Ascension at Home

“Condition of Participation: Patient rights. CFR(s): 484.50 Condition of participation: Patient rights. The patient and representative (if any), have the right to be informed of the patient’s rights in a language and manner the individual understands. The HHA must protect and promote the exercise of these rights. This Condition is not met as evidenced by: Based on record review and interview, the home health agency failed to ensure patients received all services as outlined in the plan of care (See Tag G436); failed to advise the patient and physician that a discharge for cause was being considered (See Tag G464); failed to make efforts to resolve the problem (See Tag G466); failed to provide contact information for other agencies or providers (See Tag G468); failed to document the problem and efforts made to resolve the problem (See Tag G470); and failed to investigate the complaint (See Tag G478). Findings include: The cumulative effect of these systemic problems had the potential to impact all 533 active patients which resulted in the agency being found out of compliance with the Condition of Participation 42 CFR 484.50 Patient Rights.”

“Care planning, coordination, quality of care CFR(s): 484.60 Condition of participation: Care planning, coordination of services, and quality of care. Patients are accepted for treatment on the reasonable expectation that an HHA can meet the patient’s medical, nursing, rehabilitative, and social needs in his or her place of residence. Each patient must receive an individualized written plan of care, including any revisions or additions. The individualized plan of care must specify the care and services necessary to meet the patient-specific needs as identified in the comprehensive assessment, including identification of the responsible discipline(s), and the measurable outcomes that the HHA anticipates will occur as a result of implementing and coordinating the plan of care. The individualized plan of care must also specify the patient and caregiver education and training. Services must be furnished in accordance with accepted standards of practice. This Condition is not met as evidenced by: Based on record review and interview, the home health agency failed to document the correct date and time verbal orders were received from the physician (See G576); failed to ensure services were provided only as ordered by a physician or allowed practitioner (See G580); failed to ensure the plan of care (POC) was reviewed with the physician at start of care (SOC) and/or at recertification (See G588); failed to ensure the physician or allowed practitioner was promptly notified of the need to alter the plan of care (POC) related to discharge (See G590); and failed to document collaboration with the patient, caregiver and physician regarding discharge (See G598). Findings include: The cumulative effect of these systemic problems had the potential to impact all 533 active patients which resulted in the agency being found out of compliance with the Condition of Participation 42 CFR 484.60 Care Planning, Coordination of Services and Quality of Care.”

“EP Training and Testing CFR(s): 484.102(d) §403.748(d), §416.54(d), §418.113(d), §441.184(d), §460.84(d), §482.15(d), §483.73(d), §483.475(d), §484.102(d), §485.68(d), §485.542(d), §485.625(d), §485.727(d), §485.920(d), §486.360(d), §491.12(d), §494.62(d). *[For RNCHIs at §403.748, ASCs at §416.54, Hospice at §418.113, PRTFs at §441.184, PACE at §460.84, Hospitals at §482.15, HHAs at §484.102, CORFs at §485.68, REHs at §485.542, CAHs at §486.625, “Organizations” under 485.727, CMHCs at §485.920, OPOs at §486.360, and RHC/FHQs at §491.12:] (d) Training and testing. The [facility] must develop and maintain an emergency preparedness training and testing program that is based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, policies and procedures at paragraph (b) of this section, and the communication plan at paragraph (c) of this section. The training and testing program must be reviewed and updated at least every 2 years. *[For LTC facilities at §483.73(d):] (d) Training and testing. The LTC facility must develop and maintain an emergency preparedness training and testing program that is based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, policies and procedures at paragraph (b) of this section, and the communication plan at paragraph (c) of this section. The training and testing program must be reviewed and updated at least annually. *[For ICF/IIDs at §483.475(d):] Training and testing. The ICF/IID must develop and maintain an emergency preparedness training and testing program that is based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, policies and procedures at paragraph (b) of this section, and the communication plan at paragraph (c) of this section. The training and testing program must be reviewed and updated at least every 2 years. The ICF/IID must meet the requirements for evacuation drills and training at §483.470(i). *[For ESRD Facilities at §494.62(d):] Training, testing, and orientation. The dialysis facility must develop and maintain an emergency preparedness training, testing and patient orientation program that is based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, policies and procedures at paragraph (b) of this section, and the communication plan at paragraph (c) of this section. The training, testing and orientation program must be evaluated and updated at every 2 years. This Standard is not met as evidenced by: Based upon record review and interview, the home health agency failed to provide documentation of emergency preparedness (EP) training upon hire for 7 of 7 employee records reviewed who were hired in the past year (Occupational Therapist (OT) 1, Physical Therapist (PT) 1, Registered Nurse (RN) 2, RN 6, Home Health Aide (HHA) 1, HHA 2 and HHA 3). Findings include: 1. A review of agency policy “Emergency Operations” indicated all associates, including contract associates, will receive initial and annual training regarding the EOP and their role in plan development, plan testing and plan evaluation. 2. The review of the employee record for OT 1 evidenced a hire date of 8/22/23. The personnel filed for OT 1 failed to evidence documentation of EP training upon hire. 3. The review of the employee record for PT 1 evidenced a hire date of 8/10/23. The personnel filed for PT 1 failed to evidence documentation of EP training upon hire. 4. The review of the employee record for RN 2 evidenced a hire date of 5/03/23. The personnel filed for RN 2 failed to evidence documentation of EP training upon hire. 5. The review of the employee record for RN 6 evidenced a hire date of 3/25/24. The personnel filed for RN 6 failed to evidence documentation of EP training upon hire. 6. The review of the employee record for HHA 1 evidenced a hire date of 12/04/23. The personnel filed for HHA 1 failed to evidence documentation of EP training upon hire. 7. The review of the employee record for HHA 2 evidenced a hire date of 5/24/23. The personnel filed for HHA 2 failed to evidence documentation of EP training upon hire. 8. The review of the employee record for HHA 3 evidenced a hire date of 10/17/23. The personnel filed for HHA 3 failed to evidence documentation of EP training upon hire. 9. During an interview on 4/30/24 beginning at 9:00 AM, Corporate Human Resources Person 2 indicated the HR department does not have access to the online learning courses transcripts. During an interview on 4/30/24 beginning at 2:30 PM, the Administrator indicated all employees are required to do EP training upon hire and annually but was unable to provide documentation of the initial EP training for the above employees.”

“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 record review and interview, the home health agency failed to analyze the after-action response to determine if the Emergency Plan (EP) plan needed revision for the EP activation performed in 2023 for 1 of 1 agency. Findings Include: 1. A review of agency policy “Emergency Operations” indicated the Emergency Operations plan must be tested and evaluated to determine where revisions are needed to strengthen and improve response outcomes and the Administrator is responsible to plan at least 1 testing exercise each year. 2. The “Compassus Emergency Operations Plan Home Health” last approved March 30, 2023 was provided for review. The plan included documentation of an emergency plan activation that occurred on January 25, 2023. The agency failed to analyze the results of the emergency activation to determine if the plan needed to be revised. 3. During an interview on 4/29/24 beginning at 2:00 PM, the Administrator indicated the home health agency did not have any follow-up analysis documentation to provide regarding the emergency activation in 2023.”

“Program data CFR(s): 484.65(b)(1),(2),(3) Standard: Program data. (1) The program must utilize quality indicator data, including measures derived from OASIS, where applicable, and other relevant data, in the design of its program. (2) The HHA must use the data collected to- (i) Monitor the effectiveness and safety of services and quality of care; and (ii) Identify opportunities for improvement. (3) The frequency and detail of the data collection must be approved by the HHA’s governing body. This Standard is not met as evidenced by: Based on record review and interview, the home health agency failed to ensure the governing body approved the frequency and detail of data collection for 1 of 1 agency. Findings include: 1. The QAPI policy indicated (The governing body… Approves the frequency and detail of the data collection performed within the QAPI program. 2. The governing body meeting minutes and QAPI meeting minutes failed to evidence the governing body approved the frequency and detail of data collection. 3. On 4/29/24 at 4:01 PM, the Administrator relayed that she and her DCS’s (Director of Clinical Services) put together the frequency and detail of data collection and then it goes to regional quality and then to clinical excellence.”

“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 record review and interview, the home health agency failed to ensure all entries in the clinical record were appropriately authenticated, dated, and timed, for 3 of 12 active patient records reviewed (Patient #1, #3, and #10). Findings include: 1. Patient #1’s clinical record included a plan of care (POC) for certification period 3/06/24 to 5/04/24 signed by Registered Nurse (RN) 2. The POC includes a signature date of 12/29/23. The POC failed to include an appropriate signature date for the RN. 2. On 4/26/24 at 1:45 PM, RN 2 relayed she didn’t know why the POC was dated 12/29/23 as she doesn’t enter a date when she signs. RN 2 indicated 12/29/23 was the date of the verbal order for start of care and should not be on there as the date for a recertification in March. 3. Patient #3’s clinical record included a start of care (SOC) on 4/10/24 and a POC for certification period 4/10/24 to 6/08/24 signed by RN 3. The POC evidenced an RN electronic signature date of 4/08/24. The POC failed to include an appropriate signature date for RN 3. During an interview on 4/25/24 beginning at 1:45 PM, RN 3 indicated the POC is created during the SOC visit and they were unaware the POC signature date was prior to the SOC date on Patient #3’s POC. 4. Patient #10’s clinical record included a start of care (SOC) on 4/01/24 and a POC for certification period 4/01/24 to 5/30/24. The POC evidenced an RN electronic signature date of 3/28/24 The POC failed to include an appropriate signature date for RN 3. During an interview on 4/25/24 beginning at 1:45 PM, RN 3 indicated the POC is created during the SOC visit and they were unaware the POC signature date was prior to the SOC date on Patient #10’s POC. 5. During an interview on 4/25/24 beginning at 3:02 PM, the Alternate Clinical Manager and Corporate Person 1 indicated they were unsure why the POC signature date was prior to the SOC date.”

“Receive all services in plan of care CFR(s): 484.50(c)(5) Receive all services outlined in the plan of care. This Element is not met as evidenced by: Based on record review and interview, the home health agency failed to ensure patients were informed of a delay in the start of therapy services for 2 of 2 records which evidenced a lapse in time for therapy service(s) initiation (Patient #10 and 11). Findings include: 1. A review of agency policy “Patients’ Rights” indicated the patient has the right to participate in, be informed about, and consent or refuse care in advance of and during treatment, where appropriate, with respect to the completion of all assessments and any changes to the care being furnished and patients’ rights include at a minimum to receive all services outlined in the plan of care. 2. The review of Patient #10’s clinical record included a plan of care for the initial certification period 4/01/24 to 5/30/24. The plan of care indicated the patient was to receive an Occupational Therapy (OT) evaluation for services. The record included an initial comprehensive assessment, conducted by Registered Nurse (RN) 3 on 4/01/24, which indicated Patient #10’s need for OT services. The record included an OT evaluation visit was completed on 4/11/24 by Occupational Therapist (OT) 2. The record failed to evidence communication with the patient regarding lapse in time for OT services (4/01/24 to 4/11/24). During an interview on 4/25/24 beginning at 11:46 AM, OT 2 indicated they had been out of town and the OT Evaluation visit was set up for 4/11/24 and they were unsure if the patient had been notified of the delay in the OT Evaluation. During an interview on 4/25/24 beginning at 3:02 PM, the Alternate Clinical Manager indicated the patient should have been notified regarding the delay in services. 3. The review of Patient #11’s clinical record included a plan of care for the initial certification period 4/02/24 to 5/31/24. The plan of care indicated the patient was to receive an Occupational Therapy (OT) visit 1 time a week for 1 week effective 4/02/24. The record included an OT evaluation visit was completed on 4/16/24 by Occupational Therapist (OT) 3. The record failed to evidence communication with the patient regarding lapse in time for OT services (4/02/24 to 4/16/24). During an interview on 4/25/24 beginning at 2:57 PM, OT 3 indicated they had been on vacation and the OT Evaluation visit was conducted on 4/16/24. They indicated they notified Patient #11 regarding the delay via text message. OT 3 failed to document this communication in the clinical record for Patient #11. During an interview on 4/25/24 beginning at 3:02 PM, the Alternate Clinical Manager indicated the patient should have been notified regarding the delay in services and any communication with a patient should have been documented in a care coordination note in the clinical record.”

“Advise the patient of discharge for cause CFR(s): 484.50(d)(5)(i) (i) Advise the patient, representative (if any), the physician(s) or allowed practitioner(s), issuing orders for the home health plan of care, and the patient’s 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) that a discharge for cause is being considered; This Element is not met as evidenced by: Based on record review and interview, the home health agency failed to collaborate with the patient and physician regarding possible discharge for cause/ noncompliance for 2 of 2 discharge for cause/noncompliance patient records reviewed (Patient #14 and 16). Findings include: 1. A review of agency policy “Discharge and Transfer” indicated prior to discharge for cause, the agency must complete and document the following: Advise the patient, representative (if applicable), the physician who issued the orders and plan of care for the patient, and the patient’s primary care practitioner if different of the planned discharge for cause; make efforts to resolve the problems identified; and provide the patient/representative with contact information for other agencies or providers in the area who may be able to provide care. 2. A review of the “Home Health Patient Handbook” indicated the patient will be given advance notice of a discharge and written notice of discharge/termination of services will be provided to the patient with information on the right to appeal a discharge from service in accordance with Medicare regulations. 3. The review of Patient #14’s clinical record included a Plan of Care (POC) for the certification period 2/14/24 to 4/13/24. The clinical record failed to evidence collaboration with the patient or physician regarding a possible discharge for cause. During an interview on 4/23/24 beginning at 11:10 AM, Person C indicated Registered Nurse (RN) 2 informed Physician A’s office on 4/20/24 that Patient #14 had been discharged from home health services effective 3/18/24. Person C indicated the physician’s office medical record for Patient #14 did not include any collaboration with Physician A prior to the discharge. During an interview on 4/23/24 beginning at 11:26 AM, Person F indicated they received a telephone call on 3/20/24 from Person C, Medical Assistant (MA) for Physician A, stating Patient #14 had been discharged from home health services due to safety concerns. During an interview on 4/26/24 beginning at 1:57 PM, RN 2 indicated they did not collaborate with Patient #14 or Physician A prior to the discharge. 4. The review of Patient #16’s clinical record included a Plan of Care (POC) for the certification period 2/05/24 to 4/04/24. The clinical record failed to evidence collaboration with the patient or physician regarding a possible discharge for noncompliance. During an interview on 4/26/24 beginning at 12:43 PM, Physical Therapist (PT) 3 indicated she discussed with Patient #16’s sister regarding possible discharge for noncompliance. PT 3 indicated she did not document this discussion in Patient #16’s clinical record and did not notify the patient or physician regarding possible discharge for noncompliance. During an interview on 4/29/24 beginning at 10:41 AM, Person L, MA for Physician K, indicated the home health agency informed Physician K’s office on 3/20/24 at 2:06 PM that the home health agency would be discharging Patient #16 due to noncompliance. Person L indicated the physician’s office medical record for Patient #16 did not include any collaboration with Physician K prior to the 3/20/24 notification of discharge.”

“Make efforts to resolve the problem(s) CFR(s): 484.50(d)(5)(ii) (ii) Make efforts to resolve the problem(s) presented by the patient’s behavior, the behavior of other persons in the patient’s home, or situation; This Element is not met as evidenced by: Based on record review and interview, the home health agency failed to make efforts to resolve the problems in the patient home for 1 of 2 discharge for cause patient records reviewed (Patient #14). Findings include: 1. A review of agency policy “Discharge and Transfer” indicated prior to discharge for cause, the agency must complete and document the following: Advise the patient, representative (if applicable), the physician who issued the orders and plan of care for the patient, and the patient’s primary care practitioner if different of the planned discharge for cause; make efforts to resolve the problems identified; and provide the patient/representative with contact information for other agencies or providers in the area who may be able to provide care. 2. The review of Patient #14’s clinical record included a Start of Care (SOC) date of 2/14/24 and a Plan of Care (POC) for the certification period 2/14/24 to 4/13/24. The plan of care indicated the patient was to receive Skilled Nurse (SN) services 1 time a week for 9 weeks. The record included SN Visit notes on 2/14/24, 2/19/24, 2/26/24, 3/04/24, 3/11/24 and 3/18/24. The SN visit note dated 2/14/24 did not evidence any problems. The SN visit note dated 2/19/24 did not evidence any problems. The SN visit note dated 2/26/24 did not evidence any problems. The SN Visit note dated 3/04/24 evidenced Person F informed RN 2 regarding pending criminal court in another state and requested the Home Health Agency provide documentation to submit to the court. RN 2 documented in the nurse narrative section of the note that Patient #14 was not cooperative, and refused to position their arm up for the PICC dressing change. RN 2 documented she was uncomfortable with the patient but felt safe in the home with Person F present. The SN Visit note failed to include documentation of safety concerns in the home and failed to contain any education or discussion with the patient/caregiver regarding the importance of arm positioning during PICC dressing changes. The SN visit note dated 3/11/24 did not evidence any problems. The SN visit note failed to include any education to the patient on the importance of arm position during PICC dressing changes. The SN visit note dated 3/18/24 evidenced documentation of Patient #14’s dog loose and aggressive towards RN 2 outside the home prior to the visit. Person F was able to put the dog away in the garage prior to RN 2 entering the home. RN 2 documented Person F informed her that Patient #14 was accused of shooting a man in a drug deal and RN 2 expressed her concern for safety. Person F requested to not switch home health agencies due to Patient #14 only having 3 weeks of antibiotic therapy left. RN 2 documented that they notified the Director of Clinical Services (DCS) 1 after the visit. DCS 1 instructed RN 2 to call the physician and let them know the home health agency needs to be discharged due to safety concerns. The SN visit note failed to evidence any education or discussion with the patient/caregiver regarding potential discharge. The clinical record for Patient #14 failed to evidence documentation that DCS 1 contacted the patient and/or caregiver to attempt to make efforts to resolve the problem prior to discharge and failed to evidence the home health agency made any other efforts to resolve the problems. The clinical record failed to evidence an incident report was filed by RN 2 related to the alleged problem. 3. During an interview on 4/23/24 beginning at 11:26 AM, Person F indicated RN 2’s attitude towards Patient #14 changed after RN 2 was told about Patient #14’s pending criminal charges and she was unaware of any problems in the home. During an interview on 4/26/24 beginning at 1:57 PM, RN 2 indicated she googled Patient #14’s criminal charges after being notified by Person F on 3/04/24 and because of his criminal charges and the loose dog on 3/18/24, she no longer felt comfortable in the home. During an interview on 4/26/24 beginning at 2:58 PM, DCS 1 indicated she was not aware of any safety concerns in the home prior to the 3/18/24 visit and indicated she did not discuss the problems with the patient and/or caregiver prior to discharge.”

“Provide contact info other services CFR(s): 484.50(d)(5)(iii) (iii) Provide the patient and representative (if any), with contact information for other agencies or providers who may be able to provide care; and This Element is not met as evidenced by: Based on record review and interview, the home health agency failed to provide the patient and/or representative with contact information for other home health agencies who may be able to provide care for 1 of 2 discharge for cause patient records reviewed (Patient #14). Findings include: 1. A review of agency policy “Discharge and Transfer” indicated prior to discharge for cause, the agency must complete and document the following: Advise the patient, representative (if applicable), the physician who issued the orders and plan of care for the patient, and the patient’s primary care practitioner if different of the planned discharge for cause; make efforts to resolve the problems identified; and provide the patient / representative with contact information for other agencies or providers in the area who may be able to provide care. 2. The review of Patient #14’s clinical record evidenced a Start of Care (SOC) date of 2/14/24 and a discharge for cause date of 3/18/24. The clinical record failed to include documentation that Patient #14 was provided with discharge information or contact information for other agencies or providers in the area. During an interview on 4/26/24 beginning at 1:57 PM, RN 2 indicated they did not notify Patient #14 of the discharge for cause. During an interview on 4/26/24 beginning at 2:58 PM, the Administrator indicated the home health agency did not send Patient #14 any information after the discharge.”

“Document efforts to resolve problems CFR(s): 484.50(d)(5)(iv) (iv) Document the problem(s) and efforts made to resolve the problem(s), and enter this documentation into its clinical records; This Element is not met as evidenced by: Based on record review and interview, the home health agency failed to document the efforts made to resolve the problem for 1 of 2 discharge for cause patient records reviewed (Patient #14). Findings include: 1. A review of agency policy “Discharge and Transfer” indicated prior to discharge for cause, the agency must complete and document the following: Advise the patient, representative (if applicable), the physician who issued the orders and plan of care for the patient, and the patient’s primary care practitioner if different of the planned discharge for cause; make efforts to resolve the problems identified; and provide the patient / representative with contact information for other agencies or providers in the area who may be able to provide care. 2. The review of Patient #14’s clinical record included a Plan of Care (POC) for the certification period 2/14/24 to 4/13/24. The plan of care indicated the patient was to receive Skilled Nurse (SN) services 1 time a week for 9 weeks. The record included SN Visit notes on 2/14/24, 2/19/24, 2/26/24, 3/04/24, 3/11/24 and 3/18/24. The SN visit note dated 3/18/24 evidenced RN 2 notified Director of Clinical Services (DCS) 1 after their visit of safety concerns in the home. DCS 1 instructed RN 2 to call the physician and let them know the home health agency needs to be discharged due to safety concerns. The clinical record failed to evidence documentation of efforts made to resolve the problems that were cited for discharge for cause. 3. During an interview on 4/23/24 beginning at 11:26 AM, Person F indicated they offered during the 3/18/24 visit to put the dog in the garage for all future visits. During an interview on 4/26/24 beginning at 1:57 PM, RN 2 indicated she had no further contact with Patient #14 or Person F after the 3/18/24 SN Visit. During an interview on 4/26/24 beginning at 2:58 PM, the Administrator indicated the home health agency had not made any efforts to discuss or resolve the safety problem at Patient #14’s home.”

“Investigate complaints made by patient CFR(s): 484.50(e)(1)(i) The HHA must— (i) Investigate complaints made by a patient, the patient’s representative (if any), and the patient’s caregivers and family, including, but not limited to, the following topics: (A) Treatment or care that is (or fails to be) furnished, is furnished inconsistently, or is furnished inappropriately; (B) Mistreatment, neglect, or verbal, mental, sexual, and physical abuse, including injuries of unknown source, and/or misappropriation of patient property by anyone furnishing services on behalf of the HHA. This Element is not met as evidenced by: Based on record review and interview, the agency failed to investigate 1 of 1 complaint regarding discharge for cause (Patient #14). Findings include: 1. A review of agency policy “Complaints, Communication, Accessibility of Services” indicated the Administrator is responsible to ensure all aspects of complaint investigation, reporting, tracking, and communication are carried out, including escalation from the program to the corporate compliance team/legal counsel if indicated and indicated all complaints and grievances are documented, investigated and resolved as much as feasible to the satisfaction of the complainant. 2. The review of the agency complaint log evidenced Other Person F filed a complaint with the home health agency on 3/21/24 regarding poor communication from the agency regarding the non-visit discharge. During an interview on 4/23/24 beginning at 11:26 AM, Person F, caregiver for Patient #14, indicated they received a telephone call on 4/20/24 from Person C, Medical Assistant for Physician A, stating Patient #14 had been discharged from the home health agency due to safety concerns. Person F received a call from Director of Clinical Services (DCS) 1 later that day stating that Patient #14 had been discharged for safety concerns due to the dog getting out. Person F indicated they requested an appeal to the discharge but was not provided with any information. Person F was expecting to hear back from the Administrator after the Administrator discussed the complaint situation with the DCS. Person F indicated they had not received any further calls regarding this matter. 3. Patient #14’s clinical record failed to include documentation the Administrator communicated with DCS 1 regarding Person F’s complaint allegations. During an interview on 4/26/24 beginning at 2:58 PM, the Administrator indicated they didn’t follow up any further with Person F because Person F just wanted their complaint to be heard and Patient #14 was getting the peripherally inserted central catheter (PICC) dressing changes at a local outpatient clinic.”

“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 observation, record review, and interview, the home health agency failed to ensure a review of all medications the patient was taking for 6 of 7 patients with home visit observations (Patient #1, #2, #3, #4, #5, and #7). Findings include: 3. Patient #2’s clinical record evidenced a Start of Care (SOC) on 3/19/24 and included a current medication list as of 4/22/24. The clinical record failed to evidence the Registered Nurse (RN) Case Manager conducted a medication review or reconciliation of Patient #2’s medications. During a home visit observation conducted with Patient #2 and RN 2 on 4/22/24 beginning at 4:00 PM, RN 2 failed to reconcile medications during the visit. Surveyor comparison of the home health agency’s medication list against the medications in the home evidenced the following discrepancies: a) Amlodipine (used to treat blood pressure) 5 milligram (mg), 1 tablet daily. The home health agency’s records failed to evidence an order for Lorazepam. b) Albuterol inhaler (used to treat shortness of breath) 90 micrograms (mcg), 2 puffs every 6 hours as needed. The home health agency’s records failed to evidence an order for Albuterol. c) Atorvastatin (used to treat high cholesterol) 40 mg, 1 tablet daily. The home health agency’s records failed to evidence the correct prescribed dose for Atorvastatin. d) Spiriva (used to treat Chronic Obstructive Pulmonary Disease) 2.5 mcg/actuation, 2 puffs daily. The home health agency’s records failed to evidence the correct prescribed dose for Spiriva. e) Venlafaxine Extended Release (ER) (used to treat depression) 75 mg, 1 capsule daily. The home health agency’s records failed to evidence the correct prescribed dose for Venlafaxine. f) Calcium (used as a supplement) 600 mg + Vitamin D 20 mg, 1 tablet daily. The home health agency’s records failed to evidence an order for Calcium+Vitamin D. g) Vitamin D3 (used as a supplement) 125 mcg, 1 tablet daily. The home health agency’s records failed to evidence an order for Vitamin D3. h) Vitamin B12 (used as a supplement) 5000 mcg, 1 tablet daily. The home health agency’s records failed to evidence an order for Vitamin B12. i) Aspirin (used as a blood thinner) 81 mg, 1 tablet daily. The home health agency’s records failed to evidence an order for Aspirin. j) Advanced Probiotic (used to improve digestion), 1 capsule daily. The home health agency’s records failed to evidence an order for Advance Probiotic. k) Folic Acid (used as a supplement) 800 mcg, 1 tablet daily. The home health agency’s records failed to evidence an order for Folic Acid. l) Fexofenadine HCL (used to treat allergies) 180 mg, 1 tablet daily. The home health agency’s records failed to evidence an order for Fexofenadine. m) Potassium Chloride ER (used as a supplement) 20 milliequivalent (mEq), 1 tablet daily. The home health agency’s records have this medication listed as an active medication. Per Patient 32, they are no longer taking this medication. During an interview on 4/22/24 beginning at 4:47 PM, RN 2 indicated they review medications in the home every visit. 4. Patient #3’s clinical record evidenced a Start of Care (SOC) on 4/10/24 and included a current medication list as of 4/22/24. The clinical record failed to evidence the Registered Nurse (RN) Case Manager conducted a medication review or reconciliation of Patient #3’s medications. During a home visit observation conducted with Patient #3 and RN 5 on 4/23/24 beginning at 9:16 AM, RN 5 failed to reconcile medications during the visit. Surveyor comparison of the home health agency’s medication list against the medications list obtained from the Assisted Living Facility (ALF) evidenced the following discrepancies: a) Acetaminophen (used to treat pain/fever) 500 milligram (mg), 1-2 tablets three times a day as needed effective 4/09/24. The home health agency’s records failed to evidence the correct prescribed dose for Acetaminophen. During an interview on 4/24/24 beginning at 1:45 PM, RN 5 indicated they reconcile medications every visit. 5. Patient #4’s clinical record evidenced a Start of Care (SOC) on 10/20/23 and included a current medication list as of 4/22/24. The clinical record failed to evidence the Registered Nurse (RN) Case Manager conducted a medication review or reconciliation of Patient #4’s medications. During a home visit observation conducted with Patient #4 and Licensed Practical Nurse (LPN) 1 on 4/23/24 beginning at 3:30 PM, LPN 1 failed to reconcile medications during the visit. LPN 1 gave Other Person M a printed medication list at the end of the home visit observation. Surveyor comparison of the home health agency’s medication list against the medications in the home evidenced the following discrepancies: a) Metformin (used to treat diabetes) 500 milligram (mg). The home health agency medication list has this medication listed twice: 2 tablets daily effective 3/13/24 and 1 tablet twice a day effective 4/19/24. Other Person M, wife of Patient #4 verified that Patient #4 is taking 1 tablet of Metformin twice a day. The home health agency’s records failed to evidence the correct prescribed dose for Metformin. b) Ozempic (used to treat Diabetes) 0.25 mg, 1 dose weekly on Wednesdays per Other Person M. The home health agency’s records failed to evidence an order for Ozempic. During an interview on 4/23/24 beginning at 4:33 PM, LPN 1 indicated they try to perform a medication reconciliation weekly. During an interview on 4/24/24 beginning at 11:20 AM, RN 1 indicated they reconcile medications in the home every visit. 1. The Initial and Comprehensive Assessment policy indicated the comprehensive assessment includes a “…review of all medications the patient is currently using.” 2. On 4/22/24 at 3:33 PM, observed COTA 1 providing care for Patient #1. The COTA reviewed the medications in the home and discovered Melatonin gummies 5 milligrams (mg) that were not on Patient #1’s medication list. COTA 1 asked if the medication was new, and Patient #1’s caregiver relayed the patient had been taking the medication nightly since prior to agency admission. Patient #1’s clinical record indicated a start of care (SOC) date of 1/6/24 and included a medication list. Patient #1’s medication list printed on 4/22/24 failed to include Melatonin gummies. The clinical record failed to evidence a complete medication review was completed to include the Melatonin gummies at the SOC assessment visit or any subsequent visit prior to the 4/22/24 home visit observation. During the entrance conference on 4/22/24 beginning at 9:18 AM, the Administrator relayed the patient’s medications should be reviewed in the home at admission and at every visit by every staff member except for home health aides. 6. On 4/23/24 at 9:35 AM, observed PT 1 providing care for Patient #5. PT 1 did not reconcile the medication list against the medication bottles in the home. Isosorb Mono ER 60 mg was observed in the home. Patient #5 relayed they had been taking Isosorb Mono ER since 2016. Senokot 8.6 mg/50 mg as needed was not observed to be in the home. Patient #5 indicated they were not taking Senokot and did not think they had ever had it in the home. Patient #5’s clinical record indicated a SOC date of 3/28/24 and included a medication list. The medication list failed to include Isosorb Mono 60 mg. The medication list included Senokot 8.6 mg/50 mg as needed. The clinical record indicated PT 1 completed the initial comprehensive assessment for Patient #5. On 4/26/24 at 1:42 PM, PT 1 relayed he goes through the medication list and reconciles medications at every visit and relayed he looks at the medication bottles in the home at SOC and as needed. 7. On 4/24/24 at 10:03 AM, observed RN 4 providing care for Patient #7. Observed Levothyroxine 50 microgram (mcg) daily, a medication used to treat low thyroid hormone levels, and Losartan/HCTZ (hydrochlorothiazide) 50 mg/12.5 mg, a medication used to treat high blood pressure, in the home. Patient #7 relayed they had been taking both medications at those dosages since at least February of 2024. During the home visit, RN 4 relayed she checks medication bottles in the home at SOC. Patient #7’s clinical record evidenced a SOC date of 4/17/24. The medication list included Levothyroxine 25 mcg daily and Losartan 50 mg daily. The medication list failed to include the correct dose of Levothyroxine and failed to include the correct blood pressure medication.”

“All orders recorded in plan of care CFR(s): 484.60(a)(3) All patient care orders, including verbal orders, must be recorded in the plan of care. This Element is not met as evidenced by: Based on record review and interview, the home health agency failed to document the correct date and time verbal orders were received from the physician for 2 of 12 active records reviewed (Patient #2 and 10). Findings include: 1. A review of agency policy “Written and Verbal Orders” indicated the individual receiving the order must record and sign it, date it, and enter the time received immediately and have the person prescribing person sign it in accordance with State and Federal regulations. The policy also indicated a valid verbal order indicates the individual who received the order spoke directly with the prescriber and had the opportunity to ask clarifying questions and validate understanding of the order with the prescriber. 2. Patient #2’s clinical record included a Plan of Care (POC) for certification period 3/19/24 to 5/17/24. The POC evidenced a verbal order was received on 3/19/24 at 3:20 PM. The Skilled Nurse (SN) comprehensive assessment dated 3/19/24 indicated DCS 1 left a voicemail with Physician A’s office. A client coordination note report dated 3/22/24 indicated DCS 1 received a POC verbal order from Physician A’s office on 3/20/24. The POC for Patient #2 failed to evidence the correct verbal order date and time. During an interview on 4/26/24 beginning at 2:50 PM, DCS 1 indicated they received a verbal order from Physician A’s office on 3/20/24 and they were unsure if the client coordination note report was sent to the physician for signature. During an interview on 4/24/24 beginning at 3:02 PM, the Administrator indicated the client coordination notes are not sent to the physician for signature. 3. Patient #10’s clinical record included a POC for certification period 4/01/24 to 5/30/24. The POC evidenced a verbal order was received on 4/01/24 at 1:28 PM. The Skilled Nurse (SN) comprehensive assessment dated 4/01/24 indicated RN 3 received a POC approval verbal order from Physician I’s office on 4/01/24 at 3:00 PM. The POC for Patient #10 failed to evidence the correct verbal order time. During an interview on 4/25/24 beginning at 1:25 PM, RN 3 indicated they document the actual time the verbal order was received in the SN visit note narrative and were unsure why the POC had a different verbal order time received. During an interview on 4/24/24 beginning at 3:02 PM, the Administrator indicated verbal order times should be the same on the POC and the SN Visit note narrative and should be the actual time the verbal order was received.”

“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 record review and interview, the home health agency failed to ensure services were provided only as ordered by a physician or allowed practitioner for 7 of 12 active patient records reviewed (Patient #1, #2, #4, #9, #10, #11, and #12). Findings include: 1. The Written and Verbal Orders policy, revised 1/31/24, indicated “If the order is verbal… It is provided and documented by a licensed nurse, therapist, or other authorized individual; and… The individual receiving the order must record and sign it, date it, and enter the time received immediately and have the prescribing person sign it in accordance with State and Federal regulations… A valid verbal order indicates the individual who received the order spoke directly with the prescriber and had the opportunity to ask clarifying questions and validate understanding of the order with the prescriber… Orders should be returned signed to the medical record within 30 days…” 2. Patient #1’s clinical record included a POC for certification period 3/06/24 to 5/04/24 and an add on order for occupational therapy. The order included an occupational therapy frequency of 1 time per week for 8 weeks, effective 3/10/24. The order indicated a verbal order date and time of 3/0/24 at 9:15 AM. The clinical record failed to include who Occupational Therapist (OT) 2 spoke with to take the verbal order. The written order for OT services was returned to the agency signed by the provider on 3/13/24. Patient #1’s clinical record included a visit note documenting the care Certified Occupational Therapist (COTA) provided for Patient #1 on 3/12/24. The agency failed to ensure there was a valid verbal or written order for OT services prior to the COTA visit on 3/12/24. On 4/26/24 at 1:48 PM, OT 2 relayed she typically when doing a start of care (SOC) or recertification evaluation, she leaves a voicemail at the provider’s office with POC information, and they can call with questions. OT 2 relayed that if there is a change such as adding on home health aide or social worker services, she will leave a voicemail and wait for a return call with verbal orders for that change. OT 2 indicated when taking a verbal order, she includes what the order is for and who she spoke with. OT 2 further indicated that the verbal order date and time on the POC is the date and time she left a voicemail for the provider. OT 2 relayed she did not know who she spoke with at the provider’s office and relayed there was no record of who she spoke with in her calendar. 3. Patient #12’s clinical record included a POC for certification period 1/19/24 to 3/18/24 with a skilled nursing (SN) frequency of 1 time per week for 1 week and 2 times per week for 8 weeks. The POC indicated a verbal order date and time of 1/19/24 at 11:32 AM and was returned signed by the physician on 1/31/24 at 1:31 PM. Patient #12’s clinical record indicated RN 1 left a message for the patient’s physician on 1/19/24 regarding SN treatment and visit frequency for certification period 1/19/24 to 3/18/24. The clinical record failed to include documentation of a call back from the physician to provide verbal orders for SN treatments and frequency. Patient #12’s clinical record also included a POC for certification period 3/19/24 to 5/17/24 with a skilled nursing (SN) frequency of 2 times per week for 9 weeks. The POC indicated a verbal order date and time of 3/15/24 at 11:25 AM and was returned signed by the physician on 3/20/24 at 3:31 PM. The clinical record failed to include documentation of whether a voicemail was left or a person was spoken with at the physician’s office. Patient #12’s clinical record included visit notes that indicated LPN 1 performed wound care on, including but not limited to, 1/24/24, 1/26/24, 1/31/24 at 8:55 AM, and 3/20/24 at 6:29 AM. On 4/29/24 at 12:10 PM, RN 1 relayed she usually has to leave a message with Patient #12’s doctor’s office and gets a call back, but that could take a day or two. RN 1 indicated the call back with verbal orders should be documented in a coordination note, but she could not find documentation of a return call from Patient #12’s doctor regarding verbal orders for the POC. The review of Patient #2’s clinical record included a start of care (SOC) on 3/19/24 and a POC for certification period 3/19/24 to 5/17/24 with orders for Skilled Nurse (SN) service frequencies of 1 visit a week for 1 week; 2 visits a week for 2 weeks; 1 visit a week for 1 week; 2 visits a week for 2 weeks then 1 visit a week for 3 weeks. The record evidenced SN visits were performed on 3/19/24, 3/25/24, 3/28/24 and 4/01/24. The record evidenced a client coordination note report dated 3/22/24 that indicated DCS 1 received a POC verbal order from Physician A’s office on 3/20/24. The record failed to evidence documentation this client coordination note was sent to the physician for signature and failed to include a signed written order for the POC frequencies was obtained prior to the above visits performed. During an interview on 4/26/24 beginning at 2:50 PM, DCS 1 indicated they were unsure if the client coordination note report was sent to the physician for signature. During an interview on 4/24/24 beginning at 3:02 PM, the Administrator indicated the client coordination notes are not sent to the physician for signature. The review of Patient #4’s clinical record included a start of care (SOC) on 10/20/23 and a recertification POC for certification period 4/17/24 to 6/15/24 with orders for Skilled Nurse (SN) service frequencies of 1 visit a week for 1 week; then 2 visits a week for 8 weeks. The record evidenced SN visits were performed on 4/19/23, 4/23/24 and 4/26/24. The record failed to evidence documentation of a verbal order or a signed written order for the POC frequencies was obtained prior to the above visits performed. During an interview on 4/24/24 beginning at 11:20 AM, RN 1 indicated they did not receive verbal orders from the physician regarding the recertification POC for Patient #4. The review of Patient #9’s clinical record included a start of care (SOC) on 4/13/24 and a POC for certification period 4/13/24 to 6/11/24 with orders for Skilled Nurse (SN) service frequencies of 1 visit a week for 10 weeks. The record evidenced SN visits were performed on 4/19/24 and 4/23/24. The record failed to evidence documentation of a verbal order or a signed written order for the POC frequencies was obtained prior to the above visits performed. During an interview on 4/24/24 beginning at 10:30 AM, RN 7 indicated they were unsure if they received verbal POC orders from the physician for Patient #9. The review of Patient #10’s clinical record included a start of care (SOC) on 4/01/24 and a POC for certification period 4/01/24 to 5/30/24 with orders for Occupational Therapy (OT) service frequencies of 1 visit a week for 1week. The record evidenced OT visits were performed on 4/11/24 and 4/18/24. The record failed to evidence documentation of a verbal order or a signed written order for the OT POC frequencies was obtained prior to the above visits performed. During an interview on 4/25/24 beginning at 11:46 AM, OT 2 indicated they did not receive verbal OT POC orders from the physician for Patient #10. The review of Patient #11’s clinical record included start of care (SOC) on 4/02/24 completed by Physical Therapist (PT) 2 and a POC for certification period 4/02/24 to 5/31/24 with orders for PT service frequencies of 1 visit a week for 5 weeks and Occupational Therapy (OT) service frequency of 1 visit a week for 1 week. The record evidenced PT visits were performed on 4/02/24 and 4/09/24 and an OT Evaluation visit was performed on 4/16/24. The record failed to evidence documentation of a verbal order or a signed written order for the POC frequencies was obtained prior to the above visits performed. During an interview on 4/25/24 beginning at 2:37 PM, PT 2 indicated they did not receive verbal POC orders from the physician for Patient #11. During an interview on 4/25/24 beginning at 2:57 PM, OT 3 indicated they left a voicemail with Physician N requesting OT POC frequency orders and they never received verbal OT POC orders from Physician N for Patient #11.”

“Reviewed, revised by physician every 60 days CFR(s): 484.60(c)(1) The individualized plan of care must be reviewed and revised by the physician or allowed practitioner who is responsible for the home health plan of care and the HHA as frequently as the patient’s condition or needs require, but no less frequently than once every 60 days, beginning with the start of care date. This Element is not met as evidenced by: Based on record review and interview, the home health agency failed to ensure the plan of care (POC) was reviewed with the physician at start of care (SOC) and/or at recertification for 6 of 12 active patient records reviewed (Patient #1, #4, #9, #10, #11, and #12). Findings include: 1. The Care Coordination and Plan of Care policy, revised 10/13/23, indicated “The individualized plan of care is reviewed and revised by the physician or allowed practitioner who is responsible for the home health plan of care and the agency as frequently as the patient’s condition or needs require, but no less frequently than once every 60 days, beginning with the start of care date.” 2. Patient #1’s clinical record included a start of care (SOC) date of 1/06/24 and a POC for certification period 3/06/24 to 5/04/24. The record failed to evidence documentation of collaboration with the physician for the recertification POC orders. On 4/26/24 at 1:48 PM, OT 2 relayed she typically when doing a start of care (SOC) or recertification evaluation, she leaves a voicemail at the provider’s office with POC information, and they can call with questions. OT 2 relayed that if there is a change such as adding on home health aide or social worker services, she will leave a voicemail and wait for a return call with verbal orders for that change. OT 2 indicated when taking a verbal order, she includes what the order is for and who she spoke with. OT 2 further indicated that the verbal order date and time on the POC is the date and time she left a voicemail for the provider. OT 2 relayed she did not know who she spoke with at the provider’s office and relayed there was no record of who she spoke with in her calendar. 3. Patient #12’s clinical record included a start of care (SOC) date of 1/19/24 and a POC for certification period 3/19/24 to 5/17/24. The record failed to evidence documentation of collaboration with the physician for the recertification POC orders. On 4/29/24 at 12:10 PM, RN 1 relayed she usually has to leave a message with Patient #12’s doctor’s office and gets a call back, but that could take a day or two. RN 1 indicated the call back with verbal orders should be documented in a coordination note, but she could not find documentation of a return call from Patient #12’s doctor regarding verbal orders for the POC. The review of Patient #4’s clinical record included a start of care (SOC) on 10/20/23 and a recertification POC for certification period 4/17/24 to 6/15/24. The record failed to evidence documentation of collaboration with the physician for the recertification POC orders. During an interview on 4/24/24 beginning at 11:20 AM, RN 1 indicated they left a voicemail for Physician B and did not collaborate with Physician regarding the recertification POC for Patient #4. The review of Patient #9’s clinical record included a start of care (SOC) on 4/13/24 and a POC for certification period 4/13/24 to 6/11/24. The record failed to evidence documentation of collaboration with the physician regarding the POC for Patient #9. During an interview on 4/24/24 beginning at 10:30 AM, RN 7 indicated they were unsure if they called the physician regarding POC orders for Patient #9. The review of Patient #10’s clinical record included a start of care (SOC) on 4/01/24 and a POC for certification period 4/01/24 to 5/30/24. The record failed to evidence documentation of collaboration with the physician regarding the Occupational Therapy (OT) POC for Patient #10. During an interview on 4/25/24 beginning at 11:46 AM, OT 2 indicated they were unsure if they collaborated with the physician regarding OT POC orders for Patient #10. The review of Patient #11’s clinical record included start of care (SOC) on 4/02/24 and a POC for certification period 4/02/24 to 5/31/24. The record failed to evidence documentation of collaboration with the physician regarding the POC for Patient #11. During an interview on 4/25/24 beginning at 2:37 PM, PT 2 indicated they left a voicemail with Physician N and did not collaborate with the physician regarding the POC for Patient #11. During an interview on 4/25/24 beginning at 2:57 PM, OT 3 indicated they left a voicemail with Physician N requesting OT POC frequency orders and they never received verbal OT POC orders from Physician N for Patient #11.”

“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 record review and interview, the home health agency failed to ensure the physician or allowed practitioner was promptly notified if the need to alter the plan of care (POC) related to discharge for 2 of 5 discharged patient records reviewed (Patient #14 and #16). Findings include: 1. The Care Coordination and Plan of Care policy, revised 10/13/23, indicated “The agency promptly alerts the relevant physician(s) or allowed practitioner(s) to any changes in the patient’s condition or needs that suggest… that the plan of care should be altered… Any revisions related to plans for the patient’s discharge are communicated to the patient, the representative, caregiver, all physicians or allowed practitioners issuing orders for the plan of care…” 2. Patient #14’s clinical record included a plan of care (POC) for certification period 2/14/24 to 4/13/24. The POC indicated the patient was to receive Skilled Nurse (SN) services 1 time a week for 9 weeks. The record evidenced SN Visits were completed on 2/14/24, 2/19/24, 2/26/24, 3/04/24, 3/11/24 and 3/18/24. The record failed to include documentation of collaboration with the physician regarding POC frequencies needing to be altered due to possible discharge for cause. During an interview on 4/26/24 beginning at 1:57 PM, RN 2 indicated they did not collaborate with the physician prior to the discharge. 3. Patient #16’s clinical record included a plan of care (POC) for certification period 2/05/24 to 4/04/24. The POC indicated the patient was to receive Physical Therapy (PT) services 2 times a week for 2 weeks; 1 time a week for 3 weeks and 1 time every 2 weeks for 1 week. The record evidenced PT Visits were completed on 2/06/24, 2/09/24, 2/13/24 and 2/15/24. The record failed to evidence PT visits were performed after the 2/15/24 visit and failed to include documentation that the physician was made aware of the missed PT visits and POC frequencies not being achieved. During an interview on 4/26/24 beginning at 12:43 PM, PT 3 indicated they did not collaborate with the physician regarding the missed PT visits and POC frequencies not being met for Patient #16.”

“Discharge plans communication CFR(s): 484.60(c)(3)(ii) (ii) Any revisions related to plans for the patient’s discharge must be communicated to the patient, representative, caregiver, all physicians or allowed practitioner’s issuing orders for the HHA plan of care, and the patient’s 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). This Element is not met as evidenced by: Based on record review and interview, the home health agency failed to document collaboration with the patient, caregiver and physician regarding discharge for 2 of 5 discharged patient records reviewed (Patient #14 and 16). Findings include: 1. A review of agency policy “Discharge and Transfer” indicated prior to discharge for cause, the agency must complete and document the following: Advise the patient, representative (if applicable), the physician who issued the orders and plan of care for the patient, and the patient’s primary care practitioner if different of the planned discharge for cause; make efforts to resolve the problems identified; and provide the patient / representative with contact information for other agencies or providers in the area who may be able to provide care. 2. A review of the “Home Health Patient Handbook” indicated the patient will be given advance notice of a discharge and written notice of discharge / termination of services will be provided to the patient with information on the right to appeal a discharge from service with accordance with Medicare regulations. 3. The review of Patient #14’s clinical record included a Plan of Care (POC) for the certification period 2/14/24 to 4/13/24. The clinical record failed to evidence collaboration with the patient/caregiver or physician regarding a possible discharge for cause prior to the discharge. During an interview on 4/23/24 beginning at 11:10 AM, Other Person C indicated Registered Nurse (RN) 2 informed Physician A’s office on 4/20/24 that Patient #14 had been discharged from home health services effective 3/18/24. Other Person C indicated the physician’s office medical record for Patient #14 did not include any collaboration with Physician A prior to the discharge. During an interview on 4/23/24 beginning at 11:26 AM, Other Person F, caregiver for Patient #14, indicated they received a telephone call on 4/20/24 from Other Person C, Medical Assistant (MA) for Physician A, stating Patient #14 had been discharged from home health services due to safety concerns. During an interview on 4/26/24 beginning at 1:57 PM, RN 2 indicated they did not collaborate with Patient #14 or Physician A prior to the discharge. 4. The review of Patient #16’s clinical record included a Plan of Care (POC) for the certification period 2/05/24 to 4/04/24. The clinical record failed to evidence collaboration with the patient or physician regarding a possible discharge for noncompliance prior to the discharge. During an interview on 4/26/24 beginning at 12:43 PM, Physical Therapist (PT) 3 indicated she had a discussion with Patient #16’s sister regarding possible discharge for noncompliance. PT 3 indicated she did not document this discussion in Patient #16’s clinical record and did not notify the patient or physician regarding possible discharge for noncompliance. During an interview on 4/29/24 beginning at 10:41 AM, Other Person L indicated the home health agency informed Physician K’s office on 3/20/24 at 2:06 PM that the home health agency will be discharging Patient #16 due to noncompliance. Other Person L indicated the physician’s office medical record for Patient #16 did not include any collaboration with Physician K prior to the 3/20/24 notification of discharge.”

“Onsite supervisory visit every 14 days CFR(s): 484.80(h)(1)(i) (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) 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 paragraph (g) of this section, must complete a supervisory assessment of the aide services being provided no less frequently than every 14 days; and (B) The home health aide does not need to be present during the supervisory assessment described in paragraph (h)(1)(i)(A) of this section. This Element is not met as evidenced by: Based on record review and interview, the home health agency failed to ensure the registered nurse (RN) supervised the home health aide (HHA) for 1 of 2 active clinical records reviewed of patients receiving HHA services (Patient #6). Findings include: 1. The Supervision of Home Health Aides procedure indicated when a patient who is receiving HHA services is also receiving skilled services from the agency, a RN or other appropriately skilled professional “… must make an onsite visit to the patient’s home no less frequently than every 14 days.” The procedure further indicated “In cases where both skilled nursing and therapy services are involved, the skilled nurse (RN) makes the supervisory visit… Home health aide supervision must be documented within the clinical record.” 2. Patient #6’s clinical record indicated a start of care (SOC) date of 2/05/24 and included orders for skilled nursing (SN), physical therapy (PT), and home health aide (HHA) services. The record evidenced HHA 1 performed HHA visits on, including but not limited to, 2/07/24, 2/09/24, 2/13/24, 2/16/24, 2/20/24, 2/23/24, 2/27/24, 3/01/24, 3/06/24, 3/14/24, 3/20/24, 3/26/24, 4/04/24, 4/11/24, 4/18/24. The clinical record failed to evidence RN 1 performed HHA supervisory visits. On 4/26/24 at 3:19 PM, RN 1 relayed she supervises HHAs every 14 days, and that is documented in the nurse visit note. RN 1 relayed there is a way to document both HHA supervision and LPN supervision in the same nurse note. RN 1 indicated she was unsure who was responsible for supervising the HHA caring for Patient #6. RN 1 further indicated she believed occupational therapy (OT) was also in the home and that if OT is on the case, then either the RN or OT could supervise the HHA. On 4/26/24 at 3:36 PM, the Administrator relayed an RN should supervise HHAs except for therapy only patients and that aide supervisory visits should be performed every 2 weeks. The Administrator further relayed she went all the way back to the SOC date and did not find any HHA supervisory visits in Patient #6’s clinical record.”

“Must have a written agreement CFR(s): 484.105(e)(2)(i-iv) An HHA must have a written agreement with another agency, with an organization, or with an individual when that entity or individual furnishes services under arrangement to the HHA’s patients. The HHA must maintain overall responsibility for the services provided under arrangement, as well as the manner in which they are furnished. The agency, organization, or individual providing services under arrangement may not have been: (i) Denied Medicare or Medicaid enrollment; (ii) Been excluded or terminated from any federal health care program or Medicaid; (iii) Had its Medicare or Medicaid billing privileges revoked; or (iv) Been debarred from participating in any government program. This Element is not met as evidenced by: Based on record review and interview, the home health agency failed to provide a valid written contract for 1 of 1 contracted employee (Registered Nurse 6). Findings include: 1. A review of agency policy “Services Under Arrangement” indicated Compassus executes a written agreement whenever another agency, organization, or individual will provide services to a patient. 2. The review of the contracted employee record for RN 6 evidenced a contract hire date of 3/25/24. The personnel filed for RN 6 failed to evidence a signed contract upon hire. 3. During an interview on 4/30/24 beginning at 3:06 PM, the Administrator confirmed the home health agency did not have a current written contract for RN services for RN 6.”

“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 record review and interview, the home health agency failed to submit the discharge summary to the physician within 5 days of discharge for 1 or 2 discharge for cause records reviewed (Patient #14). Findings include: 1. A review of agency policy “Discharge and Transfer” indicated Compassus sends all necessary medical information pertaining to the patient’s current course of illness and treatment, post-discharge goals of care, and treatment preferences health care practitioner receiving or continuing care for the patient to ensure safe and effective care transitions. The summary is provided to the receiving clinician/practitioner within five (5) business days of the date of discharge. 2. Patient #14’s clinical record evidenced a discharge date of 3/18/24 and a discharge summary that was faxed to the physician on 4/01/24. The clinical record failed to evidence the discharge summary was faxed to the physician within 5 days of discharge for cause. 3. During an interview on 4/26/24 beginning at 1:57 PM, RN 2 indicated they did not complete the discharge summary until 4/01/24. 4. During an interview on 4/26/24 beginning at 2:58 PM, the Administrator indicated the discharge summary should have been faxed within 5 days of discharge.”