A&d Health Care Professional

“Participate in care CFR(s): 484.50(c)(4)(i,ii,iii,iv,v,vi,vii,viii) Participate in, be informed about, and consent or refuse care in advance of and during treatment, where appropriate, with respect to-- (i) Completion of all assessments; (ii) The care to be furnished, based on the comprehensive assessment; (iii) Establishing and revising the plan of care; (iv) The disciplines that will furnish the care; (v) The frequency of visits; (vi) Expected outcomes of care, including patient-identified goals, and anticipated risks and benefits; (vii) Any factors that could impact treatment effectiveness; and (viii) Any changes in the care to be furnished. This Element is not met as evidenced by: Based on observation, interview and record review, the agency failed to ensure that 2 (P-8, P-18) of 18 sampled records reviewed, was included in the overall planning of care, including informing the patient/caregiver in advance of the days in which services would be provided and disciplines that will furnish care, resulting in a lack of inclusion in planning, lack of informed consent, the potential for missed visits and unmet care needs. Findings include: P-8: The patient’s start of care (SOC) was 3/7/24. The certification period of review was 5/6/24 through 5/28/24 with diagnoses that included Epilepsy and Dementia. On 5/21/24 at 12:30 p.m., during a scheduled survey home visit with the Occupational Therapist, it was noted that the patient’s visit calendar was void of the required proposed visits to be made. Upon completion of the visit, the Occupational Therapist informed the patient, “I’m going to be here next Tuesday”, initially not providing a visit time. The Therapist then stated, “I’ll probably be here between noon and 1:00 p.m., to which the patient responded, “I’m not sure about that time, because they (staff) usually bring my lunch around that time.” There was no evidence that the patient had been included in the overall planning of his care, as per this requirement. These findings were reviewed with and acknowledged by the Alternate Administrator during an interview on 5/28/24 at 9:40 a.m. P-18: The patient’s SOC was 4/19/24 with diagnoses that included Atrial Fibrillation and Pneumonia. During a scheduled survey home visit with the Physical Therapist, it was noted that the patient’s calendar was void of the required proposed visits to be made. Upon completion of the visit, when setting up the next visit, the Physical Therapist stated, “Let me check my schedule...” The Physical Therapist failed to ensure the patient was included in the planning of his care. These findings were reviewed with and acknowledged by the Alternate Administrator during an interview on 5/28/24.”

“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 observation, interview and record review, the Agency failed to ensure the patient received proper written notice (Notice of Medicare Provider Non-Coverage) in advance of the agency terminating on-going care for 1 (P-7) of 4 discharged records, resulting in the patient being denied the right to appeal the decision to end Medicare covered services. Findings include: P-7: The patient’s start of care was 5/10/24 with diagnoses that included bilateral lower extremity Cellulitis with/ wounds, Congestive Heart Failure and Diabetes Mellitus. On 5/21/24, upon arrival to the agency, it was noted that a home survey planned discharge visit with the Skilled Nurse was scheduled for this date at 11:00 a.m. During the home visit, the patient’s admission packet was reviewed and noted to contain the Notice of Medicare Provider Non-Coverage form. It was further noted that the form was blank. The Skilled Nurse failed to provide proper notice of discharge in advance of the agency terminating on-going care. The record review on 5/22/24 at 9:00 a.m., revealed that Skilled Nursing was the only service provided during this period of care. These findings were reviewed with and acknowledged by the Alternate Administrator during an interview on 5/28/24 at 9:23 a.m.”

“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 record review and interview, the agency failed to conduct a patient-specific, comprehensive assessment that accurately reflected the patient’s current health status based on past medical history that included dates of onset, exacerbations, treatments and outcomes, and history of events leading to current home care needs in 6 of 18 records reviewed (P-1, P-2, P-3, P-4, P-5, P-6, P-12, P-13, P-14, P-15, P-16, P-17), resulting in incomplete clinical information to aide in determining the needs of the patient. Findings included: P-12: The Start of Care (SOC) was dated 5/4/24. The Plan of Care (POC) identified diagnoses of Ventral Hernia Repair, Chronic Obstructive Pulmonary Disease and Chronic Kidney Disease. During record review on 5/22/24, it was noted that the SOC comprehensive assessment dated 5/4/24, documented under “Primary Diagnosis and Other Diagnoses”, all 14 diagnoses had an exacerbation date of 5/4/24. No prior treatments, outcomes, or history of how these diagnoses led to the need for home care were documented. P-13: The Start of Care (SOC) was dated 4/17/24. The Plan of Care (POC) identified diagnoses of Diabetes Type 2 and Hypertension. During record review on 5/28/24, it was noted that the SOC comprehensive assessment dated 4/17/24, documented under “Primary Diagnosis and Other Diagnoses”, all 22 diagnoses had an exacerbation or onset date of 4/17/24. No prior treatments, outcomes, or history of how these diagnoses led to the need for home care were documented. P-14: The Start of Care (SOC) was dated 4/15/24. The Plan of Care (POC) identified diagnoses of Hemorrhage Arteriovenous Fistula and Congestive Heart Failure. During record review on 5/23/24, it was noted that the SOC comprehensive assessment dated 4/15/24, documented under “Primary Diagnosis and Other Diagnoses”, all 13 diagnoses had an exacerbation date of 4/15/24. No prior treatments, outcomes, or history of how these diagnoses led to the need for home care were documented. P-15: The Start of Care (SOC) was dated 10/12/23. The Plan of Care (POC) identified diagnoses of Metabolic Encephalopathy, Chronic Kidney Disease and Urinary Tract Infection. During record review on 5/22/24, it was noted that the SOC comprehensive assessment dated 10/12/23, documented under “Primary Diagnosis and Other Diagnoses”, all 15 diagnoses had an exacerbation date of 10/12/23. No prior treatments, outcomes, or history of how these diagnoses led to the need for home care were documented. P-16: The Start of Care (SOC) was dated 6/17/23. The Plan of Care (POC) identified diagnoses of Congestive Heart Failure, Chronic Kidney Disease and Anemia. During record review on 5/22/24, it was noted that the SOC comprehensive assessment dated 5/11/24, documented under “Primary Diagnosis and Other Diagnoses”, all 17 diagnoses had an exacerbation date of 5/11/24. No prior treatments, outcomes, or history of how these diagnoses led to the need for home care were documented. P-17: The Start of Care (SOC) was dated 4/23/24. The Plan of Care (POC) identified diagnoses of Atrial Fibrillation, Dementia, Chronic Respiratory Failure, Congestive Heart Failure and Diabetes Type 2. During record review on 5/22/24, it was noted that the SOC comprehensive assessment dated 4/23/24, documented under “Primary Diagnosis and Other Diagnoses”, all 23 diagnoses had an exacerbation date of 4/23/24. No prior treatments, outcomes, or history of how these diagnoses led to the need for home care were documented. These findings were reviewed with and acknowledged by the Staff-A during an interview on 5/28/24 at 11:50 am. P-1: The start of care (SOC) was dated 2/12/24, with diagnoses that included atrial fibrillation, type 2 diabetes mellitus, and hypertension. During record review on 5/21/24, it was noted that the SOC Comprehensive Assessment dated 2/12/24, identified 11 diagnoses under (M1021-M1033). The Plan of Care (POC), which is populated by the SOC Comprehensive Assessment data, documented under “Principal Diagnosis and Other Pertinent Diagnoses”, the same 11 diagnoses with an exacerbation date of 2/12/24. No prior treatments, outcomes, or history of how these diagnoses led to the need for home care, or how they could all be exacerbations on the same date, were documented on the SOC Comprehensive Assessment or the POC. P-2: The SOC was dated 12/6/23, with diagnoses that included pressure ulcer, hyperkalemia, and hypertension. During record review on 5/22/24, it was noted that the SOC comprehensive assessment dated 12/6/23, identified 23 diagnoses under (M1021-M1033). The POC, which is populated by the SOC Comprehensive Assessment data, documented under “Principal Diagnosis and Other Pertinent Diagnoses”, the same 23 diagnoses with an exacerbation date of 4/02/24, (The latest certification period). No prior treatments, outcomes, or history of how these diagnoses led to the need for home care, or how they could all be exacerbations on the same date, were documented on the SOC Comprehensive Assessment or the POC. P-3: The SOC was dated 4/5/24, with diagnoses that included cervical disc disorder, hypertension, diabetes. During record review on 5/23/24, it was noted that the SOC comprehensive assessment dated 4/5/24, identified 12 diagnoses under (M1021-M1033). The POC, which is populated by the SOC Comprehensive Assessment data, documented under “Principal Diagnosis and Other Pertinent Diagnoses”, 20 diagnoses with an exacerbation date of 4/05/24. No prior treatments, outcomes, or history of how these diagnoses led to the need for home care, or how they could all be exacerbations on the same date, were documented on the SOC Comprehensive Assessment, or the POC. P-4: The SOC was dated 3/27/24, with diagnoses that included heart disease, diabetes, and hypertension. During record review on 5/23/24, it was noted that the SOC comprehensive assessment dated 3/27/24, identified 17 diagnoses under (M1021-M1033). The POC, which is populated by the SOC Comprehensive Assessment data, documented under “Principal Diagnosis and Other Pertinent Diagnoses”, 20 diagnoses with an exacerbation date of 3/27/24. No prior treatments, outcomes, or history of how these diagnoses led to the need for home care, or how they could all be exacerbations on the same date, were documented on the SOC Comprehensive Assessment, or the POC. P-5: The SOC was dated 2/8/24, with diagnoses that included atrial fibrillation, osteoarthritis, and hypertension. During record review on 5/28/24, it was noted that the SOC comprehensive assessment dated 2/8/24, identified 12 diagnoses under (M1021-M1033). The POC, which is populated by the SOC Comprehensive Assessment data, documented under “Principal Diagnosis and Other Pertinent Diagnoses”, 9 diagnoses with an exacerbation date of 2/8/24. No prior treatments, outcomes, or history of how these diagnoses led to the need for home care, or how they could all be exacerbations on the same date, were documented on the SOC Comprehensive Assessment, or the POC. P-6: The SOC was dated 4/29/24, with diagnoses that included type 2 diabetes mellitus. During record review on 5/28/24, it was noted that the SOC comprehensive assessment dated 4/29/24, identified 9 diagnoses under (M1021-M1033). The POC, which is populated by the SOC Comprehensive Assessment data, documented under “Principal Diagnosis and Other Pertinent Diagnoses”, 19 diagnoses with an exacerbation date of 4/29/24. No prior treatments, outcomes, or history of how these diagnoses led to the need for home care, or how they could all be exacerbations on the same date, were documented on the SOC Comprehensive Assessment, or the POC. The findings were reviewed with and acknowledged by the Director of Medicare Program (Staff-A) on 5/28/24 at 12:45 p.m.”

“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 Activity of Daily Living/Grooming needs were adequately met in the patient’s home for 1 (P-9) of 1 patient who required assistance with grooming, from a total of 18 sampled patient’s reviewed, resulting in the potential for loss of self-esteem, poor hygiene and unmet care needs. Findings include: Policy: “Admission to Service” 9/13 stated, “Clients ae admitted to service based on the reasonable expectation that their medical, nursing, psychological, and social needs can be adequately met in the client’s place of residence.” P-9: The patient’s start of care was 5/6/24 with diagnoses that included Congestive Heart Failure and Amyotrophic Lateral Sclerosis. On 5/21/24, Upon arrival to this agency, this surveyor was informed that a scheduled survey home visit with the Home Health Aide (HHa) was pending, as the HHa had to report to Jury Duty and would call with updates. During the clinical record review on 5/22/24 at 11:05 a.m., Section M1800 of the Initial Comprehensive Assessment dated 5/6/24, completed by the Physical Therapist documented, “Someone must assist the patient to groom self, someone must help the patient put on clothing, someone must help to maintain toileting hygiene...” A Physician’s order dated 5/10/24 ordered HHa services to begin 5/12/24. There was no documented evidence that grooming assistance, by way of a Home Health Aide (HHa) had been offered or provided based on the patient’s identified needs. On 5/22/24 and 5/23/24, the Alternate Administrator reported, the HHa had to report to Jury Duty again and stated, “I’m assuming she must have been selected.” On 5/28/24 during an interview, the Alternate Administrator was queried about the HHa’s availability to assist with the patient’s grooming. The Alternate Administrator picked up her cell phone and stated, “I’m not sure, let me find out.” No information had been provided by the survey’s exit. The agency failed to ensure the patient’s ADL needs were adequately met in the patient’s home.”

“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 ensure the comprehensive assessment included an accurate review of all medications to determine potential adverse effects or duplicate drug therapy in 5 of 18 (P-1, P-3, P-12, P-14, P-17) records reviewed, resulting in the potential for harmful medication effects for all patients serviced by this agency. Findings include: P-1: The start of care (SOC) was dated 2/12/24, with diagnoses that included atrial fibrillation, type 2 diabetes mellitus, and hypertension. During record review on 5/21/24, it was noted that the initial Start of Care (SOC) Comprehensive Assessment stated (under M2001 Drug Regimen Review), “No issues found during review.” The record failed to include a medication interaction or duplicate drug therapy report, or any documentation related to the Drug Regimen Review. P-3: The start of care (SOC) was dated 4/5/24, with diagnoses that included cervical disc disorder, type 2 diabetes mellitus, and hypertension. During record review on 5/23/24, it was noted that the initial SOC Comprehensive Assessment stated (under M2001 Drug Regimen Review), “Yes, issues found during review.” The record failed to include a medication interaction or duplicate drug therapy report, or any documentation related to the Drug Regimen Review findings. The findings were reviewed with and acknowledged by the Director of Medicare Program (Staff-A) on 5/28/24 at 12:45 p.m. P-12: The Start of Care (SOC) was dated 5/4/24. The Plan of Care (POC) identified diagnoses of Ventral Hernia Repair, Chronic Obstructive Pulmonary Disease and Chronic Kidney Disease. During record review on 5/22/24, section M2001 of the “Comprehensive Assessment” dated 5/4/24 and completed by the Registered Nurse (RN), documented “No - Issues found during review.” There was no documented evidence in the clinical record that a drug interaction review had in fact been conducted to identify any adverse reactions or effects. P-14: The Start of Care (SOC) was dated 4/15/24. The Plan of Care (POC) identified diagnoses of Hemorrhage Arteriovenous Fistula and Congestive Heart Failure. During record review on 5/23/24, section M2001 of the “Comprehensive Assessment” dated 5/4/24 and completed by the RN, documented “No - Issues found during review.” There was no documented evidence in the clinical record that a drug interaction review had in fact been conducted to identify any adverse reactions or effects. P-17: The Start of Care (SOC) was dated 4/23/24. The Plan of Care (POC) identified diagnoses of Atrial Fibrillation, Dementia, Chronic Respiratory Failure, Congestive Heart Failure and Diabetes Type 2. During record review on 5/22/24, section M2001 of the “Comprehensive Assessment” dated 5/4/24 and completed by the RN, documented “Yes - Issues found during review.” Additionally, the RN documented “Yes” under “M2003 Medication Follow-up: Did the agency contact a physician by midnight of the next calendar day and complete prescribed/recommended actions in response to the identified potential clinically significant medication issues?” There was no documented evidence in the clinical record that a drug interaction review had in fact been conducted to identify any adverse reactions or effects, or documented evidence that the physician had been notified of the above findings. Furthermore, the RN documented, “…Medications reviewed with spouse, she has questions regarding if he should resume spironolactone diuretic in addition to Lasix. SN (Skilled Nurse) advised family and patient to schedule a follow-up visit with PCP (Primary Care Physician) regarding medications to be prescribed moving forward. Spouse states she will schedule PCP appointment…” The agency failed to coordinate with the physician to complete an accurate medication profile. These findings were reviewed with and acknowledged by the Staff-A during an interview on 5/28/24 at 11:30 am.”

“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 agency failed to ensure the plan of care included objectively measurable goals and interventions specific to the individualized needs of the patient in 8 records (P-2, 4, 7, 8, 12, 13, 14, 15, 16, 17), and failed to include safety precautions for 2 records (P-1, 2) from a total of 18 sampled records reviewed, resulting in the potential for poor patient outcomes and unmet care needs. Findings include: P-1: The start of care (SOC) was dated 2/12/24, with diagnoses that included atrial fibrillation, type 2 diabetes mellitus, and hypertension. During record review on 5/21/24, it was noted that the plan of care (POC) dated 2/12/24, failed to include diabetic safety precautions for a patient with a diagnosis of diabetes. P-2: The SOC was dated 12/6/23, with diagnoses that included pressure ulcer, hyperkalemia, and hypertension. During record review on 5/22/24, it was noted that the nursing goals on the POC dated 4/2/24, were not measurable. For example, one goal stated, “Demonstrate compliance with methods to control/relieve depression.” another stated, “Demonstrate compliance with fall prevention measures.” There was no evidence of how these goals could be objectively measured to ascertain progress toward goals. The POC also failed to include bleeding/anticoagulant safety precautions for a patient with Heparin (Anticoagulant) ordered. P-4: The SOC was dated 3/27/24, with diagnoses that included heart disease, diabetes, and hypertension. During record review on 5/23/24, it was noted that the nursing goals on the POC dated 3/27/24, were not measurable. For example, one goal stated, “Monitor patient for chest pain, extreme fatigue, shortness of breath, pain in the neck, jaw, upper abdomen, or back, and numbness in the extremities.” another stated, “Evaluate wound/pressure ulcer for healing, measure wound(s), teach wound care/dressing.” There was no evidence of how these goals could be objectively measured to ascertain progress toward goals. The findings were reviewed with and acknowledged by the Director of Medicare Program (Staff-A) on 5/28/24 at 12:45 p.m. P-12: The Start of Care (SOC) was dated 5/4/24. The Plan of Care (POC) identified diagnoses of Ventral Hernia Repair, Chronic Obstructive Pulmonary Disease and Chronic Kidney Disease. During record review on 5/22/24, it was noted that the goals within the POC were not measurable. For example, one goal stated, “… is stable as evidenced by absence of the following: persistent oral temperature greater than 90.0F, foul odor wound drainage, increased wound pain...” Additionally, another goal stated, “...is stable as evidenced by absence of the following: abnormal blood pressure based on physician parameters, severe headache, vision problems...” There was no evidence of how these goals could be objectively measured to ascertain progress toward goals. Additionally, the POC documented interventions to monitor “Vital sign parameters for notifying physician: …Blood sugar 150…” The patient’s EMR (Electronic Medical Record) has no documented evidence of a diagnosis of Diabetes. The agency failed to individualize the POC to the patient’s needs. P-13: The Start of Care (SOC) was dated 4/17/24. The Plan of Care (POC) identified diagnoses of Diabetes Type 2 and Hypertension. During record review on 5/28/24, it was noted that the goals within the POC were not measurable. For example, one goal stated, “…Monitor patient for abnormal blood sugar or urinalysis based on physician parameters, unusual thirst, persistent dry mouth…Teach caregiver diabetic medication management, blood sugar testing, diabetic foot care, exercise and diabetic diet.” Additionally, another goal stated, “…Monitor patient for nausea and/or vomiting, watery or bloody diarrhea, severe abdominal pain and cramps...” There was no evidence of how these goals could be objectively measured to ascertain progress toward goals. P-14: The Start of Care (SOC) was dated 4/15/24. The Plan of Care (POC) identified diagnoses of Hemorrhage Arteriovenous Fistula and Congestive Heart Failure. During record review on 5/23/24, it was noted that the POC interventions stated, “…assess for diabetic foot for skin lesions, assess for signs and symptoms of depression…” The patient’s EMR has no documented evidence of a diagnoses of Diabetes and Depression. The agency failed to individualize the POC to the patient’s needs. P-15: The Start of Care (SOC) was dated 10/12/23. The Plan of Care (POC) identified diagnoses of Metabolic Encephalopathy, Chronic Kidney Disease and Urinary Tract Infection. During record review on 5/22/24, it was noted that the goals within the POC were not measurable. For example, one goal stated, “...Monitor patient for new incidence of paralysis, new incidence of loss of sensation, unexplained pain, unusual seizures, changes in mental status...” Additionally, another goal stated, “… Monitor patient for abnormal blood pressure based on physician parameters, severe headache, vision problems, chest pain, difficulty breathing, irregular heartbeat...” There was no evidence of how these goals could be objectively measured to ascertain progress toward goals. P-16: The Start of Care (SOC) was dated 6/17/23. The Plan of Care (POC) identified diagnoses of Congestive Heart Failure, Chronic Kidney Disease and Anemia. During record review on 5/22/24, it was noted that the POC interventions stated, “…assess for diabetic foot for skin lesions, assess for signs and symptoms of depression…” The patient’s EMR has no documented evidence of a diagnoses of Diabetes and Depression. The agency failed to individualize the POC to the patient’s needs. P-17: The Start of Care (SOC) was dated 4/23/24. The Plan of Care (POC) identified diagnoses of Atrial Fibrillation, Dementia, Chronic Respiratory Failure, Congestive Heart Failure and Diabetes Type 2. During record review on 5/22/24, it was noted that the goals within the POC were not measurable. For example, one goal stated, “…is stable as evidenced by absence of the following: unexplained weight gain of 1-3 lbs. in 24 hours, unexplained palpitations, unexplained increase in dependent edema….” Additionally, another goal stated, “…is stable as evidenced by absence of the following: unexpected personality changes, new incidence of urinary or fecal incontinence...” there was no evidence of how these goals could be objectively measured to ascertain progress toward goals. These findings were reviewed with and acknowledged by the Staff-A during an interview on 5/28/24 at 11:45 am. P-7: The patient’s start of care (SOC) was 5/10/24 with diagnoses that included Bilateral lower extremity Cellulitis with open wounds, Congestive Heart Failure and Diabetes Mellitus. During the clinical record review on 5/22/24 at 9:00 a.m., it was noted that the Plan of Care (POC) listed 25 diagnoses with the same exacerbation date of 5/10/24. This was the same date the patient was admitted to this agency. There were no interventions, reportable parameters or associated measurable goals to address the exacerbated diagnoses. Further, the POC documented, “INTERVENTIONS and GOALS to be addressed by Skilled Nursing, Physical Therapy, Physical Therapy Assistant, Occupational Therapy, Certified Occupational Therapy Assistant...” However, the POC only ordered Skilled Nursing services to be provided. Additionally, the POC was void of any goals that addressed the listed diagnoses. The POC failed to address the individualized, identified needs of the patient. These findings were reviewed with and acknowledged by the Alternate Administrator during an interview on 5/28/24 at 9:23 a.m. P-8: The patient’s SOC was 3/7/24 with diagnoses that included Epilepsy and Dementia. During the record review on 5/22/24 at 9:50 a.m., it was noted that the POC listed 21 diagnoses with the same exacerbation date of 3/7/24. There were no interventions, reportable parameters or associated measurable goals to address the exacerbated diagnoses. Further, the POC documented, “INTERVENTIONS/GOALS to be addressed by Skilled Nursing, Physical Therapy, Physical Therapy Assistant, Occupational Therapy, Certified Occupational Therapy Assistant, ****verbalize pain controlled at acceptable level...” However, the POC only ordered Occupational Therapy services to be provide. Additionally, the POC was void of any goals that addressed the listed diagnoses and listed interventions in its place, such as, monitor patient for chest pain, monitor patient for temporary confusion, monitor for new incidence of paralysis...” The POC failed to capture and address the individualized, identified needs of the patient. These findings were reviewed with and acknowledged by the Alternate Administrator during an interview on 5/28/24 at 9:40 a.m. who reported, “I think we’re going to have to just redo the entire Plan of Care.””

“Promptly alert relevant physician of changes CFR(s): 484.60(c)(1) The HHA must promptly alert the relevant physician(s) or allowed practitioner(s) to any changes in the patient’s condition or needs that suggest that outcomes are not being achieved and/or that the plan of care should be altered. This Element is not met as evidenced by: Based on observation, interview and record review, the Registered Nurse failed to ensure the Physician was promptly notified of 1 (P-7) patient observed during a home visit, who experienced a how heart rate, and failed to ensure services were provided only as ordered by the physician in 1 of 18 (P-13) records reviewed, from a total of 18 sampled records reviewed, resulting in the potential for unidentified, untreated health concerns and unmet care needs. Findings include: P-13: The Start of Care (SOC) was dated 4/17/24. The Plan of Care (POC) identified diagnoses of Diabetes Type 2 and Hypertension. During record review on 5/28/24, it was noted that the POC ordered Skilled Nursing (SN) at a frequency of 1w4 (one time a week for four weeks). The POC had orders to notify the physician with “Blood sugar 150.” During the comprehensive assessment on 4/17/24, the RN (Registered Nurse) documented a FBS (Fasting Blood Sugar) of 254. Additionally, on 5/1/24, the RN documented a FBS of 182. Furthermore, on 5/7/24, the RN documented a FBS of 256. There was no documented evidence in the clinical record that the physician had been notified of the patients elevated blood sugar. These findings were reviewed with and acknowledged by the Staff-A during an interview on 5/28/24 at 11:40 am. P-7: The patient’s start of care (SOC) was 5/10/24 with diagnoses that included Bilateral lower extremity Cellulitis, Congestive Heart Failure and Diabetes Mellitus. On 5/21/24 at 11:00 a.m., a scheduled survey home visit was conducted with the Skilled Nurse. During the visit, the nurse took the patient’s pulse/heart rate and oxygen levels with the use of an electronic device. The patient’s pulse read 54, which was below the physician specified reportable parameters to report Pulse/heart rate levels lower than 60. The nurse responded, “Wow, that’s kind of low for you” and proceeded with the visit. By the end of the survey on 5/28/24, there was no documented evidence that the nurse promptly notified the Physician of the patient’s change in condition, as per this requirement. These findings were reviewed with and acknowledged by the Alternate Administrator during an interview on 5/28/24 at 9:23 a.m.”

“Coordinate care delivery CFR(s): 484.60(d)(4) Coordinate care delivery to meet the patient’s needs, and involve the patient, representative (if any), and caregiver(s), as appropriate, in the coordination of care activities. This Element is not met as evidenced by: Based on record review and interview, the agency’s skilled professional services failed to coordinate and maintain communication with the physician regarding the patient’s condition and medication for 1 of 18 (P-15) resulting in the potential of unmet care needs. Findings include: P-15: The Start of Care (SOC) was dated 10/12/23. The Plan of Care (POC) identified diagnoses of Metabolic Encephalopathy, Chronic Kidney Disease and Urinary Tract Infection. During record review on 5/22/24, it was noted that the RN (Registered Nurse) completed a discharge summary on 10/6/23 that states, “…End of abx (antibiotic) therapy was on a weekend and appearance had minimally improved, family was encouraged to contact PCP (Primary Care Physician) to see if they wanted to extend abx through the weekend to which they did extend x5 more days. At completion of abx extension, LE (Left Extremity) edema, blisters and redness had greatly improved if not resolved…” The RN failed to coordinate care and follow-up with the physician regarding the patient’s assessment and potential medication need. This finding was reviewed with and acknowledged by the Staff-A during an interview on 5/28/24 at 11:30 am.”

“Patient medication schedule/instructions CFR(s): 484.60(e)(2) Patient medication schedule/instructions, including: medication name, dosage and frequency and which medications will be administered by HHA personnel and personnel acting on behalf of the HHA. This Element is not met as evidenced by: Based on observation, interview and record review, it was determined that the agency failed to provide 3 (P-7, P-8, P-18) of 5 patients observed during home visits, with a Medication Profile that included the names, dosages and frequencies of the patient’s prescribed medications, in plain language, from a total of 18 sampled records reviewed, resulting in lack of direction for medication administration and the potential for improper use of medications. Findings include: P-7: The patient’s start of care (SOC) was 5/10/24 with diagnoses that included Cellulitis Bilateral Lower Extremities with open wounds, Congestive Heart Failure and Diabetes Mellitus. On 5/21/24 at 11:00 a.m., during a scheduled survey home visit with the Skilled Nurse, it was noted that there was no Medication Profile in the patient’s admission packet that listed the patient’s prescribed medications, dosages and side effects. These findings were reviewed with and acknowledged by the Alternate Administrator during an interview on 5/28/24 at 9:23 a.m. P-8: The patient’s SOC was 3/7/24. The certification period of review was 5/6/24 through 5/28/24 with diagnoses that included Epilepsy and Dementia. On 5/21/24 at 12:30 p.m., during a scheduled survey home visit with the Occupational Therapist, it was noted that there was no Medication Profile in the patient’s admission packet that listed the patient’s prescribed medications, dosages and side effects. These findings were reviewed with and acknowledged by the Alternate Administrator during an interview on 5/28/24 at 9:40 a.m. P-18: The patient’s SOC was 4/19/24 with diagnoses that included Atrial Fibrillation and Pneumonia. During a scheduled survey home visit with the Physical Therapist, it was noted that there was no Medication Profile in the patient’s admission packet that listed the patient’s prescribed medications, dosages and side effects. These findings were reviewed with and acknowledged by the Alternate Administrator during an interview on 5/28/24.”

“Interdisciplinary assessment of the patient CFR(s): 484.75(b)(1) Ongoing interdisciplinary assessment of the patient; This Element is not met as evidenced by: Based on observation, record review and interview, it was determined that the agency failed to ensure the registered nurse performed baseline and ongoing assessments of the patient’s health status and needs in 2 (P-7, P-10) records of patients who required ongoing monitoring, from a total of 18 sampled records reviewed, resulting in the potential for unidentified health concerns, decline in physical functioning, and poor patient outcomes. Findings included: P-7: The patient’s start of care (SOC) was 5/10/24 with diagnoses that included Bilateral lower extremity Cellulitis, Congestive Heart Failure and Diabetes Mellitus. On 5/21/24 at 11:00 a.m., a scheduled survey home visit was conducted with the Skilled Nurse. During the visit, the nurse took the patient’s pulse and oxygen levels with the use of an electronic device. The patient’s pulse read 54, which was outside of the reportable parameters on the lower end. The nurse said, “Wow, that’s kind of low for you.” The nurse then proceeded with the visit but did not reassess the patient’s pulse manually for accuracy, in accordance with professional standards. While completing the assessment form, the nurse stated, “We haven’t been checking your weights” and turned to the patient’s wife and inquired, “Do you happen to have a weight for him?” There was no documented evidence that the nurse had been monitoring the patient’s weights to assess for fluid overload. On 5/22/24 at 9:00 a.m. during the clinical record review, it was noted that the plan of care (POC) ordered skilled nursing to monitor the patient’s vital signs and unexplained weight gain of 1-3 lbs. in 24 hours. The nurse failed to accurately assess the patient’s health status as indicated in the plan of care. These findings were reviewed with and acknowledged by the Alternate Administrator during an interview on 5/28/24 at 9:23 a.m. P-10: The patient’s SOC was 3/14/24 with diagnoses that included Hypertensive heart Disease with Heart Failure, Respiratory Failure, Acute Kidney Failure and Obesity. During the record review on 5/22/24 at 2:05 p.m., it was noted that the POC ordered Skilled nursing services to monitor patient for unexplained weight gain of 1-3 lbs. in 24 hours, unexplained increase in dependent edema...” A reported weight of 845 lbs. was documented at the SOC in addition to the patient being bedbound. In the section titled Cardiovascular-Edema, the nurse documented, “observations as expected for patient.” There was no quantitative measurement of edema established. In the remaining skilled nurse visit notes dated 3/21/24, 3/29/24 and 4/5/24, the nurse documented, Edema: observations as expected for patient. There was no documented evidence that the skilled nurse assessed the patient for fluid overload. These findings were reviewed with and acknowledged by the Alternate Administrator during an interview on 5/28/24 at 12:35 p.m. When queried as to what methods were used to monitor the patient’s weight, edema and potential fluid overload, the Alternative Administrator looked through the skilled nurses visit notes and acknowledged there was no evidence to support the patient had been assessed for weight gain, increased edema and fluid overload.”

“Required items in clinical record CFR(s): 484.110(a)(1) The patient’s current comprehensive assessment, including all of the assessments from the most recent home health admission, clinical notes, plans of care, and physician or allowed practitioner orders; This Element is not met as evidenced by: Based on observation, record review and interview, the agency failed to ensure clinical notes were accurate for 1 of 18 (P-17) records reviewed, resulting in the potential to negatively affect the health and well-being of these patients. Findings include: P-17: The Start of Care (SOC) was dated 4/23/24. The Plan of Care (POC) identified diagnoses of Atrial Fibrillation, Dementia, Chronic Respiratory Failure, Congestive Heart Failure and Diabetes Type 2. During record review on 5/22/24, it was noted that the POC contained “Vital Sign parameters for notifying physician…Weight gain > 2 pounds in 24 hours and/or 5 pounds in 1 week…Paroxysmal Atrial Fibrillation is stable as evidenced by absence of the following: unexplained weight gain of 1-3 lbs in 24 hours…” The comprehensive assessment completed by the RN (Registered Nurse) dated 4/23/24 documented a weight of 255lbs. The following RN visit on 4/30/24 stated, “Weight Not Assessed.” The RN documented a weight of 236lbs during the following visit dated 5/10/24. This surveyor completed an in-home observation visit on 5/21/24 and the patient weight was not obtained, and the RN documented, “Weight Not Assessed.” The agency failed to ensure that the medical record was complete and accurate. This finding was reviewed with and acknowledged by the Staff-A during an interview on 5/28/24 at 11:50 am.”

“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 ensure the transfer/discharge summaries were complete, provided the patient’s current health status at the time of transfer/discharge, progress toward goals, services provided, medications and other related information required to maintain continuity of care in 1 (P-1) of 4 records in which the patient was discharged/transferred from the agency’s services, from a total of 18 sampled records reviewed, resulting in the potential for unidentified continuing health concerns and unmet care needs. Findings include: P-1: The start of care (SOC) was dated 2/12/24, with diagnoses that included atrial fibrillation, type 2 diabetes mellitus, and hypertension. During record review on 5/21/24, it was noted that the skilled nursing (SN) discharge summary dated 2/26/24, and the physical therapy (PT) transfer/discharge summary dated 4/12/24, failed to include progress toward goals, response to treatments, services provided, and other needed information to maintain continuity of care when discharged or transferred. The findings were reviewed with and acknowledged by the Director of Medicare Program (Staff-A) on 5/28/24 at 12:45 p.m.”