Every finding on record at Virginia Gay Hospital

A Recertification Survey was conducted by the Department of Inspections, Appeals and Licensing from 11/12/24 through 11/14/24 and the home health agency was found to be operating in compliance with the requirements of the Establishment of Emergency Preparedness.

A Recertification Survey was conducted by the Department of Inspections, Appeals and Licensing from 11/12/24 through 11/14/24 and the home health agency was found to be operating out of compliance with the following standard level regulatory requirements. The agency reported a census of 44 patients at the time of the survey.

A review of all current medications CFR(s): 484.55(c)(5) A review of all medications the patient is currently using in order to identify any potential adverse effects and drug reactions, including ineffective drug therapy, significant side effects, significant drug interactions, duplicate drug therapy, and noncompliance with drug therapy. This ELEMENT is not met as evidenced by: Based on agency staff interviews, clinical record reviews, and policy review, the home health agency failed to ensure the drug regimen review identified at a minimum the effectiveness of drug therapy, drug side effects, actual or potential drug interactions, duplicate drug therapy, and/or patient compliance with medications for 3 of 7 sampled patients (Patients #1, #2 and #4). Failure to ensure medications reviewed at the time of each drug regimen review are current and accurate and failure to identify actual/ potential concerns increased the potential for unidentified medication interactions and side effect risks to the patient at the time of each comprehensive assessment. 3. Patient #4 had an admission date of 08/11/2022. Review of the clinical record revealed the following: a. The POC, dated 09/29/2024 to 11/27/2024, included orders for skilled nursing services and orders for medications. b. The DRR completed on 9/25/24, identified significant drug interactions, ineffective drug therapy, significant side effects, and noncompliance with drug therapy, but failed to identify duplicate medications of Lantus, (long acting insulin) and Jardiance, (oral hypoglycemic agent) (antidiabetic medications). The agency failed to address all 5 components of the DRR. The above findings were reviewed with the Administrator and the Clinical Manager. Findings include: According to agency policy, titled Drug Regimen Review Policy, dated 3/1/24, the drug regimen review includes compliance with drug therapy, significant side effects, drug interactions, ineffective drug therapy, duplicative drug therapy and drug reconciliation. During an interview on 11/14/24 at 8:32 AM, Clinical Manager, reported the RNs (registered nurses) utilize a report generated by the EMR (electronic medical record) that identifies drug interactions and duplicate medications, this was why the specifics regarding drug interactions and duplicate medications are not typed in the comment box on the drug regimen review document. During an interview on 11/14/24 at 9:31 AM, Staff C, Secretary, reported the agency is now able to get the EMR to show the list of drug interactions, duplicate medications, side effects and allergies to show on a report. Staff C instructed the surveyors on how to access this information. 1.Patient #1 had a start of care date of 11/1/24. Clinical record review revealed: a. Plan of Care, dated 11/1/24 to 12/30/24, included medication orders for acetaminophen and Tramadol (pain medications) and Plavix (clopidogrel) and aspirin (anticoagulants). b. Drug regimen review document, dated 11/1/24, identified the question are there any adverse side effects, drug interactions, duplicate therapy, ineffective drug or potential contradictions, marked yes. In the comment box: interactions only, see interaction flowsheet. c. Undated drug regimen review report identified no duplicate medications. The RN failed to identify the duplicate pain medications of acetaminophen and Tramadol, and the duplicate anticoagulant medications of Plavix (clopidogrel) and aspirin. 2. Patient #2 had a start of care date of 12/10/18. Clinical record review revealed: a. Plan of Care , dated 11/4/24 to 1/2/25, included medication orders for acetaminophen and Tramadol (pain medications) and Lantus (long-acting insulin) and Novolog (rapid-acting insulin) (antidiabetic medications). b. Drug regimen review document, dated 11/1/24, identified the question are there any adverse side effects, drug interactions, duplicate therapy, ineffective drug or potential contradictions, marked yes. In the comment box: see interaction review. The RN failed to identify the duplicate pain medications of acetaminophen and Tramadol, and the duplicate antidiabetic medications of Lantus and Novolog.

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 agency staff interview, clinical record review and agency policy review, the agency failed to administer drugs, services and treatment as ordered by the physician for 2 of 7 sampled patients (Patient's #2 and #4). Failure to ensure staff obtain physician orders for administration of medications, services and treatments provided by agency staff placed agency patients at risk for inconsistent care/treatment and possible harm. 2.Patient #4 had a start of care date of 8/11/22. Clinical record review revealed the following: a. The Plan of Care, (POC) dated 09/29/2024 to 11/27/2024, included physician orders for skilled nursing services and medications. b. The comprehensive assessment dated 9/25/24, revealed the patient utilized oxygen therapy during the night, and lymphedema leg pump therapy (compression pumps to aide in reduction of swelling) daily. The POC lacked any orders for oxygen or lymphedema pumps. c. During an interview with Staff B, Clinical Manager, on 11/14/24 at 8:30 AM, Staff B, Clinical Manager acknowledged the lack of physician orders for oxygen therapy and lymphedema pump therapy. d. The updated POC, dated 10/25/24, included home health aide frequencies for 1-2 times per week effective from 9/29/24. e. The signed physician order, dated 10/15/24, lacked specific frequency and duration for the home health aide visits. The clinical record lacked orders for treatments and services the patient was receiving. The above findings were reviewed with Administrator and the Clinical Manager. Findings include: According to the agency policy, titled Documentation Guidelines, dated 7/2024, drugs, services and treatments are administered only as ordered by a physician. 1.Patient #2 had a start of care date of 12/10/18. Clinical record review revealed: a. Plans of Care, dated 9/5/24 to 11/3/24 and 11/4/24 to 1/2/25, included physician orders for SN (skilled nurse) to change Dexacom continuous glucose monitor every 10 days and set up medications for the patient once weekly. b. Skilled nurse visit note, dated 10/6/24, identified the SN changed the Dexacom glucose monitor. c. Skilled nurse visit note, dated 10/17/24, identified the SN changed the Dexacom glucose monitor, 11 days after the last Dexacom change. d. Skilled nurse visit note, dated 10/27/24, identified the SN changed the Dexacom glucose monitor. e. Skilled nurse visit note, dated 11/7/24, identified the SN changed the Dexacom glucose monitor, 11 days after the last Dexacom change. f. Skilled nurse visit notes, dated 9/16/24, 10/14/24 and 10/28/24, identified the SN set up the patient’s medications for 2 weeks. During an interview on 11/14/24 at 8:32 AM, Clinical Manager, reported she contacted the SN who confirmed medications are being set up every other week for 2 weeks at a time, she did not write the order clearly to identify this. Clinical Manager confirmed the Dexacom had not been changed every 10 days as ordered. The skilled nurse failed to change the Dexacom glucose monitor every 10 days as ordered and set up medications weekly as ordered.

The recertification survey, dated 12/20/21 to 12/22/21, identified the home health agency was found to be in substantial compliance in relation to emergency preparedness regulations.

The Department of Inspections and Appeals conducted a Recertification Survey in conjunction with a COVID-19 Focused Infection Control Survey 12/20/21 through 12/22/21. The home health agency was found to be in substantial compliance in relation to CMS and Centers for Disease Control and Prevention (CDC) recommended practices to prepare for COVID-19. The recertification survey found the home health agency operating out of compliance with the following standard level home health regulations:

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 2 sampled patients requiring a resumption of care assessment (Patient #3). The agency provided services to 50 patients at the time of the survey and performed 14 resumption of care assessments in the previous 6 months. 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. Findings include: According to the agency policy, titled Comprehensive and OASIS (Outcome and Assessment Information Set Assessment, dated 2/2021, an update to the comprehensive assessment will be completed within 48 hours of the patients return to the home from a hospital admission of 24 hours or more for any reason other than diagnostic tests, or on physician-ordered resumption date. Patient #3 had a start of care date of 10/1/21. Clinical record review revealed the update to the comprehensive assessment at the time of resumption of care, dated 10/13/21, documented the patient was discharged from an inpatient facility, discharge date unknown; agency referral date 10/13/21. The document was electronically signed by the nurse as completed on 10/16/21, 3 days after the assessment visit, 1 day late as required by regulation and the agency policy. The clinical record review revealed hospital discharge documents with an admission dated of 10/4/21 and a discharge date of 10/13/21. The Administrator, Clinical Manager, and Staff C, Registered Nurse, received the above findings and the agency provided no additional information prior to the end of the survey.

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 agency policy review, clinical record review and agency staff interview, the agency failed to follow a Plan of Care established and periodically reviewed by a physician or notify the physician of the need to vary frequency of visits or inability to perform treatments/services as originally ordered on the Plan for Care for 3 of 7 sampled patients (Patients #4, #6 and #7). The agency reported a census of 50 patients at the time of the survey. Failure to follow a Plan of Care established by a physician placed patients at risk of not receiving safe, individualized and consistent care designed to meet each patient's health care needs. 3. Patient #4 had a start of care date of 9/20/2. Clinical record review revealed the following: a. The Plan of Care, dated 9/20/21 to 11/18/21, included physician orders for occupational therapy to evaluate and treat. b. The occupational therapy evaluation, dated 10/29/21, included physician orders for frequency and duration 1 time a week for 1 week, 2 times a week for 2 week for a total of 5 visits. c. The clinical record included documentation of occupational therapy visits for the week 10/29 to 10/30/21, dated 10/29/21 (week 1). d. The clinical record included documentation of occupational therapy visits for the week 10/31 to 11/6/21, dated 11/2 and 11/4/21 (week 2). e. The clinical record included documentation of occupational therapy visits for the week of 11/7 to 11/13/21, dated 11/9/21 (week 3). f. The clinical record included documentation of occupational therapy visits for the week of 12/14 to 12/20/21, dated 12/18/21 (week 4). g. The clinical record lacked documentation of physician notification of occupational therapy missed visit the week of 11/7 to 11/13/21 and occupational therapy visit for the week of 12/14-12/20/21. The clinical record lacked documentation of why the visit was not made and communication with the physician to discuss the inability to follow the Plan of Care. The above findings reported to Staff A, Administrator, Staff B, Clinical Manager and Staff C, RN. Agency staff provided no further information prior to the end of the survey. 2. Patient #7 had a start of care date of 5/21/21 and discharge date of 6/29/21. Clinical record review revealed the following: a.The Plan of Care, dated 5/21/21 to 7/19/21, included physician orders for occupational therapy to evaluate and treat. b.The occupational therapy evaluation, dated 5/26/21, included physician orders for frequency and duration 1 time a week for 1 week, 2 times a week for 1 week, 1 time a week for 2 weeks for a total of 5 visits. c.The clinical record included documentation of occupational therapy visits, dated 5/26/21, 6/8/21, 6/16/21 and 6/22/21. d.The clinical record lacked documentation of an occupational therapy visit the week of 5/30/21 to 6/5/21. e.The clinical record lacked documentation of physician notification of occupational therapy missed visit the week of 5/30/21 to 6/5/21. The clinical record lacked documentation of why the visit was not made and communication with the physician to discuss the inability to follow the Plan of Care. According to the agency policy, dated 10/2020, titled Clinical Records; orders for care may indicate a specific range in the frequency of visits. When a range of visits is ordered , the upper limit of the range is considered the specific frequency. If the Home Health Agency, (HHA) misses a visit or service as required by the plan of care, HHA staff will notify the responsible physician of the missed visit. 1. Patient #6 had a start of care date of 5/27/2021 and discharge date of 7/1/2021. Clinical record review revealed the following:The Plan of Care, dated 5/27/21 to 7/25/21, included physician orders for skilled nurse visits 1-2 times for 1 week and 1-2 times week for nine weeks, home health aide visits 1-2 times per week for 1 week and 1-2 times per week for nine weeks, occupational therapy to evaluate and treat and physical therapy to evaluate and treat. The clinical record lacked documentation of physician notification of home health aide missed visits the weeks of 5/27 to 5/29/21, 5/30 to 6/5/21, and home health aide visits documented cancelled 6/11 and 6/25/21. The occupational therapy evaluation dated 6/2/21 included physician orders for frequency and duration 1 time per week for 1 week, 2 times per week for 2 weeks for a total of 5 visits. The clinical record lacked documentation of physician notification of occupational therapy missed visits the weeks of 6/6 to 6/12/21, 6/13 to 6/19/21 and 6/20 to 6/26/21. Two of five ordered visits were missed. The physical therapy evaluation dated 5/28/21 included physician orders for frequency and duration 1 time per week for 1 week, 2 times per week for 4 weeks. The clinical record lacked documentation of physician notification of one physical therapy visit missed the week of 6/6 to 6/12/21 The clinical record lacked documentation of why the visit was not made and lacked any communication with the physician to discuss the inability to follow the Plan of Care. The clinical record lacked any interim physician orders for a change in home health aide visit frequency, the occupational therapy frequency and the physical therapy frequency.

All orders recorded in plan of care CFR(s): 484.60(a)(3) All patient care orders, including verbal orders, must be recorded in the plan of care. This ELEMENT is not met as evidenced by: Based on clinical record review and agency staff interview, the agency failed to update the Plan of Care with all new physician orders for 7 of 7 sampled patients with interim orders. (Patients #1, #2, #3, #4, #5, #6 and #7). The agency reported a current census of 50 patients at the time of the survey. Failure to update the Plan of Care increased the potential for medication errors in administration or inaccurate provision of care. Findings include: During an interview on 12/20/21 at 8:20 AM, Clinical Manager reported the agency was not doing plan of care updates. 6. Patient #1 had a start of care date of 6/16/21. The POC's, dated 10/14/21 to 12/12/21 and 12/13/21 to 2/10/22, included physician orders for skilled nursing services. The patient's clinical record lacked documentation of a working Plan of Care. The clinical record included the following interim physician orders for the POC dated 10/14/21 to 12/12/21: a. Interim physician order dated 11/17/21: included Furosemide (diuretic) 20 mg daily by mouth and stop pantaprozole sodium (for gastic reflux) 40 mg, stop barrier cream to bottom daily and stop Furosemide 40 mg daily by mouth on 11/16/21. b. Interim physician order dated 12/7/21: change metformin (diabetic medication) 500 mg twice a day to 850 mg daily by mouth. c. Interim physician order dated 12/8/21: discontinue alphagan (glaucoma medication) eye drops 1 drop twice a day to the left eye and start azopt (glaucoma medication) 1 drop twice a days to the left eye. The clinical record lacked documentation of Plan of Care updates for the interim physician orders. 7. Patient #1 had a start of care date of 6/16/21. The POC, dated 9/20/21 to 11/18/21, included physician orders for skilled nursing and home care aide services. The patient's clinical record lacked documentation of a working Plan of Care. The clinical record included the following interim physician orders for the POC dated 9/20/21 to 11/18/21: a. Interim physician order dated 10/21/21, discontinue mybetriq 50 mg daily. b. Interim Physician order dated10/27/21, included physical therapy services 2 times a week for 4 weeks and 1 time a week for 1 week. c. Interim physician order dated 10/25/21, venipuncture for INR and effective 10/28/21 atorvastatin 10 mg daily by mouth and discontinue lovastatin 10 mg daily by mouth. d. Interim physician order dated 11/12/21, venipuncture for INR. e. Interim physician order dated 11/17/21 venipuncture for INR on 11/19/21 and change furosemide from 20 mg to 40 mg daily by mouth. The clinical record lacked documentation of Plan of Care updates for the interim physician orders and PT treatment plan. The agency failed to provide an update to the patient's POC. The above findings reported to Staff A, Administrator, Staff B, Clinical Manager and Staff C, RN. Agency staff provided no further information prior to the end of the survey. 4. Patient #2 had a start of care date of 8/04/2014. The POC's, dated 8/26/21 to 10/24/21 and 10/25/21 to 12/23/21, included physician orders for skilled nursing and home health aide services. The patient's clinical record lacked documentation of a working Plan of Care. The clinical record included interim physician orders, dated 12/20/2021: Ok for nurse to provide fingernail care. Aide to apply TED hose. The patient's clinical record lacked documentation of Plan of Care updates. 5. Patient #6 had a start of care date of . The POC, dated 5/27/21 to 7/23/21 included physician orders for skilled nursing, home health aide services, physical therapy and occupational therapy. The clinical record included interim physician orders: a. Physical Therapy dated 5/28/21;1 time per week for 1 week and 2 times per week for 4 weeks b. Occupational Therapy dated 6/2/21; 1 time per week for 1 week and 2 times per week for 2 weeks. The clinical record lacked documentation of Plan of Care updates including the PT treatment plan and OT treatment plan. 1.Patient #3 had a start of care date of 10/1/21. Clinical record review revealed the following: a. The Plans of Care, dated 10/1/21 to 11/29/21 and 11/30/21 to 1/28/22, included orders for skilled nursing services, physical therapy (PT) and occupational therapy (OT) to evaluate and then per PT/OT plan of care. b. Interim physician order, dated 10/5/21, for triamcinolone for 7 days. c. OT evaluation and treatment plan, dated 10/15/21, with visit frequency 1 time a week for 1 week, 2 times a week for 3 weeks. d. Interim physician order, dated 10/16/21, to hold home care services due to hospitalization, resume home care services, and medication orders for the following: acetaminophen, amiodarone, cephalexin, furosemide, metoprolol succinate, lidocaine patch, and oxygen. e. PT evaluation and treatment plan, dated 10/19/21, with visit frequency 2 times a week for 4 weeks. f. Interim physician order, dated 10/27/21, for hydrocodone/acetaminophen. g. Interim physician orders, dated 11/5/21, for cefdinir, doxycycline, hydrocodone/acetaminophen, and venipuncture for BMP (basic metabolic panel) and magnesium. h. Interim physician order, dated 11/12/21, for entresto and spironolactone. i. Interim physician orders, dated 11/28/21, for prednisone and venipuncture for BMP and magnesium. j. Interim physician order, dated 12/2/21, for potassium chloride. k. Interim physician order, dated 12/11/21, to hold hoe health services due to hospitalization, resume home health services, medication orders for the following: folic acid, metoprolol succinate, ondansetron, senna, simethicone, and thiamine. l. PT evaluation and treatment plan, dated 12/14/21, with visit frequency 2 times a week for 4 weeks. m. OT evaluation and treatment plan, dated 12/15/21, with visit frequency 1 time a week for 1 week. The clinical record lacked documentation of Plan of Care updates for the interim physician orders, PT treatment plans and OT treatment plans. 2. Patient #5 had a start of care date of 11/29/21. Clinical record review revealed the following: a. The Plan of Care, dated 11/29/21 to 1/27/22, included orders for skilled nursing services, home health aide services, PT and OT to evaluate and then per PT/OT plan of care. b. PT evaluation and treatment plan, dated 11/29/21, with visit frequency 2 times a week for 3 weeks and 1 time a week for 1 week. c. OT evaluation and treatment plan, dated 11/29/21, with visit frequency 2 times a week for 2 weeks and 1 time a week for 2 weeks. The clinical record lacked documentation of Plan of Care updates for the PT treatment plan and OT treatment plan 3. Patient #7 had a start of care date of 5/21/21 and a discharge date of 6/29/21. Clinical record review revealed the following: a. The Plan of Care, dated 5/21/21 to 7/19/21, included orders for skilled nursing services, home health aide services, PT and OT to evaluate and then per PT/OT plan of care. b. PT evaluation and treatment plan, dated 5/24/21, with visit frequency 2 times a week for 4 weeks. c. OT evaluation and treatment plan, dated 5/26/21, with visit frequency 1 time a week for 1 week, 2 times a week for 1 week, 1 time a week for 2 weeks. The clinical record lacked documentation of Plan of Care updates for the PT treatment plan and OT treatment plan

Reviewed, revised by physician every 60 days CFR(s): 484.60(c)(1) The individualized plan of care must be reviewed and revised by the physician or allowed practitioner who is responsible for the home health plan of care and the HHA as frequently as the patient's condition or needs require, but no less frequently than once every 60 days, beginning with the start of care date. This ELEMENT is not met as evidenced by: Based on clinical record review, agency policy review and agency staff interview, the agency failed to ensue a current plan of care completed every 60 days to provide services only as ordered by the physician for 1 of 7 sampled patients (Patient #4). The agency reported a current census of 50 patients at the time of the survey. Failure to ensure staff obtain physician orders for provision of services provided by agency staff placed agency patients at risk for inconsistent care/treatment and possible harm. Findings include: Review of the agency's policy, titled Clinical Records, dated 10/2020, identified the individual plan of care will be reviewed and revised by the physician who is responsible for the home health plan of care and the home health agency as frequently as the patient's condition or needs require, but no less frequently than once every 60 days, beginning with the start of care date. Patient #5 had a start of care date of 9/20/21. Review of the clinical record revealed the following: A Plan of Care (POC), dated 9/20/21 to 11/18/21, included a physician order for skilled nurse and home health services. The POC included orders for patient medications, for the skilled nurse to complete assessment of lung sounds, trim toenails as needed, manage and evaluate the plan of care, assess medication compliance, assess/instruct patient/caregiver on anticoagulant use/management and venipuncture for INR as ordered. Review of the clinical record failed to include a POC for the date beginning 11/19/21. During an interview on 12/21/21 at 2:40 PM, the Staff B, Clinical Manager stated the POC did not have the orders for disciplines completed. The system did not generate a POC to print and send to the Physician. The agency failed to complete a POC every 60 days to ensure current physician orders. The above findings reported to Staff A, Administrator, Staff B, Clinical Manager and Staff C, RN. Agency staff provided no further information prior to the end of the survey.

Services by skilled professionals CFR(s): 484.75(a) Standard: Provision of services by skilled professionals. Skilled professional services are authorized, delivered, and supervised only by health care professionals who meet the appropriate qualifications specified under §484.115 and who practice according to the HHA's policies and procedures. This STANDARD is not met as evidenced by: Based on clinical record review, agency policy review and agency staff interview, the agency failed to ensure clinicians followed agency policies and procedures when assessing wounds to agency patients for 2 of 2 sampled patients with wound care. (Patients #1 and #3). The agency reported a current census of 50 patients at the time of the survey and 7 patients with wounds requiring wound assessment at the time of the survey. Failure to follow agency policies and procedures when providing patient care may result in inadequate and unsafe patient care practices. Findings include: According to the agency policy, titled Skin/Wound Assessment, dated 2/2021, all open wounds will be measured for length, width, and depth at least weekly unless otherwise ordered on the plan of care. During an interview on 12/20/21 at 1:58 PM, Clinical Manager reported wounds are measured weekly, usually the first visit of the week, and includes length, width, and depth. 2. Patient #1 had a start of care date of 6/16/21. The clinical record review revealed: a. The POC, dated 10/14/21 to 12/12/21 and 12/13/21 to 2/10/21, included orders for skilled nurse services 2 to 3 times a week and provide wound care to apply betadine to all wounds, cover with gauze or abd dressing, wrap with kerlix and secure with paper tape daily. b. The skilled nursing visit note, dated 11/11/21, identified the patient had 7 open wounds. The wound on the right foot/left lower side identified a length of 1.3 centimeters (cm), width of 2.5 cm. The wound to the right foot, lowest right side length 1.5 cm and width 0.9 cm. The skilled nurse failed to measure wound depth. c. The skilled nursing visit notes, dated 12/8/21, identified the patient had 7 open wounds. The wound on the right foot/left lower side identified a length of 1.3 centimeters (cm), with of 2.5 but failed to measure wound depth. d. The skilled nursing visit notes, dated 12/13, 12/15 and 12/19/21 identified the wounds measured weekly but failed to document measurements. The clinical record lacked weekly wound measurements as required per agency policy for the week 12/12/21 to 12/18/21. The above findings reported to Staff A, Administrator, Staff B, Clinical Manager and Staff C, RN. Agency staff provided no further information prior to the end of the survey. 1. Patient #3 had a start of care date of 10/1/21. The clinical record review revealed: a. The update to the comprehensive assessment completed at resumption of care, dated 10/13/21, identified surgical incision on left upper chest. b. The skilled nursing visit notes, dated 11/1/21 and 11/3/21, identified surgical incision on left upper chest, wound measurement: measure weekly, but failed to include wound measurements. The clinical record lacked weekly wound measurements as required per agency policy for the week 10/31/21 to 11/6/21.

Interventions and patient response CFR(s): 484.110(a)(2) All interventions, including medication administration, treatments, and services, and responses to those interventions; This ELEMENT is not met as evidenced by: Based on clinical record review and staff interview, the agency failed to maintain a clinical record containing current information in the patient's clinical record including all current interventions and services provided in the patient record for 3 of 7 sampled patients (Patients #2, #4 and #5). The agency reported a current census of 50 patients at the time of the survey. Failure to ensure the patient's clinical record included pertinent current and accurate documentation of interventions placed agency patient's at risk for not receiving the correct interventions and for other disciplines providing services to have unclear or inaccurate information regarding the patient's condition. 3. Patient #4 had a start of care date of 9/20/21. Review of the clinical record revealed the following: The POCs, dated 9/20/21 to 11/18/21 and 11/19/21 to 1/17/22, included physician orders for skilled nursing and home health aide services. On 12/22/21 at 2:45 AM Staff F, Home Care Aide provided the surveyor with a copy of home health aide documentation dated 11/22, 11/24, 11/29, 12/2, 12/6, 12/9, 12/13, 12/16 and 12/20/21. The clinical record failed to include all documentation of home health aide services completed. The above findings reported to Staff A, Administrator, Staff B, Clinical Manager and Staff C, RN. Agency staff provided no further information prior to the end of the survey. 2. Patient# 5 had a start of care date of 11/29/21. Clinical record review revealed the following: The Plan of Care, dated 11/29/21 to 1/27/22, included orders for skilled nursing, home health aide services, physical therapy and occupational therapy evaluation. On 12/21/21 at 9:39 AM, Staff C, Registered Nurse, provided the surveyor with therapy notes needing filed on the paper chart for Patient #5, including: occupational therapy visit notes, dated 12/6/21 and 12/8/21, and physical therapy visit notes, dated 12/7/21 and 12/9/21; all visit notes were date stamped 12/15/21, as being received by the agency. On 12/21/21 at 10:25 AM, Clinical Manager provided a copy of the home health aide assignment and notes, dated 11/30/21, 12/3/21, 12/7/21, 12/10/21, 12/14/21, 12/17/21, and 12/21/21. The Clinical Manager reported this assignment and notes sheet was kept in a binder on the home health aide desk in the office area. The clinical record failed to include all documentation of physical therapy, occupational therapy and home health aide services completed. On 12/20/21 at 4:35 PM, during an interview, the Clinical Manager reported the Home Health Aide documentation is maintained in the office and not filed in the patient’s medical record until the page is completely filled out. Each aide has their own binder in the office containing the patient records for each patient that the aide cares for. On 12/21/21 at 8:35 PM, during an interview, the Clinical Manager reported the Home Health Aides come in to the office daily to document in their binder. 1. Patient #2 had a start of care date of 8/04/2014. Review of the clinical record revealed the following: The Plans of Care (POCs), dated 8/26/21 to 10/24/21 and 10/25/21 to 12/23/21, included physician orders for skilled nursing and home health aide services. During record review on 12/20/21,the aide documentation binder in the office charting area contained home health aide documentation dated 10/25, 10/27, 10/29, 11/01, 11/03, 11/05, 11/08, 11/10, 11/12/ 11/15, 11/17, 11/19, 11/22, 11/24, 11/29, 12/01, 12/03, 12/06, 12/10, 12/13 and 12/15/21. The clinical record failed to include all documentation of home health aide services completed.

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, agency policy review and agency staff interview, the agency failed to ensure timely authentication of skilled nurse visit notes in the patient's medical record for 6 of 7 sampled patients (Patients #1, #2, #3, #4, #6 and #7). The agency reported a current census of 50 patients at the time of the survey. Failure to maintain timely, 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. 5. Patient #1 had a start of care date of 6/16/21. The patient received skilled nurse services from the agency. The patient's clinical record included the following: a. The skilled nurse visit note dated 10/18/21, completed on 10/21/21, (2 days late). The skilled nurse visit note dated 10/22/21 completed on 10/30/21, (7 days late). The skilled nurse visit note dated10/27/21, completed on 10/30/21, (2 days late). b. The skilled nurse note, dated 11/1/21, completed on 11/4/21 (2 days late), The skilled nurse note, dated 11/10/21, completed 11/15/21 (4 days late), the skilled nurse visit note, dated 11/18/21, completed 11/23/21 (4 days late) and the skilled nurse visit note, dated 11/24/21 completed 11/29/21 (4 days late). c. The skilled nurse note, dated 12/8/21, completed 12/12/221 (3 days late), the skilled visit note, dated 12/9/21 completed 12/19/21 (9 days late), the skilled nurse visit note, dated 12/15/21, completed 12/19/21 (3 days late) and the skilled nurse visit note dated 12/16/21 completed 12/19/21 (2 days late). 6. Patient #4 had a start of care date of 9/20/21. The patient received skilled nurse and home health aide services from the agency. The patient's clinical record included the following: a. The skilled nurse visit note dated 10/25/21 completed on 10/31/21, (5 days late). The skilled nurse visit note dated 10/28/21 completed on 10/31/21, (2 days late). b. The skilled nurse visit note, dated 11/1/21, completed on 11/4/21, (2 days late). The skilled nurse visit note, dated 11/4/21, completed on 11/8/21, (3 days late). c. The skilled nurse visit note, dated 12/12/21 completed on 12/15/21 ( 2 days late). The above findings reported to Staff A, Administrator, Staff B, Clinical Manager and Staff C, RN. Agency staff provided no further information prior to the end of the survey. 3. Patient #3 had a start of care date of 10/1/21. Clinical record review revealed: a. The skilled nurse visit note, dated 10/20/21, included electronic signature by the nurse, dated as completed on 10/27/21, 6 days late per agency expectation. b. The skilled nurse visit note, dated 10/25/21, included electronic signature by the nurse, dated as completed on 10/27/21, 1 day late per agency expectation. c. The skilled nurse visit note, dated 11/3/21, included electronic signature by the nurse, dated as completed on 11/5/21, 1 day late per agency expectation. d. The skilled nurse visit note, dated 11/18/21, included electronic signature by the nurse, dated as completed on 11/21/21, 2 days late per agency expectation. 4. Patient #7 had a start of care date of 5/21/21 and a discharge date of 6/29/21. Clinical record review revealed the following: a. The skilled nurse visit note, dated 5/24/21, included electronic signature by the nurse, dated as completed on 5/27/21, 2 days late per agency expectation. b. The skilled nurse visit note, dated 6/1/21, included electronic signature by the nurse, dated as completed on 6/3/21, 1 day late per agency expectation. c. The skilled nurse visit note, dated 6/7/21, included electronic signature by the nurse, dated as completed on 6/9/21, 1 day late per agency expectation. d. The skilled nurse visit note, dated 6/14/21, included electronic signature by the nurse, dated as completed on 6/17/21, 2 days late per agency expectation. e. The skilled nurse visit note, dated 6/21/21, included electronic signature by the nurse, dated as completed on 6/23/21, 1 day late per agency expectation. Findings include: According to the agency's policy, titled Comprehensive and Oasis Assessment, dated 2/2021, the comprehensive assessment will be completed in a timely manner, consistent with the patient's immediate needs, but no later than 5 calendar days after the start of care. During an interview on 12/21/21 at 8:20 AM, Clinical Manager reported routine visit notes should be locked the day of the visit or the next day. 1. Patient #2 had a start of care date of 8/4/2014. The patient received skilled nurse, and home health aide services from the agency. The patient's clinical record included the following: The skilled nurse visit note dated 10/20/21 completed on 10/25/21, four days late. The skilled nurse visit note dated 10/29/21 completed on 10/31/21, one day late. The skilled nurse visit note dated 11/2/21 completed on 11/7/21, four days late. 2. Patient #6 had a start of care date of 5/27/2021 and a discharge date of 7/01/2021. The patient received skilled nurse, home health aide, physical therapy and occupational therapy services from the agency. The patient's clinical record included the following: The initial skilled nurse visit note including the comprehensive assessment dated 5//27/21 completed on 6/03/21, six days late.