Centercare Home Health

“Document complaint and resolution CFR(s): 484.50(e)(1)(ii) (ii) Document both the existence of the complaint and the resolution of the complaint; and This Element is not met as evidenced by: Based on an interview and record review, the agency failed to document or track investigations of complaints made by consumers and external agencies providing care to consumers/patients. Findings include: AGENCY POLICY According to the policy, titled, “Patient Complaints”, undated, (in part): “The Administrator will assure the complaint is reviewed, investigated as indicated and noted on the complaint log. The complaint log will be maintained in the agency office for a minimum of two years.” 1. The agency failed to document or track investigations of patient complaints from 6/1/24 to 8/4/24. 2. On 11/6/24 at 11:30 a.m., a documentation request list was given to the agency administrator, which included the agency complaint log. An interview with the director of nursing(DON) on 11/6/24 at 2:00 p.m., revealed she was new to the agency, and could not find the agency complaint log. 3. On 11/8/24 at 10:00 a.m., the agency was asked to locate complaints from 6/1/24 to the current date. Record review showed no evidence the agency had documented complaints from 6/1/24 to 8/4/24. An interview with the administrator on 11/8/24, at 10:15 a.m., revealed the agency had not been able to locate complaints or grievances from 6/1/24 to 8/4/24. Along with this topic the agency sent a document that discussed some complaints between dates of 6/1/24 to 8/4/24 but it failed to have all elements of a complaint investigation. The administrator stated that the agency had recognized the failure in the agency complaint process and on 8/5/24 the agency had implemented a formal process to capture all elements of patient complaints in a timely manner. The administrator went on to state all complaints would be investigated and placed on a complaint log moving forward.”

“Ensure that HHA employs qualified personnel CFR(s): 484.105(b)(1)(iv) (iv) Ensure that the HHA employs qualified personnel, including assuring the development of personnel qualifications and policies. This Element is not met as evidenced by: Based on record review and interview, the agency failed to ensure each employee had a complete personnel record. Specifically the agency failed to ensure each employee had current qualifications and licensure, a job description specific to the role they provided at the agency, and documentation of orientation to the agency was completed for 2 of 2 employees whose personnel records were reviewed. (Employee #1 and #2) Additionally the agency failed to implement agency policies and procedures regarding a criminal background check completed prior to hire and a Colorado Adult Protective Services (CAPS) check had been requested prior to hire for 1 personnel records. (Employee #2) Findings include: AGENCY POLICY According to an agency policy titled, “Personnel Records”, un-dated (read in part): “Personnel files will be established and maintained for all personnel.” According to an agency policy titled, “Criminal Background Checks”, un-dated (read in part): “Employees will not be able to start working with patients until the background check clearance has been received by the agency.” 1. Review of Employee #1’s personnel record showed a hire date of 7/8/24. a. The agency failed to ensure the personnel record for Employee #1 contained documentation of current qualifications, orientation to the agency, and a job description for Employee #1’s role as the administrator of the agency. Review of Employee #1’s personnel record failed to show evidence of current qualifications, orientation to the agency, and a job description. b. The agency failed to ensure the personnel record for Employee #1 contained documentation of current qualifications or licensure. Review of Employee #1’s personnel record failed to show evidence of current qualifications or licensure. 2. Review of Employee #2’s (Director of Nursing, DON) record showed a hire date of 7/24/24. a. The agency failed to ensure the personnel record for Employee #2 contained documentation of current qualifications, orientation to the agency, and a job description for Employee #2’s role for the agency. Review of Employee #2’s personnel record failed to show evidence of current qualifications, orientation to the agency, and a job description. b. The agency failed to include a department of regulatory agency (DORA) and CAPS checks as part of the agency’s hiring process. Record review showed no evidence that DORA or CAPS checks had been required to be completed prior to hire for Employee #2. 3. During an interview on 11/7/24 at 2:13 p.m., HR manager (Employee #3) stated she had never checked the administrator or DON’s personnel file for compliance because they were hired by a contracted service and access to their records was not available. She went on to say all other staff were hired through her and not through the contracted service and therefore the personnel files match the regulations. During an interview on 11/8/24 at 11:00 a.m., the administrator acknowledged the two employee records reviewed were incomplete and failed to have a job description, current qualifications, documentation of orientation to the agency, DORA or CAPS checks. The administrator stated he did not have time to review personnel file regulations. He further stated that he and the DON were hired by a contracted service and that he had assumed they had followed the regulations when putting the personnel files together. During this same discussion, the administrator and DON stated they will start auditing the personnel records to be compliant with the regulations in the future.”

“Only as ordered by a physician CFR(s): 484.60(b)(1) Drugs, services, and treatments are administered only as ordered by a physician or allowed practitioner. This Element is not met as evidenced by: Based on interviews and record reviews, the agency failed to ensure treatments and services were provided only as ordered by the physician for 6 of 10 patient records reviewed (Patients #1, #5, #6, #8, #9 and #10). Findings include: AGENCY POLICY According to the policy, “Physician/Provider Orders,” undated (in part): “All medications, treatment and services provided to clients must be ordered by a physician. The orders may be initiated via telephone or in writing and must be countersigned by the ordering provider/allowed licensed provider in a timely manner. All medications and treatments, that are part of the patient’s plan of care, must be ordered by the provider. All verbal orders must be “read back” to the provider to verify the accuracy of the orders and to decrease errors to inaccurate documentation of verbal orders.” 1. The clinical record for Patient #6 was reviewed on 2/27/24. The plan of care for the certification period dated 2/18/24 to 4/17/24 revealed a start of care date of 2/18/24; diagnoses included complications of procedures, stage 2 pressure ulcer of sacral region, respiratory failure, hypertensive heart and chronic kidney disease, heart failure, hypokalemia, hyperlipidemia, radiculopathy, depression and anxiety, dysphagia, seizures and morbid obesity. Plan of care orders included skilled nursing (SN) visits three times weekly for eight weeks and twice weekly for one week; physical therapy (PT) visits once weekly for one week, twice weekly for five weeks and once weekly for one week; and occupational therapy (OT) visits once weekly for one week and twice weekly for one week. Wound care orders included cleanse the abdominal wound with wound cleanser, pack with appropriate sterile packing strips and cover with 4x4 bordered gauze or equivalent; and cleanse pressure ulcer with wound cleanser and cover with barrier cream. a) The RN failed to ensure orders were received for the plan of care prior to the provision of services. Review of the start of care Outcome and Assessment Information Set (OASIS) assessment, dated 2/18/24, revealed RN #4 completed an assessment and there was no documentation she contacted the physician for verbal orders. Review of the section titled “Physician Acceptance of the Plan of Care” on the start of care assessment, RN #4 documented “Provider will accept HH [home health] order with POC [plan of care] upon receipt of fax.” Review of the record failed to show any documentation to show RN #4 contacted the physician for Patient #6 following the completion of the start of care assessment and plan of care to establish the frequencies for SN, PT and OT. Further review showed Patient #6 received three SN visits on 2/20/24, 2/22/24 and 2/26/24 to include wound care to her abdominal and sacral areas. Clinical record review failed to show the physician signed the plan of care prior to the provision of wound care services to Patient #6. During an interview on 2/29/24 at 9:49 a.m., RN #4 stated she worked part time for the agency and held a separate full-time job elsewhere. She said due to her primary employment, she was unable to call physician’s for verbal orders and relied on the office staff at the agency to provide requested orders, including plans of care, to the patient’s physicians via facsimile (fax). She stated, following her completion of the start of care assessment and development of the plan of care for Patient #6, she assumed the agency had sent the plan of care to be signed by the physician. 2. Similar findings of the agency failing to ensure the plan of care and supplemental physician orders had been established by the physician prior to the provision of services was found with Patients #1, #5, #8, #9 and #10. 3. During an interview on 2/28/24 at 1:20 p.m., OT #9 stated she was not informed by the previous director of nursing (DON) to call physicians for verbal orders once she completed a plan of care. She stated she was told the office staff at the agency would fax the orders to the physicians for signatures. She stated she did not ever see signed orders, but assumed that once the scheduler populated the patient visits on her (the OTs) schedule, she assumed the agency had received the signed orders from the physician and the clinicians had authorization to provide services. During an interview on 2/28/24 at 3:04 p.m., the administrator stated she was not aware the agency clinicians were not receiving verbal orders for plans of care and supplemental orders. During an interview on 2/29/24 at 9:49 a.m., RN #4 stated physician approval of orders was “done on the back end” in the agency office. She stated she was informed to document on her orders that the orders were received via fax. She further stated she was never made aware by the agency when signed physician orders were received for patients. During an interview on 2/29/24 at 1:04 p.m., the administrator acknowledged the agency had a systemic failure regarding ensuring physician orders, including plans of care, were not just agency requests, but complete orders, both verbal and written, approved by the physicians prior to agency staff providing services.”

“Onsite supervisory visit every 14 days CFR(s): 484.80(h)(1)(i) If home health aide services are provided to a patient who is receiving skilled nursing, physical or occupational therapy, or speech-language pathology services, a registered nurse or other appropriate skilled professional who is familiar with the patient, the patient’s plan of care, and the written patient care instructions described in §484.80(g), must make an onsite visit to the patient’s home no less frequently than every 14 days. The home health aide does not have to be present during this visit. This Element is not met as evidenced by: Based on interview and record review, the agency failed to ensure a registered nurse (RN) or other appropriate skilled professional familiar with the patient, the patient’s plan of care, and the written patient care instructions made an onsite visit to the patient’s home no less frequently than every 14 days to conduct home health aide (HHA) supervision for 1 of 5 patients receiving skilled care and HHA services (Patient #7). Findings include: AGENCY POLICY According to agency policy titled, “Home Health Aide Supervision,” undated (in part): “Supervision of Home Health Aides may be done by the appropriate Therapist at the patient’s residence at least every two (2) weeks, as allowed by state practice acts. At least once every sixty (60) days the aide must be present during the supervision for assessment of services provided.” 1. The clinical record for Patient #7 was reviewed on 2/27/24. The plan of care for the certification period dated 1/6/24 through 3/5/24, revealed a start of care date of 11/7/23; diagnoses included stage 3 pressure ulcer of right buttock, paraplegia, unspecified injury at T11-T12 level of thoracic spinal cord, ulcer of esophagus without bleeding, acute embolism and thrombosis of unspecified deep veins of left lower extremity, gastro-esophageal reflux disease (GERD), dependence on wheelchair, current use of anticoagulants and opiate analgesic, history of falling, history of nicotine dependence, and encounter for fitting and adjustment of urinary device. Plan of care orders included skilled nursing (SN) services two times a week for eight weeks and two times as needed (PRN) visits for wound care; home health aide (HHA) services three times a week for four weeks; and occupational therapy (OT) services one time a week for one week. a) The RN failed to conduct onsite visits to supervise the HHA no less frequently than every 14 days as required. Review of the plan of care dated 1/6/24 to 3/5/24, showed SN services, OT services and HHA services were ordered by Patient #7’s physician. Review of the clinical record from 1/6/24 to 2/27/24, revealed Patient #7 received SN services two times a week and HHA services three times a week as ordered. Further review of the clinical record revealed Patient #7 had not received any supervisory visits from 1/6/24 to 2/27/24. During an interview on 2/28/24 at 11:56 a.m., RN #6 stated supervisory visits for Patient #7 should have been done every 14 days. She stated she thought OT was completing them, but did not see them plotted on either the occupational therapists (OTs ) schedule or her own and stated it did not appear Patient #7 had received any HHA supervisory visits. RN #6 confirmed Patient #7 had been overlooked for supervisory visits. During an interview on 2/28/24 at 2:51 p.m., the administrator stated the supervisory visits should have been conducted every 14 days for Patient #7 and she was unsure how the agency failed to schedule them.”

“Discharge and transfer summaries CFR(s): 484.110(a)(6)(i-iii) (i) A completed discharge summary that is sent to the primary care practitioner or other health care professional who will be responsible for providing care and services to the patient after discharge from the HHA (if any) within 5 business days of the patient’s discharge; or (ii) A completed transfer summary that is sent within 2 business days of a planned transfer, if the patient’s care will be immediately continued in a health care facility; or (iii) A completed transfer summary that is sent within 2 business days of becoming aware of an unplanned transfer, if the patient is still receiving care in a health care facility at the time when the HHA becomes aware of the transfer. This Element is not met as evidenced by: Based on interview and record review, the agency failed to ensure a discharge summary was sent to the primary care practitioner within five business days of discharge for 2 of 3 patient records reviewed requiring a discharge summary (Patients #9 and #10). Findings include: AGENCY POLICY According to the policy, “Discharge Summary,” undated (in part): “When a patient is discharged from the agency, the assigned clinician will complete a Discharge Summary within (5) business days of discharge.” 1. The clinical record for Patient #10 was reviewed on 2/28/24. The plan of care for the certification period 10/16/23 to 12/14/23 revealed a start of care date of 12/20/22; diagnoses included type 2 diabetes mellitus with diabetic autonomic (poly)neuropathy, surgical procedure, gastroparesis, hypertensive heart disease with heart failure, chronic systolic (congestive) heart failure, atherosclerotic heart disease of native coronary artery without angina pectoris (chest pain), chronic respiratory failure with hypoxia, sarcoidosis, anemia, epilepsy, gastro-esophageal reflux disease (GERD), restless legs syndrome, anxiety, bilateral hearing loss, current) use of insulin and anticoagulants, dependence on supplemental oxygen, and history of pulmonary embolism, transient ischemic attack (TIA) and cerebral infarction, atrial fibrillation and urinary tract infections (UTIs). Plan of care orders included skilled nurse (SN) services one time a week for nine weeks and two times as needed (PRN) for lab draws, change of condition, or development of wound; and home health aid (HHA) services two times a week for nine weeks for assistance with activities of daily living (ADLs) and bathing. a) The agency failed to ensure Patient #10’s discharge summary was sent to the physician within five business days of the patient’s discharge. Clinical record review showed a discharge order dated 12/14/23 completed by registered nurse (RN) #6,. which stated “Effective 12/14/23 patient to be discharged from CenterCare home health.” There was no evidence in the clinical record the discharge was communicated to the physician verbally or in writing and the discharge order was not signed by the physician until 1/24/24, 40 days after the patient had discharged from the agency. During an interview on 2/29/24 at 9:09 a.m., RN #6 stated the patient was not available during the five days prior to recertification and the previous director of nursing (DON) instructed her to discharge and readmit the patient. RN #6 stated, since the patient was readmitted to the agency shortly thereafter, she did not know notification of the discharge to the physician was necessary. 2. The clinical record for Patient #9 was reviewed on 2/28/24. The plan of care for the certification period 6/25/23 to 8/23/23 revealed a start of care date of 6/25/23; diagnoses included multiple fractures of left ribs, traumatic hemothorax, acute pain due to trauma, fall on and from ladder, elevated blood pressure, psychoactive substance abuse, anxiety, amnesia, slurred speech and history of traumatic brain injury. Plan of care orders included SN services three times a week for one week, two times a week for one week, one time a week for seven weeks and two times as needed (PRN); physical therapy (PT) services one time a week for eight weeks; and occupational therapy (OT) services one time a week for eight weeks. a) The agency failed to ensure Patient #9’s discharge summary was sent to the physician within five business days of the patient’s discharge. Clinical record review showed a discharge order dated 8/11/23 completed by RN #3, which stated “Effective 8/11/23 Early DC [discharge] from the agency. Patient is not participating in RN/PT/OT visits.” There was no evidence in the clinical record the discharge was communicated to the physician, verbally or in writing and the discharge was sent to the physician via facsimile (fax) on 8/21/23, 10 days after the patient had discharged from the agency. During an interview on 2/28/24 at 2:51 p.m., the administrator/DON confirmed the first notification to the physician of Patient #9’s discharge from the agency was not made until 8/21/23.”