Pocahontas County Public Health

“EP Testing Requirements CFR(s): 484.102(d)(2) §416.54(d)(2), §418.113(d)(2), §441.184(d)(2), §460.84(d)(2), §482.15(d)(2), §483.73(d)(2), §483.475(d)(2), §484.102(d)(2), §485.68(d)(2), §485.542(d)(2), §485.625(d)(2), §485.727(d)(2), §485.920(d)(2), §491.12(d)(2), §494.62(d)(2). *[For ASCs at §416.54, CORFs at §485.68, REHs at §485.542, OPO, “Organizations” under §485.727, CMHCs at §485.920, RHCs/FQHCs at §491.12, and ESRD Facilities at §494.62]: (2) Testing. The [facility] must conduct exercises to test the emergency plan annually. The [facility] must do all of the following: (i) Participate in a full-scale exercise that is community-based every 2 years; or (A) When a community-based exercise is not accessible, conduct a facility-based functional exercise every 2 years; or (B) If the [facility] experiences an actual natural or man-made emergency that requires activation of the emergency plan, the [facility] is exempt from engaging in its next required community-based or individual, facility-based functional exercise following the onset of the actual event. (ii) Conduct an additional exercise at least every 2 years, opposite the year the full-scale or functional exercise under paragraph (d)(2)(i) of this section is conducted, that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or individual, facility-based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the [facility’s] response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the [facility’s] emergency plan, as needed. *[For Hospices at 418.113(d):] (2) Testing for hospices that provide care in the patient’s home. The hospice must conduct exercises to test the emergency plan at least annually. The hospice must do the following: (i) Participate in a full-scale exercise that is community based every 2 years; or (A) When a community based exercise is not accessible, conduct an individual facility based functional exercise every 2 years; or (B) If the hospice experiences a natural or man-made emergency that requires activation of the emergency plan, the hospital is exempt from engaging in its next required full scale community-based exercise or individual facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional exercise every 2 years, opposite the year the full-scale or functional exercise under paragraph (d)(2)(i) of this section is conducted, that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or a facility based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (3) Testing for hospices that provide inpatient care directly. The hospice must conduct exercises to test the emergency plan twice per year. The hospice must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual facility-based functional exercise; or (B) If the hospice experiences a natural or man-made emergency that requires activation of the emergency plan, the hospice is exempt from engaging in its next required full-scale community based or facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional annual exercise that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or a facility based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop led by a facilitator that includes a group discussion using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the hospice’s response to and maintain documentation of all drills, tabletop exercises, and emergency events and revise the hospice’s emergency plan, as needed. *[For PRFTs at §441.184(d), Hospitals at §482.15(d), CAHs at §485.625(d):] (2) Testing. The [PRTF, Hospital, CAH] must conduct exercises to test the emergency plan twice per year. The [PRTF, Hospital, CAH] must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise; or (B) If the [PRTF, Hospital, CAH] experiences an actual natural or man-made emergency that requires activation of the emergency plan, the [facility] is exempt from engaging in its next required full-scale community based or individual, facility-based functional exercise following the onset of the emergency event. (ii) Conduct an [additional] annual exercise or and that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or individual, a facility-based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the [facility’s] response to and maintain documentation of all drills, tabletop exercises, and emergency events and revise the [facility’s] emergency plan, as needed. *[For PACE at §460.84(d):] (2) Testing. The PACE organization must conduct exercises to test the emergency plan at least annually. The PACE organization must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise; or (B) If the PACE experiences an actual natural or man-made emergency that requires activation of the emergency plan, the PACE is exempt from engaging in its next required full-scale community based or individual, facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional exercise every 2 years opposite the year the full-scale or functional exercise under paragraph (d)(2)(i) of this section is conducted that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or individual, a facility based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the PACE’s response to and maintain documentation of all drills, tabletop exercises, and emergency events and revise the PACE’s emergency plan, as needed. *[For LTC Facilities at §483.73(d):] (2) The [LTC facility] must conduct exercises to test the emergency plan at least twice per year, including unannounced staff drills using the emergency procedures. The [LTC facility, ICF/IID] must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise. (B) If the [LTC facility] facility experiences an actual natural or man-made emergency that requires activation of the emergency plan, the LTC facility is exempt from engaging its next required a full-scale community-based or individual, facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional annual exercise that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or an individual, facility based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the [LTC facility] facility’s response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the [LTC facility] facility’s emergency plan, as needed. *[For ICF/IIDs at §483.475(d)]: (2) Testing. The ICF/IID must conduct exercises to test the emergency plan at least twice per year. The ICF/IID must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise; or. (B) If the ICF/IID experiences an actual natural or man-made emergency that requires activation of the emergency plan, the ICF/IID is exempt from engaging in its next required full-scale community-based or individual, facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional annual exercise that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or an individual, facility-based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the ICF/IID’s response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the ICF/IID’s emergency plan, as needed. *[For HHAs at §484.102] (d)(2) Testing. The HHA must conduct exercises to test the emergency plan at least annually. The HHA must do the following: (i) Participate in a full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise every 2 years; or. (B) If the HHA experiences an actual natural or man-made emergency that requires activation of the emergency plan, the HHA is exempt from engaging in its next required full-scale community-based or individual, facility based functional exercise following the onset of the emergency event. (ii) Conduct an additional exercise every 2 years, opposite the year the full-scale or functional exercise under paragraph (d)(2)(i) of this section is conducted, that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or an individual, facility-based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the HHA’s response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the HHA’s emergency plan, as needed. *[For OPOs at §486.360] (d)(2) Testing. The OPO must conduct exercises to test the emergency plan. The OPO must do the following: (i) Conduct a paper-based, tabletop exercise or workshop at least annually. A tabletop exercise is led by a facilitator and includes a group discussion, using a narrated, clinically relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. If the OPO experiences an actual natural or man-made emergency that requires activation of the emergency plan, the OPO is exempt from engaging in its next required testing exercise following the onset of the emergency event. (ii) Analyze the OPO’s response to and maintain documentation of all tabletop exercises, and emergency events, and revise the [RNHCI’s and OPO’s] emergency plan, as needed. *[ RNCHIs at §403.748]: (d)(2) Testing. The RNHCI must conduct exercises to test the emergency plan. The RNHCI must do the following: (i) Conduct a paper-based, tabletop exercise at least annually. A tabletop exercise is a group discussion led by a facilitator, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (ii) Analyze the RNHCI’s response to and maintain documentation of all tabletop exercises, and emergency events, and revise the RNHCI’s emergency plan, as needed. This Standard is not met as evidenced by: Based on agency staff interview, agency policy review and review of emergency preparedness testing documentation, the agency failed to ensure participation an emergency preparedness exercises annually. Failure to conduct or participate in emergency preparedness exercises placed patients at risk for not having trained and prepared staff to assist them in the event of an emergency. Findings include: According to the agency policy, titled Emergency Preparedness, dated 12/14/23, on the years when community wide drills do not occur, a table top drill can be conducted. The purpose of the drills is to determine the effectiveness and efficiency of the current policy and processes in place. A post drill analysis of results and an action plan will be used to identify and mitigate any gaps. Emergency preparedness training documentation included an emergency preparedness tabletop exercise, dated 8/27/24. The agency lacked any documentation of any additional training exercise in 2022 or 2023. During an interview on 9/24/24 at 4:15 PM, the Administrator reported that the agency did not participate in an additional exercise in 2022 or 2023. The findings were reviewed with the Administrator, Clinical Manager, Staff C, Registered Nurse (RN), Staff D, RN and Staff G, RN.”

“Competency evaluation CFR(s): 484.80(c)(1)(2)(3) Standard: Competency evaluation. An individual may furnish home health services on behalf of an HHA only after that individual has successfully completed a competency evaluation program as described in this section. (1) The competency evaluation must address each of the subjects listed in paragraph (b)(3) of this section. Subject areas specified under paragraphs (b)(3)(i), (iii), (ix), (x), and (xi) of this section must be evaluated by observing an aide’s performance of the task with a patient or pseudo-patient. The remaining subject areas may be evaluated through written examination, oral examination, or after observation of a home health aide with a patient, or with a pseudo-patient as part of a simulation. (2) A home health aide competency evaluation program may be offered by any organization, except as specified in paragraph (f) of this section. (3) The competency evaluation must be performed by a registered nurse in consultation with other skilled professionals, as appropriate. This Standard is not met as evidenced by: Based on review of employee personnel files and staff interview, the hospice failed to ensure 3 of 4 sampled home health aides (Staff E, Staff J and Staff K) satisfactorily demonstrated competency on the written skills examination prior to the home health aide providing service to patients. The home health agency employed 5 home health aides at the time of the survey. Failure to ensure home health aides have successfully completed a competency evaluation program increased the risk for patients to receive inadequate or inappropriate care. Findings include: On 9/25/24 at 9:30 AM during an interview, the Administrator revealed she was unaware a Registered Nurse (RN) needed to sign off on the home health aide written competency test acknowledging the test was administered and reviewed by the RN. 1.Staff E, Home Health Aide, had a hire date of 4/20/23. Staff D’s personnel filed lacked documentation a RN had administered and reviewed the written competency test, dated 4/27/23. 2. Staff J, Home Health Aide, had a hire date of 9/14/22. Staff J’s personnel file lacked documentation a RN had administered and reviewed the written competency test, dated 9/15/22. 3. Staff K, Home Health Aide, had a hire date of 4/20/23. Staff K’s personnel file lacked documentation a RN had administered and reviewed the written competency test, dated 4/23/23. The above findings were reviewed with the Administrator, Clinical Manager, Staff C, RN, Staff D, RN, and Staff G, RN.”

“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 agency interviews, clinical record reviews and agency policy reviews, the home health agency failed to ensure all clinical documentation was completed and appropriately authenticated in a timely manner for 2 of 7 sampled patients (Patients #1 and #4). Failure to ensure all clinical record documentation was completed in a timely manner increased the risk of ineffective communication between staff members providing services to its patients. Findings include: 2. Patient #1 had a start of care date of 5/9/24. Clinical record review revealed the following: a. The skilled nurse visit notes, dated 9/9/24 and 9/11/24, signed completed by Staff D, RN on 9/24/24 (8 days late per agency policy). b. The skilled nurse visit note, dated 9/11/24, signed completed by Staff D, RN on 9/24/24 (6 days late per agency policy). The agency clinical record failed to include timely documentation. The findings were reviewed with the Administrator, Clinical Manager, Staff C, Registered Nurse (RN), Staff D, RN and Staff G, RN. According to the agency policy titled Clinical Record, dated 5/14/24, clinical notes are timed visit notes and are completed within seven days of all services rendered. During an interview on 9/24/24 at 10:17 AM, the Clinical Manager reported routine visit documentation is to be completed within 5 days if possible. 1.Patient #4 had a start of care date of 2/2/24. Clinical record review revealed the following: a. The skilled nurse visit note, dated 8/27/24, signed completed by Staff D, Registered Nurse (RN) on 9/5/24 (2 days late per policy). b. The skilled nurse visit note, dated 9/10/24, signed completed by Staff B, RN on 9/25/24 (8 days late per policy). The agency clinical record failed to include timely documentation.”

“Plan of care must include the following CFR(s): 484.60(a)(2)(i-xvi) The individualized plan of care must include the following: (i) All pertinent diagnoses; (ii) The patient’s mental, psychosocial, and cognitive status; (iii) The types of services, supplies, and equipment required; (iv) The frequency and duration of visits to be made; (v) Prognosis; (vi) Rehabilitation potential; (vii) Functional limitations; (viii) Activities permitted; (ix) Nutritional requirements; (x) All medications and treatments; (xi) Safety measures to protect against injury; (xii) A description of the patient’s risk for emergency department visits and hospital re-admission, and all necessary interventions to address the underlying risk factors. (xiii) Patient and caregiver education and training to facilitate timely discharge; (xiv) Patient-specific interventions and education; measurable outcomes and goals identified by the HHA and the patient; (xv) Information related to any advanced directives; and (xvi) Any additional items the HHA or physician or allowed practitioner may choose to include. This Element is not met as evidenced by: Based on home visit observations, patient interviews, clinical record reviews and agency policy reviews, the agency failed to ensure the accurate completion of all components comprising the Plan of Care, including all supplies/equipment and medications used by the patient for 5 of 7 sampled patients (Patients #1, #2, #3, #6 and #7). Failure to maintain complete and accurate Plans of Care with current orders placed the patients at risk to not receive services, medications, supplies and/or treatments according to assessed needs and physician orders. Findings include: 4. Patient #1 had a start of care date of 5/9/24. Clinical record review revealed the following: a. The POCs, dated 7/8/24 to 9/5/24 and 9/6/24 to 11/14/24, included the following DME used by the patient: 20 Fr Foley catheter, 4 x 4 gauze, ABD pads, Foley kit, alcohol prep pads, alternating pressure relief mattress, Aquacel AG, Band aids, bed rails, betadine swabs, catheter insertion kit, catheter irrigation solution, catheter irrigation et, catheter irrigation kit, catheter leg strap, ceiling Hoyer lift, cervical collar, chest & back brace, chin/neck support brace, chux, drainage bag, edema wear, enema supplies, fingernail clippers, fingernail file, Foley catheters, glasses, grabber, handheld shower head, handicap van, heating pad, heel lift boots, kerlix, KY jelly, leg drainage bad, manual wheelchair, mattress overlay, medication boxes, mepilex with border, mepilex without border, mesh stocking sleeves, non-sterile gloves, OTC lotions, powders & creams, pill cutter, power wheelchair, Q-tips, ROHO cushion, shower chair with commode, skin prep, tape, toenail clippers, trapeze, wheelchair ramp, wound cleanser. c. During a home visit observation on 9/23/24 at 1:00 PM, with Staff G, RN, the surveyor identified the patient utilized a lifeline. d. During an interview at the same observation home visit the patient stated he/she used a warm pack for many years The POC failed to include the DME lifeline. 5. Patient #7 had a start of care date of 8/5/24 and discharged on 9/19/24. Clinical record review revealed the following: a. The POC, dated 8/5/24 to 10/3/24, included the following DME used by the patient: 4-wheeled walker, band aids, fingernail clippers, fingernail file, glasses, grab bar, handheld shower head, mepilex, nebulizer, oxygen concentration, oxygen tank, oxygen-nasal cannula, pulse oximeter. c. The skilled nurse note, dated 8/19/24, identified the patient utilized a lifeline. The POC failed to include the DME lifeline. The above items shared with the Administrator, Clinical Manager, Staff C, RN, Staff D, RN and Staff G, RN. According to the agency policy titled Plan of Care, dated 5/14/24, the plan of care is established and authorized in writing by the physician/allowed practitioner based on evaluation of the client’s immediate and long-term needs. The plan of care includes but is not limited to all pertinent diagnoses, frequency of visits, types of services and equipment required, medications and treatments and any safety measures to protect against injury. 1.Patient #2 had a start of care date of 5/10/23. Clinical record review revealed the following: a. The Plans of Care (POCs), dated 7/3/24 to 8/31/24 and 9/1/24 to 10/30/24 included the following durable medical equipment (DME) used by the patient: Alcohol pads, bath bench, bathroom scale, dentures, diabetic supplies, fingernail file, glasses, glucometer, grab bars, handheld shower, incontinent supplies, medication boxes and toenail/fingernail clippers. b. The Comprehensive Assessment, dated 8/27/24, completed by Staff B, Registered Nurse (RN), identified the patient has a platform lift in his garage that he uses. c. During a home visit observation on 9/24/24 at 1:30 PM, with Staff C, RN, the surveyor identified the platform lift in the garage. During this same visit, an interview with the patient’s daughter revealed the patient does use the lift to avoid having to carry groceries up the steps into the house. The POC failed to include the DME platform lift. 2.Patient #3 had a start of care date of 1/5/24. Clinical record review revealed the following: a. The POC, dated 9/1/24 to 10/30/24 included the following medications: Aspirin 81 milligrams (mg) 1 tablet every morning, acetaminophen 325 mg 1-2 tablets every 6-8 hours, arformoterol tartrate 15 micrograms (mcg)/2 milliliters (ml) inhalation twice per day morning and night, albuterol sulfate 108 (90 base) mcg/act inhalation 1-2 puffs every 4-6 hours as needed, alendronate sodium 70mg 1 tablet every 7 days, budesonide 0.5mg/2ml inhalation 1 vial twice per day (AM and PM), Cholecalciferol 25 mcg take 2 tablets every morning, clopidogrel bisulfate 75mg 1 tablet every morning, diclofenac sodium 1% external small amount 4 times per day (AM, Noon, PM, HS), Losartan Potassium 50mg 1 tablet every morning, omeprazole 40mg 1 capsule every morning, nystatin 100000 unit/gram external small amount twice per day as needed for rash, multiple vitamin 1 tablet every morning, ipratropium-albuterol 0.5-2.5 (3) mg/3ml inhalation 3ml four times per day, bumetanide 2mg 1 tablet daily every morning, amlodipine besylate 5mg 1 tablet daily in the morning, and prednisone 10 mg 1 tablet daily as needed for shortness of breath. b. During a home visit observation on 9/24/24 at 10:00 AM with Staff D, RN, an interview with the patient revealed the patient is taking Acetaminophen 500mg 1-2 tablets as needed. The surveyor observed the patient’s omeprazole was last refilled on 5/31/24 and the dose is 40mg with instructions to take 1 tablet by mouth twice a day. An interview with the patient identified the patient is taking the medication per the instructions on the bottle. The POC failed to include correct medications taken by the patient. 3.Patient #6 had a start of care date of 4/26/24 and a discharge date of 5/8/24. Clinical record review revealed the following: a. The POC, dated 4/26/24 to 6/24/24, included the following DME used by the patient: 2-wheeled walker, alcohol prep pads, bath bench, bathroom scale, compression stockings, diabetic supplies, edema wear, glasses and grab bars. b. The initial assessment, completed by Staff C, RN, identified patient is utilizing medication cassettes. The POC failed to identify all DME/supplies used by the patient.”

“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 observation, clinical record reviews, staff and patient interviews and policy reviews, the agency failed to administer treatments and services only as ordered by the physician for 2 of 3 sampled patients with home visits (Patients #1 and #2). Failure to ensure staff obtain physician orders for all treatments being utilized placed patients at risk for inconsistent care/treatment and possible harm. Findings include: 2.Patient #2 had a start of care date of 5/10/23. Clinical record review revealed: a. The POCs, dated 7/3/24 to 8/31/24 and 9/1/24 to 10/30/24, documented the patient had physician orders for medications and treatments. b. The comprehensive assessment, dated 8/27/24, completed by Staff B, RN, identified the patient was utilizing a cream to treat a hemorrhoid. The clinical record lacked a physician order for cream to treat a hemorrhoid. The above findings were reviewed with the Administrator, Clinical Manager, Staff C, RN, Staff D, RN, and Staff G, RN. According to agency policy, titled Plan of Care Policy, dated 5/14/24, the plan of care consist of medications which include prescription, over the counter, and herbal. Indicate if self-administered or administered by the agency. 1. Patient #1 had a start of care date of 5/9/24. Review of the clinical record revealed the following: a. The Plans of Care (POCs), dated 7/8/24 to 9/5/24 and 9/6/24 to 11/4/24, documented the patient had physician orders for medications and treatments. b. During an observational visit with Staff G, Registered Nurse (RN) the patient noted to use a warm pack to his/her neck. c,. During an interview at the same observational visit the patient stated he/she used the warm pack to the neck area for pain and had for The clinical record lacked physician orders for warm packs for patient use.”

“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 interviews, clinical record reviews and agency policy reviews, the agency failed to ensure home health aides provided care to patients only as ordered by a physician, permitted under state law and/or as directed by the skilled professional assigning the home health aide to the patient for 2 of 4 sampled patients receiving home health aide services (Patients #2 and #5). 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 the patient’s personal care needs were not adequately met. Findings include: 2.Patient #2 had a start of care date of 5/10/23. Clinical record review revealed the following: a. The POCs, dated 7/3/24 to 8/31/24 and 9/1/24 to 10/30/24, included physician orders for skilled nursing services twice monthly and home health aide visits twice weekly to assist with personal cares. b. The home health aide care plans, dated 7/3/24 to 8/31/24 and 9/1/24 to 10/30/24, identified the following interventions: shower, may offer sponge bath if client refuses. Document in comments which patient had. c. Home health aide visit notes, dated 7/23/24, 7/25/24, 7/30/24, 8/2/24, 8/9/24, 8/12/24, 8/16/24, 8/20/24, 8/22/24, 8/26/24, 8/30/24, 9/3/24, 9/5/24 and 9/9/24, identified Staff E, Aide failed to include documentation staff performed the task of providing a shower or sponge bath for the patient. d. Home health aide visit note, dated 8/6/24, identified Staff F, LPN/Aide failed to include documentation staff performed the task of providing a shower or sponge bath for the patient. The home health aide failed to provide services ordered by the physician and included in the patient’s POC. The above findings were reviewed with the Administrator, Clinical Manager, Staff C, RN, Staff D, RN, and Staff G, RN. According to the agency policy titled Home Health Aide Services Policy, dated 3/12/24, a Registered Nurse (RN) develops the plan of care with input from the client or client’s family. The assignment and duties of the home health aide will include written client care instructions prepared by the RN and in collaboration with the client, family, representative and/or caregiver. Assigned duties/tasks will be listed on the aide plan of care. The aide will be assigned to the client with consideration of the needs and geographic locations. During an interview on 9/23/24 at 10:17 AM, the Clinical Manager, identified when he aide is unable to complete an assigned task, they will call and report to the RN and write a narrative note they the reason or if they declined the service. 1. Patient #5 had a start of care date of 1/23/24. Clinical record review revealed the following: a. The Plans of Care (POCs), dated 7/21/24 to 9/18/24 and 9/19/24 to 11/17/24, included physician orders for skilled nursing services twice monthly and home health aide visits twice weekly to assist with personal cares. b. The home health aide care plan, dated 7/22/24, identified the following interventions: shower, sponge bath per request of client. Specify shower or sponge bath. c. Home health aide visit notes, dated 7/22, 7/29, 8/23, 9/9 and 9/12/24, identified Staff F, LPN/Aide failed to include documentation staff performed the task of providing a shower or sponge bath for the patient. d. Home health aide visit notes dated 8/28/24, Staff K, Aide failed to include documentation staff performed the task of providing a shower or sponge bath for the patient. The home health aide failed to provide services ordered by the physician and included in the patient’s POC.”

“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 agency policy review, clinical record review and agency staff interview, the agency failed to complete and send a transfer summary to the physician caring for the patient at the inpatient facility after transfer within 2 business days of the patient’s transfer and/or failed to complete and send a discharge summary to the physician and other health care professionals who would be providing care to the patient after discharge within 5 calendar days for 1 of 2 sampled patients with transfers/ discharges (Patient #7). Failure to send the physician and other health care professionals a summary of the patient’s care while receiving services from the agency in a timely manner may result in inadequate or inappropriate follow-up during inpatient care or after discharge. Findings include: According to the agency policy titled, Client Transfer, dated 5/23/18, a transfer summary shall be completed by the Registered Nurse. The original transfer summary form shall be sent to the new provider or facility, and a copy shall be retained for the client’s chart. The transfer summary must be completed within 2 working days. During an interview on 9/25/24 at 10:30 AM Staff C, Registered Nurse (RN) stated the transfer summary had only been sent to the primary care physician and not sent to the admitting facility. Patient #7 had a start of care date of 8/5/24 and discharged from the agency on 9/19/24. Clinical record review revealed: a. The comprehensive assessment at the time of hospital transfer, dated 8/8/24 by Staff D, RN, documented the patient transferred to the hospital. b. A home health transfer summary completed by Staff D, RN , dated 8/8/24, included identification the patient transferred to the hospital and the summary sent to the primary care physician. The agency failed to send the transfer summary to the receiving hospital. The above findings shared with the Administrator, Clinical Manager, Staff C, RN, Staff D, RN and Staff G, RN.”