Elara Caring

“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 clinical documentation was complete and appropriately authenticated and dated in accordance with currently accepted standards of practice for four patients (#1, #4, #13, and #2), out of a total sample of 17 patients. Findings include: 4.) Patient #2 was admitted to the agency in October 2025 with a diagnosis of chronic kidney disease with heart failure. Review of the Physician POC for certification period 10/16/25 through 12/14/25 indicated the following: *SN 1 time a week for 1 week, once every 2 weeks for 2 weeks, then 1 time a week for 6 weeks Review of the clinical record indicated the SN visit notes were not signed/dated on the day services were rendered: *10/31/25 SN visit, note completed 11/4/25 *11/25/25 SN visit, note completed 12/1/25 During an interview on 12/20/25 at 1:31 P.M., the Branch Manager said that all visit notes should be documented, signed, and entered in the computer within 24 hours of the visit. Review of the facility policy, titled Clinical Record Content-Skilled Home Health, dated 9/9/2020, indicated the following: *Required documentation for each service or care provided must be completed on the day the service is rendered. 1.) Patient #1 was admitted to the agency in October 2025 with a diagnosis of major depressive disorder. Review of the Physician ordered Plan of Care (POC) for certification period 10/9/25 through 12/7/25 and 12/8/25 through 2/5/26 indicated the following: *Skilled Nursing (SN) visits 1 time a week for 1 week, then 3 times a week for 3 weeks, then 2 times a week for 5 weeks. (10/9/25) Review of the clinical record indicated the SN visit notes were not signed/dated on the day services were rendered: *11/5/25 visit, note completed on 11/9/25 *11/13/25 visit, note completed on 11/16/25 *11/16/25 visit, note completed on 11/26/25 2.) Patient #4 was admitted to the agency in October 2025 with a diagnosis of bipolar disorder. Review of the Physician ordered POC for certification period 10/1/25 through 11/29/25 and 11/30/25 through 1/28/26 indicated the following: *SN visits 1 time a week for 1 week, then 2 times a week for 1 week, then 1 time a week for 7 weeks, with 2 PRN (as needed) for med changes or change in condition (10/1/25) *SN visits 4 times a week for 1 week, then 2 times a week for 6 weeks (updated 10/12/25) Review of the clinical record indicated the SN visit notes were not signed/dated on the day services were rendered: *10/18/25 visit, note completed on 10/22/25 *10/20/25 visit, note completed on 10/23/25 *11/6/25 visit, note completed on 11/16/25 *12/1/25 visit, note completed on 12/9/25 3.) Patient #13 was admitted to the agency in October 2025 with a diagnosis of pressure ulcer of the sacrum, stage IV (severe, full thickness wound exposing muscle, tendon, or bone). Review of the Physician POC for certification period 10/8/25 through 12/6/25 and 12/7/25 through 2/4/26 indicated the following: *SN 1 time a week for 7 weeks, then 1 time every 2 weeks for 2 weeks (10/8/25) *SN 2 times a week for 1 week, then 3 times a week for 1 week (updated 11/23/25) *Physical Therapy (PT) 1 time a week for 1 week, then 2 times a week for 4 weeks, then 1 time a week for 4 weeks (10/8/25) *Occupational Therapy (OT) 1 time a week for 1 week, then 2 times a week for 7 weeks (10/20/25) Review of the clinical record indicated the SN, PT, and OT visit notes were not signed/dated on the day services were rendered: *10/16/25 SN visit, note completed 10/20/25 *10/20/25 SN visit, note completed 10/24/25 *10/22/25 PT visit, note completed 11/4/25 *10/24/25 SN visit, note completed 11/4/25 *10/27/25 OT visit, note completed 11/1/25 *10/27/25 PT visit, note completed 10/31/25 *12/5/25 SN visit, note completed 12/8/25”

“Provide services in the plan of care CFR(s): 484.75(b)(3) Providing services that are ordered by the physician or allowed practitioner as indicated in the plan of care; This Element is not met as evidenced by: Based on record review and staff interview, the agency failed to ensure staff provided care and services ordered by the physician as indicated in the plan of care (POC) for two patients (#5, and #10), out of a total sample of 17 patients. Findings include: 2.Patient #10 was admitted to the agency in October 2025 with a diagnosis of Joint replacement and required skilled home care services. Review of the physician ordered POC for certification period 10/15/2025 through 12/13/2025 indicated the following: *Physical Therapy (PT) visits 1 time a week for 1 week, 2 times a week for 2 weeks, then 1 time a week for 1 week Review of the clinical record indicated that a missed PT visit occurred on 10/18/2025. The missed visit documentation did not indicate that the physician was notified of the missed visit or the reason for the missed visit. During an interview on 12/10/2025 at 3:30 P.M., the Branch Director said that documentation of the missed visit was not completed in its entirety and that the physician notification and rational for the missed visit was not addressed. Review of the agency’s policy titled, Plan of Care and Coordination of Care, dated 3/4/25, indicated the following: *Care/Services to be provided will be coordinated and will follow the patient’s written plan of care. *The plan of care will specify the care/services necessary to meet the patient-specific needs as identified in the comprehensive assessment and evaluations. 1. Patient #5 was admitted to the agency in October 2025 with a diagnosis of chronic obstructive pulmonary disease (COPD-progressive lung disease that blocks airflow, making it hard to breathe) and required skilled home care services. Review of the physician ordered POC for certification dates 10/23/25 through 12/21/25 indicated the following: *Skilled Nursing (SN) visits once a week for 1 week, 3 times a week for 2 weeks, then 2 times a week for 6 weeks Review of the clinical record indicated no documented evidence that a second SN visit was completed the weeks of 11/9/25 through 11/15/25, 11/16/25 through 11/22/25 and 11/23/25 through 11/29/25. During an interview on 12/10/25 at 12:58 P.M., the Administrator, after reviewing Patient #5’s clinical record, said that the physician ordered Plan of Care was not followed for providing skilled nursing visits, as required.”

“Communication with physicians CFR(s): 484.75(b)(7) Communication with all physicians involved in the plan of care and other health care practitioners (as appropriate) related to the current plan of care; This Element is not met as evidenced by: Based on record review, document review, and interview, the agency failed to ensure there was communication shared with the physician when services were not provided, as ordered, for one patient (#5), out of a total sample of 17 patients. Findings include: Review of the agency’s document titled, Missed Visit Best Practices, undated, indicated but was not limited to the following: Documentation/Care Coordination Requirements: *MD must be notified of missed visits and documented. *Complete each section of the Missed Visit Note; reason for missed visit, any additional details related to the missed visit, name and method of physician/provider notification. Patient #5 was admitted to the agency in October 2025 with a diagnosis of chronic obstructive pulmonary disease (COPD-progressive lung disease that blocks airflow, making it hard to breathe). Review of the physician ordered Plan of Care for certification period 10/23/25 through 12/21/25 indicated the following: *Skilled Nursing (SN) visits once a week for 1 week, 3 times a week for 2 weeks, then 2 times a week for 6 weeks Review of the clinical record indicated no documented evidence that a second SN visit was completed the weeks of 11/9/25 through 11/15/25, 11/16/25 through 11/22/25, and 11/23/25 through 11/29/25. Further review of the clinical record did not indicate Missed Visit Notes for SN for the weeks reviewed including documentation that the physician was notified of the missed visits. During an interview on 12/10/25 at 12:58 P.M., the Administrator, after reviewing the patient’s clinical record, said there was no documentation in the clinical record that the physician had been notified of the missed visits, as required.”