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, policy 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 6 patients (#7, #8, #9, #10, #1 and #5), out of a total sample of 17 patients. Findings include: 5.) Patient #1 was admitted to the agency in October 2025 with a diagnosis of irritable bowel syndrome and severe calorie malnutrition. Review of the Physician ordered POC for certification period 10/14/25 through 12/12/25 and 12/13/25 through 2/10/26 indicated the following: *SN visits 2 times a week for 2 weeks, then 1 time a week for 7 weeks *PT visit 1 time a week for 1 week, then 2 times a week for 3 weeks, and then 1 time a week for 5 weeks Review of the clinical record indicated the SN and PT visit notes were not signed/dated on the day services were rendered: *10/31/25 PTA visit, note completed on 11/3/25 *11/6/25 PTA visit, note completed on 11/10/25 *11/7/25 SN visit, note completed on 11/10/25 *11/19/25 PTA visit, note completed on 11/24/25 *11/26/25 PTA visit, note completed on 12/1/25 *12/2/25 SN visit, note completed on 12/5/25 *12/18/25 SN visit, note completed on 12/21/25 6.) Patient #5 was admitted to the agency in October 2025 with a diagnosis of secondary malignant neoplasm of bone. Review of the Physician ordered POC for certification period 10/27/25 through 12/25/25 indicated the following: *SN 1 time a week for 1 week, then 2 times a week for 2 weeks, then 1 time a week for 6 weeks, with 3 PRN (as needed) *PT 1 time a week for 6 weeks (effective 11/2/25) Review of the clinical record indicated the PT notes were not signed/dated on the day services were rendered: *11/6/25 PT visit, note completed on 11/16/25 *11/10/25 PT visit, note completed on 11/13/25 *11/24/25 PT visit, note completed on 11/30/25 During an interview on 12/22/25 at 11:00 A.M., the Branch Manager said that notes are expected to be completed on the same day as the visit. She said the visit notes for the above patients were not completed timely as required. Review of the agency’s policy entitled Clinical Record Content-Skilled Home Health, dated 9/9/20, indicated the following: *Required documentation for each service or care provided must be completed on the day the services are rendered. 1.Patient #7 was admitted to the agency in May 2025 with a diagnosis of pneumonia and required home care services. Review of the physician ordered Home Health Plan of Care (POC) for certification period 5/8/25 through 7/6/25, indicated the following: -Skilled Nurse (SN) visit: once a week for 9 weeks. -Physical Therapy (PT) visit: once a week for 1 week, 2 times a week for 2 weeks, and once a week for 5 weeks. Review of the clinical record indicated the SN and PT visit notes were not signed/dated on the day services were rendered: *5/8/25 SN visit, note completed on 5/10/25. *5/29/25 PT visit, note completed on 6/1/25. *6/22/25 PT visit, note completed on 6/28/25. 2. Patient #8 was admitted to the agency in September 2025 with a diagnosis of aftercare following joint replacement surgery and required home care services. Review of the physician ordered Home Health POC for certification period 9/19/25 through 11/17/25, indicated the following: -PT visit: once a week for 1 week, 2 times a week for 4 weeks. -Occupational Therapy (OT) visit: effective 9/21/25, 2 times a week for 2 weeks. Review of the clinical record indicated the PT and OT visit notes were not signed/dated on the day services were rendered: *9/23/25 Physical Therapy Assistant (PTA) visit, note completed on 9/25/25. *9/25/25 PTA visit, note completed on 9/28/25. *9/25/25 OT visit, note completed on 9/29/25. 3. Patient #9 was admitted to the agency in October 2025 with a diagnosis of an exacerbation of Diverticulosis (bulging pouches in the lining of the colon) of the intestine and required home care services. Review of the physician order Home Health POC for certification period 10/4/25 through 12/2/25, indicated the following services: -SN visit: once a week for 7 weeks. Review of the clinical record indicated a SN visit note was not signed/dated on the day services were rendered: *10/4/25 SN visit, note completed on 10/7/25. 4. Patient #10 was admitted to the agency in May 2025 with a diagnosis of aftercare following joint replacement surgery and required home care services. Review of the physician ordered Home Health POC for certification period 5/17/25 through 7/15/25, indicated the following: -SN visit: once a week for 3 weeks. -PT visit: effective 5/18/25, 3 times a week for 1 week, 2 times a week for 1 week, and once a week for 1 week. -OT visit: effective 5/18/25, once a week for 2 weeks. Review of the clinical record indicated the SN, PT and OT visit notes were not signed/dated on the day services were rendered: *5/17/25 SN visit, note completed on 5/19/25. *5/21/25 PTA visit, note completed on 5/23/25. *5/21/25 OT visit, note completed on 5/26/25. *5/23/25 PTA visit, note completed on 5/27/25. *5/28/25 PTA visit, note completed on 5/30/25. *5/28/25 SN visit, note completed on 5/31/25. *5/29/25 OT visit, note completed on 6/2/25. *5/30/25 PTA visit, note completed on 6/2/25.”

“Written notice for non-covered care CFR(s): 484.50(c)(8) Receive proper written notice, in advance of a specific service being furnished, if the HHA believes that the service may be non-covered care; or in advance of the HHA reducing or terminating on-going care. The HHA must also comply with the requirements of 42 CFR 405.1200 through 405.1204. This Element is not met as evidenced by: Based on record review, policy review, and interview, the agency failed to ensure the Notice of Medicare Non-Coverage (NOMNC-an official Centers for Medicare and Medicaid Services {CMS} form that informs beneficiaries when their Medicare-covered skilled services, home health or outpatient rehabilitation services are ending and explains the right to appeal the decision) was provided prior to discharge for 1 patient (#9), out of a total sample of 17 patients. Findings include Review of the agency’s policy entitled Patient Transfer/Discharge, dated 11/1/24, indicated the following: *Medicare and Medicare Health Maintenance Organization (HMO) patients will be issued a NOMNC at least two calendar days before Medicare covered services end or the second to the last day of services if care is not being provided daily, or per state requirements, which explains the patient’s right to an immediate independent review of the proposed discontinuation of services. If the patient chooses such independent review, the Home Health Agency (HHA) will immediately contact the state’s Quality Improvement Organization (QIO) office to facilitate the process. Patient #9 was admitted to the agency in October 2025 with a diagnosis of an exacerbation of Diverticulosis (bulging pouches in the lining of the colon) of the intestine and required home care services. Review of the physician order Home Health Plan of Care for certification period 10/4/25 through 12/2/25, indicated the following services: -Skilled Nurse visit (SNV): once a week for 7 weeks. Review of signed physician order, dated 10/27/25, indicated patient to be discharged on 10/30/25. Review of the clinical record indicated the NOMNC notice was provided and signed by the patient on 10/30/25, not 2 days prior to discharge as required. During an interview on 12/23/25 at 12:15 P.M., the Branch Administrator said a NOMNC should be provided 2 days prior to services being discontinued. She said for Patient #9, the nurse should have provided the NOMNC as soon as the physician order was obtained, and it could have been provided verbally. She said the NOMNOC was not provided timely as required.”