Clover Home Health Care

“Authentication CFR(s): 484.110(b) Standard: Authentication. All entries must be legible, clear, complete, and appropriately authenticated, dated, and timed. Authentication must include a signature and a title (occupation), or a secured computer entry by a unique identifier, of a primary author who has reviewed and approved the entry. This Standard is not met as evidenced by: Based on record review and interview, the home health agency failed to ensure all plan of care (POC) certification period entries in the clinical record were appropriately dated for 1 of 3 active patient records reviewed (Patient #5). Findings include: 1. Patient #5’s clinical record included a start of care (SOC) on 2/27/24 and a POC for certification period 2/22/24 to 4/21/24 signed by RN 1. The POC evidenced the incorrect certification period dates. The POC failed to include the correct certification period of 2/27/24 to 4/26/24. 2. During an interview on 5/08/24 beginning at 3:29 PM, the Alternate Clinical Manager relayed there was an issue with the POC certification period dates in the electronic medical record and the home health agency had it corrected. 3. The Alternate Clinical Manager was unable to provide documentation of the corrected certification dates on Patient #5’s POC.”

“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 the patient received the Occupational Therapy evaluation for 1 of 1 active record which evidenced a missed therapy evaluation (Patient #1). Findings include: A review of agency policy “Homecare Referral Policy” indicated the person responsible for admitting the client must verify all information and modify the referral information as needed. Patient #1’s clinical record included a referral received on 2/08/24. The referral requested Physical Therapy (PT) and Occupational Therapy (OT) Evaluations and treat per Medicare guidelines. The clinical record evidenced the PT evaluation was completed on 2/14/24. The clinical record failed to evidence the OT evaluation was performed. During an interview on 5/08/24 beginning at 3:52 PM, the Administrator relayed the OT Evaluation had been missed and was not completed for Patient #1.”

“Skilled professional performs assessment CFR(s): 484.55(a)(2) When rehabilitation therapy service (speech language pathology, physical therapy, or occupational therapy) is the only service ordered by the physician or allowed practitioner, who is responsible for the home health plan of care, and if the need for that service establishes program eligibility, the initial assessment visit may be made by the appropriate rehabilitation skilled professional. This Element is not met as evidenced by: Based on record review and interview, the home health agency failed to ensure an initial assessment was completed by a Physical Therapist (PT) within 48 hours, for 2 of 2 patient records reviewed with a referral for PT services (Patient #1, #6). 2. The clinical record for Patient #6 included a physician’s order which indicated an order to start care on 3/22/24. The record failed to evidence an initial assessment or start of care was completed within 48 hours of the physician ordered start of care date of 3/22/24. In an interview on 5/10/24 beginning at 2:50 PM the Alternate Administrator/Alternate Director of Nursing indicated they did not know the reason for the delay for Patient #6, and it is not documented as to why. Findings include: 1. A review of agency policy “Comprehensive Client Assessment” indicated the initial assessment visit must be held either within 48 hours of referral or within 48 hours of the client’s return home, or on the physician ordered start of care date. 2. Patient #1’s clinical record evidenced a referral for PT and OT services was received on 2/08/24. The referral indicated a Start of Care (SOC) date of 02/12/24. The initial assessment was performed by PT 1 on 02/14/24. The clinical record failed to evidence a physician order to perform the initial assessment greater than 48 hours after referral was received and failed to include collaboration documentation with Patient #1 regarding the delay in SOC. During the entrance conference on 5/08/24 beginning at 9:50 AM, the Alternate Clinical Manager indicated the initial assessment should be completed within 48 hours of receiving the referral. During an Interview on 5/08/24 beginning at 3:29 PM, the Administrator indicated the initial assessment should have occurred within 48 hours after the referral was received and confirmed the clinical record for Patient #1 failed to include any communication documentation with the patient regarding the delay in SOC.”

“Patient’s needs CFR(s): 484.55(c)(4) The patient’s medical, nursing, rehabilitative, social, and discharge planning needs; This Element is not met as evidenced by: Based on record review and interview the agency failed to ensure the patient’s medical, nursing, rehabilitative, social, and discharge planning needs were met for 1 of 4 active patient records (Patient #6) and 1 of 3 closed records reviewed (Patient #2). Findings include: 1. The clinical record for Patient #6 included a comprehensive assessment dated 3/29/24 which revealed the patient required assistance with grooming, dressing, bathing, toileting, transfers, ambulation, and meal assistance. The clinical record failed to evidence documentation that aide services were offered. In an interview on 5/10/24 beginning at 2:50 PM, the Alternate Administrator/Alternate Director of Nursing indicated there was no documentation of an offer for home health aide nor documentation of refusal for home health aide services. 2. The closed clinical record for Patient #2 included a comprehensive assessment dated 11/27/24 revealed the patient required assistance with grooming, dressing, bathing, toileting, ambulation and meal assistance. The clinical record filed to evidence documentation that aide services were offered. In an interview on 5/8/24 beginning at 2:55 PM, the Alternate Administrator/Alternate Director of Nursing indicated there was no documentation and they did not know why aide services were not offered.”

“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 home health agency failed to ensure a review of all medications the patient was taking for 1 of 4 active patients records reviewed (Patient #1). Patient #1’s clinical record evidenced a Start of Care (SOC) on 2/14/24 and included a current medication list as of 5/08/24. The clinical record failed to evidence the Registered Nurse (RN) Case Manager conducted a medication review or reconciliation of Patient #1’s medications. The clinical record included a signed Plan of Care (POC) by Nurse Practitioner [NP] B on 4/30/24 with a note to see attached up to date medication list. The home health agency’s list of medications, failed to evidence they updated Patients medication list upon notification on 4/30/24. At time of review on 5/08/24, the following medications remained listed as active medications and the medications were not on the active medication list provided by NP 3 on 4/30/24: Diclofenac 1% topical gel (used to treat osteoarthritis), 2 grams to back 4 times a day. Dulaglutide (used to treat Diabetes) 0.75 milligram (mg)/0.5 milliliter (ml) weekly. Ondansetron (used to treat nausea/vomiting) 8 mg, 1 tablet every 6 hours as needed. Zinc oxide 40% topical paste (used to treat skin irritation) as needed. Alogliptin (used to treat Diabetes) 12.5 mg, 1 tablet every day. During the entrance conference on 5/08/24 beginning at 9:40 AM, the Alternate Clinical Manager indicated medications should be reconciled at every visit and during an interview at 4:35 PM, the Alternate Clinical Manager confirmed the above medication discrepancies for Patient #1.”

“At discharge CFR(s): 484.55(d)(3) At discharge. This Element is not met as evidenced by: Based on record review and interview the agency failed to ensure comprehensive assessment was completed at time of discharge for 1 of 1 closed records reviewed receiving Home Health Aide services (Patient #3). The Findings Include: A review of the closed clinical record for Patient #3 revealed a plan of care for the recertification period of 02/06/24 to 4/5/24, with orders for skilled nursing. The record revealed a discharge date of 4/1/24 and failed to evidence a comprehensive assessment was completed at the time of discharge. During an interview on 5/10/24, beginning at 2:50 PM, the Alternate Administrator/Alternate Director of Nursing indicated they placed the patient on hold until the end of the certification period and discharged on 4/01/24 without a discharge assessment visit.”

“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 record review and interview, the home health agency failed to ensure the plan of care (POC) included all medications for 1 of 4 active records reviewed (Patient #1) and 1 of 3 discharge records reviewed (Patient #2). Findings include: The closed clinical record for Patient #2 included a referral for Skilled Nursing, Physical Therapy, and Occupational Therapy dated 11/16/23. The record revealed a comprehensive assessment (CA) dated 11/27/23. The referral for services, dated 11/16/2024, included a list of medications indicating Patient was prescribed aspirin, atorvastatin, azelastine, cholecalciferol, apixaban, fluticasone propionate, guaifenesin, empagliflozin, metoprolol tartrate, omeprazole, child multivitamin plus iron, magnesium glycinate, omega 3, Riley’s butt cream, levothyroxine, albuterol sulfate, Benadryl, naloxone, loperamide, phenol, and mupirocin. The plan of care for Patient #2, dated 11/27/2024 failed to evidence Patient’s medications. The clinical record for Patient #2 failed to evidence addendums to the initial plan of care to include medications, their doses, frequency, route, and reason for usage. During an interview on May 8, 2024, beginning at 2:55 PM, the alternate administrator / alternate director of nursing indicated they did not know why the medications are not on the plan of care as they should be. Patient #1’s clinical record included a POC for certification period 4/14/24 to 6/12/24 signed by Nurse Practitioner B on 4/30/24 with a note to see attached up to date medication list. Surveyor comparison of Entity C’s medication list against the home health agency medication list evidenced medication discrepancies regarding Diclofenac 1% topical gel, Dulaglutide, Ondansetron, Zinc oxide 40% topical paste, and Alogliptin. During the entrance conference on 5/08/24 beginning at 9:40 AM, the Alternate Clinical Manager indicated medications should be reconciled at every visit and during an interview at 4:35 PM, the Alternate Clinical Manager confirmed the POC for Patient #1 did not reflect the correct medications.”

“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 3 of 4 active patient records reviewed (Patient #1) and 1 of 3 closed records (Patient #4). Findings include: Patient #1’s clinical record included a start of care (SOC) on 2/14/24 and a 5/01/24 Resumption of Care (ROC) POC for certification period 4/14/24 to 6/12/24 with orders for Physical Therapy (PT) service frequencies of 2 visits a week for 4 weeks. The record evidenced PT visits were performed on 4/16/24, 4/18/24 and 5/03/24. The clinical record for Patient #1 failed to include a signed written order or a verbal order for the POC frequencies was obtained prior to the above visits performed. During an interview on 5/08/24 beginning at 12:18 PM, PT 1 indicated they normally leave a message for the physician and were unsure if they called the physician or received verbal orders for the POC for Patient #1. Patient #4’s clinical record included a recertification POC for certification period 12/21/23 to 2/18/24 with orders for Skilled Nurse (SN) service frequencies of 1 visit every other week for 9 weeks. The record evidenced SN visits were performed on 1/20/24 and 2/03/24. The clinical record for Patient #4 failed to include a signed written order or a verbal order for the POC frequencies was obtained prior to the above visits performed. During an interview on 5/08/24 beginning at 1:58 PM, Registered Nurse 2 relayed they were unsure if they collaborated with the attending for the recertification POC for Patient #4. During an interview on 5/08/24 beginning at 3:29 PM, the Alternate Clinical Manager relayed the recertification POC was not signed by the attending. The clinical record for Patient #6 indicated a Plan of Care with a start date of 3/29/24 indicating services of Physical Therapy twice per week for one week, three times per week for three weeks, twice per week for five weeks and zero times per week for one week. The Plan of Care indicated Occupational Therapy orders to evaluate and treat. The record failed to evidence a verbal order for services. In an interview on 5/10/24 beginning at 11:40 AM, the Alternate Administrator/ Alternate Director of Nursing indicated there was no verbal order for Physical Therapy or Occupational Therapy. The clinical record for Patient #7 indicated a Plan of Care with a recertification period of 5/1/24-6/29/24 indicating services of skilled nursing zero times per week for eight weeks, once per week for one week and three as needed visits up to 1 hour every 56-60 days and home health aide twice per week for one week, three times per week for eight weeks up to 4 hours visit/ 3 times per week for nine weeks. The record failed to evidence a verbal order for services. In an interview on 5/10/24 beginning at 10:43 AM, the Alternate Administrator/Alternate Director of Nursing indicated there was no verbal order for services. The closed clinical record for Patient #2 indicated a Plan of Care with a start date of 11/27/23 indicating services of Skilled Nursing once per week for three weeks, Physical Therapy once per week for three weeks and Occupational Therapy once per week for two weeks. The record failed to evidence a verbal order for services.”

“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 3 of 7 patient records reviewed (Patient #1, 4, and 5). 1. Patient #1’s clinical record included a start of care (SOC) on 2/14/24 and a recertification POC for certification period 4/14/24 to 6/12/24. The record for Patient #1 failed to evidence documentation of collaboration with the attending for the recertification POC orders. During an interview on 5/08/24 beginning at 12:18 PM, PT 1 indicated they normally leave a message for the physician and were unsure if they called the physician or received verbal orders for the POC for Patient #1. 2. Patient #4’s clinical record included a SOC on 8/23/23 and a recertification POC for certification period 12/21/23 to 2/18/24. The record for Patient #4 failed to evidence documentation of collaboration with the attending for the recertification POC orders. During an interview on 5/08/24 beginning at 1:58 PM, Registered Nurse 2 relayed they were unsure if they collaborated with the attending for the recertification POC for Patient #4. 3. Patient #5’s clinical record included a start of care (SOC) on 2/27/24 and a recertification POC for certification period 4/27/24 to 6/25/24. The record for Patient #5 failed to evidence documentation of collaboration with the attending for the recertification POC orders. During an interview on 5/08/24 beginning at 1:58 PM, Registered Nurse 2 relayed they call the physician for POC orders and it should have been documented in the communication note.”

“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 1 of 3 discharged patient records reviewed (Patient # 4). Findings include: Patient #4’s clinical record included a Plan of Care (POC) for the certification period 12/21/23 to 2/18/24. The clinical record failed to evidence collaboration with the patient/caregiver or physician regarding a possible discharge prior to the discharge. During an interview on 5/08/24 beginning at 1:44 PM, the Alternate Clinical Manager indicated they did not collaborate with the patient or attending prior to discharge and they faxed the discharge summary to the attending after the discharge.”