Excellent Home Health Care, Inc.

“Clinical records CFR(s): 484.110 Condition of participation: Clinical records. The HHA must maintain a clinical record containing past and current information for every patient accepted by the HHA and receiving home health services. Information contained in the clinical record must be accurate, adhere to current clinical record documentation standards of practice, and be available to the physician(s) or allowed practitioner(s) issuing orders for the home health plan of care, and appropriate HHA staff. This information may be maintained electronically. This Condition is not met as evidenced by: Based on a review of Clinical Records, Agency Policy, and staff interviews, it was determined the Agency failed to ensure the contents of the Clinical Records were safeguarded against unauthorized use. This has the potential to affect all patients being served by the Agency. Findings included: 1. The Agency failed to ensure that Clinical records were safeguarded against unauthorized use (G1028). The cumulative effect of these systemic practices resulted in the Agency’s inability to protect and maintain confidential patient information.”

“Conformance with physician orders CFR(s): 484.60(b) Standard: Conformance with physician or allowed practitioner orders. This Standard is not met as evidenced by: Based on the clinical records review and staff interview, it was determined that for 3 of 7 clinical records reviewed (Pts. #1, 5 and 6), the Agency failed to ensure staff conform with the physician orders. Findings include: 1.Pt.#1 was admitted to Home Health Services on 10/04/23 with diagnosis of Type 2 Diabetes Mellitus without complications. The clinical record was reviewed on 01/23/24 at 11:30 AM. The clinical record contained a POC dated 12/03/23, that required the SN service 1 time a week for 9 weeks. The SN orders included to notify the doctor of abnormal blood glucose results. The clinical record lacked the blood glucose results for 10/04/23 (week #1) and 12/20/23 (weeks #3). 2. Pt.#5 was admitted to Home Health Services on 10/04/23 with diagnosis of Polyosteoarthritis, Unspecified. The clinical record was reviewed on 01/23/24 at 12:15 PM. The clinical record contained a POC dated 10/04/23, that required the SN service 1 time a week for 9 weeks. The SN orders included to notify the doctor of pain greater than 6. The SN did not notify the doctor of the Patient’s pain level of 8 on 10/11/23 and 10/30/23. 3. Pt.#6 was admitted to Home Health Services on 09/01/23 with Diagnosis of Peripheral Vascular Disease, Unspecified. The clinical record was reviewed on 01/23/24 at 1:00 PM. The clinical record contained a recertification POC dated 10/31/23, that required the SN service 1 time a week for 9 weeks. The clinical record lacked the SN visits after 11/20/23 (week #3) for 2 weeks. The same recertification period included orders for the OT and PT services. The clinical record lacked the OT visits and PT visits for the recertification period of 10/31/23. 4. The above findings were confirmed during the interview, with the Clinical Manager on 01/24/24 between 12:30 PM and 1:30 PM.”

“Protection of records CFR(s): 484.110(d) Standard: Protection of records. The clinical record, its contents, and the information contained therein must be safeguarded against loss or unauthorized use. The HHA must be in compliance with the rules regarding protected health information set out at 45 CFR parts 160 and 164. This Standard is not met as evidenced by: Based on clinical records review, Agency policy review and staff interview, it was determined that for 7 of 7 clinical records reviewed (Pts. #1, 2, 3, 4, 5, 6 and 7), the Agency failed to safeguard clinical records against unauthorized use. Findings include: 1. The following clinical records were reviewed between 01/23/24 and 01/25/24. Pt # 1 SOC 10/04/23 Pt# 2 SOC 01/16/24 Pt# 3 SOC 11/23/23 Pt# 4 SOC 10/27/23 Pt# 5 SOC 10/04/23 Pt# 6 SOC 09/01/23 Pt# 7 SOC 10/12/23 The paper clinical records included clinical assessments and notes that contained clinical information pertaining to the patient being reviewed on the front side of the paper, and on the reverse side, included clinical information not pertaining to the patient being reviewed. 2. During an interview with the Clinical Manager on 01/24/24 at 11:30 AM, the Clinical Manager stated “we have some field nurses that are not efficient with charting in the computer. So we have computer and paper clinical files. When the clinician does paper documentation I load and do the data entry in the computer. Once I do the data entry, I print the OASIS and documents and put everything in the paper chart. We print the documents with recycle paper.” The Agency was recycling their own paper utilizing the office copy machine and printing patient documents for clinical records on the back of other clinical documents belonging to other patients. 3. The Agency policy titled “Clinical record contents and maintenance” was reviewed on 01/25/24 at 9:30 AM. The policy required.... “ The clinical record will be maintained in such a manner that all information is assembled and filed in a timely manner and in accordance with law and regulation...” 4. During interviews with the Clinical Manager on 01/24/24 at 11:00 AM and on 01/25/24 at 9:30 AM finding of Agency maintaining paper clinical records utilizing recycled paper, with information not pertaining specifically to the individualized patient was confirmed.”

“Have a confidential clinical record CFR(s): 484.50(c)(6) Have a confidential clinical record. Access to or release of patient information and clinical records is permitted in accordance with 45 CFR parts 160 and 164. This Element is not met as evidenced by: Based on clinical records review, Agency policy review and staff interview, it was determined for 7 of 7 clinical records reviewed (Pts. #1, 2, 3, 4, 5, 6 and 7), the Agency failed to ensure patient confidentiality was maintained with clinical documents. Findings include: 1. The following clinical records were reviewed between 01/23/24 and 01/25/24. Pt # 1 SOC 10/04/23 Pt# 2 SOC 01/16/24 Pt# 3 SOC 11/23/23 Pt# 4 SOC 10/27/23 Pt# 5 SOC 10/04/23 Pt# 6 SOC 09/01/23 Pt# 7 SOC 10/12/23 The paper clinical records included clinical assessments and notes containing clinical information pertaining to the patient being reviewed on the front side of the paper, and on the reverse side, included clinical information not pertaining to the patient being reviewed. 2. During an interview with the Clinical Manager on 01/24/24 at 11:30 AM. the Clinical Manager stated “we have some field nurses that are not efficient with charting in the computer. So, we have computer and paper clinical files. When the clinician does paper documentation I load and do the data entry in the computer. Once I do the data entry, I print the OASIS and documents and put everything in the paper chart. We print the documents with recycle paper.” The Agency was recycling their own paper utilizing the office copy machine and printing patient documents for clinical records on the back of other clinical documents belonging to other patients. 3. The Agency policy titled “Clinical record contents and maintenance” was reviewed on 01/25/24 at 9:30 AM. The policy required.... “ The clinical record will be maintained in such a manner that all information is assembled and filed in a timely manner and in accordance with law and regulation...” 4. During interviews with the Clinical Manager on 01/24/24 at 11:00 AM and on 01/25/24 at 9:30 AM finding of Agency not having confidential clinical records was confirmed.”

“Onsite supervisory visit every 14 days CFR(s): 484.80(h)(1)(i) If home health aide services are provided to a patient who is receiving skilled nursing, physical or occupational therapy, or speech-language pathology services, a registered nurse or other appropriate skilled professional who is familiar with the patient, the patient’s plan of care, and the written patient care instructions described in §484.80(g), must make an onsite visit to the patient’s home no less frequently than every 14 days. The home health aide does not have to be present during this visit. This Element is not met as evidenced by: Based on clinical records review and staff interview, it was determined the RN failed to supervise the Aide in the home every 14 days. This was found in 2 of 2 (Pts. #1 and 4) clinical records reviewed with the Aide services. 2. Pt.# 4 was admitted to Home Health Services on 10/27/23 with diagnosis of Type 2 Diabetes Mellitus without complications. The clinical record was reviewed on 01/23/24 at 1:00 PM. The POC for certification period 12/27/23 to 02/24/24 contained orders to provided Aide services of 1 time a week for 9 weeks. The clinical record contained completed Aide visits for weeks 1 to week 4 of certification period with no RN supervision. 3. Finding of RN not completing Aide supervision every 14 days was confirmed during an interview with the Clinical Manager on 01/24/24 at 11:30 AM. Findings include: 1.Pt.#1 was admitted to Home Health Services on 12/03/23 with diagnosis of Type 2 Diabetes Mellitus without complications. The clinical record was reviewed on 01/23/24 at 11:30 AM, with orders for the Aide services of 2 times a week for 2 weeks and 1 time a week for 7 weeks (10/10/23 – 11/23/23). The clinical record lacked the Aide supervision by the RN, on 11/21/23 (week #8). The last documented Aide Supervision was 11/05/23 (week #6, more than 14 days).”