Good Samaritan Society-Home Care

“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 observation, agency staff interviews, clinical record review and policy review, the agency failed to ensure agency staff properly authenticated all clinical entry notes and/or completed within the agency’s expected timeframe for 7 of 7 sampled patients. (Pt #1, #2, #3, #4, #5, #6, and #7) Failure to ensure all clinical record documentation was dated, timed and signed with staff title and/ or completed within the agency’s expected timeframe, increased the risk of ineffective communication between staff members providing services to its patients. Findings include: According to the agency policy titled Documentation Standards, Home Health, Therapy / Rehab - Enterprise, dated 3/4/24, authentication of medical records must include a signature and a title, or a secured computer entry by a unique identifier of a primary author who has reviewed and approved the entry. During an interview on 2/6/25, at 2:00 PM, the Administrator stated the expectation for credentials in the Electronic Medical Record (EMR) for staff, is an electronic signature which includes the date, time, name and title/credentials for each entry in to the EMR. 1.Patient #1 had a start of care date of 1/15/25. Clinical record review revealed the following: a. The Skilled Nurse (SN) initial comprehensive assessment dated 1/15/25, completed by Staff B, Registered Nurse (RN) , included a clinician signature, but lacked a completion date / time and clinician credentials. b. The initial Physical Therapy (PT) evaluation dated 1/23/25, completed by Staff E, Physical Therapist (PT), included clinician signature, date and time, but lacked clinicians credentials. c. The PT service notes dated 1/29/25, 1/31/25 and 2/3/25 completed by Staff G, PT, included clinician signature, date and time, but lacked clinicians credentials. d. The initial Occupational Therapy (OT) evaluation dated 1/23/25, completed by Staff F, Occupational Therapist (OT), included clinician signature, date and time, but lacked clinicians credentials. 2. Patient #2 had a start date of 12/25/24. Clinical record review revealed: a. The initial OT Evaluation dated 1/2/25, completed by Staff F, OT, included clinician signature, date and time, but lacked clinician credentials. b. The OT service notes dated 1/6/25 and 1/25/2/5, completed by Staff F, OT, included clinician signature, date and time, but lacked clinicians credentials. c. The OT service notes dated 1/8/25 and 1/15/25, completed by Staff H, OT, included clinician signature, date and time, but lacked clinicians credentials. d. The initial PT evaluation dated 12/31/24, completed by Staff E, PT, included clinician signature, date and time, but lacked clinicians credentials. e. The PT service note, dated 1/8/25, completed by Staff E, PT, included clinician signature, date and time, but lacked clinicians credentials. 3. Patient #3 had a start of care date of 3/6/2024. Clinical record review revealed the following: a. The SN service notes dated 1/27/25, 1/29/25, 2/3/25 and 2/5/25, completed by Staff B, RN, included clinician signature, date and time, but lacked clinicians credentials. 4. Patient #4 had a start of care date of 7/12/24. Clinical record review revealed the following: a. The initial comprehensive assessment dated 7/12/24, completed by Staff I, RN, included clinician signature, date and time, but lacked clinicians credentials. b. The recertification comprehensive assessment completed on 9/5/24 by staff B, RN, included clinician signature, date and time, but lacked clinicians credentials. c. The comprehensive assessment for resumption of care completed on 1/27/25, Staff B, RN , included clinician signature, date and time, but lacked clinicians credentials. 5. Patient #5 had a start of care date of 12/26/24. Clinical record review revealed the following : a. Clinical nursing notes dated 12/27/24, 1/2/25, 1/10/25 and 1/21/25, completed by Staff B, RN, included clinician signature, date and time, but lacked clinicians credentials. 6. Patient #6 had a start of care date of 12/6/2024 and a discharge date of 1/3/2025. Clinical record review revealed the following: a. The initial OT evaluation note dated 12/11/24, completed by Staff F, included clinician signature, date and time, but lacked clinicians credentials. b. The OT service note dated 12/20/24, and 1/1/25, completed by Staff H, included clinician signature, date and time, but lacked clinicians credentials. c. The OT service noted dated 1/8/25, completed by Staff F, included clinician signature, date and time, but lacked clinicians credentials. d. The Initial PT evaluation dated 12/12/24, completed by Staff E, PT, included clinician signature, date and time, but lacked clinicians credentials. e. The discharge PT summary note, dated 1/31/25, completed by Staff E, PT, included clinician signature, date and time, but lacked clinicians credentials. 7. Patient # 7 had a start of care date of 6/18/2024 and a discharge date of 9/24/24. Clinical record review revealed the following: a. The comprehensive assessment for recertification note dated 8/15/24, completed by Staff B, RN, included clinician signature, date and time, but lacked clinicians credentials. b. The SN service note dated 9/11/24, completed by Staff B, RN, included clinician signature, date and time, but lacked clinicians credentials. c. The PT service note dated 8/11/24, completed by Staff E, PT, included clinician signature, date and time, but lacked clinicians credentials. d. The SN discharge assessment, dated 9/24/24, completed by Staff B, included clinician signature, date and time, but lacked clinicians credentials. The agency failed to ensure all clinical record documentation was dated, timed and signed with clinician name and credentials. The above findings were reviewed with the agency Administrator.”

“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 observations, staff and patient interviews, clinical record review and policy review, the agency failed to ensure the accurate completion of all components comprising the Plan of Care, including all supplies and equipment used by the patient for 3 of 3 sampled patients with surveyor home visit observation (Patients #1 #2 and #3). Failure to maintain complete and accurate Plans of Care with current orders placed the patients at risk to not receive services, medications and/or treatments according to assessed needs and physician orders. Findings include: According to agency policy titled Care Planning and Care Coordination, dated 9/23/24: the Plan of Care (POC), should be patient specific and include complete medication and treatment orders, all equipment and supplies, functional, nutritional and safety needs. 1.Patient #1 had a start of care date of 1/15/25, with a primary diagnosis of post acute care of a surgically repaired patella (knee) fracture. Clinical record review and home observation revealed the following: a. The POC dated 1/15/25 to 3/16/25, included Durable Medical Supplies (DME) utilized by the patient as a hospital bed, walker and a grabber tool. During a home observation visit 2/4/25, at 1:30 PM with Staff C, Registered Nurse (RN), the surveyor also noted the patient was utilizing a lift chair, urinal and a wheelchair. During the observation visit, the patient verbalized he/she used the urinal when he/she felt to unsteady to get the the bathroom and sometimes utilized the wheelchair to get around when he/she was afraid of falling. 2. Patient #2 had a start of care date of 12-24-24, with a primary diagnosis of compression fractures in her lower back. Clinical record review and home observation revealed the following: a. The POC dated 12/24/24 to 2/21/24, included a list of DME the patient utilized in the home as a walker, grab bars and medication planners. During a home observation visit on 2/4/25 at 9:00 AM, the surveyor observed an elevated toilet seat, a cane and a quarter bed rail, patient verbalized assisted him/her in turning while in bed. 3. Patient #3 had a start of care date of 3/6/24 with a diagnosis of chronic leg ulcers. Clinical record review and observation visit revealed the following: a. The POC dated 12/31/24 to 2/28/25 included a list of DME the patient utilized in the home as a wound care supplies, electric scooter, grab bars, and hand held shower. During a home observation visit on 2/5/25 at 7:30 AM, the patient verbalized the use of a electric hospital bed. The agency failed to include all of the DME patient was utilizing on the POC. The above findings were reviewed with the agency Administrator.”

“Promptly alert relevant physician of changes CFR(s): 484.60(c)(1) The HHA must promptly alert the relevant physician(s) or allowed practitioner(s) to any changes in the patient’s condition or needs that suggest that outcomes are not being achieved and/or that the plan of care should be altered. This Element is not met as evidenced by: Based on observations, patient and staff interviews, record review and policy review, the agency failed to report changes in patient clinical findings or changes in patient needs to the physician for 1 of 7 sampled patients. (Patient #5) Failure to communicate the patient’s status with the physician placed agency patients at risk for unidentified worsening of conditions, inappropriate treatments, or unmet home health care needs. Findings include: According to the agency policy titled Care Planning and Care Coordination, dated 9/23/24: Collaboration ad communication relevant to the patients care should be ongoing and include the team, the physician, and the patient /support system. The Plan of Care (POC) must be reviewed and revised by the provider as frequently as the patient’s condition requires. Significant changed in the patients condition are communicated in a timely manner and documented in the patient record. During an interview on 2/6/25, at 1:30 PM, the Administrator reported the parameters for vital signs are included in the POC, and any vital sign readings outside of those parameters need to be reported to the physician. The Administrator also reported orthostatic blood pressure readings (blood pressure readings that are taken sitting down and then upon standing to see if there is a significant drop in the readings) are attempted on all patients when possible as part of a quality program to reduce hospitalizations. The Home Health Aides (HHA) are educated and are checked off on the skill of obtaining orthostatic blood pressure readings. The HHA’s are also educated on the parameters and carry laminated cards to know when those readings are outside of the parameters indicating the HHA need to notify the Registered Nurse (RN) Case Manager. 1.Patient #5 had a start of care date of 12/26/24 with a primary diagnosis of congestive heart failure (CHF). Clinical record revealed the following: a. The POC dated 12/26/24 to 2/4/25 included physician orders to call if blood pressure readings were greater than 160/90 or or less than 90/50. b. Home Health Aide Note dated 12/30/24, Staff D, HHA, revealed orthostatic blood pressure readings outside of the parameters with blood pressure seated of 165/70 and upon standing 181/76, with documentation RN Case Manager was notified. The documentation lacked physician notification of blood pressure readings outside of the parameters. c. Home Health Aide Note dated 1/6/25, Staff D, HHA, revealed orthostatic blood pressure readings outside of the parameters with blood pressure seated of 195/78 and upon standing 189/95, with documentation RN Case Manager was notified. The documentation lacked physician notification of blood pressure readings outside of the parameters. d. Home Health Aide Note dated 1/13/25, Staff D, HHA, revealed orthostatic blood pressure readings outside of the parameters with blood pressure seated of 185/86 and upon standing 194/86, with documentation RN Case Manager was notified. The documentation lacked physician notification of blood pressure readings outside of the parameters. e. Home Health Aide Note dated 1/28/25, Staff D, HHA, revealed orthostatic blood pressure readings outside of the parameters with blood pressure seated of 171/76 and upon standing 165/78, with documentation RN Case Manager was notified. The documentation lacked physician notification of blood pressure readings outside of the parameters. The agency failed to alert the physician of vital signs outside of the ordered parameters. The above findings were reviewed with the agency Administrator.”