Select Health Informatics Consulting Services Inc.

“Plan of care CFR(s): 484.60(a)(1) Each patient must receive the home health services that are written in an individualized plan of care that identifies patient-specific measurable outcomes and goals, and which is established, periodically reviewed, and signed by a doctor of medicine, osteopathy, or podiatry acting within the scope of his or her state license, certification, or registration. If a physician or allowed practitioner refers a patient under a plan of care that cannot be completed until after an evaluation visit, the physician or allowed practitioner is consulted to approve additions or modifications to the original plan. This Standard is not met as evidenced by: Based on record review and interview, the agency failed to ensure patient’s plans of care were signed by the physician in a timely manner for 5 patients (RR#2, HV#1, HV#2, HV#3 and DC#2) in a total sample of 7 patients. Findings include: 5. For Patient DC2, with a start of care date 9/19/23, the agency failed to ensure the plan of care (POC) was signed by the physician. Review of the agency Plan of Care policy, effective 12/2016 included the following: The POC is provided to the attending MD for review, approval, signature and return to the agency within 30 days. Review of the clinical record indicated that a plan of care was developed for DC2 on 9/19/23. DC2 received services from 9/12/23 until discharge on 11/7/23. The plan of care was not sent to the physician for review until 12/5/23, after the patient had been discharged and as of the survey was not signed. During an interview on 1/4/23 at 3:20 P.M., the Administrator said that the plan of care should have been signed by the physician within 30 days. Review of the agency’s Policy Number C:44, dated 12/2016, Orders: Signed In 30 Days, indicated: POLICY: Orders are signed by the physician within time frames established by state/federal regulations and our Agency’s policy, but at least within 30 days. PROCEDURE: All plans of care, verbal orders and changes in orders will be signed by the certifying physician within 30 days and filed in the patient’s clinical file. Every effort to obtain the MD signed order in the specified timeframe will be taken and documented, including resending and going to the MD office. 1. For Patient RR#2, the plan of care for the period of 10/19/23 - 12/17/23 was documented as signed by the physician on 12/1/23, 43 days after the start of the episode and 13 days past due based on the agency’s policy. 2. For Patient HV#1, the plan of care for the period of 10/25/23 - 12/23/23 was documented as signed by the physician on 12/18/23, 54 days after the start of the episode and 24 days past due based on the agency’s policy. 3. For Patient HV #2, the plan of care for the period of 11/25/23 - 1/23/23 had not been signed by the physician as of 1/8/24, 50 days after the start of the episode and 20 days past due based on the agency’s policy. 4. For Patient HV#3, the plan of care for the period of 11/9/23 - 1/7/24 had not been signed by the physician as of 1/8/24, 60 days after the start of the episode and 30 days past due based on the agency’s policy.”

“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 interview, the agency failed to provide written patient care instructions for a home health aide for 1 (HV#1) of 1 patients receiving home health aide services in a total sample of 7 patients. Findings include: Patient HV#1 was admitted to the agency in 2/2023 with a diagnosis of schizoaffective disorder. Review of Patient HV#1’s plan of care for the certification period of 10/25/23 - 12/23/23 indicated HV#1 was to receive visits from a home health aide 12 hours per week. Further record review indicated a written home health aide care plan was not completed for the certification period of 10/25/23 - 12/23/23, until 12/19/23. Patient HV#1 received home health aide services on 10/30/23, 11/4/23, 11/6/23, 11/13/23 and 11/20/23 without a written home health aide care plan in place. During an interview on 1/3/24 at 1:00 P.M., the Administrator said she could not provide an explanation as to why the written home health aide care plan was not completed.”

“Mistreatment, neglect or abuse CFR(s): 484.50(e)(1)(i)(B) (i)(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 employee file review and interview, the agency failed to obtain nurse aide registry checks in accordance with state requirements for 3 of 6 employee files (#2, #3 and #6) reviewed. Findings include: The Massachusetts Department of Public Health Regulations at 105 CMR 155.010 (E)(3) requires all home health agencies, homemaker agencies, and hospice programs to contact the registry prior to hiring an individual who will provide direct care to patients or have access to patients or their property to ascertain if there is any sanction, finding or adjudicated finding of patient or resident abuse, neglect, mistreatment or misappropriation of patient or resident property against the prospective employee. On 1/8/24, 6 employee files were reviewed for proper screening prior to employment. Included in the screening were nurse aide registry checks. The results include: 1. Employee #2 was hired as a Registered Nurse on 10/14/23. There was no documentation that a nurse aide registry check was conducted until 1/8/24, during the survey. 2. Employee #3 was hired as a Licensed Practical Nurse on 8/11/23. There was no documentation that a nurse aide registry was conducted until 1/8/24, during the survey. 3. Employee #6 was hired as a Registered Nurse on 8/24/23. There was no documentation that a nurse aide registry was conducted until 1/8/24, during the survey. During an interview on 1/8/24 at 2:00 P.M., the Administrator said she had just conducted the nurse aide registry checks and not prior to hire as required.”

“Health, psychosocial, functional, cognition CFR(s): 484.55(c)(1) The patient’s current health, psychosocial, functional, and cognitive status; This Element is not met as evidenced by: Based on interview, record review and policy review, the agency failed to ensure that staff completed a comprehensive assessment to assist in the development of a plan of care for 1 of 7 patients (DC2). Findings include: Review of the agency’s Policy Number C:7, revised 12/2016, Assessments, included the following: All Patients referred to our Agency will receive an assessment according to the Physician services ordered. Patients with orders for discipline-specific orders (Therapy, Medical Social Services, Skilled nursing), will have a specific discipline-specific assessment completed. An initial (start of care (SOC)/resumption of care (ROC)) assessment will be performed by the primary care Registered Nurse (RN) (unless therapy only case) within 48 hours of the patient referral, discharge from a facility to home or specific date specified by the MD. It will be completed timely, no later than 5 calendar days after SOC. The Follow-Up (Recertification) assessment will be performed at least every 60 days if the need for skilled care exists, and goals are unmet. The recertification assessment visit may only be done on day 56-60. This is the legal window of time allowable for recertification. Once completed, the assessment must be uploaded to the state agency on or before day 30 from the assessment date. If for some reason the assessment is not completed for a recert on time, an order must be obtained from the MD for the late recert. For Patient DC2, with a SOC date of 9/19/23, the agency failed to ensure that a comprehensive assessment was completed to assist in the development of a plan of care. Review of the clinical record failed to indicate a comprehensive assessment was completed for DC2 for the SOC date of 9/19/23. A plan of care was developed on 9/22/23, for the certification period of 9/19/23 to 11/17/23, without a completed comprehensive assessment. During an interview on 1/4/23 at 4:15 P.M., the Administrator said she was unable to find an assessment had been completed to assist in the development of the plan of care for DC2.”

“Last 5 days of every 60 days unless: CFR(s): 484.55(d)(1)(i,ii,iii) The last 5 days of every 60 days beginning with the start-of-care date, unless there is a- (i) Beneficiary elected transfer; (ii) Significant change in condition; or (iii) Discharge and return to the same HHA during the 60-day episode. This Element is not met as evidenced by: Based on record review and interview, the agency failed to conduct a comprehensive assessment during the last 5 days of a 60 day period for 1 patient (HV#1) out of a sample of 7 patients. Finding include: Patient HV#1 was admitted to the agency in 2/2023 with a diagnosis of schizoaffective disorder. Review of the record indicated a comprehensive assessment was not completed within 5 days prior to the certification period of 10/25/23 - 12/23/23. The comprehensive assessment was not completed until 12/19/23, which was 59 days after the certification period began. During an interview on 1/3/24 at 1:00 P.M., the Administrator said she could not provide an explanation as to why the assessment was not completed.”

“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 only provide services when ordered by a physician for 1 patient (DC#1) in a sample of 7 patients. Findings include: Patient DC#1 was admitted to the agency in 6/2023 with a diagnosis of cellulitis of the right lower leg. Review of the certification period 8/14/23 - 10/12/23 indicated Patient DC#1 was to receive skilled nursing visits 3 times a week. Review of the record indicated there was a physician’s order dated 10/8/23 to discharge Patient DC#1 from the agency due to noncompliance with skilled nurses’ visits and the patient requested to be discharged to another agency. Further review of the record indicated that Patient DC#1 received physical therapy after Patient DC#1 was discharged from the agency without a physician’s order. Specifically, Patient DC#1 was seen by the physical therapist on 10/12/23, 10/16/23, 10/20/23, 10/23/23, 10/26/23, 10/31/23 and 11/3/23. During an interview on 1/4/23 at 3:00 P.M., the Administrator said she could not explain why the Physical Therapist saw Patient DC#1 after discharge.”

“Preparing clinical notes CFR(s): 484.75(b)(6) Preparing clinical notes; This Element is not met as evidenced by: Based on record review and interview, the agency failed to ensure that all clinical notes are prepared in a timely, accurate manner for 3 patients (HV#1, HV#2 and HV#3), in a total sample of 7 patients. Findings include: 1. For Patient HV #1, the agency failed to document skilled nursing visit notes in a timely manner. Patient HV#1 was admitted to the agency in 2/2023 with diagnosis of schizoaffective disorder. For the certification period of 10/25/23 - 12/23/23 and 12/24/23 - 2/21/24, Patient HV#1’s plan of care indicated Patient HV#1 was to receive skilled nursing visits 2 times a day, 7 days a week for medication management. Review of Patient HV#1’s record indicated there were no nursing notes documented for the evening visits on 11/6/23,11/7/23, 11/8/23, 11/9/23, 11/10/23, 11/12/23, 11/13/23, 11/15/23, 11/16/23, 11/18/23, 11/20/23, 11/21/23, 11/24/23, 11/25/23, 11/28/23, 12/4/23, 12/5/23, 12/7/23, 12/11/23, 12/12/2, 12/13/23, 12/16/23, 12/18/23, 12/21/23, 12/22/23,12/23/23, 12/24/23, 12/25/23, 12/26/23, 12/27/23, 12/28/23, 12/29/23, 12/30/23 and 1/3/24. 2. For Patient HV#2, the agency failed to document skilled nursing visit notes in a timely manner. Patient HV#2 was admitted to the agency in 9/2023 with a diagnosis of schizophrenia. For the certification period of 11/25/23 - 1/23/24, Patient HV#2’s plan of care indicated Patient HV#2 was to receive skilled nursing visits 2 times a day, 7 days a week for medication management. Review of Patient HV #2’s record indicated there were no nursing notes documented for the evening visits on 11/25/23, 11/28/23, 12/4/23, 12/5/23, 12/7/23, 12/11/23, 12/12/23, 12/13/23, 12/18/23, 12/21/23, 12/24/23, 12/25/23, 12/26/28, 12/27/23, 12/28/23, 12/29/23 and 12/30/23. 3. For Patient HV#3, the agency failed to document skilled nursing visit notes in a timely manner. Patient HV#3 was admitted to the agency in 7/2023 with a diagnosis of schizophrenia. For the certification period of 11/9/23 - 1/7/24, Patient HV#3’s plan of care indicated Patient HV#3 was to receive skilled nursing visits 2 times a day, 7 days a week for medication management. Review of Patient HV#3’s record indicated there were no nursing notes documented for the evening visits on 12/3/23, 12/4/23, 12/5/23, 12/11/23, 12/12/23, 12/13/23, 12/18/23, 12/21/23, 12/22/23, 12/23/23, 12/24/23, 12/25/23, 12/26/23, 12/27/23, 12/28/23, 12/29/23, 12/30/3, 12/31/23, 1/1/23 and1/2/23. During the entrance conference on 1/3/24 at 9:30 A.M., the Administrator said the expected timeframe for skilled nursing notes to be documented is 36 hours. Upon further interview on 1/4/24 at 1:00 P.M., the Administrator said documentation has been an ongoing problem for the agency.”

“A qualified HH aide successfully completed: CFR(s): 484.80(a)(1)(i-iv) A qualified home health aide is a person who has successfully completed: (i) A training and competency evaluation program as specified in paragraphs (b) and (c) respectively of this section; or (ii) A competency evaluation program that meets the requirements of paragraph (c) of this section; or (iii) A nurse aide training and competency evaluation program approved by the state as meeting the requirements of §483.151 through §483.154 of this chapter, and is currently listed in good standing on the state nurse aide registry; or (iv) The requirements of a state licensure program that meets the provisions of paragraphs (b) and (c) of this section. This Element is not met as evidenced by: Based on record review of personnel files and interview, the Agency failed to maintain sufficient documentation for home health aide training, for 1 home health aide (HHA #2) in a total of 2 home health aide personnel records reviewed. Findings include: HHA #2 was hired on 1/19/18. Review of HHA #2’s personnel file indicated there was no documentation that a 75 hour certified home health aide training program was completed which included 75 hours total training, with at least 16 hours devoted to supervised practical training. A certificate was provided by the administrator on 1/10/23 from ONCourse Learning, dated 4/13/19, which indicated HHA #2 completed the following distance learning qualification: Home Health Training with 75 credit hours. The certificate also indicated to “see subsequent pages for details on which activities were satisfied in order to achieve this Certificate of Completion.” This certificate indicated the course was completely taken online, with no supervised practical trainings as required. In addition, there were no subsequent pages provided to see what was completed to earn the certificate. During an interview on 1/10/24 at 1:30 P.M., the Administrator said she was unable to find the subsequent pages.”

“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 interview, record review and policy review, the agency failed to ensure staff sent a completed transfer summary to the health care professional who will be responsible for providing care and services after the patients transfer for 3 of 3 patients transferred (DC1, DC2 and RR1). Findings include: 3. For Patient HV#3, with a start of care date of 7/12/23, the agency failed to ensure a discharge summary was sent to the receiving agency within 72 hours of a transfer. Review of the record indicated Patient HV#3 was transferred to an inpatient facility on 10/18/23. Although a transfer summary was completed, there was no evidence that a discharge summary was sent to the receiving facility. During an interview on 1/4/23 at 2:15 P.M., the Administrator said staff are supposed to attach the fax confirmation sheet into the medical record, she had checked the fax log and was unable to find confirmation that the transfer summary was sent so she was not sure if it was and staff just didn’t attach the confirmation or they didn’t send it. Review of the agency Transfer policy, effective 12/2016, included the following: When an active open case meets the condition for transfer to another agency or facility, a transfer summary shall be completed and forwarded to both the primary MD and the receiving agency within 72 hours of transfer. 1. For Patient #DC2, with a start of care date of 9/19/23, the agency failed to ensure a discharge summary was sent to the receiving agency within 72 hours of a transfer. a. Review of the clinical record indicated that Patient DC2 was transferred to an acute care hospital on 10/10/23. A transfer summary was completed, but the clinical record failed to indicate that a transfer summary was sent to the receiving acute care hospital. b. Review of the clinical record indicated that Patient DC2 was discharged from the agency on 11/7/23. Nursing completed a transfer summary indicating DC2 was transferred to an acute care hospital; Physical Therapy completed a transfer summary indicating DC2 remained in the community. The clinical record failed to indicate that either transfer summary was sent to the receiving acute care hospital or receiving home care agency. During an interview on 1/4/23 at 3:15 P.M., the Administrator said that she was not able to find evidence that the transfer summaries were sent to the receiving provider for either the 10/10/23 transfer or the 11/7/23 transfer. She further said the nursing transfer summary for 11/7/23 was inaccurate. DC2 was transferred to another Home Health Agency, not an acute care hospital. 2. For Patient #RR1, with a start of care date of 12/12/23, the agency failed to ensure a discharge summary was sent to the receiving agency within 72 hours of a transfer. a. Review of the clinical record indicated that Patient DC2 was transferred to an acute care hospital on 10/7/23. A transfer summary was completed, but the clinical record failed to indicate that a transfer summary was sent to the receiving acute care hospital.”