Living Hope Home Health Care

“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: This CONDITION is NOT MET as evidenced by: Based on observation, interview and record review, the Home Health Agency (HHA) failed to ensure the Condition of Participation regarding Care Planning, Coordination, Quality of Care was met as follows: 1. The HHA failed ensure to review and revised the Plan of Care (POC) for two of seven sampled patients (Patient 1 and Patient 5). This deficient practice had the potential to result in patients not receiving the identified needs and services, and a decline in over all health status. (Refer to G586). 2. The HHA failed to notify the medical doctor of a change in condition as indicated in the plan of care, for three of seven sample patients (Patient 1, Patient 3, and Patient 4). For Patient 1, the medical doctor was not notify of Patient 1’s presence of pitting edema (excess fluid accumulation, causing swelling) of the feet and a low (81.4 Fahrenheit) temperature reading while on a joint home visit. For Patient 3, the medical doctor was not notified of Patient 3’s blood pressure of 150/99 during the home visit. For Patient 4, the medical doctor was not notified of Patient 4’s body temperature of 90.3 F, and blood pressure of 101/58 during the home visit. This deficient practice resulted in the medical doctor was not aware of the patient’s current health status and services not being provided to Patient 1, Patient 3, and Patient 4 by the HHA, that could cause delayed and lack of care and services provided to Patient 1, Patient 3, and Patient 4. (Refer to G590). The cumulative effect of these systemic practices resulted in the failure of the HHA to deliver statutorily (written rules or law) mandated compliance with Federal Regulations for Care Planning, Coordination of Services, and Quality of Care to ensure highest quality health care is provided to patients assessed to receive home health services.”

“Organization and administration of services CFR(s): 484.105 Condition of participation: Organization and administration of services. The HHA must organize, manage, and administer its resources to attain and maintain the highest practicable functional capacity, including providing optimal care to achieve the goals and outcomes identified in the patient’s plan of care, for each patient’s medical, nursing, and rehabilitative needs. The HHA must assure that administrative and supervisory functions are not delegated to another agency or organization, and all services not furnished directly are monitored and controlled. The HHA must set forth, in writing, its organizational structure, including lines of authority, and services furnished. This Condition is not met as evidenced by: This CONDITION is NOT MET as evidenced by: Based on observation, interview, and record review, the Home Health Agency (HHA) failed to ensure the Condition of Participation regarding Organization and Administration of Services was met as follows: 1. The HHA failed to ensure a Clinical Manager was available during all operating hours of the HHA to oversee the nursing care provided to seven of seven sampled patients (Patient 1, Patient 2, Patient 3, Patient 4, Patient 5, Patient 6, and Patient 7). This failure resulted in lack of nursing oversight, to ensure services were provided according to accepted standards of care and federal guidelines. (Refer to G 950). 2. The HHA failed to ensure the Clinical Manager (Director of Nurses – DON) ensured two of seven sampled patients (Patient 1 and Patient 5) individualized plan of care (POC) was updated to indicate the current care planned. This failure had the potential to result in patients not receiving the identified needs and services, and have a decline in health status, that could affect their quality of care and well-being. It also had the potential to result in confusion about the current treatments the patients were receiving. (Refer to G 968). The cumulative effect of these systemic practices resulted in the failure of the HHA to ensure the provision of a quality health care in a safe environment. During the Recertification survey, notified ADM that policies will be requested for the review, the ADM stated they need to ask consultant prior providing policies. No policies were received from the facility prior exiting the facility.”

“Clinical records CFR(s): 484.110 Condition of participation: Clinical records. The HHA must maintain a clinical record containing past and current information for every patient accepted by the HHA and receiving home health services. Information contained in the clinical record must be accurate, adhere to current clinical record documentation standards of practice, and be available to the physician(s) or allowed practitioner(s) issuing orders for the home health plan of care, and appropriate HHA staff. This information may be maintained electronically. This Condition is not met as evidenced by: This CONDITION is NOT MET as evidenced by: Based on observation, interview, and record review, the Home Health Agency (HHA) failed to ensure the Condition of Participation regarding Clinical Records was met as follows: 1.The HHA failed to ensure the plan of care accurately reflected the services provided for three of seven sampled patients (Patient 3 , Patient 4 and Patient 5). This failure resulted in falsification of patient records. (Refer to G1012). 1. The HHA failed to ensure three of seven sampled patients (Patient 1, Patient 2, and Patient 5) clinical records indicated the author of the note. This failure resulted in an incomplete medical record. (Refer to G1024). The cumulative effect of these systemic practices resulted in the failure of the HHA to ensure the provision of a quality health care in a safe environment.”

“Review and revision of the plan of care CFR(s): 484.60(c) Standard: Review and revision of the plan of care. This Standard is not met as evidenced by: Based on observation, interview, and record review, the Home Health Agency (HHA) failed to review and/or revised the Plan of Care (POC) for two of seven sampled patients (Patient 1 and Patient 5). This deficient practice had the potential to result in patients not receiving the identified needs and services, and a decline in overall health status A review of Patient 1’s medical record form titled “Patient Profile” indicated a start of care date of 1/4/2024 with a primary diagnosis of wedge compression fracture of fourth thoracic vertebra (broken rib). A review of Patient 1’s medical record form titled “Home Health Certification and Plan of Care” dated from 1/4/2024 to 3/3/2024, listed under section “Medications: Dose/Frequency/Route (N)ew (C)hanged – Ferrous sulfate (iron medication); telmisartan (high blood pressure medication); Tudca (gallbladder medication); Osyco (calcium supplement); lorazepam (anti-anxiety medication); atenolol (high blood pressure medication)”. Form also indicated “medication reconciliation every SN (Skilled Nurse) visit.” A review of Patient 1’s Electronic Medical Record (EMR – computerized medical records) indicated there were two medical doctor’s orders. A review of Patient 1’s medical record form titled “Order/Telephone Order” dated 1/4/2024, indicated Medical Doctor 1 (MD1) ordered the following medications - Ferrous sulfate; telmisartan; Tudca; Osyco; lorazepam; and atenolol. During a concurrent observation and interview during the joint home visit on 2/13/2024 at 1:50 p.m. with the Administrator/License Vocational Nurse 1 (ADM/LVN1) to Patient 1’s home, Patient 1 provided her home medications for review. Patient 1 stated those were all the medications she was taking. The following medications were not in the patient’s home: Ferrous sulfate; telmisartan; Tudca; Osyco; lorazepam; and atenolol. ADM/LVN1 stated maybe the Director of Nurses (DON) forgot to discontinue the medications. The HHA failed to ensure Patient 1’s plan of care was revised to ensure it reflected the current medications being taken. The survey team was not able to interview on the revision of the plan of care process due to the DON not being available in person, during the time the surveyors were at the HHA. No other knowledgeable registered nurse was available during the survey process. 2. A review of Patient 5’s record titled, “Patient Profile”, indicated a start of care date on 12/22/2023, with a primary diagnosis of hypertensive heart disease without heart failure (high blood pressure). During an interview on 2/13/2024, at 3:46 p.m., Patient 5’s caregiver (CG 2) stated services with the HHA began in January even though the doctor had placed the order for HHA services back in December 2023. CG 2 stated a nurse came to visit Patient 5 one time in January 2024, and no other nurses had come since then. CG 2 stated Patient 5 was receiving Physical Therapy services from the agency twice a week. A record review of Patient 5’s record titled, “Home Health Certification and Plan of Care”, for certification period 12/22/2023 to 2/19/2023, indicated the skilled nurse was to visit Patient 5 once a week for one week (1w1), twice a week for two weeks (2w1), and once a week for seven weeks (1w7). Further review of the record did not indicate Physical Therapy services. A record review of Patient 5’s record titled, “Home Plan of Care”, dated 12/22/2023, indicated, “Your care plan is ordered by your physician (doctor) and includes: Skilled Nursing…Physical Therapy…” The survey team was not able to interview on the revision of the plan of care process due to the DON not being available in person, during the time the surveyors were at the HHA. No other knowledgeable registered nurse was available during the survey process. The HHA failed to ensure Patient 5’s plan of care was revised and updated to reflect the services being given as reported by CG 2.”

“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 interview and record review the Home Health Agency (HHA) failed to ensure three of seven sampled patients (Patient 1, Patient 2, and Patient 5) clinical records indicated the author of the note. This failure resulted in an incomplete medical record. 1. A review of Patient 1’s medical record form titled “Patient Profile” indicated a start of care date of 1/4/2024 with a primary diagnosis of wedge compression fracture of fourth thoracic vertebra (broken rib). A review of Patient 1’s medical record form titled “LVN Supervisory Note” dated 2/2/2024, indicated sections “Printed Name” & “RN/Supervisor Signature” were left blank. The form did not indicate who the author was. There was no documented evidence a registered nurse supervised the skilled nurse. A review of Patient 1’s medical record form titled “LVN Supervisory Note” dated 2/7/2024, indicated all sections were left blank. Form also indicated sections “Printed Name” & “RN/Supervisor Signature” were left blank. There was no documented evidence a registered nurse supervised the skilled nurse. The HHA failed to ensure Patient 1’s clinical records indicated the author of the note. The survey team was not able to interview about the authentication process, due to the Director of Nursing (DON) not being available in person, during the time the surveyors were at the HHA. No other knowledgeable registered nurse was available during the survey process. 2. A review of Patient 2’s medical record form titled “Patient Profile” indicated a start of care date of 12/30/2023 with a primary diagnosis of essential hypertension (high blood pressure). A review of Patient 2’s medical record form titled “LVN Supervisory Note” dated 1/21/2024, indicated sections “Printed Name” & “RN/Supervisor Signature” were left blank. Form did not state who the author was. A review of Patient 2’s medical record form titled “LVN Supervisory Note” dated 1/30/2024, indicated all sections were left blank. Form also indicated sections “Printed Name” & “RN/Supervisor Signature” were left blank. There was no documented evidence a registered nurse supervised the skilled nurse. The HHA failed to ensure Patient 2’s clinical records indicated the author of the note. The survey team was not able to interview about the authentication process, due to the DON not being available in person, during the time the surveyors were at the HHA. No other knowledgeable registered nurse was available during the survey process. 3. A review of Patient 5’s record titled, “Patient Profile”, indicated a start of care date on 12/22/2023, with a primary diagnosis of hypertensive heart disease without heart failure (high blood pressure). During a concurrent interview and record review on 2/14/2024, at 2:50 p.m., the ADM/LVN 1 reviewed Patient 5’s record titled, “LVN Supervisory Note”, dated 1/20/24. The ADM/LVN 1 stated initially she did not know who entered the note because the note was not signed. The ADM/LVN 1 then stated the Director of Nurses (DON) was the one who entered the note because she was there during the visit. Continued review of the record did not indicate the author of the note. The HHA failed to ensure Patient 5’s clinical records indicated the author of the note. The survey team was not able to interview about the authentication process, due to the DON not being available in person, during the time the surveyors were at the HHA. No other knowledgeable registered nurse was available during the survey process.”

“Administrator CFR(s): 484.115(a) Standard: Administrator, home health agency. (1) For individuals that began employment with the HHA prior to January 13, 2018, a person who: (i) Is a licensed physician; (ii) Is a registered nurse; or (iii) Has training and experience in health service administration and at least 1 year of supervisory administrative experience in home health care or a related health care program. (2) For individuals that begin employment with an HHA on or after January 13, 2018, a person who: (i) Is a licensed physician, a registered nurse, or holds an undergraduate degree; and (ii) Has experience in health service administration, with at least 1 year of supervisory or administrative experience in home health care or a related health care program. This Standard is not met as evidenced by: Based on interview and record review the Home Health Agency (HHA) failed to ensure a qualified Administrator was hired for the day-to-day operations of the HHA. This failure resulted in placing the patients at risk to receive possible unsafe and ineffective care practices. A review of HHAs Administrator/License Vocational Nurse 1 (ADM/LVN1) form titled “Employment Application” dated 2/11/2019, indicated positioned applied for was for CEO (Chief Executive Officer – responsible for leading an entire organization). It also indicated it was electronically signed by ADM/LVN1 on 2/11/2019. A review of HHA form titled “Job Description – Administrator” indicated “Qualifications: A person who is a licensed physician, or is a registered nurse, or has training and experience in health services administration and at least on (1) year of supervisory or administrative experience in home health care or related health program.” Form also indicated it was signed by ADM/LVN1 on 2/11/2019. A review of ADM/LVN1 resume, indicated ADM/LVN1 had experience as an LVN. During an interview on 1/12/2024 at 11:15 a.m. with the ADM/LVN1, ADM/LVN1 was unable to complete an entrance conference or provide requested documents. ADM stated will wait for her son the Office Assistant (OA) to provide information requested. During a concurrent interview and record review on 2/13/2024 at 11:40 a.m. with the ADM/LVN1 of her employee file, ADM/LVN1 stated her role as the administrator was to “take care of everyday job”. ADM/LVN1 stated, “I come here if office manager is not here, I come. I check all. If the patient is referred, I check to see if patient has Medicare and who referred the patient. I check day by day job, whoever is missing their job I am reminding them. If office manager is not here, I call him and tell them they should be there. If someone is out, I cover for them.” ADM stated she has worked as an active License Vocational Nurse for the past 20 year and that, that was her first administrative job. ADM stated she did not have administrative experience or education. ADM stated when she needs assistance performing her administrative role/duties, she calls her sons for assistance. ADM stated she was also a visiting Skilled Nurse (SN) conducting home visits to all five active patients. The survey team was not able to interview about the day to day operations of the HHA, due to the Director of Nursing ( DON) not being available in person, during the time the surveyors were at the HHA. No other knowledgeable registered nurse was available during the survey process.”

“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 observation, interview, and record review, the Home Health Agency (HHA) failed to review and document all medications each patient was currently using for three of seven sampled patients (Patient 1, Patient 3, and Patient 4). This deficient practice placed the patients at risk of drug-to-drug interaction and harm by not knowing which medications the patients were taking. 1. A review of Patient 1’s medical record form titled “Patient Profile” indicated a start of care date of 1/4/2024 with a primary diagnosis of wedge compression fracture of fourth thoracic vertebra (broken rib). A review of Patient 1’s medical record form titled “Home Health Certification and Plan of Care” dated from 1/4/2024 to 3/3/2024, listed under section “Medications: Dose/Frequency/Route (N)ew (C)hanged – Ferrous sulfate (iron medication); telmisartan (high blood pressure medication); Tudca (gallbladder medication); Osyco (calcium supplement); lorazepam (anti-anxiety medication); atenolol (high blood pressure medication).” Form also indicated “medication reconciliation every SN (Skilled Nurse) visit.” A review of Patient 1’s medical record form titled “Patient Medication Profile” dated 1/4/2024, listed the following medications - Ferrous sulfate; telmisartan; Tudca; Osyco; lorazepam; and atenolol. A review of Patient 1’s Electronic Medical Record (EMR – computerized medical records) indicated there were two medical doctor’s orders. A review of Patient 1’s medical record form titled “Order/Telephone Order” dated 1/4/2024, indicated Medical Doctor 1 (MD1) ordered the following medications - Ferrous sulfate; telmisartan; Tudca; Osyco; lorazepam; and atenolol. During a concurrent observation and interview during the joint home visit on 2/13/2024 at 1:50 p.m. with the Administrator/License Vocational Nurse 1 (ADM/LVN1) to Patient 1’s home, Patient 1 provided her home medications for review. Patient 1 stated these were all the medications she was taking. The following medications were not in the patient’s home: Ferrous sulfate; telmisartan; Tudca; Osyco; lorazepam; and atenolol. The ADM/LVN1 stated maybe the Director of Nurses (DON) forgot to discontinue the medications. The HHA failed to ensure Patient 1’s medication profile accurately reflected the medications currently being taken. 2. A review of Patient 3’s document titled, “Patient Profile”, indicated a start of care date on 11/25/2023, with a primary diagnosis of atherosclerotic heart disease of native coronary artery without angina pectoris (accumulation of plaque inside the walls of blood vessels). During a concurrent observation, interview, and record review, at the home visit on 2/13/2023, at 3:10 p.m., the ADM/LVN 1 reviewed the medications Patient 3 was taking. Patient 3’s record titled, “Patient Medication Profile,” dated episode period 1/24/2024-3/23/2024, indicated the patient was taking Losartan (for high blood pressure) and Oxybutynin (to prevent spasms). Losartan and Oxybutynin were not at the home. Patient 3’s caregiver (CG 1) stated the doctor had discontinued the medications since last year. Further observation of medication review by the ADM/LVN 1, indicated Patient 3 was taking “Olmesartan Medoxomil” (for high blood pressure), and was not included in the medication profile. A bottle of Metoprolol” (for high blood pressure) at the home indicated 100 mg (mg-milligrams, unit of measurement). The medication profile indicated Patient 3 was taking 50 mg. The HHA failed to ensure the medication profile accurately reflected the medications Patient 3 was taking. 3. A review of Patient 4’s document titled, “Patient Profile”,indicated a start of care date on 11/25/2023, with a primary diagnosis of atherosclerotic heart disease of native coronary artery without angina pectoris (accumulation of plaque inside the walls of blood vessels). During a concurrent observation, interview, and record review, at the home visit on 2/13/2023, at 3:27 p.m., the ADM/LVN 1 reviewed the medications Patient 4 was taking. Patient 4’s record titled, “Patient Medication Profile”, dated episode period 1/24/2024-3/23/24 indicated Patient 4 was taking 10 mg of Lisinopril (for high blood pressure). The medication bottle at Patient 4’s home for Lisinopril indicated 20 mg 1 tablet daily. The CG 1 stated the 20 mg dose has been since last year. The HHA failed to ensure the medication profile accurately reflected the medications Patient 3 was taking. The survey team was not able to conduct an interview with the DON regarding the medication review process, due to the DON not being available in person, during the time the surveyors were at the HHA. There were no other knowledgeable registered nurse was available during the survey process.”

“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 observation, interview, and record review the Home Health Agency (HHA) failed to notify the medical doctor of a change in condition as indicated in the plan of care, for three of seven sample patients (Patient 1, Patient 3, and Patient 4). For Patient 1, the medical doctor was not notify of Patient 1’s presence of pitting edema (excess fluid accumulation, causing swelling) of the feet and a low (81.4 Fahrenheit) temperature reading while on a joint home visit. For Patient 3, the medical doctor was not notified of Patient 3’s blood pressure of 150/99 during the home visit. For Patient 4, the medical doctor was not notified of Patient 4’s body temperature of 90.3 F, and blood pressure of 101/58 during the home visit. This deficient practice resulted in the medical doctor was not aware of the patient’s current health status and services not being provided to Patient 1, Patient 3, and Patient 4 by the HHA, that could cause delayed and lack of care and services provided to Patient 1, Patient 3, and Patient 4. 1. A review of Patient 1’s “Patient Profile” indicated a start of care date of 1/4/2024 with a primary diagnosis of wedge compression fracture of fourth thoracic vertebra (broken rib). A review of Patient 1’s “Home Health Certification and Plan of Care” dated from 1/4/2024 to 3/3/2024, indicated under section “SN (Skilled Nurse) to perform/monitor/teach to patient/PCG (patient care giver) to monitor weight weekly and notify MD for any presence of pitting edema…” It also indicated for the SN to notify the MD of any s/s (signs and symptoms) … and for temperature less than 96F.” During a concurrent observation and interview during the joint home visit on 2/13/2024 at 1:50 p.m. with the Administrator/License Vocational Nurse 1 (ADM/LVN1) at Patient 1’s home, the ADM/LVN1 assessed Patient 1’s feet and ankles. The ADM/LVN stated the “right side has more edema, its pitting.” The ADM/LVN1 checked Patient 1’s temperature and Patient 1’s temperature was 81.4 Fahrenheit. ADM/LVN1 was asked if that was a normal reading. ADM/LVN1 stated, “Yes, for her it is.” During a concurrent interview and record review on 2/14/2024 at 3:40 p.m. with the ADM/LVN1 of Patient 1’s Electronic Medical Record (EMR), ADM/LVN1 stated yesterday’s (2/13/2024) visit note was not documented yet for Patient 1. ADM stated she had 1-2 days to complete the visit note. The ADM stated she informed Patient 1’s doctor of her feet edema and low temperature reading, but that she had not documented anything yet. Patient 1’s medical records did not include doctor notification or planned care documentation for Patient 1’s edema and low temperature reading in Patient 1’s EMR. The survey team was not able to interview the DON regarding the process for notification to the doctor when a change of condition occurs, due to the DON was not being available in person, during the time the surveyors were at the HHA. There were no other knowledgeable registered nurses available during the survey process. Based on Patient 1’s medical record review, there was no documented evidence the HHA notified the doctor about Patient 1’s temperature of 81.4 F and pitting edema. 2. A review of Patient 3’s “Patient Profile” indicated a start of care date on 11/25/2023, with a primary diagnosis of atherosclerotic heart disease of native coronary artery without angina pectoris (accumulation of plaque inside the walls of blood vessels). A review of Patient 3’s “Home Health Certification and Plan of Care” dated from 1/24/2024 to 3/23/2024, indicated the SN is to continue to notify the doctor if the diastolic blood pressure was greater than 90 mmHg (mmHg-unit of measurement milliliters of mercury). During a concurrent observation and interview of the home visit on 2/13/2024, at 3:05 p.m., the ADM/LVN 1 took Patient 3’s blood pressure readings. The ADM/LVN 1 stated Patient 3’s blood pressure was 150/99 because the doctor changed the blood pressure medication. During an interview on 2/14/2024, at 3:42 p.m., the ADM/LVN 1 stated she called Patient 3’s office and spoke to the nurse practitioner (NP) at the beginning, the NP stated she did not remember when, and stated she wrote it on her notes. The ADM/LVN 1 stated the reason Patient 3’s blood pressure was high was because of the new medication, stated, “I don’t remember the name” of the medication and it would take a while for the medication to work. During a record review of Patient 3’s electronic medical record on 2/14/2024, there was no note about the notification to the doctor or nurse practitioner of Patient 3’s blood pressure. The survey team was not able to interview the DON regarding the process for notification to the doctor when a change of condition occurs, due to the DON not being available in person, during the time the surveyors were at the HHA. No other knowledgeable registered nurse was available during the survey process. The Patient 3’s doctor was notified of the diastolic blood pressure greater than 90 mmHG as indicated in the plan of care. 3. A review of Patient 4’s “Patient Profile”, indicated a start of care date on 11/25/2023, with a primary diagnosis of atherosclerotic heart disease of native coronary artery without angina pectoris (accumulation of plaque inside the walls of blood vessels). A review of Patient 4’s “Home Health Certification and Plan of Care” dated from 1/24/2024 to 3/23/2024, indicated the SN to continue to notify the doctor if the diastolic blood pressure was less than 60 mmHg and if the temperature was less than 96.0F. During a concurrent observation and interview of the home visit on 2/13/2024, at 3:17 p.m., the ADM/LVN 1 took Patient 4’s blood pressure and temperature readings. The ADM/LVN 1 stated Patient 4’s blood pressure was 101/58 and temperature was 90.3 F. CG 1 stated Patient 4’s diastolic blood pressure readings was sometimes 50 and stated, “is that ok?”. The ADM/LVN 1 stated a little low was okay, but the CG 1 needed to notify the doctor. The survey team was not able to interview the DON regarding the process for notification to the doctor when a change of condition occurs, due to the DON not being available in person, during the time the surveyors were at the HHA. No other knowledgeable registered nurse was available during the survey process. There was no evidence that Patient 4’s doctor was notified of the diastolic blood pressure less than 60 mmHg and if the temperature was less than 96.0 F as indicated in the plan of care.”

“Nursing services supervised by RN CFR(s): 484.75(c)(1) Nursing services are provided under the supervision of a registered nurse that meets the requirements of §484.115(k). This Element is not met as evidenced by: Based on observation, interview, and record review the Home Health Agency (HHA) failed to perform supervisory visits for their License Vocational Nurse (LVN) services for three of seven sampled patients (Patient 1, Patient 2, and Patient 5). This failure resulted in patients being cared for by staff who were not following the plan of care, which had the potential to result in health status decline, hospitalization, and/or death. 1. A review of Patient 1’s medical record form titled “Patient Profile” indicated a start of care date of 1/4/2024 with a primary diagnosis of wedge compression fracture of fourth thoracic vertebra (broken rib). A review of Patient 1’s medical record form titled “Home Health Certification and Plan of Care” dated from 1/4/2024 to 3/3/2024, indicated under section “SN (Skilled Nurse) to perform/monitor/teach to patient/PCG (patient care giver); Monitor weight weekly and notify MD for any… presence of pitting edema…” It also indicated “SN to notify MD of any s/s (signs and symptoms) … and temperature less than 96F.” During a concurrent observation and interview during the joint home visit on 2/13/2024 at 1:50 p.m. with the Administrator/License Vocational Nurse 1 (ADM/LVN 1) to Patient 1’s home, the ADM/LVN1 assessed Patient 1’s feet and ankles. The ADM/LVN 1 stated, “right side has more edema, its pitting”. The ADM/LVN 1 checked Patient 1’s temperature and stated Patient 1’s temperature was 81.4 Fahrenheit. The ADM/LVN1 was asked if that was a normal reading. The ADM/LVN1 stated, “yes, for her it is.” During a concurrent interview and record review on 2/14/2024 at 3:40 p.m. with the ADM/LVN1 of Patient 1’s Electronic Medical Record (EMR), the ADM/LVN1 stated yesterday’s (2/13/2024) visit note was not documented yet for Patient 1. The ADM stated she had 1-2 days to complete the visit note. The ADM stated she informed Patient 1’s doctor of her feet edema and low temperature reading, but that she had not documented anything yet. Patient 1’s medical records did not include doctor notification or planned care documentation for Patient 1’s edema and low temperature reading in Patient 1’s EMR. A review of Patient 1’s medical record form titled “LVN Supervisory Note” dated 2/2/2024, indicated sections “Printed Name” & “RN/Supervisor Signature” were left blank. The form did not indicate who the author was. There was no documented evidence a registered nurse supervised the skilled nurse. A review of Patient 1’s medical record form titled “LVN Supervisory Note” dated 2/7/2024, indicated all sections were left blank. The Form also indicated sections “Printed Name” & “RN/Supervisor Signature” were left blank. There was no documented evidence a registered nurse supervised the skilled nurse. The HHA failed to ensure the ADM/LVN 1 was supervised to ensure the plan of care was being followed. The survey team was not able to interview on the skilled nurse supervision process, due to the DON not being available in person, during the time the surveyors were at the HHA. No other knowledgeable registered nurse was available during the survey process. 2. A review of Patient 2’s medical record form titled “Patient Profile” indicated a start of care date of 12/30/2023 with a primary diagnosis of essential hypertension (high blood pressure). A review of Patient 2’s medical record form titled “LVN Supervisory Note” dated 1/21/2024, indicated sections “Printed Name” & “RN/Supervisor Signature” were left blank. Form does not state who the author was. A review of Patient 2’s medical record form titled “LVN Supervisory Note” dated 1/30/2024, indicated all sections were left blank. Form also indicated sections “Printed Name” & “RN/Supervisor Signature” were left blank. There was no documented evidence a registered nurse supervised the skilled nurse. The survey team was not able to interview on the skilled nurse supervision process, due to the DON not being available in person, during the time the surveyors were at the HHA. No other knowledgeable registered nurse was available during the survey process. 3. A review of Patient 5’s record titled, “Patient Profile” indicated a start of care date on 12/22/2023, with a primary diagnosis of hypertensive heart disease without heart failure (high blood pressure). During an interview on 2/13/2024, at 3:46 p.m., Patient 5’s caregiver (CG 2) stated services with the HHA began in January even though the doctor had placed the order for HHA services back in December 2023. CG 2 stated a nurse came to visit Patient 5 one time in January 2024, and no other nurses had come since then. CG 2 stated Patient 5 was receiving Physical Therapy services from the agency twice a week. A record review of Patient 5’s record titled, “Home Health Certification and Plan of Care” for certification period 12/22/2023 to 2/19/2023, indicated the skilled nurse was to visit Patient 5 once a week for one week (1w1), twice a week for two weeks (2w1), and once a week for seven weeks (1w7). During a concurrent interview and record review on 2/14/2024, at 2:50 p.m., the ADM/LVN 1 reviewed Patient 5’s record titled, “LVN Supervisory Note” dated 1/20/24. The ADM/LVN 1 stated initially she did not know who entered the note because the note was not signed. The ADM/LVN 1 then stated the Director of Nurses (DON) was the one who entered the note because she was there during the visit. The HHA failed to ensure there was documented evidence a registered nurse supervised the skilled nurse to ensure nursing visits were being provided according to the plan of care. The survey team was not able to interview on the skilled nurse supervision process, due to the DON not being available in person, during the time the surveyors were at the HHA. No other knowledgeable registered nurse was available during the survey process.”

“Ensure clinical manager is available CFR(s): 484.105(b)(1)(iii) (iii) Ensure that a clinical manager as described in paragraph (c) of this section is available during all operating hours; This Element is not met as evidenced by: Based on observation, interview, and record review, the Home Health Agency (HHA) failed to ensure a Clinical Manager was available during all operating hours of the HHA to oversee the nursing care provided to seven of seven sampled patients (Patient 1, Patient 2, Patient 3, Patient 4, Patient 5, Patient 6, and Patient 7). This failure resulted in lack of nursing oversight, to ensure services were provided according to accepted standards of care and federal guidelines. On 2/12/2024 at 10:00 a.m. a recertification survey was announced to the HHA representative. During a concurrent observation and interview on 2/12/2024 at 10:45 a.m., the Administrator/License Vocational Nurse 1 (ADM/LVN1), ADM/LVN 1 arrived to the HHA. The ADM/LVN1 was informed of needed Director of Nurses (DON) participation in the recertification survey. During an interview on 2/12/2024 at 11:30 a.m., the ADM/LVN1 stated the DON did not answer earlier when she called her. The ADM/LVN1 stated she would attempt to contact DON again for assistance. During an observation on 2/12/2024 at 1:20 p.m. the DON arrived at facility. On 2/12/2024, at 2:35 p.m., the DON was informed by the survey team to be present for the remainder of the survey. During an interview on 2/13/2024 at 10:45 a.m., the Office Assistant (OA) stated DON was not available due to visiting hospice patients. During an interview on 2/13/2024 at 11:17 a.m. with ADM/LVN1, ADM/LVN1 stated DON was not going to be able to assist with the recertification survey that day due to being at “her other job”. During an interview on 2/13/2024 at 1:30 p.m. with ADM/LVN1, ADM/LVN1 stated unable to locate another skilled nurse to conduct home visits. During an interview on 2/14/2024 at 1:37 p.m. with ADM/LVN1, ADM/LVN1 was requested to notify DON of needed survey assistance. ADM/LVN1 stated she will do her best to contact DON. During an interview on 2/14/2024 at 1:51 p.m. with ADM/LVN1, ADM/LVN1 stated she was calling DON, but DON did not answer. During a telephone interview on 2/14/2024 at 2:04 p.m. with the DON, DON stated she worked last night, but would take a quick shower and be at HHA to assist with recertification survey. During an interview on 2/14/2024, at 2:50 p.m., the OA stated the DON called angrily because the survey team was making her come in. The OA stated the DON stated she was sleepy because she worked last night, and she knew she did not have to come in and can be available over the phone. The OA stated the DON was available over the phone for interviews. During an interview on 2/14/2024 at 3:54 p.m. with OA, OA stated DON would be at HHA in 10 minutes. During an observation on 2/14/2024 at 4:00 p.m., the DON had not arrived at facility. Cross reference tags 536, 586, 590, 726.”

“Assure implementation of plan of care CFR(s): 484.105(c)(5) Assuring the development, implementation, and updates of the individualized plan of care. This Element is not met as evidenced by: Based on observation and record review, the Home Health Agency (HHA) failed to ensure the Clinical Manager (Director of Nurses – DON) ensured two of seven sampled patients’ (Patient 1 and Patient 5 ) individualized plan of care (POC) was updated to indicate the current care planned. This failure had the potential to result in patients not receiving the identified needs and services, and have a decline in health status, that could affect their quality of care and well-being. It also had the potential to result in confusion about the current treatments the patients were on. 1. A review of Patient 1’s medical record form titled “Patient Profile”, indicated a start of care date of 1/4/2024 with a primary diagnosis of wedge compression fracture of fourth thoracic vertebra (broken rib). A review of Patient 1’s medical record form titled “Home Health Certification and Plan of Care” dated from 1/4/2024 to 3/3/2024, listed under section “Medications: Dose/Frequency/Route (N)ew (C)hanged – Ferrous sulfate (iron medication); telmisartan (high blood pressure medication); Tudca (gallbladder medication); Osyco (calcium supplement); lorazepam (anti-anxiety medication); atenolol (high blood pressure medication)”. Form also indicated “medication reconciliation every SN (Skilled Nurse) visit.” A review of Patient 1’s Electronic Medical Record (EMR, computerized medical records) indicated there were two medical doctor’s orders. A review of Patient 1’s medical record form titled “Order/Telephone Order” dated 1/4/2024, indicated Medical Doctor 1 (MD1) ordered the following medications: Ferrous sulfate, telmisartan, Tudca, Osyco, lorazepam, and atenolol. During a joint home visit on 2/13/2024 at 1:50 p.m. with the Administrator/License Vocational Nurse 1 (ADM/LVN1) to Patient 1’s home, Patient 1 provided her home medications for review. Patient stated those were all the medications she was taking. The following medications were not in the patient’s home: Ferrous sulfate, telmisartan, Tudca, Osyco, lorazepam; and atenolol. ADM/LVN1 stated maybe the Director of Nurses (DON) forgot to discontinue the medications. The Clinical Manager failed to ensure Patient 1’s plan of care was revised to ensure it reflected the current medications being taken. The survey team was not able to interview on the process to update of the plan of care due to the DON not being available in person, during the time the surveyors were at the HHA. No other knowledgeable registered nurse was available during the survey process. 2. A review of Patient 5’s medical record titled “Patient Profile”, indicated a start of care date on 12/22/2023, with a primary diagnosis of hypertensive heart disease without heart failure (high blood pressure). During an interview on 2/13/2024, at 3:46 p.m., Patient 5’s caregiver (CG 2) stated services with the HHA began in January even though the doctor had placed the order for HHA services back in December 2023. CG 2 stated a nurse came to visit Patient 5 one time in January 2024, and no other nurses had come since then. CG 2 stated Patient 5 was receiving Physical Therapy services from the agency twice a week. A record review of Patient 5’s record titled, “Home Health Certification and Plan of Care”, for certification period 12/22/2023 to 2/19/2023, indicated the skilled nurse was to visit Patient 5 once a week for one week (1w1), twice a week for two weeks (2w1), and once a week for seven weeks (1w7). Further review of the record did not indicate Physical Therapy services. A record review of Patient 5’s record titled, “Home Plan of Care”, dated 12/22/2023, indicated, “Your care plan is ordered by your physician (doctor) and includes: Skilled Nursing…Physical Therapy…” The survey team was not able to interview on the process to update of the plan of care due to the DON not being available in person, during the time the surveyors were at the HHA. No other knowledgeable registered nurse was available during the survey process. The Clinical Manager failed to ensure Patient 5’s plan of care was revised and updated to reflect the services being given as reported by CG 2. During the Recertification survey, notified ADM that policies will be requested for the review, the ADM stated they need to ask consultant prior providing policies. No policies were received from the facility prior exiting the facility.”

“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 observation, interview, and record review, the HHA failed to ensure the plan of care accurately reflected the services provided for three of seven sampled patients (Patient 3, Patient 4, and Patient 5). This failure resulted in falsification of patient records. 1. A review of Patient 3’s document titled, “Patient Profile”, indicated a start of care date on 11/25/2023, with a primary diagnosis of Atherosclerotic heart disease of native coronary artery without angina pectoris (accumulation of plaque inside the walls of blood vessels). A record review of Patient 3’s document titled, “Home Health Certification and Plan of Care”, for certification period 1/24/2024 to 3/23/2024, indicated skilled nursing visits once a week for nine weeks (1w9). A record review of Patient 3’s records titled, “Nursing Progress Note”, for dates 1/31/2024, 1/24/2024, 2/7/2024, indicated the Administrator/Licensed Vocational Nurse 1 (ADM/LVN 1) had visited Patient 3. A review of Patient 4’s document titled, “Patient Profile”, indicated a start of care date on 11/25/2023, with a primary diagnosis of Atherosclerotic heart disease of native coronary artery without angina pectoris (accumulation of plaque inside the walls of blood vessels). A record review of Patient 4’s document titled, “Home Health Certification and Plan of Care”, for certification period 1/24/2024 to 3/23/2024, indicated skilled nursing visits once a week for nine weeks (1w9). A record review of Patient 4’s records titled, “Nursing Progress Note”, for dates 1/31/2024, 1/24/2024, 2/7/2024, indicated the ADM/LVN 1 had visited Patient 4. During an observation of the home visit on 2/13/2024, at 3:00 p.m., the ADM/LVN 1, visited Patient 3 and Patient 4 at the same residence. Caregiver 1 (CG 1) was present during the visit. During an interview on 2/13/2024, at 3:02 p.m., CG 1 stated nursing visits for Patient 3 and Patient 4 were every two weeks. The ADM/LVN 1 interrupted the interview and stated, “I come every week”. During an interview on 2/13/2024, at 3:35 p.m., CG 1 stated nursing visits for Patient 3 and Patient 4 were every two weeks. During an interview on 2/13/2024, at 3:38 p.m., the ADM/LVN 1 stated she did not know why CG 1 said the nurse comes every two weeks, because she visits Patient 3 and Patient 4 every week. The survey team was not able to interview about the discrepancy in CG 1’s interview and services based on the plan of care, due to the Director of Nursing (DON) not being available in person, during the time the surveyors were at the HHA. No other knowledgeable registered nurse was available during the survey process. Based on CG 1’s interview and record review’s, the HHA falsified Patient 3 and Patient 4’s clinical records. 2. A review of Patient 5’s record titled, “Patient Profile”, indicated a start of care date on 12/22/2023, with a primary diagnosis of hypertensive heart disease without heart failure (high blood pressure). During an interview on 2/13/2024, at 3:46 p.m., Patient 5’s caregiver (CG 2) stated services with the HHA began in January even though the doctor had placed the order for HHA services back in December 2023. CG 2 stated a nurse came to visit Patient 5 one time in January 2024, and no other nurses had come since then. CG 2 stated Patient 5 was receiving Physical Therapy services from the agency twice a week. CG2 stated she did not know why the documents provided to her by the HHA were “back dated to December”. A record review of Patient 5’s record titled, “Home Health Certification and Plan of Care”, for certification period 12/22/2023 to 2/19/2023, indicated the skilled nurse was to visit Patient 5 once a week for one week (1w1), twice a week for two weeks (2w1), and once a week for seven weeks (1w7). Further review of the record did not indicate Physical Therapy services. A record review of Patient 5’s record titled, “Home Plan of Care”, dated 12/22/2023, indicated, “Your care plan is ordered by your physician (doctor) and includes: Skilled Nursing…Physical Therapy…” A record review of Patient 5’s records titled, “Nursing Progress Note”, for dates 12/25/2023, 12/29/2023, 1/3/2024, 1/10/2024, 1/17/2024, 1/24/2024, 1/31/2024, 2/7/2024, indicated the ADM/LVN 1 had visited Patient 5. The survey team was not able to interview about the discrepancy in CG 2’s interview and services based on the plan of care, due to the DON not being available in person, during the time the surveyors were at the HHA. No other knowledgeable registered nurse was available during the survey process. Based on CG 2’s interview and record review’s, the HHA falsified Patient 5’s clinical records.”