Baypoint Home Health, Inc.

“5 calendar days after start of care CFR(s): 484.55(b)(1) The comprehensive assessment must 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. This Element is not met as evidenced by: Based on interview and record review, for one of seven sampled patients (Patient 1), the agency failed to complete a comprehensive assessment in a timely manner when Patient 1’s comprehensive assessment was completed seven days after the start of care. This failure had the potential to result in the lack of coordination of care for Patient 1. During an interview on 5/6/24 at 1:20 p.m. with Director of Patient Care Services (DPCS), DPCS stated information on Patient 1 will be completed by the end of the day. DPCS stated Registered Nurse (RN) 3 will complete comprehensive assessment and will be in Patient 1’s clinical record before the home visit on 5/7/24. During review of Patient 1’s “Oasis Nursing Services SOC/ROC (Start of Care/Resumption of Care) for visit date 4/29/24, the SOC form indicated it was electronically signed by RN 3 on 5/6/24 (seven days after Start of Care). During a review of the agency’s policy and procedure (P&P), undated, titled “Clinical Notes Submission Policy”, the P&P indicated, for Start of Care OASIS, the prescribed timetable Submission is 48 to 72 fours after the initial visit.”

“Patient medication schedule/instructions CFR(s): 484.60(e)(2) Patient medication schedule/instructions, including: medication name, dosage and frequency and which medications will be administered by HHA personnel and personnel acting on behalf of the HHA. This Element is not met as evidenced by: Based on observation, interview, and record review, the agency failed to ensure all staff reviewing patient’s medications for one of seven sample selected patients (Patient 2), when Physical Therapist (PT) did the evaluation visit for Patient 2 and did not review the medications with the Patient/Care Givers (CG). This failure practice had the potential to result in medication errors for Patient 2 and the potential for Patient 2 to receive medications which were not ordered by the physician. A review of Patient 2’s “Plan of Care” indicated Patient 2 was admitted to the agency with multiple diagnoses including Schizophrenia (a serious mental condition of a type involving a breakdown in the relation between thought, emotion, and behavior, leading to faulty perception, inappropriate actions and feelings, withdrawal from reality and personal relationships into fantasy and delusion, and a sense of mental fragmentation). During an observation on 5/7/24 at 10:00 a.m. with PT, PT did not review the medications for Patient 2 with the Patient/CGs and did not ask the CGs if there was any change of Patient 2’s medications. During an interview on 5/7/24 at 10:40, with PT, PT stated as a therapist he does not review the medication during the visits and that is a nurse’s responsibility to check the medications. During an interview on 5/8/24 at 9:30 a.m., with the Director of Patient Care Services (DPCS), DPCS stated all the clinicians (Home Health staff) should review the medications and ask the patients/CGs if there is any change of the medication on each visit. A review of the agency’s policy and procedure “Ongoing Assessments” revised April 2021 indicated “… 2. Using the standards of care identified by the organization, the clinician will reassess the patient… M. Compliance with treatment and/or medications…7. The physician (or other authorized licensed independent practitioner) will be notified to verify any changes in medications…””

“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 interview and record review, the agency failed to ensure the staff would follow the care plan frequency of visits for one of seven sample selected patients (Patient 7), when the agency’s clinicians (Home Health staff) did not visit Patient 7 based on the frequency in the plan of care. This failure in practice had the potential to result in Patient 7 not receiving appropriate care that was needed. A review of Patient 7’s “Plan of Care” indicated Patient 7 was admitted to the agency with multiple diagnoses including right leg ulcers. A review of the “Plan of Care” indicated the visit frequency for the nurse visits was 1W1 (one visit for one week), 2W2 (two visits a week for two weeks) and 1W1. A review of Patient 7’s chart indicated the nurses did not visit Patient 7 based on the plan of care frequency (visits made on 4/3/24, 4/11/24 and 4/17/24), and they stopped seeing Patient 7 after 4/17/24’s visit. During a concurrent interview and record review on 5/8/24 at 11:55 a.m. with the Director of Patient Care Services (DPCS), DPCS reviewed Patient 7’s visits and stated there were no documents that indicated Patient/CG refused the care and no explanation about any missed visits by the nurses. DPCS stated there was no documentation about physician’s notification about missed visits or change of plan of care. During an interview on 5/8/24 at 12:00 p.m. with Registered Nurse (RN) 1, RN 1 stated she made a mistake to not visit Patient 7 and should have followed the frequency of visits and made sure about the healing of the wounds. RN1 also stated that she did not communicate about the missed visits with the DPCS. A review of the agency’s policy and procedure, “Missed Visits,” revised October 2019, indicated “… A. Notify the physician and clinical supervisor of the missed visit and reason for missed visit…” A review of the agency’s policy and procedure “Care Planning Process,” revised October 2019, indicated “… The care planning decisions will be reflected in the specific services that will be provided and the associated actions planned and implemented to meet individualized patient problems and goals… Clinicians will inform the patient’s physician of any changes that suggest a need to alter the plan of care…””

“Required items in clinical record CFR(s): 484.110(a)(1) The patient’s current comprehensive assessment, including all of the assessments from the most recent home health admission, clinical notes, plans of care, and physician or allowed practitioner orders; This Element is not met as evidenced by: Based on interview and record review, for one of seven sampled patients (Patient 6), the agency failed to ensure Patient 6’s clinical record included all visit notes since start of care date. This failure had the potential to result in the lack of information among clinical team members about Patient 6’s progress. During a review of Patient 6’s “Plan of Care” (POC), dated 3/30/24, the “POC” indicated frequency of visits as one weekly visit effective 3/30/24, twice weekly visits for two weeks starting 3/31/24 and ending 4/13/24, and one per week visit starting 4/14/24, for a total of six visits for Patient 6. During a concurrent interview and review of Patient 6’s clinical record on 5/8/24 at 12:45 p.m. with Director of Patient Care Services (DPCS), DPCS stated all the visit notes made from 3/31/24 had not been entered or plotted yet. Patient 6’s clinical record indicated one of six visit notes was completed and entered. During a telephone interview on 5/8/24 at 1:14 p.m. with Registered Nurse (RN) 1, RN 1 stated she did not enter all her visit notes from 3/31/24 to present. RN 1 stated it was the agency’s policy that all visit notes be entered in the clinical record not later than 48 hours after the actual visit. During the interview, RN 1 stated she was working on entering all her visit notes in Patient 6’s clinical record. During a review of the agency’s policy and procedure (P&P), undated, titled “Clinical Notes Submission Policy”, the P&P indicated the following prescribed timetable submission: -All visit notes for actual visits made on a Monday and Tuesday are due Thursday by 5:00 p.m. - All visit notes for actual visits made on Wednesday and Thursday are due Monday of the following week by 5:00 p.m. - All visit notes for actual visits made on Friday and Saturday are due Tuesday of the following week.”