Cerro Gordo County Department of Public Health

“EP Training Program CFR(s): 484.102(d)(1) §403.748(d)(1), §416.54(d)(1), §418.113(d)(1), §441.184(d)(1), §460.84(d)(1), §482.15(d)(1), §483.73(d)(1), §483.475(d)(1), §484.102(d)(1), §485.68(d)(1), §485.542(d)(1), §485.625(d)(1), §485.727(d)(1), §485.920(d)(1), §486.360(d)(1), §491.12(d)(1). *[For RNCHIs at §403.748, ASCs at §416.54, Hospitals at §482.15, ICF/IIDs at §483.475, HHAs at §484.102, REHs at §485.542, “Organizations” under §485.727, OPOs at §486.360, RHC/FQHCs at §491.12:] (1) Training program. The [facility] must do all of the following: (i) Initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles. (ii) Provide emergency preparedness training at least every 2 years. (iii) Maintain documentation of all emergency preparedness training. (iv) Demonstrate staff knowledge of emergency procedures. (v) If the emergency preparedness policies and procedures are significantly updated, the [facility] must conduct training on the updated policies and procedures. *[For Hospices at §418.113(d):] (1) Training. The hospice must do all of the following: (i) Initial training in emergency preparedness policies and procedures to all new and existing hospice employees, and individuals providing services under arrangement, consistent with their expected roles. (ii) Demonstrate staff knowledge of emergency procedures. (iii) Provide emergency preparedness training at least every 2 years. (iv) Periodically review and rehearse its emergency preparedness plan with hospice employees (including nonemployee staff), with special emphasis placed on carrying out the procedures necessary to protect patients and others. (v) Maintain documentation of all emergency preparedness training. (vi) If the emergency preparedness policies and procedures are significantly updated, the hospice must conduct training on the updated policies and procedures. *[For PRTFs at §441.184(d):] (1) Training program. The PRTF must do all of the following: (i) Initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles. (ii) After initial training, provide emergency preparedness training every 2 years. (iii) Demonstrate staff knowledge of emergency procedures. (iv) Maintain documentation of all emergency preparedness training. (v) If the emergency preparedness policies and procedures are significantly updated, the PRTF must conduct training on the updated policies and procedures. *[For PACE at §460.84(d):] (1) The PACE organization must do all of the following: (i) Initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing on-site services under arrangement, contractors, participants, and volunteers, consistent with their expected roles. (ii) Provide emergency preparedness training at least every 2 years. (iii) Demonstrate staff knowledge of emergency procedures, including informing participants of what to do, where to go, and whom to contact in case of an emergency. (iv) Maintain documentation of all training. (v) If the emergency preparedness policies and procedures are significantly updated, the PACE must conduct training on the updated policies and procedures. *[For LTC Facilities at §483.73(d):] (1) Training Program. The LTC facility must do all of the following: (i) Initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected role. (ii) Provide emergency preparedness training at least annually. (iii) Maintain documentation of all emergency preparedness training. (iv) Demonstrate staff knowledge of emergency procedures. *[For CORFs at §485.68(d):](1) Training. The CORF must do all of the following: (i) Provide initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles. (ii) Provide emergency preparedness training at least every 2 years. (iii) Maintain documentation of the training. (iv) Demonstrate staff knowledge of emergency procedures. All new personnel must be oriented and assigned specific responsibilities regarding the CORF’s emergency plan within 2 weeks of their first workday. The training program must include instruction in the location and use of alarm systems and signals and firefighting equipment. (v) If the emergency preparedness policies and procedures are significantly updated, the CORF must conduct training on the updated policies and procedures. *[For CAHs at §485.625(d):] (1) Training program. The CAH must do all of the following: (i) Initial training in emergency preparedness policies and procedures, including prompt reporting and extinguishing of fires, protection, and where necessary, evacuation of patients, personnel, and guests, fire prevention, and cooperation with firefighting and disaster authorities, to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles. (ii) Provide emergency preparedness training at least every 2 years. (iii) Maintain documentation of the training. (iv) Demonstrate staff knowledge of emergency procedures. (v) If the emergency preparedness policies and procedures are significantly updated, the CAH must conduct training on the updated policies and procedures. *[For CMHCs at §485.920(d):] (1) Training. The CMHC must provide initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles, and maintain documentation of the training. The CMHC must demonstrate staff knowledge of emergency procedures. Thereafter, the CMHC must provide emergency preparedness training at least every 2 years. This Standard is not met as evidenced by: Based on review of emergency preparedness training rosters, review of the emergency preparedness plan and policies and staff interview, the agency failed to ensure training in emergency preparedness for 1 of 1 sampled individual providing services under arrangement (contract staff), consistent with their expected role for the calendar years of 2022 and 2023 (Staff C). The agency currently utilized a total of 6 contracted staff (Physical Therapists and Occupational Therapists) to provide services to patients. Lack of emergency preparedness training for staff puts patients at risk should an emergency situation arise and staff would be needed to assist patients to ensure patient safety. Findings include: During an interview on 12/11/24 at 9:00 AM, Administrator/Clinical Manager reported contracted staff have never been trained on Emergency Preparedness since they are contracted and not hired employees. Staff C, LPT (Licensed Physical Therapist), had a hire date of April 2013. The agency was unable to provide any documentation identifying Emergency Preparedness training had been completed for Staff C. The agency failed to provide Emergency Preparedness training for contracted staff. The above findings were reviewed with the Administrator/Clinical Manager and the Home Care Aide Manager.”

“Home health aide assignments and duties CFR(s): 484.80(g)(1) Standard: Home health aide assignments and duties. Home health aides are assigned to a specific patient by a registered nurse or other appropriate skilled professional, with written patient care instructions for a home health aide prepared by that registered nurse or other appropriate skilled professional (that is, physical therapist, speech-language pathologist, or occupational therapist). This Standard is not met as evidenced by: Based on agency interviews, clinical record reviews and agency policy review, the agency failed to provide individualized and specific written patient care instructions from a registered nurse to agency home health aides for 4 of 4 sampled patients receiving home health aide services (Patients #2, #3, #5 and #6). Failure to ensure agency registered nurses provided patient specific written instructions directing the care provided by the agency’s home health aides for each patient increased the risk agency patients would receive inappropriate or inconsistent home health aide services. Findings include: 3. Patient #5 had a start of care date of 11/1/17. Clinical record review revealed: a. Plans of Care, dated 9/25/24 to 11/23/24 and 11/24/24 to 1/22/25, included physician orders for skilled nurse and home health aide services. b. Aide care plan, dated 6/3/22, included instructions that directed the aide to provide nail care-clean, clip and file toe or fingernails. The care plan failed to identify the frequency the task was to be completed. c. Aide visit notes, dated 10/8, 10/11, 10/15, 10/18, 10/22, 10/25, 10/29, 11/5, 11/8, 11/12, 11/15, 11/19, 11/22, 11/26, 12/3 and 12/6/24, for the task nail care-clean, clip and file toe or fingernails was documented as not applicable this visit. The nurse failed to identify the frequency for the task nail care. 4. Patient# 6 had a start of care date of 6/17/24 and a discharge date of 7/1/24. Clinical record review revealed: a. Plan of Care, dated 6/17/24 to 8/15/24, included physician orders for skilled nurse and home health aide services. b. Aide care plan, dated 6/17/24, included special instructions related to: Mobility: walker, cane or wheelchair, independent, needs assist; Wounds/incisions/dressings: Ability to safely make decisions regarding care – patient or caregiver. The nurse failed to individualize the special instructions for the patient. During an interview on 12/11/24 at 9:30 AM, Administrator/Clinical Manager reported/confirmed the nurse failed to individualize the special instructions for the patient. The above findings were reviewed with the Administrator/Clinical Manager and the Home Care Aide Manager. According to the agency policy, titled Assignment and Supervision of Home Care Aides, revised 9/2024, the Registered Nurse (RN) completes the home health aide care plan. The home health aide care plan includes specific tasks, including frequency and the RN makes notations regarding pertinent information for the aide to provide care to the patient. During an interview on 12/10/24 at 2:19 PM, the Administrator/Clinical Manager stated an RN completes the home health aide care plan. The care plan is specific and unique to the patient and identifies frequency of tasks to be completed. 1.Patient #2 had a start of care date of 6/30/2017. Clinical record review revealed: a. Plans of Care, dated 9/21/24 to 11/19/24 and 11/20/24 to 1/18/25, included orders for skilled nurse and home health aide services . b. Aide care plan, dated 5/31/22, included instructions that directed the aide to provide nail care-clean, clip and file toe or fingernails. The care plan failed to identify the frequency the task was to be completed. c. Aide visit notes, dated 10/8, 10/10, 10/14, 10/21, 10/23, 10/29, 10/31, 11/4, 11/7, 11/11, 11/12, 11/14, 11/18, 11/21, 11/26, 12/2 and 12/5/24, for the task nail care-clean, clip and file toe or fingernails was documented as not applicable this visit. The nurse failed to identify the frequency for the task nail care. 2.Patient #3 had a start of care date of 6/10/24. Clinical record review revealed: a. Plan of Care, dated 10/8/24 to 12/6/24, included orders for skilled nurse and home health aide services . b. Aide care plan, dated 6/10/24, included instructions that directed the aide to provide nail care-clean, clip and file toe or fingernails. The care plan failed to identify the frequency the task was to be completed. c. Aide visit notes, dated 10/15, 10/22,10/28, 11/1, 11/5, 11/8, and 11/14/24, for the task nail care-clean, clip and file toe or fingernails was documented as not applicable this visit. The nurse failed to identify the frequency for the task of nail care.”

“Health, psychosocial, functional, cognition CFR(s): 484.55(c)(1) Standard: Content of the comprehensive assessment. The comprehensive assessment must accurately reflect the patient’s status, and must include, at a minimum, the following information: (1) The patient’s current health, psychosocial, functional, and cognitive status; This Element is not met as evidenced by: Based on clinical record review, agency policy review, and agency staff interview, the agency failed to complete wound assessments for 1 of 3 sampled patients with wounds (Patient #5). Failure to accurately and thoroughly complete wound assessments placed patients at an increased risk of inappropriate treatment. Findings include: According to the agency policy, titled Patient Care Wound Assessment Documentation Policy, dated 10/2024, open wounds will be measured weekly, measurements will be documented by length, width and depth. During an interview on 12/10/24 at 2:19 PM, Administrator/Clinical Manager reported wounds should be measured weekly, measurements include length, width and depth. Any open areas should be measured as well as blisters and reddened areas. Patient #5 had a start of care date of 11/1/17. Clinical record review revealed: a. The Plan of Care, dated 9/25/24 to 11/23/24 and 11/24/24 to 1/22/25, included orders for skilled nurse services. b. The skilled nurse visit note, dated 10/25, 10/29, 11/1, 11/8 and 12/6/24, included documentation of bilateral leg wounds care completed. The notes failed to include documentation of measurements of the bilateral leg wounds. The agency failed to document weekly measurements of the patient’s bilateral leg wounds. During an interview on 12/11/24 at 10:30 AM, Administrator/Clinical Manager reported she had reviewed the clinical record and was unable to find additional wound measurements. The above findings were reviewed with the Administrator/Clinical Manager and the Home Care Aide Manager.”

“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, 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 5 of 7 sampled patients (Patients #1, #3, #4, #5, and #7). 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. 4.Patient #3 had a start of care date of 6/10/24. Clinical record review revealed: a. The Plan of Care, dated 10/8/24 to 12/6/24 and 12/7/24 to 2/4/25 included physician orders for skilled nursing services and medications. b. The recertification comprehensive assessment, dated 10/7/24 and 12/4/24, completed by Staff B, Registered Nurse (RN), identified a drug regimen review was completed and no changes were made to medications. c. During a home visit observation and interview on 12/10/24 at 12:30 PM, with Staff B, RN, interview with the patient revealed patient’s aunt sets up his/her medication. The surveyor identified the following medication discrepancies: 1)The POCs identified the patient takes Vitamin C 1000 milligram (mg) tablets with instructions to take one tablet by mouth once a day. The bottle in the home is Vitamin C 500mg tablets. During an interview, the patient reported he/she takes Vitamin C 500mg one time a day and has done so since the start of care on 6/10/24. 2)The POCs identified the patient takes Cyclobenzaprine 10mg tablets with instructions to take one tablet by mouth three times a day as needed for muscle spasms. The bottle in the home is Cyclobenzaprine 5mg tablets with instructions to take one tablet by mouth three times a day as needed for muscle spasms. The patient reported he/she has not taken the medication since the start of care on 6/10/24 due to physician prescribing a different muscle relaxant. 3) The POCs identified the patient takes Colace sodium (laxative) 50mg capsules with instructions to take one capsule by mouth in the morning. The bottle in the home is Docusate Sodium 100mg capsules. The patient reported taking Docusate Sodium 100mg, one capsule by mouth at bedtime for over a year. 4) The POCs identified the patient takes Sucralfate 1 gram tablets with instructions to take one tablet by mouth four times a day (before meals and at bedtime) for stomach inflammation. The patient reported the doctor discontinued Sucralfate at least two months ago. The agency failed to include a drug regimen review that identified medication discrepancies, ineffective drug therapy and side effects. 5.Patient #4 had a start of care date of 11/20/24. Clinical record review revealed: a. Plan of Care, dated 11/20/24 to 1/18/24, included physician orders for skilled nursing services and medications. b. The start of care comprehensive assessment, dated 11/20/24, failed to include a drug regimen review that identified ineffective drug therapy and side effects. The above findings were reviewed with the Administrator/Clinical Manager and the Home Care Aide Manager. Findings include: During an interview on 12/9/24 at 4:05 PM, Administrator/Clinical Manager reported the drug regimen review is usually documented in the comprehensive assessments in the narrative note at the end of the visit note. Some staff do not document in the narrative and answer the medication questions in the comprehensive assessment. During an interview on 12/11/24 at 9:40 AM, Administrator/Clinical Manager reported drug interactions and duplicate medications are identified on the medication tab in the electronic medical record. 1.Patient #1 had a start of care date of 12/2/24. Clinical record review revealed: a. Plan of Care, dated 12/2/24 to 1/30/25, included physician orders for medications. b. The Start of Care comprehensive assessment, dated 12/2/24, failed to include a drug regimen review that identified effective drug therapy, side effects and noncompliance. 2. Patient #5 had a start of care date of 11/1/17. Clinical record review revealed: a. Plans of Care, dated 7/27/24 to 9/24/24, 9/25/24 to 11/23/24 and 11/24/24 to 1/22/25, included physician orders for medications. b. The recertification comprehensive assessments, dated 7/23/24 and 11/19/24, included documentation the patient has a VA (Veterans Administration) home based primary care nurse for medication management. The documentation failed to include a drug regimen review that identified effective drug therapy, side effects and noncompliance. c. The recertification comprehensive assessment, dated 9/20/24, included documentation the patient has a VA (Veterans Administration) home based primary care nurse for medication management and requires combination therapy for cardiac health. The documentation failed to include a drug regimen review that identified effective drug therapy, side effects and noncompliance. 3. Patient #7 has a start of care date of 8/21/24 and a discharge date of 9/5/24. Clinical record review revealed: a. Plan of Care, dated 8/21/24 to 10/19/24, included physician orders for medications. b. Start of Care comprehensive assessment, dated 8/21/24, included documentation of compliance and side effects. The documentation failed to include a drug regimen review that identified effective drug therapy. c. Discharge summary, dated 9/5/24, failed to include a drug regimen review that identified effective drug therapy, side effects and noncompliance.”

“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 home visit observation, patient/caregiver interview and admission packet review, the agency failed to provide agency patients with a written medication list, including medication name, dosage and frequency for 1 of 3 sampled patients with home visits (Patient #3). Failure to provide the medication list to the patient put the patient and caregiver at risk for not knowing all medications patient is taking and put the patient at risk for inappropriate medication administration. Findings include: Patient #3 had a start of care date of 6/10/24 and received skilled nursing and home care aide services. During a home visit observation with Staff B, Registered Nurse (RN), on 12/10/24 at 12:30 PM, review of the agency admission packet revealed no medication list for the patient. During an interview, the patient and the patient’s caregiver stated they were not given a current medication list from the agency. The agency failed to provide the patient or caregiver written information regarding the patient’s medication regimen. The above findings were reviewed with the Administrator/Clinical Manager and the Home Care Aide Manager.”

“HH aide training program topics CFR(s): 484.80(b)(3) A home health aide training program must address each of the following subject areas: (i) Communication skills, including the ability to read, write, and verbally report clinical information to patients, representatives, and caregivers, as well as to other HHA staff. (ii) Observation, reporting, and documentation of patient status and the care or service furnished. (iii) Reading and recording temperature, pulse, and respiration. (iv) Basic infection prevention and control procedures. (v) Basic elements of body functioning and changes in body function that must be reported to an aide’s supervisor. (vi) Maintenance of a clean, safe, and healthy environment. (vii) Recognizing emergencies and the knowledge of instituting emergency procedures and their application. (viii) The physical, emotional, and developmental needs of and ways to work with the populations served by the HHA, including the need for respect for the patient, his or her privacy, and his or her property. (ix) Appropriate and safe techniques in performing personal hygiene and grooming tasks that include -- (A) Bed bath; (B) Sponge, tub, and shower bath; (C) Hair shampooing in sink, tub, and bed; (D) Nail and skin care; (E) Oral hygiene; (F) Toileting and elimination; (x) Safe transfer techniques and ambulation; (xi) Normal range of motion and positioning; (xii) Adequate nutrition and fluid intake; (xiii) Recognizing and reporting changes in skin condition; and (xiv) Any other task that the HHA may choose to have an aide perform as permitted under state law. (xv) The HHA is responsible for training home health aides, as needed, for skills not covered in the basic checklist, as described in paragraph (b)(3)(ix) of this section. This Element is not met as evidenced by: Based on agency staff interview, clinical record review and personnel file review, the agency failed to ensure 1 of 1 sampled home health aide (Staff E), assigned to perform tasks requiring extra skills exceeding the level of basic home health skills for 1 of 4 sampled patients (Patient #3) with home health aide services, had documented evidence of competency by a registered nurse in the assigned task area prior to independently performing the task with a patient. The agency provided home health aide services to 30 patients at the time of the survey and employed 5 home health aides. Failure to ensure home health aides successfully complete a competency evaluation in any assigned extra skills which exceed the level of basic home health aide skills placed the patients at risk to receive inadequate or unsafe home health aide services. Findings include: The Medicare Conditions of Participation require home health agencies to determine competence of home health aides in those skills which exceed the general basic home health aide skills areas prior to assigning the home health aide to a patient who would require the task to be performed. Patient #3 had a start of care date of 6/10/24. Clinical record review revealed: a. Aide care plan, dated 11/29/24, included Registered Nurse (RN) directions for the aide to complete the extra skills of assist client with emptying nephrostomy bags and nephrostomy site cares, remove old dressing, cleanse around site with soap and water, cover with split gauze and secure with tape. b. Aide visit note documentation, dated 12/3/24, completed by Staff E, Home Health Aide, identified she assisted with emptying nephrostomy bags and completed nephrostomy site cares. c. Staff E, Home Health Aide, had a hire date of 1/4/22. Staff E’s personnel file lacked documentation an RN had evaluated the Home Health Aide and determined Staff E was proficient in the tasks of emptying nephrostomy bags and completing nephrostomy site cares. During an interview on 12/10/24 at 3:35 PM, Staff D, Home Care Aide Manager, reported extra skills competencies are identified in each home health aide’s file. Staff D stated she did not have competencies for emptying nephrostomy bags or nephrostomy site cares in Staff E’s personnel file. The agency failed to ensure home health aides successfully complete a competency evaluation in assigned extra skills. The above findings were reviewed with the Administrator/Clinical Manager and the Home Care Aide Manager.”

“Services provided by HH aide CFR(s): 484.80(g)(2) A home health aide provides services that are: (i) Ordered by the physician or allowed practitioner; (ii) Included in the plan of care; (iii) Permitted to be performed under state law; and (iv) Consistent with the home health aide training. This Element is not met as evidenced by: Based on agency staff interviews, clinical record reviews and agency policy review, the agency failed to ensure home health aides provided care to agency patients only as ordered by the physician, permitted under state law and/or as directed by the skilled professional assigning the home health aide to the patient for 4 of 4 sampled patients receiving home health aide services (Patients #2, #3, #5 and #6). Failure to ensure home health aide services are provided only as ordered by the physician, permitted under state law and/or as directed by the skilled professional assigning the home health aide to the patient and according to the plan of care increased the risk that patients’ personal care needs were not adequately met. Findings include: 3. Patient #5 had a start of care date of 11/1/17. Clinical record review revealed: a. Plans of Care, dated 9/25/24 to 11/23/24 and 11/24/24 to 1/22/25, included physician orders for skilled nurse and home health aide services. b. Aide care plan, dated 6/3/22, included instructions that directed the aide to provide bath- tub or shower every visit; shampoo-in shower/bath or at sink; nail care-clean, clip and file toe or fingernails; and skin and foot care includes observing for concerns and reporting issues to nurse. c. Aide visit notes, dated 10/8, 10/11, 10/15, 10/18, 10/25, 10/29, 11/5, 11/8, 11/19, 11/22, 11/26, 12/3 and 12/6/24, included documentation the tasks bath- tub or shower every visit, shampoo-in shower/bath or at sink, and skin and foot care includes observing for concerns and reporting issues to nurse were marked as done. The task nail care-clean, clip and file toe or fingernails was marked not applicable this visit. d. Aide visit notes, dated 10/22, 11/12, 11/15, included documentation the tasks bath- tub or shower every visit, and skin and foot care includes observing for concerns and reporting issues to nurse were marked as done. The task shampoo-in shower/bath or at sink was marked as refused. The task nail care-clean, clip and file toe or fingernails was marked not applicable this visit. The aide failed to identify which bath type was completed, where shampoo was completed, if there were any concerns reported to the nurse or the reason why the task nail care was not completed. 4. Patient# 6 had a start of care date of 6/17/24 and a discharge date of 7/1/24. Clinical record review revealed: a. Plan of Care, dated 6/17/24 to 8/15/24, included physician orders for skilled nurse and home health aide services. b. Aide care plan, dated 6/17/24, included special instructions related to: Mobility: walker, cane or wheelchair, independent, needs assist; Wounds/incisions/dressings: Ability to safely make decisions regarding care – patient or caregiver. c. Aide visit notes, dated 6/21, 6/24, 6/27 and 7/1/24, included documentation the task special instructions related to: Mobility: walker, cane or wheelchair, independent, needs assist; Wounds/incisions/dressings: Ability to safely make decisions regarding care – patient or caregiver were marked as done. The aide failed to identify which of the special instructions were followed. The above findings were reviewed with the Administrator/Clinical Manager and the Home Care Aide Manager. According to the agency policy, titled Assignment and Supervision of Home Care Aides, revised 9/2024, home health aide duties will be assigned and supervised by either a registered nurse or home care aide manager according to regulatory guidelines. The Registered Nurse (RN) completes the home health aide care plan that includes specific tasks, including frequency and the RN makes notations regarding pertinent information for the aide to provide care to the patient. Personal care is provided under the supervision of an RN, ordered by a physician and follows a plan of care. During an interview on 12/10/24 at 2:19 PM, the Administrator/Clinical Manager stated an RN completes the home health aide care plan. The care plan is specific and unique to the patient and identifies frequency of tasks to be completed. The Administrator/Clinical Manager reported if more than one option is given for a task, the aide documents which task was completed. If the aide is unable to complete an assigned task, the aide documents patient refused. 1.Patient #2 had a start of care date of 6/30/2017. Clinical record review revealed: a. Plans of Care (POC), dated 9/21/24 to 11/19/24 and 11/20/24 to 1/18/25, included physician orders for skilled nursing and home health aide services. b. Aide care plan, dated 5/31/22, included instructions that directed the aide to apply lotion to extremities and back every visit; assist to dress after every visit; bath in tub or shower every visit; light housekeeping every visit; nail care-clean, clip and file toe or fingernails; and shampoo in shower/bath or at sink. c. Aide visit notes, dated 10/8, 10/10, 10/14, 10/21, 10/23, 10/29, 10/31, 11/4, 11/7, 11/11, 11/12, 11/14, 11/18, 11/21, 11/26, 12/2 and 12/5/24 documented not applicable this visit for the task of nail care-clean, clip and file toe or fingernails. d. Aide visit notes, dated 10/8, 10/10, 10/14, 10/21, 10/23, 10/28, 10/29, 10/31, 11/4, 11/7, 11/11, 11/12, 11/14, 11/18, 11/21, 11/26, 12/2 and 12/5/24 documented done for the tasks of bath in tub or shower every visit and shampoo in shower/bath or at sink. The home health aide failed to specify which bath type was completed and where shampoo was completed. The home health aide failed to provide services that are ordered by the physician, included in the plan of care, permitted under state law and consistent with home health aide training. 2.Patient #3 had a start of care date of 6/10/24. Clinical record review revealed: a. POC, dated 10/8/24 to 12/6/24, included orders for skilled nursing and home health aide services. b. Aide care plan, dated 6/11/24, included instructions that directed the aide to apply lotion to extremities and back every visit; assist to dress after every visit; bath in tub or shower every visit; light housekeeping every visit; nail care-clean, clip and file toe or fingernails; shampoo in shower/bath or at sink; and sponge bath-total, partial, bed. Effective 11/29/24, the tasks of emptying nephrostomy bags as patient directs and nephrostomy site cares were added. c. Aide visit notes, dated 10/15, 10/22, 10/28, 11/1, 11/5, 11/8, 11/14 and 11/20/24 documented not applicable this visit for the task of nail care-clean, clip and file toe or fingernails. d. Aide visit notes, dated 10/15, 10/22, 11/1, 11/5, 11/8, 11/14 and 11/20/24 documented done for the tasks of bath in tub or shower every visit and shampoo in shower/bath or at sink. The home health aide failed to specify which bath type was completed and where shampoo was completed. e. Aide visit note, dated 10/28/24 documented done for the task of sponge bath: total, partial, bed. The home health aide failed to specify type of sponge bath completed. The home health aide failed to provide services that are ordered by the physician, included in the plan of care, permitted under state law and consistent with home health aide training.”

“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, agency policy review and staff interview, the agency failed to ensure the patients clinical record included Physical Therapy and Occupational Therapy documentation for 2 of 2 sampled patients with therapy services (Patients #3 and #6). Failure to ensure the patient’s clinical record included pertinent current and accurate documentation including therapy evaluations and visit notes placed agency patients at risk for not receiving appropriate services. 2.Patient #4 had a start of care date of 11/20/24. Clinical record review revealed the Plan of Care, dated 11/20/24 to 1/18/25 included orders for Physical Therapy to assess and evaluate. During an interview on 12/11/24 at 9:45 AM, the Administrator/Clinical Manager stated the Physical Therapy evaluation may not have been uploaded into the patient’s clinical record. At 10:40 AM, the Administrator/Clinical Manager confirmed the therapy evaluation had not been uploaded to the agency electronic medical record and provided the surveyor with a paper copy of the following: Physical Therapy evaluation note, dated 11/27/24. The clinical record lacked documentation of Physical Therapy evaluation. The above findings were reviewed with the Administrator/Clinical Manager and the Home Care Aide Manager. Findings include: According to the agency’s policy, titled Documentation Clinical Record Policy, dated 08/2024, identified clinical records should accurately reflect a picture of patient needs and home care response to those needs resulting in the most appropriate outcome for the patient. During an interview on 12/10/24 at 9:33 AM, Administrator/Clinical Manager reported therapy evaluations and visit notes are on a different computer drive and are uploaded to the agency’s electronic medical record by the Administrator/Clinical Manager. Documents are sent weekly to Administrator/Clinical Manager on Tuesdays and uploaded to the electronic medical record by the end of that week. 1.Patient# 6 had a start of care date of 6/17/24 and a discharge date of 7/1/24. Clinical record review revealed the Plan of Care, dated 6/17/24 to 8/15/24, included physician orders for Physical Therapy to assess and evaluate and Occupational Therapy to assess and evaluate. During an interview on 12/10/24 at 9:33 AM, Administrator/Clinical Manager reported the therapy notes may not have been uploaded to the clinical record. At 9:40 AM the Administrator/Clinical Manager confirmed the therapy documentation had not been uploaded to the agency electronic medical record and provided the surveyor with paper copies of the following: a. Physical Therapy evaluation note, dated 6/19/24; b. Physical Therapy visit notes, dated 6/21/24, 6/29/24 and 7/1/24; and c. Occupational Therapy evaluation, dated 6/19/24. The clinical record lacked documentation of Physical Therapy and Occupational Therapy evaluations and visit noted.”