Christian Home Health Services

“Infection Prevention CFR(s): 484.70(a) Standard: Infection Prevention. The HHA must follow accepted standards of practice, including the use of standard precautions, to prevent the transmission of infections and communicable diseases. This Standard is not met as evidenced by: Based on observation and interview the agency failed to ensure their staff followed accepted standards of practice to prevent the transmission of infections in 2 of 3 observations of direct care (physical therapist [PT] 2 and registered nurse [RN] 1. Findings include: During an observation of a home visit on 10/1/24 beginning at 2:00 PM, Registered nurse (RN) 1 provided wound care for Patient #1. During wound care, RN was gloved, during care for wound, proceeded to open a screw top saline bottle from the wound care field and pour saline onto sponge then used the moist sponge to cleanse wounds to right hip. RN failed to evidence to disinfect the saline bottle prior to touching nor change gloves before contact with wounds. After completing wound care, RN placed used supplies to a barrier then proceeded to wipe the stethoscope, blood pressure cuff, oximeter (measures oxygen saturation), thermometer, and scissors with disinfectant wipes that she brought in her bag of supplies. RN placed wiped supply items were placed in a supply bag in less than two minutes. The disinfectant wipes, Walgreen multi-use disinfectant wipes, indicated for effective disinfection, saturate and allow a 4 minute dry time. RN 1 failed to follow directions for use for effective disinfection of supplies. During an interview on 10/1/24 beginning at 3:00 PM after the home visit, RN 1 relayed she did not know what the dry time was for the disinfectant wipes. 410 IAC 17-12-1(m) During a home visit observation on 10/3/24 beginning at 1:15 PM for Patient 8, Physical Therapist 2 (PT 2) retrieved blood pressure cuff from clinician bag, used the blood pressure cuff on the patient, returned to bag without decontamination. PT 2 retrieved hand grips from clinician bag, handed to patient for use and returned to bag without decontamination. PT 2 assisted patient with foot pedals brought in with PT 2 at the start of the visit, proceeded with exercises and placed them next to the clinician bag. Once the visit was completed, PT 2 picked up clinician bag and foot pedals without decontamination and carried out of the home. During an interview on 103/24 beginning at 2:30 PM, PT 2 indicated he maintains a separate bag and equipment for each patient and when the patient is discharged, he throws out the equipment. PT 2 further indicated there were no patient identifiers on the bag or equipment and he selected the correct bag because he knew which bag is for the patient. During an interview on 10/8/24 beginning at 2:30 PM, the Administrator indicated the agency supplies thermometers to each patient. The administrator indicated the agency supplies equipment such as a blood pressure cuff to each clinician for use and other equipment would belong to the clinician unless the patient had their own in their home. The administrator indicated equipment being brought into or removed from the home for the purpose of the clinician visit should be decontaminated. The administrator indicated they did not know why PT 2 did not decontaminate the equipment.”

“Home health aide assignments and duties CFR(s): 484.80(g)(1) Standard: Home health aide assignments and duties. Home health aides are assigned to a specific patient by a registered nurse or other appropriate skilled professional, with written patient care instructions for a home health aide prepared by that registered nurse or other appropriate skilled professional (that is, physical therapist, speech-language pathologist, or occupational therapist). This Standard is not met as evidenced by: Based on record review and interviews, the agency failed to ensure home health aides (HHA) were assigned to a specific patient tasks by the registered nurse (RN), with written patient care instructions in 1 of 4 active patient records with and RN and HHA on service (Patient #4). Findings include: The agency policy titled “Certified Home Health Aide” indicated the HHA would receive a patient assignment sheet detailing care to be provided. The clinical record for Patient #4 revealed a HHA plan of care dated 5/524 to 7/3/24. As of the date of the record review on 10/7/24, the record failed to evidence a HHA plan of care past 7/3/24. HHA visits continued at once a week including visit dates: 8/22/24, 8/31/24, 9/5/24, 9/12/24, 9/19/24, and 9/26/24. On 10/8/24, the clinical record included a HHA plan of care for care dates 9/2/24 to 10/31/24 entered by registered nurse (RN) 2 was completed on 10/8/24 at 10:41 AM. During an interview on 10/8/24 beginning at 12:40 PM, RN 1 relayed she did not realize there was no HHA plan of care, she thought it was automatically generated in the electronic medical record. During an interview on 10/8/24 beginning at 2:15 PM, RN 2 revealed he has not provided care for Patient #4 but he created the HHA plan of care for dates 9/2/24 to 10/31/24 on 10/7/24. 410 IAC 17-14-1(m)”

“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 agency failed to ensure entries were appropriately authenticated in the clinical record in 2 of 5 active clinical records reviewed with a home health aide (HHA) on service (Patients #4). Findings include: The clinical record of Patient #4 included scheduled visits for the HHA on 9/19/24, 9/26/24, and 10/3/24 that had no documentation and marked “not yet started” on the date of the record review, 10/7/24. The clinical record failed to evidence documentation of care provided to Patient nor missed visit notifications. During an interview on 10/7/24 beginning at 1:00 PM, Registered Nurse (RN) 2 indicated he is responsible for scheduling visits. When asked if the visits were completed on 9/19/24, 9/26/24, and 10/3/24, he revealed he did not know. During an interview on 10/7/24 beginning at 11:24 AM, HHA 2 relayed she was supposed have visit documentation completed within 24-48 hours. When asked about visits on 9/19/24, 9/26/24, and 10/3/24, HHA revealed she completed the visits but did not document the visits. The clinical record for Patient #4 included a HHA plan of care dated 5/524 to 7/3/24 and HHA visits were conducted through 9/26/24. The record failed to evidence the HHA plan of care was updated after 7/3/24. During an interview on 10/8/24 beginning at 2:15 PM, RN 2 indicated the clinical record did not have an updated HHA care plan past 7/3/24. RN 2 indicated he created one on 10/7/24 and backdated. RN 2 further indicated the HHA plan of care was created after speaking to RN 1, the case manager for Patient. 410 IAC 17-15-1(b)”

“Patient’s or legal representative’s signature CFR(s): 484.50(a)(2) Obtain the patient’s or legal representative’s signature confirming that he or she has received a copy of the notice of rights and responsibilities. This Element is not met as evidenced by: Based on record review and interview the agency failed to evidence patient’s legal representative was provided with written notice of the patient’s rights and responsibilities, transfer and discharge policies during the initial assessment visit, in advance of furnishing care 1 of 1 clinical record reviewed of a patient who resided on a memory care unit of an assisted living facility [ALF] and who received Physical Therapy Services (Patient #2) and in 2 of 3 active clinical records reviewed with a diagnosis of dementia and whom resided in an assisted living facility (Patient #4). Findings include: The clinical record of Patient #4 revealed a referral dated 8/29/22 requesting home health services for a home health aide and skilled nursing; the referral document included Patients diagnosis of dementia. The initial assessment was the comprehensive assessment, dated 9/13/22 by registered nurse (RN) 1. The assessment indicated Patient was forgetful, with cognitive impairment, and history of dementia. The clinical record failed to evidenced Patients’ designated health care representative was provided and received Patients Patient Rights documents before the provision of skilled services. During an interview on 10/8/24 beginning at 2:15 PM, Administrator relayed the agency did not have information regarding the responsible party and did not know who the designated individual to make health care decisions for Patient #4. 410 IAC 17-12-3(a)(2) The record reviewed on 10/3/24 included a plan of care with a start of care date of 5/24/24 for certification period 5/24/24 – 7/23/24 which indicated Patient #2 resided in a memory care at an assisted living facility and had a surrogate decision maker. The record failed to identify the party responsible for the patient. The record included a four-page document titled “Admission Service Agreement” which revealed the patient signed the admission documents. During an interview on 10/7/24 at 3:50 PM the Administrator indicated if a patient was a resident in a memory care facility, they would have a designated person sign on the patient’s behalf. The administrator indicated that was not evidenced in the record for Patient #2.”

“RN performs assessment CFR(s): 484.55(a)(1) A registered nurse must conduct an initial assessment visit to determine the immediate care and support needs of the patient; and, for Medicare patients, to determine eligibility for the Medicare home health benefit, including homebound status. The initial assessment visit must be held either within 48 hours of referral, or within 48 hours of the patient’s return home, or on the physician or allowed practitioner - ordered start of care date. This Element is not met as evidenced by: Based on record review and interview, the agency failed to conduct an initial assessment to determine the immediate care and support needs of the patient within 48 hours of patient referral in 2 of 4 active clinical records reviewed (Patients #3 and 5) . Findings include: On 10/1/24 Registered Nurse 2 provided a document and indicated it was the referral for Patient #5; the document was an order for wound care, dated 11/6/23, and provided by Entity G. The clinical record for Patient #5 indicated an initial assessment to determine patients needs was on 11/10/2023, when the start of care and comprehensive assessment was conducted. During an interview on 10/8/24 beginning at 1:30 PM the administrator indicated they did not know why there was a delay in conducting the initial assessment for patients immediate needs and further indicated there was no documentation, nor notification to the ordering provider for the reason for or the need for the delay in assessing Patient. The agency policy titled “Referral/Intake Process” indicated the patient is evaluated for admission within 24-48 hours of receiving the referral unless otherwise ordered by the physician. The clinical record for Patient #3 revealed a referral for home health care dated 5/7/24. The clinical record revealed a start of care dated 6/12/24. The record failed to evidence physician notification nor order for the delay. During an interview on 10/7/24 beginning at 12:15 PM, Administrator relayed the initial assessment was not within 48 hours because they had to call the doctor for orders. 410 IAC 17-14-1(a)(1)(A)”

“Health, psychosocial, functional, cognition CFR(s): 484.55(c)(1) Standard: Content of the comprehensive assessment. The comprehensive assessment must accurately reflect the patient’s status, and must include, at a minimum, the following information: (1) The patient’s current health, psychosocial, functional, and cognitive status; This Element is not met as evidenced by: Based on record review and interview the agency failed evidence the patients comprehensive accurately reflect the patient’s current health, psychosocial, functional, and cognitive status through comprehensive assessment for 2 of 3 active patients reviewed receiving physical therapy services (Patient #2 and 3). The Findings Include: The record for Patient #2 reviewed on 10/3/24 included a comprehensive assessment dated 9/17/24 completed by Physical Therapist 3 which indicated a primary diagnosis of Alzheimer’s Disease. The comprehensive assessment (CA) revealed the patient to be oriented to self only and required 24-hour supervision The CA indicated the patient ‘s activity level to be up as tolerated. The CA failed to evidence an assessment of risk for elopement was completed. In an interview on 10/7/24 beginning at 3:50 PM the Administrator indicated the risk for elopement was not identified as a safety measure for Patient #2 and was not on the plan of care. #The agency policy titled “Referral/Intake Process” indicated the patient is evaluated for admission within 24-48 hours of receiving the referral unless otherwise ordered by the physician. #The clinical record of Patient #1 revealed a referral for home health care dated 12/14/22 from Patient’s physician, Other D. The clinical record revealed a start of care and initial assessment on 12/28/22. The record failed to evidence physician notification nor order for the delay. During an interview on 10/7/24 beginning at 10:30, Administrator relayed it takes extra time to obtain physician orders and receive a face to face (a practitioner’s documentation of an encounter with the patient). #The clinical record for Patient #3 revealed a referral for home health care dated 5/7/24. The clinical record revealed a start of care dated 6/12/24. The record failed to evidence physician notification nor order for the delay. During an interview on 10/7/24 beginning at 12:15 PM, Administrator relayed the initial assessment was not within 48 hours because they had to call the doctor for orders. 410 IAC 17-14-1(a)(1)(A)”

“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 record review and interview, the agency failed to provide a comprehensive assessment that accurately reflects the patient’s status including a review of all medications in 1 of 1 active record reviewed who resided in a group home [Patient #1] and 2 of 3 active records reviewed who resided in an assisted living facility (Patients # 2 and 4). Findings include: #The clinical record for Patient #1 revealed a comprehensive reassessment completed on 8/16/24. The medication profile included the following medications: Calmoseptine, Valium, Augmentin, Sulfacetamide, Tizanidine, Sertraline, Divalproex, Naproxen, Alprazolam, Baclofen, Quetiapine, Escitalopram, Acetaminophen-Codeine, Docusate, Loperamide, and Magnesium hydroxide. The medication interaction identifier in the electronic medical record failed to include Sulfacetamide, Baclofen, Calmoseptine, Divalproex, Docusate, Escitalopram, Naproxen, Quetiapine, Valium, and Acetaminophen-Codeine in the interactions. According to Drugs.com, there was a major interaction between the following: Codeine and Alprazolam, Quetiapine and Escitalopram, Tizanidine and Escitalopram, Sertraline and Escitalopram, Codeine and Quetiapine, Codeine and Tizanidine, Codeine and Diazepam, and Codeine and Baclofen. There was a moderate interaction between the following: Codeine and Divalproex, Sertraline and Divalproex, Sertraline and Quetiapine, Baclofen and Divalproex, Baclofen and Tizanidine, Baclofen and Quetiapine, Baclofen and Escitalopram, Magnesium and Quetiapine, Magnesium and Escitalopram, Loperamide and Quetiapine, Loperamide and Escitalopram, Divalproex and Tizanidine, Divalproex and Quetiapine, Divalproex and Escitalopram, Tizanidine and Quetiapine, Codeine and Sertraline, Codeine and Loperamide, Codeine and Escitalopram, Naproxen and Sertraline, Naproxen and Escitalopram, Diazepam and baclofen, Diazepam and Divalproex, Sertraline and Baclofen, Diazepam and Quetiapine, Diazepam and Escitalopram, Alprazolam and Baclofen, Alprazolam and Divalproex, Alprazolam and Quetiapine, Alprazolam and Escitalopram, and Magnesium and Divalproex. During an interview on 10/7/24 beginning at 10:30 AM, Administrator relayed there were medication not included in the medication reconciliation and she was not aware there was an issue in which the electronic medical record did not include medications in the interactions. #The clinical record for Patient #4 revealed a comprehensive reassessment completed on 8/31/24. The medication profile included: Imodium, Atorvastatin, Sertraline, Aldactone, Norco, Lisinopril, Ipratropium-albuterol, Fluticasone, Lasix, Aspirin, Levothyroxine, Montelukast, Pantoprazole, Biotin, Albuterol, Cholestyramine, Humalog, Depakote, Metformin, Potassium, Memantine, Carisoprodol, and Gabapentin. The medication interaction identifier in the electronic medical record failed to include Ipratropium, Fluticasone, Albuterol, Humalog, and Loratadine in the interactions. According to Drugs.com, there was a moderate interaction between Albuterol and Metformin, Sertraline, Humalog, Lasix, and Loperamide; there is a moderate interaction between Humalog and Lisinopril, Sertraline, Metformin, Lasix. During an interview on 10/8/24 beginning at 2:15 PM, Administrator relayed some of the medications were not reconciled. 410 IAC 17-14-1(a)(1)(B) The record reviewed for Patient #2 on 10/3/24 included a comprehensive assessment (CA) dated 9/17/24 for certification period 9/21/24-11/19/24 that indicated medications were reconciled. The electronic health record indicated the medications were last reviewed on 5/24/24. During an interview on 10/7/24 with the Administrator, Alternate Administrator and Registered Nurse 2 (RN 2), RN 2 reviewed the electronic health record and indicated the last medication profile review was completed on 5/24/24. RN 2 provided a drug-interactions report dated 10/7/24. No other information regarding medication reconciliation was provided prior to survey exit.”

“Primary caregiver(s), if any CFR(s): 484.55(c)(6)(i,ii) The patient’s primary caregiver(s), if any, and other available supports, including their: (i) Willingness and ability to provide care, and (ii) Availability and schedules; This Element is not met as evidenced by: Based on record review and interview the agency failed to ensure the comprehensive assessment accurately reflect the patient’s primary caregiver willingness and ability to provide care, availability or schedule for 1 of 1 patients residing on a memory care unit receiving physical therapy services (Patient #2). The Findings Include: The record reviewed for Patient #2 on 10/3/24 included a comprehensive assessment (CA) dated 9/17/24 for certification period 9/21/24-11/19/24 indicated the patient to live on a memory care unit in an assisted living facility. The comprehensive assessment failed to evidence the caregiver willingness or ability to provide care, availability or schedules of caregivers, nor care coordination with caregivers. During an interview on 10/7/24 beginning at 3:50 PM, the Administrator indicated it should be included in the CA but was not included for Patient #2.”

“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 observation, record review and interview, the agency failed to ensure the individualized plan of care included the types of services, supplies, and equipment required; all medications and treatments; safety measures to protect against injury; or any additional items the home health agency or allowed practitioner may choose to include for 5 of 6 active patient records reviewed (Patient #1, 2, 3, 4, 5). The Findings Include: *During an observation for Patient #2; who resided on a memory care unit, on 10/3/24 beginning at 11:15 AM, it was noted the patient to have a wheelchair in their private apartment and a wander guard on their person. The record reviewed on 10/3/24 for Patient #2 included a recertification comprehensive assessment (CA) completed by physical therapist 3 (PT 3) on 9/17/24 for certification period 9/21/24-11/19/24 indicated a diagnosis of Alzheimer’s dementia and resided on a memory care in an assisted living facility. The plan of care signed by PT 3 on 9/17/24 failed to evidence documentation of durable medical equipment or necessary supplies. During an interview on 10/7/24 beginning at 3:50 PM the administrator indicated those items should be included on the plan of care but it is not included for Patient #2. *The record reviewed for Patient #5 on 10/7/24 included a comprehensive assessment (CA) dated 9/4/24 for certification period 9/5/24-11/3/24 that indicated medications were reconciled. The plan of care signed by RN 1 on 9/4/24 indicated Cephalexin (used to treat infection) 250 mg one per capsule every morning, afternoon and evening for 10 days, bleeding precautions, and infection control precautions. The plan of care failed to evidence measurable goals or interventions for bleeding. During an interview on 10/8/24 beginning at 1:30 PM with the Administrator, Alternate Administrator and Registered Nurse 2 (RN 2), RN 2 reviewed the electronic health record and indicated the last medication profile review was completed on 9/6/24. RN 2 indicated that the patient was no longer on the cephalexin. RN 2 indicated the medication change should have removed from the plan of care at the time of the recertification, and it was not. The administrator indicated there should have been interventions for bleeding but there were not. #The agency policy titled “Plan of Treatment” indicated an individualized plan of treatment should include all pertinent diagnoses, patient allergies, medications and treatments, types of services and supplies required, frequency and duration of visits, and measurable treatment goals. #During a home visit for on 10/1/24 beginning at 2:00 PM, Patient #1 resided at Entity A, a group home for the disabled. During an interview on 10/1/24 beginning at 1:55 PM, RN 1 relayed Patient required 24-hour care, provided by Entity A staff. She revealed Patient had a Baclofen pump (surgically implanted device that delivers muscle relaxant medication to the spinal canal) and Patient received wound care from Entity B, under the care of a physician, Other C. RN 1 relayed she would speak to staff at Entity B at least once a week regarding Patient’s care. The clinical record for Patient #1 included a plan of care dated 8/19/24 to 10/17/24 that included a principal diagnosis of a stage 4 pressure ulcer (severe wound that extends into the muscle, bone, tendon, or joint) on the right hip and indicated the RN was to provide wound care once a week. The plan of care failed to evidence Entity A, the care/services Patient had received from Entity A, nor the wound care clinic and physician, Entity B and Other C. The clinical record included wound care order documents from Entity B (wound care clinic) dated 8/15/24 that indicated the right hip wound treatment should be done three times a week with RN to wound care once per week: cleanse wound with saline or sterile water, apply alginate (absorbent wound dressing), apply collagen (wound care that supports tissue growth), apply Venelex (wound ointment) to area around wound, then cover with dressing. The left hip wound should be covered with dry protective dressing. The plan of care failed to include specified wound treatment for right and left hip wounds. The plan of care medication profile failed to include Venelex ointment nor the baclofen pump. #During a home visit on 10/2/24 beginning at 1:30 PM, Patient #3 resided at Entity D, an assisted living facility. Upon arrival, Patient was receiving personal care from staff at Entity D. A staff nurse, Other E at Entity D, provided medication orders and allergy information which included the allergies: Etodolac (a nonsteroidal anti-inflammatory), Vancomycin (antibiotic), Invokana (diabetes medication), Keflex (antibiotic), Zithromax (antibiotic), Iodinated contrast media (contrast used in medical imaging), Sulfa (a class of antibiotics), and Biotin (Vitamin B7). The clinical record of Patient #3 included a plan of care dated 8/11/24 to 10/9/24 which indicated Patient has no known allergies (NKA). The plan of care failed to evidence the assisted living facility where Patient resides, Patient allergies, nor the services required for Patient’s care. #The clinical record for Patient #4 included a comprehensive reassessment dated 8/31/24 which revealed Patient’s respiratory status includes continuous oxygen use at 2 liters per minute. The plan of care dated 9/2/24 to 10/31/24 revealed oxygen as supplies required for Patient but failed to include dosage and times for oxygen. During an interview on 10/8/24 beginning at 2:15 PM, Administrator relayed the oxygen flow rate and when used was not included in the plan of care. 410 IAC 17-13-1(a)(1)(C),17-13-1(a)(1)(D)(ix)”

“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 agency failed to ensure that drugs, services, and treatments are administered only as ordered by a physician in 2 of 6 [Patients # 1 and 5] active clinical records reviewed and 1 of 2 closed clinical records reviewed (Patient #7). Findings include: # #The agency policy titled “Plan of treatment” indicated the written plan of treatment should be approved by the attending physician and include all treatments, services, and supplies. #The clinical record for Patient #1 included a plan of care dated 8/19/24 to 10/17/24 included a principal diagnosis of stage 4 pressure ulcer (severe wound that extends into the muscle, bone, tendon, or joint) of the right hip and indicated the nurse visit once a week was to include wound care. The plan of care included a signature from the attending physician (or Allowed Practitioner), Other E. The clinical record included wound care order documents from Entity B under physician, Other C, dated 8/15/24 that indicated the right hip wound treatment should be done three times a week (RN to do treatment once a week): cleanse wound with saline or sterile water, apply alginate (absorbent wound dressing), apply collagen (wound care that supports tissue growth), apply Venelex (wound ointment) to area around wound, then cover with dressing. The left hip wound should be covered with dry protective dressing. The plan of care failed to evidence wound care physician (Other C) as an allowed practitioner, orders from attending physician (Other D) to accept orders from wound care physician, nor wound care order verification from attending physician. During an interview on 10/8/24 beginning at 2:15 PM, Administrator revealed that Other C, the wound care physician, was an ordering physician for Patient #1 but was not included in the plan of care. Administrator relayed Patient has one signing physician, Other D, and there was not an order signed by Other D to accept orders from Other C. 410 IAC 17-13-1(a) *The record for Patient #5 reviewed on 10/7/24 indicated a resumption of care comprehensive assessment was completed on 7/18/24 by RN 1 and a recertification comprehensive assessment was completed on 9/4/24. The record failed to evidence verbal or written orders for the resumption of care nor the recertification of care. In an interview on 10/8/24 beginning at 1:30 PM, the Administrator indicated there was no documentation of verbal or written orders for the resumption of care nor the recertification of care for Patient #5. *The discharge record for Patient #7 reviewed on 10/8/24 included a physician signed plan of care with a start date of 7/1/24 for certification period 7/1/24 – 8/29/24 completed by Physical Therapist 1 (PT 1) on 7/1/24. The plan of care failed to evidence a visit frequency for skilled services. The record included a discharge comprehensive assessment completed by PT 1 dated 8/12/24. During an interview on 10/8/24 beginning at 12:20 PM the Administrator indicated there was no notice of discharge nor order for discharge for Patient #7.”

“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 interviews the agency failed to ensure the supervisory assessment of a home health aide (HHA) was completed no less frequently than every 14 days in 1 of 1 active clinical record with a partial review done to assess supervisory visits (Patient #9). Findings include: The agency policy titled “Supervisory Visits” indicated the registered nurse (RN) may make a supervisory visit every week but no less frequently than every two weeks. The clinical record for Patient #9 revealed a HHA supervisory visit completed by RN 1 on 9/16/24. The record failed to evidence supervisory visit for HHA from 9/16/24 to the date of record review on 10/7/24, a total of 21 days. During an interview on 10/8/24 beginning at 12:40 PM, RN 1 relayed she was not scheduled for any supervisory visits past 9/16/24. During an interview on 10/8/24 beginning at 2:15, RN 2 relayed it was his responsibility to schedule supervisory visits and he was late assigning the visits in the electronic medical record. RN 2 revealed he entered the supervisory visits 10/8/24.”

“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 agency failed to evidence 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 home health agency within 5 business days of the patient’s discharge for 1 of 2 discharged records reviewed (Patient #7). The Findings Include: The clinical record for Patient #7 included a discharge comprehensive assessment dated 8/12/24 and a discharge summary, dated 8/27/24, each were completed by Physical Therapist 1 (PT 1). The record failed to evidence a discharge summary was sent to the primary care provider or other healthcare professionals. During an interview on 10/8/24 beginning at 12:20 PM the administrator indicated the discharge summary was sent to the provider for Patient #7 on 9/20/24, though did not know why it was late.”