Cherokee Regional Home Health

“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 in a timely manner for 4 of 7 sampled patients (Patients #3, #5, #6 and #7). 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: 3. Patient #3 had a start of care date of 4/23/24. Clinical record review revealed: a. The skilled nurse visit note, dated 7/16/24, signed completed 7/19/24 (1 day late) by Staff D, RN. Agency staff failed to complete documentation in a timely manner. 4. Patient #5 had a start of care date of 8/7/24. Clinical record review revealed: a. The skilled nurse visit note, dated 8/12/24, signed completed 8/15/24 (1 day late) by Staff C, RN. b. The physical therapy visit note, dated 8/16/24, signed completed 8/26/24 (8 days late) by Staff E, PT. c. The skilled nurse visit note, dated 9/9/24, signed completed 9/17/24 (6 days late) by Staff C, RN. Agency staff failed to complete documentation in a timely manner. The above findings shared with the Administrator and Staff C, RN. According to the agency policy titled Home Health and Hospice Clinical Record Documentation, dated 12/2023, all electronic documentation is expected to be completed, signed and submitted into the electronic medical record (EMR) as soon as possible but no later than 2 days for routine charting. During an interview on 8/17/24 at 9:00 AM, the Clinical Manager confirmed routine visit documentation is to be completed within 2 days of the visit. 1.Patient #6 had a start of care date of 4/1/24 and a discharge date of 5/16/24. Clinical record review revealed: a. The skilled nurse visit note, dated 4/13/24, signed completed 4/17/24 (2 days late) by Staff C, Registered Nurse (RN). b. The skilled nurse visit note, dated 4/18/24, signed completed 4/22/24 (2 days late) by Staff C, RN. 2.Patient #7 had a start of care date of 3/6/24 and a discharge date of 3/24/24. Clinical record review revealed: a. The skilled nurse visit note, dated 3/11/24, signed completed 3/15/24 (2 days late) by Staff C, RN. b. The physical therapy visit note, dated 3/12/24, signed completed 3/17/24 (3 days late) by Staff E, Physical Therapist (PT). c. The occupational therapy visit note, dated 3/13/24, signed completed 3/25/24 (10 days late) by Staff G, Occupational Therapist (OT). d. The skilled nurse visit note, dated 3/14/24, signed completed 3/18/24 (2 days late) by Staff C, RN. e. The physical therapy visit note, dated 3/15/24, signed completed 3/18/24 (1 day late) by Staff F, Physical Therapy Assistant (PTA). f. The skilled nurse visit note, dated 3/21/24, signed completed 3/25/24 (2 days late) by Staff C, RN. g. The physical therapy visit note, dated 3/22/24, signed completed 3/25/24 (1 day late) by Staff E, PT. The agency clinical record failed to include timely documentation.”

“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 ineffective drug therapy, significant side effects, significant drug interactions, duplicate drug therapy, and noncompliance with drug therapy for 6 of 7 sampled patients (Patients #1, #2, #3, #5, #6 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 #2 had a start of care date of 3/9/23. Clinical record review revealed: a. Start of Care comprehensive assessment, dated 3/29/23, completed by Staff C, RN, included documentation a Drug Regimen Review (DRR) was completed. b. DRR identified duplicate drug therapy and non compliance with drug therapy but failed to address ineffective drug therapy, significant side effects and significant drug interactions. The RN failed to complete a drug regimen review that included 3 of 5 required components; ineffective drug therapy, significant side effects and significant drug interactions. 5.Patient #6 had a start of care date of 4/1/24 and a discharge date of 5/16/24 . Clinical record review revealed: a. Start of Care comprehensive assessment, dated 4/1/24, completed by Staff C, RN, included documentation a DRR was completed. b. DRR identified duplicate drug therapy and non compliance with drug therapy but failed to address ineffective drug therapy, significant side effects and significant drug interactions. c. Resumption of Care comprehensive assessment, dated 4/9/24, completed by Staff H, RN, included documentation a DRR was completed. d. DRR identified duplicate drug therapy and non compliance with drug therapy but failed to address ineffective drug therapy, significant side effects and significant drug interactions. e. Comprehensive assessment completed at discharge, dated 5/16/24, completed by Staff C, RN, included documentation a DRR was completed. f. DRR identified duplicate drug therapy and non compliance with drug therapy but failed to address ineffective drug therapy, significant side effects and significant drug interactions. The RN failed to complete a drug regimen review that included 3 of 5 required components; ineffective drug therapy, significant side effects and significant drug interactions. 6.Patient #7 had a start of care date of 3/6/24 and a discharge date of 3/24/24. Clinical record review revealed the following: a. Start of Care comprehensive assessment, dated 3/6/24, completed by Staff C, RN, included documentation a DRR was completed. b. DRR identified duplicate drug therapy and non compliance with drug therapy but failed to address ineffective drug therapy, significant side effects and significant drug interactions. c. Comprehensive assessment completed at discharge, dated 3/24/24, completed by Staff D, RN, included documentation a DRR was completed. d. DRR identified duplicate drug therapy and non compliance with drug therapy but failed to address ineffective drug therapy, significant side effects and significant drug interactions. The RN failed to complete a drug regimen review that included 3 of 5 required components; ineffective drug therapy, significant side effects and significant drug interactions. The above information was shared with the Administrator and Staff C, RN. 2. Patient #3 had a start of care date of 4/23/24. Clinical record review revealed: a. Start of Care comprehensive assessment, dated 4/23/23, included documentation the DRR completed for adverse side effects, drug interactions, duplicate therapy, ineffective drug and potential contradictions. The DRR identified “yes” and identified duplicate medications. The DRR failed to answer individual details for adverse side effects, drug interactions, ineffective drug therapy or potential contradiction. The RN failed to complete a drug regimen review that included 4 of 5 required components of ineffective drug therapy, significant side effects, potential drug interactions and non-compliance with therapy. 3. Patient #5 had a start of care date of 4/23/24. Clinical record review revealed: a. Start of Care comprehensive assessment, dated 4/23/24, included documentation the DRR completed for adverse side effects, drug interactions, duplicate therapy, ineffective drug and potential contradictions. The DRR identified “yes” and identified duplicate medications. The DRR failed to answer individual details for adverse side effects, drug interactions, ineffective drug therapy or potential contradiction. b. Resumption of Care comprehensive assessment, dated 9/4/24, included documentation the DRR completed for adverse side effects, drug interactions, duplicate therapy, ineffective drug and potential contradictions. The DRR identified “yes” and identified duplicate medications. The DRR failed to answer individual details for adverse side effects, drug interactions, ineffective drug therapy or potential contradiction. The RN failed to complete a drug regimen review that included 4 of 5 required components of ineffective drug therapy, significant side effects, potential drug interactions and non-compliance with therapy. According to the agency policy, titled Drug Regimen Review Home Health, dated December 2023, the Registered Nurse, (RN) will complete the drug regimen review contained in the EMR on admission, resumption of care, significant change in condition, recertification and discharge. During an interview with Staff B, Clinical Manager, on 9/17/24 at 9:00 AM, the Registered Nurse, (RN) completes the drug regimen review in the electronic medical record with admission, recertification, resumption of care, and discharge comprehensive assessments and when a new medication is added or a current medication is changed. The provider is given a copy of the drug regimen review which shows duplicate medications, potential or adverse reactions, any needed labs associated with the medications and any side effects noted with the patient. 1. Patient #1 had a start of care date of 8/16/2024. Clinical record review revealed: a. Start of Care comprehensive assessment, dated 08/16/24, included documentation of side effects and compliance, but lacked documentation of duplicate drug therapy, potential drug interactions, ineffective drug therapy, b. Resumption of Care comprehensive assessment, dated 9/10/24 included documentation of side effects and compliance, but lacked documentation of duplicate drug therapy, potential drug interactions, ineffective drug therapy, The RN failed to complete a drug regimen review that included the 5 required components of ineffective drug therapy, significant side effects, potential drug interactions, duplicate drug therapy and non-compliance with therapy.”

“HH aide supervision elements CFR(s): 484.80(h)(4)(i-vi) Home health aide supervision must ensure that aides furnish care in a safe and effective manner, including, but not limited to, the following elements: (i) Following the patient’s plan of care for completion of tasks assigned to a home health aide by the registered nurse or other appropriate skilled professional; (ii) Maintaining an open communication process with the patient, representative (if any), caregivers, and family; (iii) Demonstrating competency with assigned tasks; (iv) Complying with infection prevention and control policies and procedures; (v) Reporting changes in the patient’s condition; and (vi) Honoring patient rights. This Element is not met as evidenced by: Based on clinical record review, agency policy review and staff interview, the agency failed to ensure registered nurses supervising home health aides maintained documentation of a review of all required supervisory elements included following the patient plan of care, maintaining open communication with patient/caregiver, demonstrating competency of all assigned tasks, complying with infection prevention and control policies, reporting changes in the patient condition and honoring patient rights for 1 of 1 sampled pediatric patients receiving home health aide services (Patient #4). A total of 30 patients received home health aide services and the agency employed 4 home health aides at the time of the survey. Failure to ensure the supervision of home health aides by registered nurses maintained documentation of a review of all required supervisory elements increased the risk of agency staff not meeting the patients’ personal care needs. Findings include: According to the agency’s policy, titled Home Health Aide Services, dated 12/2023, the home health Registered Nurse (RN) will assume responsibility for supervision of the home health aide. The home health aide supervision must ensure that aides furnish care in a safe and effective manner including at least the following elements: maintaining an open communication process with the patient, representative, caregivers and family, the home health aide is following the patient’s plan of care for completion of tasks assigned to a home health aide by the registered nurse or other appropriate skilled professional, the home health aide demonstrated competency with assigned tasks, complying with infection prevention and control policies and procedures, reports changes in the patient’s condition appropriately and honoring of the patient’s rights. During interview on 9/17/24 at 9:00 AM, the Clinical Manager stated the home health aide supervision documented in the skilled nurse visit report or can be documented in a journal note if a nursing visit not completed. Patient #4 had a start of care date of 3/24/22 and a pediatric patient. Clinical record review revealed the following: a. The Plans of Care, 7/11/24 to 9/8/24 and 9/9/24 to 11/4/24, included orders for skilled nursing and home health aide services. b. Skilled nursing visit notes, dated 7/15, 7/29 and 8/26/24, included documentation home health aide supervision was completed and the aide followed the care plan and demonstrated competency. The notes lacked documentation the nurse assessed the aide’s ability to meet the following required supervisory elements: maintaining open communication with patient/caregiver, complying with infection prevention and control policies, reporting changes in the patient condition and honoring patient rights. During an interview on 9/17/24 at 1:38 PM the Administrator stated pediatric patient supervision documented on the electronic medical record system. The program automatically pulls the shorter supervision form. She concurred the form did not include all of the supervisory components. The agency failed to supervise pediatric home health aide services to include all supervisory elements. The above findings were reviewed with the Administrator and Staff C, RN.”