because he called the agency’s clinical manager (Employee #7) to alert them with patient concerns. On 11/19/24 at 10:44 a.m., an interview with the nurse aide (Employee #3) about Patient #1’s care confirmed there were some behavioral issues that were not directed at the nurse or any staff just about medications related to his diagnosis of ADHD. She went on to say that she did not document the behavioral issues or any concerns in the medical record but she alerted the agency’s clinical manager (Employee #7). An interview conducted on 11/19/24 at 3:40 p.m. with the administrator and DON revealed their lack of experience with home health care processes and regulations. They acknowledged that the agency failed to review Patient #1's record to ensure the reported change of conditions were properly recorded. They acknowledged the agency failed to communicate any change in behaviors or conditions with the patient to the medical provider. The administrator stated the agency was new to the electronic medical record's fax to physician procedures and admitted to the physician not getting notified of patients missed visits or any other patient concerns per the home health regulations or agency policy. 2. A clinical record for Patient #2 was reviewed on 11/19/24. Patient #2's start of care was 5/29/24 and the certification period was 7/30/24 to 9/27/24. Diagnoses include type 2 diabetes mellitus with hyperglycemia, type 2 diabetes mellitus with diabetic nephropathy, type 2 diabetes mellitus with polyneuropathy, depression, anxiety disorder, and chronic obstructive pulmonary disease (COPD). Plan of care (POC) orders include skilled nursing (SN) visits two times a day for 60 days for medication management, medication teaching, medication administration of insulin. a. The agency failed to promptly alert the physician or allowed practitioner with any changes in the patient's condition. (Patient #2) Record review revealed that Patient #2 missed visits on 8/23/24, 8/28/24, 9/3/24, 9/5/24, 9/8/24, 9/9/24, and 9/12/24. Documentation from the DON stated that the reason for the missed visits was an unsafe environment. There was no evidence in the record of the physician being notified of this change in the patient's living environment or plan of care. Record review revealed no documented communication with Patient #2’s physician until noted in a discharge order dated 9/27/24, created 10/12/24, and faxed 10/13/24 which read, per Patient #2’s physician, to discharge the patient from the agency due to the unsafe environment in the patient's house on 9/27/24. On 11/19/24 at 5:11 p.m., an interview with the administrator and DON revealed that they had admitted to stopping skilled nurse visits for Patient #2 on 9/16/24 and discharging Patient #2 from services on 9/27/24 prior to contacting the physician. They believed the patient's case manager would alert the physician about the patient's home conditions. The DON stated that the patient's home was unsafe for staff, so they educated the patient on medication administration until her home was deemed safe to resume care. She thought that because the agency was working with the case manager, she did not need to notify the physician for not following the plan of care. Both the DON and administrator acknowledged that the physician was not notified about the patient’s issues in a timely manner. The administrator noted that the agency was new to the electronic medical record's fax-to-physician procedures and admitted that the physician had not been notified of the patient's missed visits or any other concerns per home health regulations or agency policy. She followed up with plans to retrain all staff on electronic health record documentation immediately.

Discharge plans communication CFR(s): 484.60(c)(3)(ii) (ii) Any revisions related to plans for the patient's discharge must be communicated to the patient, representative, caregiver, all physicians or allowed practitioner's issuing orders for the HHA 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). This ELEMENT is not met as evidenced by: Based on interviews and record reviews the agency failed to alert the patient, physician or allowed practitioner to revisions related to discharge plans for Patient #1. Findings Include: AGENCY POLICY According to agency policy titled, "Transfer/Discharge Criteria," dated 2/2022 (read in pertinent parts): "Discharge for cause: behavior of the patient or caregiver interferes with the Agency’s ability to provide care. If the Agency has determined that the patient or caregiver or others have behavior that is a barrier to the patient’s success, or the safety of the staff and discharge may be considered: The Agency must document all efforts to resolve any issues. The Agency must provide the patient and or authorized representative with verbal and written information that discharge is being considered and how the issues may be resolved. The Agency must contact the physician, or allowed practitioner issuing orders for the home health plan of care, and the patients primary care practitioner or other health care professionals who will be responsible for providing care and services to the patient after discharge that discharge is being considered. The Agency must provide the patient or representative with contact information of other agencies that may be able to provide care. The Agency must be aware and follow any state regulations regarding a discharge for cause or immediate discharge. In the event of an emergent discharge the Agency will notify the health department, the case manager (if applicable), the MD within 48 hours of the need for an emergent discharge." 1. The clinical record for Patient #1 was reviewed on 11/18/24. Plan of care orders for the certification period dated 8/5/24 to 10/3/24 revealed a start of care date of 6/6/24; diagnoses included epilepsy, attention deficit hyperactivity disorder (ADHD), chronic insomnia, depression and a history of asthma attacks. Plan of care orders included home health aide services twice a day for 60 days, for activities of daily living, and skilled nursing services twice a day for 60 days for medication administration, and to assess for signs and symptoms of depression at each visit. a. The agency failed to alert the patient, physician or allowed practitioner to revisions related to discharge plans for Patient #1. A review of Patient #1’s record revealed the Director of Nursing (DON, Employee #1) had discontinued skilled nursing services on 9/16/24, stating the patient refused to take medication despite the lack of clinical documentation and medication logs to support that statement. Further review showed no evidence of ever notifying the patient, and the physician was not notified until 11/20/24, at the time of the survey. On 9/29/24, the DON had created a verbal discharge order to discharge the patient from the home health agency effective date of 9/29/24 but failed to show evidence of the physician being notified until 10/13/24. An interview conducted on 11/19/24 at 3:40 p.m., with the administrator and DON revealed that they had utilized the nurse aide to notify the patient of the impending discharge and the reasons for it, but they had failed to document the date and time of this conversation in the medical record. An in depth conversation occurred about nurse aide and nurse roles as it related to patient discharge responsibilities, at which the DON and administrator confirmed that discharge procedures for home health patients was a nurse responsibility and they should not have used the nurse aide to inform the patient of the discharge from the agency. They acknowledged that the agency had not communicated with the medical provider about the impending discharge or actual discharge from the agency in a timely or safe manner. The administrator stated that the agency was new to the electronic medical record's fax to physician procedures and admitted that the physician had not been notified according to agency policy. She acknowledged that the clinical documentation lacked accuracy and timely reporting and the agency will retrain the staff immediately to ensure compliance in the future.