Independence Home Health of Broward County

“Responsible for all day-to-day operations CFR(s): 484.105(b)(1)(ii) (ii) Be responsible for all day-to-day operations of the HHA; This Element is not met as evidenced by: Based on record review, interview and the Home Health Agency (HHA)’s Policy and Procedure review, the HHA failed to ensure the HHA’s Administrator provided oversight for all of the HHA’s patient care and services for 2 of 3 sampled active patients (Patient #1 and #3). The findings included: 1) Review of the HHA’s Policy and Procedure provided by the Director of Nursing/Administrator titled, “Administrator: Defined” revised on March 2018 documents, “The Governing Body had appointed the administrator to run the agency’s day to day operations…The Administrator of the agency has the following responsibilities: planning, organizing, directing and evaluating operations to ensure the provision of adequate and appropriate care and services…” Review of Patient #1’s clinical record documents 41 completed Skilled Nurse visits from 11/12/27/24 to 11/27/24. Further review reveals the patient’s clinical record lacks written evidence of a physician’s ordered Plan Of Care for care and services provided by the Skilled Nurse’s visits. Continued review of Patient #1’s clinical record reveals a “Resumption Of Care,” dated 12/09/24 that lacks written evidence of a physician’s ordered Plan Of Care for the care and services provided by the Skilled Nurse’s visits. Further review reveals the patient’s clinical record documents 52 completed Skilled Nurse’s visits for care and services from 12/10/24 to 12/27/24 that lacks written evidence of a physician’s ordered Plan Of Care for the care and services provided by the Skilled Nurse’s visits. Review of Patient #1’s clinical record documents a “Resumption Of Care Assessment,” dated 01/03/25 that lacks written evidence of physician’s orders for the “Resumption Of Care “on 01/03/25. Review reveals the patient’s clinical record documents 11 completed Skilled Nurse’s visits from 01/03/25 to 01/07/25 to provide care and services; the patient’s clinical record lacks written evidence of a physician’s ordered Plan Of Care for the care and services provided by the Skilled Nurse’s visits. Review of Patient #1’s clinical record documents a “Recertification Assessment,” dated 01/08/25 that lacks written physician’s orders for the resumption of care on 01/08/25. Review reveals the patient’s clinical record documents 11 completed Skilled Nurse visits to provide care and services from 01/08/25 to 01/10/25 and the patient’s clinical record lacks written evidence of a physician’s Plan Of Care for the care and services provided by the Skilled Nurse’s visits. Patient #1’s Skilled Nurse’s visit “notes,” for 01/05/25, 01/11/125 and 01/12/25 was not available in the patient’s record for review. On 01/16/25 at 2:45 PM, during an interview, the Administrator/Director of Nursing (Adm/DON) confirmed the findings; the Adm/DON was apprised that Skilled Nurse’s visit “notes” for 01/05/25, 01/11/125 and 01/12/25 were not available in the patient’s record for review; stated that the Skilled Nurse was asked to “turn in the notes” and she would check on the timeframe for the documentation of the patient’s notes to be sent to the HHA’s office. 2) Review of Patient #3’s clinical record documents a “Start Of Care on 07/09/24; review of the patient’s physician’s Plan Of Care for the certification period for 07/09/24 to 09/06/24, lacks written evidence of a Skilled Nurse visit frequency. Further review reveals a written physician’s order, dated 07/09/24, for Skilled Nurse visits three (3) times a day to assess patient… SN (Skilled Nurse) to instruct caregiver on IV (Intravenous) procedure as per MD (Physician)’s order. Continued review reveals the patient received a Skilled Nurse visit every week, not three (3) times a day as per the physician’s ordered Plan Of Care. Review of Patient #3’s clinical record documents a “Recertification Assessment” visit on 12/31/24; the Skilled Nurse documented a “dressing change” and a “blood draw” to be “done by the Skilled Nurse weekly…plan for next visit change PICC (Peripherally Inserted Central Catheter) line dressing and draw blood sample…” Review reveals the patient’s clinical record documents two (2) completed Skilled Nurse visits, one on 01/06/25 and another on 01/13/25; the patient’s clinical record lacks written evidence of a physician’s written Plan Of Care for services and care provided by the Skilled Nurse’s visits. On 01/16/25 at 4:25 PM, a side-by-side review of Patient #3’s clinical record and an interview was conducted with the Adm/DON.; the Adm/DON confirmed that Patient #3 did not have a physician’s ordered written Plan Of Care for the certification period of 01/05/25 to 03/05/25; the Adm/DON was apprised of the patient’s Plan Of Care documentation for the certification period from 07/09/24 to 09/06/24 related to the Skilled Nurse’s visit frequency and of the Skilled Nurse’s visit completed on 01/06/25 and on 01/13/25 without physician’s orders; the AD/DON stated the patient’s Skilled Nurse’s visit frequency was rectified on the next certification period and that she was not aware of the patient not having a written Plan Of Care for the HHA to provide care and services. On 01/16/25 at 5:01 PM, an interview with the Administrator/DON and the Chief of Operations Officer by telephone was conducted; the Adm/DON was asked how the patient’s Plan Of Care was “generated” and replied that she refers to the physician’s orders to create the Plan Of Care, once the information is populated, it is sent to the physician; the Adm/DON was asked who was responsible for the Plan Of Care, who reviews it for completion and accuracy and stated that it should be the DON and the Administrator and the Adm/DON stated that she was not aware of the lack of the patient’s Plan Of Care completion as required.”

“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 the Home Health Agency (HHA)’s Policy and Procedure review, record review and interview, the HHA failed to ensure the patient’s clinical record for patients receiving Skilled Nursing services included the physician’s Plan Of Care and the completed Skilled Nurse’s notes for 2 of 3 sampled current/active patients receiving Skilled Nursing care (Patient #1 and #3). The findings included: 1) Review of the HHA’s Policy and Procedure, provided by the Director of Nursing/Administrator titled, “Plan of Care-CMS#485 and Physician Orders” revised on March 2019 documents, “…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…each patient must receive the home health services that are written in an individualized plan of care…” Review of the HHA ‘s Policy and Procedure, provided by the Director of Nursing/Administrator titled, “Medical Record Content” revised on March 2018 documents, “The agency will initiate and maintain an individual and accurate medical record for each patient receiving care in compliance with all federal/state laws and regulations…each medical record will contain the following:…ongoing assessments, including…all assessments of most recent home health admission…identification of problems, interventions and goals (care planning) for each discipline and updates to the plan of care…”. Review of the HHA’s Policy and Procedure, provided by the Director of Nursing/Administrator titled, “Timely Submission of Patient Documentation” revised on October 2017 documents “…itineraries with all visit reports attached. Must be submitted the next scheduled workday, not exceeding three (3) business days…”. Review of Patient #1’s clinical record documents a “Start Of Care on 05/16/24, a diagnosis of Diabetes Mellitus Type 2 with chronic kidney disease and review of the patient’s physician’s Plan Of Care, for the certification period, 09/13/24 to 11/11/24 documents Skilled Nurse visits to provide care and services, two per day. Review of the Skilled Nurse Visit “calendar” documents a Skilled Nurse visit was completed three times a day and not two times a day per the physician’s ordered Plan Of Care. Review of Patient #1’s clinical record documents 41 completed Skilled Nurse’s visits to provide care and services from 11/12/27/24 to 11/27/24. Further review reveals the patient’s clinical record lacks written evidence of a physician’s ordered Plan Of Care for the care and services provided by the Skilled Nurse’s visits. Review of Patient #1’s clinical record reveals a “Resumption Of Care,” dated 12/09/24 that lacks written evidence of a physician’s ordered Plan Of Care for the Skilled Nurse’s visits. Review reveals the patient’s clinical record documents 52 completed Skilled Nurse Visits to provide care and services from 12/10/24 to 12/27/24 and the patient’s clinical record lacks written evidence of a physician’s ordered Plan Of Care for the care and services provided by the Skilled Nurse’s visits. Review of Patient #1’s clinical record documents a “Resumption Of Care Assessment,” dated 01/03/25 that lacks written physician’s orders for the “Resumption Of Care on 01/03/25. Review reveals the patient’s clinical record documents 11 completed Skilled Nurse’s visits to provide care and services from 01/03/25 to 01/07/25 and the patient’s clinical record lacks written evidence of a physician ordered Plan Of Care for the care and services provided by the Skilled Nurse’s visits. Review of Patient #1’s clinical record documents a “Recertification Assessment,” dated 01/08/25 that reveals the lack of written physician’s orders for the resumption of care on 01/08/25. Review reveals the patient’s clinical record documents 11 completed Skilled Nurse visits to provide care and services from 01/08/25 to 01/10/25 and the patient’s clinical record lacks written evidence of a physician’s Plan Of Care for the care and services provided by the Skilled Nurse’s visits. Patient #1’s Skilled Nurse’s visit “notes,” for 01/05/25, 01/11/125 and 01/12/25 was not available in the patient’s record for review. On 01/16/25 at 2:45 PM, a side-by-side review of Patient #1’s completed Skilled Nurse visits and the physician’s Plan Of Care was conducted with the Administrator/Director of Nursing (Adm/DON), the Adm/DON confirmed the patient had Skilled Nurse visits, a Resumption Of Care and a Recertification completed without a written physician’s Plan Of Care as required; the Adm/DON was apprised that the Skilled Nurse’s visit “Note” for 01/05/25, 01/11/125 and 01/12/25 was not available for review in the patient’s record and stated the nurse was asked to turn in the notes and that the HHA will “figure out a way to be more efficient.” 2) Review of Patient #3’s clinical record documents a “Start Of Care” on 07/09/24 with diagnoses that included Malignant Otitis Externa, Left Ear and Diabetes Mellitus Type 2. Review of the patient’s physician’s Plan Of Care for the certification period for 07/09/24 to 09/06/24 lacks written evidence of a Skilled Nurse visit frequency. Further review reveals a written physician’s order dated 07/09/24 for Skilled Nurse visits three (3) times a day to assess patient, monitor vital signs, teach disease process, provide instructions about medication administration and management, including side and adverse effects. Evaluate patient needs, compliance with medical regimen and report any abnormalities to MD (Medical Doctor). Involve family/ caregivers in plan of care. SN to instruct caregiver on IV (Intravenous) procedure as per MD order. Review reveals the patient received a Skilled Nurse’s visit to provide care and services every week. Review of Patient #3’s clinical record documents a “Recertification Assessment” visit on 12/31/24; the Skilled Nurse documented a dressing change and a “blood draw” to be “done by nurse weekly…plan for next visit change PICC (peripherally inserted central catheter) line dressing and draw blood sample…” Review reveals the patient’s clinical record documents two (2) completed Skilled Nurse visits, one on 01/06/25 and another on 01/13/25; the patient’s clinical record lacks written evidence of a physician’s written Plan Of Care for services and care provided by the Skilled Nurse’s visits. On 01/16/25 at 4:25 PM, a side-by-side review of Patient #3’s clinical record and an interview was conducted with the Adm/DON.; the Adm/DON confirmed that Patient #3 did not have a physician’s ordered written Plan Of Care for the certification period of 01/05/25 to 03/05/25; the Adm/DON was apprised of the patient’s Plan Of Care documentation for the certification period from 07/09/24 to 09/06/24 related to the Skilled Nurse’s visit frequency and of the Skilled Nurse’s visit completed on 01/06/25 and on 01/13/25 without physician’s orders; the AD/DON stated the patient’s Skilled Nurse’s visit frequency was rectified on the next certification period and that she was not aware of the patient not having a written Plan Of Care for the HHA to provide care and services.”