Med Care Home Health Care

“Infection control education CFR(s): 484.70(c) Standard: Education. The HHA must provide infection control education to staff, patients, and caregiver(s). This Standard is not met as evidenced by: Based on interview and record review, the agency failed to provide documented evidence to ensure that all staff, including contracted staff, had received training/in-services in infection control, resulting in the potential for the development and spready of infection to staff and all patients actively serviced by this agency. Findings include: On 8/26/24 at 12:15 p.m., during a review of the agency’s Infection Control documents provided by the Administrator (Adm #1), there was a document titled “Zoom Meeting/In-Service” dated 9/13/23. The document contained multiple topics such as handwashing technique, start of care paperwork, bag technique... Upon further review, there was no identification of who received the above training as there was no corresponding list of names or signatures provided. These findings were reviewed with and acknowledged by Adm #1 during an interview on 8/28/24 at 4:02 p.m.”

“Services under arrangement CFR(s): 484.105(e)(1) The HHA must ensure that all services furnished under arrangement provided by other entities or individuals meet the requirements of this part and the requirements of section 1861(w) of the Act (42 U.S.C. 1395x (w)). This Standard is not met as evidenced by: Based on record review and interview, the agency failed to ensure 1 of 2 contracts (Contractor#1) met the requirements of section 1861(w) of the Act (42 U.S.C. 1395x(w)), resulting in the potential to adversely affect the finances of all patients that receive contracted services. Findings include: Contractor#1: The contract with Contractor#1 dated June 24,2024 was reviewed on 8/2724. Contractor#1 is a provider of physical therapy service and is currently providing physical therapy services for the home health agency. During review of the contract, it was noted that the contract failed to include the regulatory language of section 1861(w) of the Act (42 U.S.C 1395x(w)). The agency failed to have a policy regarding contracted services. The findings were reviewed with and acknowledged by the administrator (Adm#1) during an interview on 8/27/24 at 2:40 p.m.”

“Patient’s or legal representative’s signature CFR(s): 484.50(a)(2) Obtain the patient’s or legal representative’s signature confirming that he or she has received a copy of the notice of rights and responsibilities. This Element is not met as evidenced by: Based on record review and interview, the agency failed to obtain the patient’s or legal representatives signature confirming receipt of a copy of rights and responsibilities for 1 of 7 (P-7) records reviewed, resulting in no assurance that this patient had received a copy of his/her rights and responsibilities. Findings include: P-7: This patient was admitted to home care services on 7/15/24 with diagnoses of a recent fall resulting in a fracture of the right humerus, history of falls, and chronic pain. During record review on 8/27/24, it was noted that there was no start of care paperwork or electronic documentation that evidenced the patient’s or legal representative’s signature confirming that he/she had received a copy of the notice of rights and responsibilities. The start of care assessment on 7/15/24 was conducted by PT#3, a physical therapist contracted by the agency. An interview was conducted with the administrator (Adm#1) and the intake coordinator (OS#2) on 8/27/24 at 1:45 p.m. Adm#1 reviewed the patient’s hard chart (paperwork) and acknowledged that PT#3 had not turned in the start of care paperwork at the office. Adm#1 was queried regarding when staff, including contracted staff, were expected to turn in paperwork or complete their documentation in the electronic medical record. Adm#1 stated that paperwork is due within 7 days and that they have sent emails and text messages to PT#3 in their attempts to get the paperwork. The statement by Adm#1 fails to align with the agency’s policy titled, Timely Submission of Patient Documentation (revised February 2024) which states, Itineraries with all visit reports attached, must be submitted the next scheduled workday, not exceeding three (3) business days. All patient visit reports from contract personnel must be submitted within three (3) business days from the date of the visit. PT#3 has had 44 days in which to turn the appropriate paperwork. There was no documented evidence of the patient’s or legal representative’s signature confirming receipt of a copy of rights and responsibilities.”

“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 1 (P-2) of 2 patients observed during home visits, from a total of 7 sampled records reviewed, were included in the overall planning of care including informing the patient/caregiver in advance of the days in which services would be provided, resulting lack of inclusion in planning, the potential for missed visits and unmet care needs. Findings include: P-2: The patient’s start of care was 7/31/24 with diagnoses that included Ischemic Right Lower Leg Ulcer and Diabetes Mellitus. During the record review on 8/27/24 at 10:00 a.m., it was noted that Skilled Nursing (SN), Occupational Therapy (OT) and Physical Therapy (PT) services were ordered to be provided. On 8/27/24 at 1:00 p.m., a scheduled survey home visit was conducted with the Physical Therapist (PT #1). During the visit, a review of the patient’s admission packet revealed that there was no calendar of proposed visits to be made by any of the above ordered disciplines. Upon completion of the visit, the patient inquired which discipline would be coming back for a return visit, the PT or Physical Therapy Assistant (PTA #1), to which PT #1 replied, “Oh you like him?” The agency failed to ensure the patient was included in the overall planning of her care. These findings were reviewed with and acknowledged by the Administrator during an interview on 8/28/24 at 3:50 p.m.”

“RN performs assessment CFR(s): 484.55(a)(1) A registered nurse must conduct an initial assessment visit to determine the immediate care and support needs of the patient; and, for Medicare patients, to determine eligibility for the Medicare home health benefit, including homebound status. The initial assessment visit must be held either within 48 hours of referral, or within 48 hours of the patient’s return home, or on the physician or allowed practitioner - ordered start of care date. This Element is not met as evidenced by: Based on record review and interview, the agency failed to ensure an initial assessment was conducted within 48 hours of referral for 1 of 7 (P-6) records reviewed, resulting in a delay in determining the immediate care and support needs for this post-operative patient. Findings include: P-6: This patient was admitted to home care services on 7/5/24 with diagnoses of post-operative care for lumbar region fusion of spine and post laminectomy syndrome. During record review on 8/27/24, it was noted that the referral for home care was dated 6/18/24. The start of care initial assessment was conducted by RN#1 (registered nurse) on 7/5/24, which is 17 days after the date of the physician referral for home care services. An interview was conducted with the administrator (Adm#1), the clinical manager (CM#1), the office manager (OS#1), and the intake coordinator (OS#2) on 8/29/24 at 10:30 a.m. CM#1 explained that this physician sends referrals early. OS#2 explained that the patient had surgery on 6/18/24 (the date of the referral) and the referral was received at the office on 7/1/24. There was no explanation offered or documentation to explain the delay in the initial assessment from the date of 7/1/24 to the start of care on 7/5/24. There was no documented evidence the patient had requested a delay in care and no evidence the physician was informed of the delay in determining the immediate care and support needs for this post-operative patient.”

“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 all pertinent patient-specific interventions and measurable outcomes and goals for 7of 7 (P#’s 1, 2, 3, 4, 5, 6, 7) records reviewed, resulting in patients not receiving care specific to their individual needs and the potential for poor patient outcomes. Findings include: P-6: This patient was admitted to home care services on 7/5/24 with diagnoses of post-operative care for lumbar region fusion of spine and post laminectomy syndrome. During record review on 8/27/24, it was noted that the 7/5/24 plan of care failed to include interventions and measurable goals related to the patient’s primary diagnosis of post-operative care for lumbar region fusion of the spine. The initial comprehensive assessment documented by the nurse (RN#1) on 7/5/24 notes that the patient’s lower spine surgical wound has the following dimensions 12 cm long x 0.4 cm wide x 0 cm depth with minimal serous drainage. RN#1 notes she performed the following wound care treatment: Cleansed with sterile saline and Betadine. Pat dry. Applied sterile ABD pad as dressing with additional sterile 4 x 4 gauze pads for additional padding and protection. The plan of care failed to include wound care treatments and interventions. The plan of care documented one short term goal: patient/caregiver will learn proper wound care technique within 2 weeks and one long term goal: patient will incorporate foods into diet which will aid with wound healing within 7 weeks. Thes goals were not stated in measurable terms that would enable staff to perform an objective evaluation of the patient’s progress towards his goals. The finding was reviewed with and acknowledged by the administrator (Adm#1) and the clinical manager (CM#1) during an interview on 8/29/24 at 10:30 a.m. P-7: This patient was admitted to home care services on 7/15/24 with diagnoses of a recent fall resulting in a fracture of the right humerus, history of falls, and chronic pain. During record review on 8/27/24, it was noted that the 7/15/24 plan of care created by the physical therapist failed to include interventions and measurable goals related to the patient’s primary diagnoses. The plan of care documented one patient personal goal: Want to have full range of motion at right shoulder and like to get strong. No other goals were listed on the plan of care. There were no measurable goals or interventions established by the physical therapist. The findings were reviewed with and acknowledged by the administrator (Adm#1) and the clinical manager (CM#1) during an interview on 8/29/24 at 10:30 a.m. P-1: The patient’s start of care (SOC) was 7/19/24 with diagnoses that included Hypertensive Heart Disease with Heart Failure, Dizziness and giddiness, COPD and Morbid Obesity. During the clinical record review on 8/26/24 at 1:30 p.m., it was noted that all the diagnoses listed on the plan of care (POC) all had an exacerbation/onset date of 7/19/24 (date of admission). The listed weight parameters were unclear and stated, “Weight 2.00 lbs Notify MD.” The pain scale instructed to report pain greater than 8, however, the patient had 0/10 pain at the time of admission. The set pain parameter was not based on the patient’s baseline assessment of pain. The POC included Diabetic parameters, however, the patient’s record did not reflect a diagnosis of Diabetes. Further, there were no Skilled Nursing interventions, No CHF management and no associated measurable goals. These findings were reviewed with and acknowledged by the Administrator (Adm #1) during an interview on 8/28/24 at 3:15 p.m. The agency’s Biller (OS #1) and Quality Assurance staff (QA #1) were both present during the interview. OS #1 stated, “I see what’s happening with the care plans and the parameters. They’re all generic.” QA #1 reported, “This was a new nurse, and she didn’t complete her notes, so the care plan was incomplete.” P-2: The patient’s SOC was 7/31/24 with diagnoses that included Ischemic Right Lower Leg Ulcer, Diabetes Mellitus, Hypertension, Chronic Kidney Disease and Cerebral Infarct. During the record review on 8/27/24 at 10:00 a.m., it was noted that all the diagnoses listed on the POC had an onset/exacerbation date of 7/31/24 (date of admission to agency). The reportable weight parameters were unclear and stated, “Weight 2.00 lbs Notify MD.” There were no Skilled Nursing interventions and no associated measurable goals that addressed the identified diagnoses (Diabetes, Wounds...). These findings were reviewed with and acknowledged by the Adm #1 during an interview on 8/28/24 at 3:50 p.m. QA #1, who was also present during the interview reported, “This was the same nurse as before. She didn’t complete her work.” P-3: The Start of Care (SOC) was dated 3/14//24. The Plan of Care (POC) for the certification period 3/14/24 to 5/12/24 identified diagnoses of Congestive Heart Failure (CHF), Anemia, Diabetes type 2 (DN2), Hypertension (HTN), and muscle weakness. The patient was receiving skilled nursing services 1xweekx4 weeks. Upon review of the goals on the Plan of Care, it was noted the goals were not objectively measurable. Examples included: “Patient discussed the goals with the assessing clinician; will be able to demonstrate proper energy conserving measures within 2-3 weeks; Patient and Caregiver will know signs of hyperglycemia and hypoglycemia within 3 weeks.” These goals are not objectively measurable to determine the patient’s progress towards achieving the goals. In addition, the plan of care failed to include diabetic precautions to address the patient’s diagnosis of diabetes. Also, the patient has a diagnosis of Congestive Heart Failure. The Plan of Care included weight parameters, however, failed to include orders for the frequency of weighing and recording the patient’s weight to address the patient’s diagnosis of Congestive Heart Failure. P-4: The SOC was dated 7-12-24. The POC for the certification period 7-12-24 to 9-9-24 identified diagnoses of Diabetes type 2, Below the knee amputation of left leg, Phantom limb syndrome with pain, and Hypertension (HTN). The patient was receiving Physical Therapy services 1xweekx1, 2xweekx2weeks, 1xweekx6weeks. Upon review of the Plan of Care, it was noted the goals were not objectively measurable. Examples included: “Improve strength for both Upper Extremity and right Lower Extremity with Caregiver Assist in 9 weeks; Patient able to perform sit to stand and transfers with prosthetic left leg CGA (Caregiver Assist) in 9 weeks with safety.” {sic}. These goals are not objectively measurable to determine the patient’s progress towards achieving the goals. P-5: This patient was admitted on 2/7/24. The Plan of Care for the certification period 8/5/2024 to 10/3/24 failed to include the patient’s diagnoses; and the goals on the Plan of Care were not objectively measurable. Examples include: “Patient will incorporate more fruit and vegetables into diet within 2 weeks; Patient will administer proper wound care technique and learn how to prevent pressure ulcers from occurring within 4 weeks.” These goals are not objectively measurable to determine the patient’s progress towards achieving the goals. The findings were reviewed with and acknowledged by the Administrator (Adm#1) and the clinical manager (CM#1) during an interview on 8/29/24 at 1:00 p.m. P-3: The Start of Care (SOC) was dated 3/14//24. The Plan of Care (POC) for the certification period 3/14/24 to 5/12/24 identified diagnoses of Congestive Heart Failure (CHF), Anemia, Diabetes type 2 (DN2), Hypertension (HTN), and muscle weakness. The patient was receiving skilled nursing services 1xweekx4 weeks. Upon review of the goals on the Plan of Care, it was noted the goals were not objectively measurable. Examples included: “Patient discussed the goals with the assessing clinician; will be able to demonstrate proper energy conserving measures within 2-3 weeks; Patient and Caregiver will know signs of hyperglycemia and hypoglycemia within 3 weeks.” These goals are not objectively measurable to determine the patient’s progress towards achieving the goals. In addition, the plan of care failed to include diabetic precautions to address the patient’s diagnosis of diabetes. Also, the patient has a diagnosis of Congestive Heart Failure. The Plan of Care included weight parameters, however, failed to include orders for the frequency of weighing and recording the patient’s weight to address the patient’s diagnosis of Congestive Heart Failure. P-4: The SOC was dated 7-12-24. The POC for the certification period 7-12-24 to 9-9-24 identified diagnoses of Diabetes type 2, Below the knee amputation of left leg, Phantom limb syndrome with pain, and Hypertension (HTN). The patient was receiving Physical Therapy services 1xweekx1, 2xweekx2weeks, 1xweekx6weeks. Upon review of the Plan of Care, it was noted the goals were not objectively measurable. Examples included: “Improve strength for both Upper Extremity and right Lower Extremity with Caregiver Assist in 9 weeks; Patient able to perform sit to stand and transfers with prosthetic left leg CGA (Caregiver Assist) in 9 weeks with safety.” {sic}. These goals are not objectively measurable to determine the patient’s progress towards achieving the goals. P-5: This patient was admitted on 2/7/24. The Plan of Care for the certification period 8/5/2024 to 10/3/24 failed to include the patient’s diagnoses; and the goals on the Plan of Care were not objectively measurable. Examples include: “Patient will incorporate more fruit and vegetables into diet within 2 weeks; Patient will administer proper wound care technique and learn how to prevent pressure ulcers from occurring within 4 weeks.” These goals are not objectively measurable to determine the patient’s progress towards achieving the goals. The findings were reviewed with and acknowledged by the Administrator (Adm#1) and the clinical manager (CM#1) during an interview on 8/29/24 at 1:00 p.m. P-1: The patient’s start of care (SOC) was 7/19/24 with diagnoses that included Hypertensive Heart Disease with Heart Failure, Dizziness and giddiness, COPD and Morbid Obesity. During the clinical record review on 8/26/24 at 1:30 p.m., it was noted that all the diagnoses listed on the plan of care (POC) all had an exacerbation/onset date of 7/19/24 (date of admission). The listed weight parameters were unclear and stated, “Weight 2.00 lbs Notify MD.” The pain scale instructed to report pain greater than 8, however, the patient had 0/10 pain at the time of admission. The set pain parameter was not based on the patient’s baseline assessment of pain. The POC included Diabetic parameters, however, the patient’s record did not reflect a diagnosis of Diabetes. Further, there were no Skilled Nursing interventions, No CHF management and no associated measurable goals. These findings were reviewed with and acknowledged by the Administrator (Adm #1) during an interview on 8/28/24 at 3:15 p.m. The agency’s Biller (OS #1) and Quality Assurance staff (QA #1) were both present during the interview. OS #1 stated, “I see what’s happening with the care plans and the parameters. They’re all generic.” QA #1 reported, “This was a new nurse, and she didn’t complete her notes, so the care plan was incomplete.” P-2: The patient’s SOC was 7/31/24 with diagnoses that included Ischemic Right Lower Leg Ulcer, Diabetes Mellitus, Hypertension, Chronic Kidney Disease and Cerebral Infarct. During the record review on 8/27/24 at 10:00 a.m., it was noted that all the diagnoses listed on the POC had an onset/exacerbation date of 7/31/24 (date of admission to agency). The reportable weight parameters were unclear and stated, “Weight 2.00 lbs Notify MD.” There were no Skilled Nursing interventions and no associated measurable goals that addressed the identified diagnoses (Diabetes, Wounds...). These findings were reviewed with and acknowledged by the Adm #1 during an interview on 8/28/24 at 3:50 p.m. QA #1, who was also present during the interview reported, “This was the same nurse as before. She didn’t complete her work.” P-6: This patient was admitted to home care services on 7/5/24 with diagnoses of post-operative care for lumbar region fusion of spine and post laminectomy syndrome. During record review on 8/27/24, it was noted that the 7/5/24 plan of care failed to include interventions and measurable goals related to the patient’s primary diagnosis of post-operative care for lumbar region fusion of the spine. The initial comprehensive assessment documented by the nurse (RN#1) on 7/5/24 notes that the patient’s lower spine surgical wound has the following dimensions 12 cm long x 0.4 cm wide x 0 cm depth with minimal serous drainage. RN#1 notes she performed the following wound care treatment: Cleansed with sterile saline and Betadine. Pat dry. Applied sterile ABD pad as dressing with additional sterile 4 x 4 gauze pads for additional padding and protection. The plan of care failed to include wound care treatments and interventions. The plan of care documented one short term goal: patient/caregiver will learn proper wound care technique within 2 weeks and one long term goal: patient will incorporate foods into diet which will aid with wound healing within 7 weeks. Thes goals were not stated in measurable terms that would enable staff to perform an objective evaluation of the patient’s progress towards his goals. The finding was reviewed with and acknowledged by the administrator (Adm#1) and the clinical manager (CM#1) during an interview on 8/29/24 at 10:30 a.m. P-7: This patient was admitted to home care services on 7/15/24 with diagnoses of a recent fall resulting in a fracture of the right humerus, history of falls, and chronic pain. During record review on 8/27/24, it was noted that the 7/15/24 plan of care created by the physical therapist failed to include interventions and measurable goals related to the patient’s primary diagnoses. The plan of care documented one patient personal goal: Want to have full range of motion at right shoulder and like to get strong. No other goals were listed on the plan of care. There were no measurable goals or interventions established by the physical therapist. The findings were reviewed with and acknowledged by the administrator (Adm#1) and the clinical manager (CM#1) during an interview on 8/29/24 at 10:30 a.m.”

“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, record review and interview, the agency failed to ensure its skilled discipline promptly notified the Physician for 1 (P-2) of 1 patient who experienced a significant change in condition, from a total of 7 sampled records reviewed, resulting in the potential for untreated, unrelieved symptoms, worsening of health conditions and unmet care needs. Findings include: P-2: The patient’s start of care was 7/31/24 with diagnoses that included Ischemic Right Leg Ulcer with Femoral/Tibial Bypass, and Diabetes Mellitus. During the record review on 8/27/24 at 10:00 a.m., it was noted that the Plan of Care ordered Skilled Nursing (SN) and Physical Therapy (PT) services to be provided. The Initial Comprehensive Assessment dated 7/31/24, documented, “Two surgical wound [sic] on the right leg that reduces mobility due to pain..., Has there been a sudden/acute change in their mental status: No.” On 8/27/24 at 1:00 p.m., a scheduled survey home visit was conducted with the Physical Therapist (PT #1). During the visit, the patient complained of 7/10 pain to her right upper thigh area and increased swelling to her right leg. The patient then stated, “I don’t understand why it keeps swelling like this. Why does it do that?” To which PT #1, offered no response. PT #1 then told the patient, “Call your doctor.” Upon completion of the visit, PT #1 was queried about the patient’s complaints of pain and swelling and his responsibility and responded, “I mean, I’ll include it in my notes.” PT then went on to state, “I also noticed she (patient) seemed really confused during the visit today. Thats something new.” The Initial Comprehensive Assessment documented there was no alteration in mental status at the time of admission. This information evidenced a change in the patient’s mental status. The onsite home visit was then concluded. By the end of the survey on 8/29/24, there was no documentation within the clinical record about the patient’s concerns of increased swelling and newly identified change in mental status, and no documented evidence that the Physician, or any other member of the interdisciplinary team had been promptly notified. These findings were discussed with and acknowledged by the Administrator during an interview on 8/28/24 at 3:50 p.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 failed to coordinate the delivery of occupational therapy services for 2 of 2 (P-3, P-7) records reviewed in which occupational therapy was ordered to provide care, resulting in a lack of coordinated care delivery to meet the occupational therapy needs of these patients. Findings include: P-3: The Start of Care (SOC) was dated 3/14//24. The Plan of Care (POC) for the certification period 3/14/24 to 5/12/24 identified diagnoses of Congestive Heart Failure (CHF), Anemia, Diabetes type 2 (DN2), Hypertension (HTN), and muscle weakness. It was noted on the Referral and Face-to-Face Encounter the following order: “The opening discipline is to evaluate for the need for the following: Skilled Nursing, Physical Therapy, and Occupational Therapy.” The patient was receiving skilled nursing services 1xweekx4 weeks, and physical therapy was ordered to evaluate and treat. However, there was no documentation found in the record that indicated the patient had been evaluated by the Nurse or Physical Therapist for the need of occupational therapy, and there were no orders submitted for Occupational Therapy. During an interview with the clinical manager on August 29 at 1:00 p.m., the clinical manager agreed that there were no orders for occupational therapy and stated, “the physical therapist decided he could address the health issues and need for occupational services through the physical therapy services he was providing.” P-7: This patient was admitted to home care services on 7/15/24 with diagnoses of a recent fall resulting in a fracture of the right humerus, history of falls, and chronic pain. During record review on 8/27/24, it was noted that the medical record contained a physician order dated, and fax stamped on 7/15/24. The order is for home health care with physical therapy and occupational therapy services for a patient with a right arm fracture. The 7/15/24 plan of care orders weekly physical therapy services and orders occupational therapy (OT) to evaluate and treat this patient. There was no documented evidence that OT services had been provided or that services had been delayed or declined by the patient. During an interview on 8/27/24 at 1:30 p.m., the clinical record is reviewed with the administrator (Adm#1) to point out that a 7/15/24 physician order and the 7/15/24 plan of care both document orders for OT services for this patient. Adm#1 explained that this is a new contracted physical therapist, and he did not notify the office of the need for OT services. The agency and the physical therapist failed to ensure to coordinate OT services for this patient who may have benefitted from receiving such services.”

“Patients receive education and training CFR(s): 484.60(d)(5) Ensure that each patient, and his or her caregiver(s) where applicable, receive ongoing education and training provided by the HHA, as appropriate, regarding the care and services identified in the plan of care. The HHA must provide training, as necessary, to ensure a timely discharge. This Element is not met as evidenced by: Based on observation, interview and record review, the agency failed to ensure the skilled discipline provided education and training on needed exercises for 1 (P-2) of 1 patient who required ongoing Physical Therapy services, from a total of 7 sampled records reviewed, resulting in the potential for physiological decline and delay in meeting therapy goals. Findings include: P-2: The patient’s start of care was 7/31/24 with diagnoses that included Ischemic Right Leg Ulcer and Diabetes Mellitus. During the record review on 8/27/24 at 10:00 a.m., it was noted that Skilled Nursing (SN) and Physical Therapy (PT) services were ordered to be provided. On 8/27/24 at 1:00 p.m., a scheduled survey home visit was conducted with PT #1. Upon arrival, the patient was observed ambulating with a slow guarded gait with use of a 4-point walker. The patient exhibited facial grimaces upon sitting and standing and complained of 7/10 pain to her right upper thigh/groin area where her surgical site was located. PT #1 explained that therapy would help. During the visit, the patient was queried as to whether she performed home exercises in PT #1’s absence to which she responded, “I sit on the side of my bed.” When asked if she was given any instructional exercises to be done in PT #1’s absence, both the patient and the patient’s granddaughter, who was present during the visit, responded, “No.” PT #1 was present during this interview yet offered no response. The PT failed to provide education and training on needed exercises to assist in meeting the patient’s identified therapy goals. These findings were reviewed with and acknowledged by the Administrator during an interview on 8/28/24 at 3:50 p.m.”

“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, the agency failed to ensure the skilled discipline conducted assessments as appropriate for 1 (P-2) of 1 patient observed during a home visit, who experienced unrelieved pain and a change in baseline condition, from a total of 7 sampled records reviewed, resulting in the potential for worsening of health condition, unidentified, untreated health concerns and unmet care needs. Findings include: P-2: The patient’s start of care was 7/31/24 with diagnoses that included Ischemic Right Leg Ulcer with Femoral/Tibial Bypass, and Diabetes Mellitus. During the record review on 8/27/24 at 10:00 a.m., it was noted that the Plan of Care ordered Skilled Nursing (SN) and Physical Therapy (PT) services to be provided. The Initial Comprehensive Assessment dated 7/31/24, documented, “Two surgical wound [sic] on the right leg that reduces mobility due to pain..., Has there been a sudden/acute change in their mental status: No.” Further, the patient complained of 7/10 pain to right surgical site at the start of care. On 8/27/24 at 1:00 p.m., a scheduled survey home visit was conducted with the Physical Therapist (PT #1). During the visit, PT #1 failed to assess the patient’s pain level prior to beginning exercises. Shortly after, the patient complained of 7/10 pain to her right upper thigh area and swelling to her right leg. The patient then stated, “I don’t understand why it keeps swelling. Why does it do that?” To which PT #1, offered no response or assessment of the patient’s areas of complaint of increased swelling. PT #1 then told the patient, “Call your doctor.” Upon completion of the visit, PT #1 was queried about the patient’s complaints of pain and swelling and his responsibility and responded, “I mean, I’ll include it in my notes.” PT then went on to state, “I also noticed she seemed really confused during the visit. Thats something new.” PT did not assess the patient’s newly identified episode of confusion once noticed. The Initial Comprehensive Assessment documented there was no alteration in mental status at the time of admission. This evidenced a change in the patient’s mental status. The onsite home visit was then concluded. Additionally, by the end of the survey on 8/29/24, there was no documentation within the clinical record about the patient’s concerns of increased swelling and newly identified change in mental status to allow for ongoing interdisciplinary reassessments. These findings were discussed with and agreed by the Administrator during an interview on 8/28/24 at 3:50 p.m.”

“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 interview, the agency failed to ensure services were provided in accordance with the Physician’s orders for 3 (P-1, P-2, P-7) patients who required Therapy services, from a total of 7 sampled records reviewed, resulting in the potential for physiological decline and unmet care needs. Findings include: P-7: This patient was admitted to home care services on 7/15/24 with diagnoses of a recent fall resulting in a fracture of the right humerus, history of falls, and chronic pain. During record review on 8/27/24, it was noted that the physician’s order/referral for home care dated 7/15/24 ordered physical therapy and occupational therapy (OT) services to be provided. The 7/15/24 plan of care orders weekly physical therapy services and orders OT to evaluate and treat this patient. There was no documented evidence that OT services had been provided or that services had been delayed or declined by the patient. During an interview on 8/27/24 at 1:30 p.m., the clinical record is reviewed with the administrator (Adm#1) to point out that a 7/15/24 physician order and the 7/15/24 plan of care both document orders for OT services for this patient. Adm#1 explained that this is a new contracted physical therapist, and he did not notify the office of the need for OT services. Policy: Plan of Care-CMS #485 and Physician/Practitioners Orders, 9.10.5, dated 2/2024 stated, “Care and services provided will be provided according to Physician/Practitioner orders.” P-1: The patient’s start of care was 7/19/24 with diagnoses that included Hypertensive Heart Disease with Heart Failure. During the record review on 8/26/24 at 1:30 p.m., it was noted that the patient was ordered to receive Skilled Nursing (SN) and Physical Therapy (PT) services. Upon further review, it was noted that PT made the initial attempt to see the patient in the 3rd week of service on 8/1/24. There was no documented evidence that the patient declined services or requested a later start time to begin therapy services. Further, there was no documented evidence that PT made an effort to see the patient prior to the 3rd week of care. These findings were reviewed with and acknowledged by the Administrator (Adm #1) during an interview on 8/28/24 at 3:15 p.m. who responded, “They (disciplines) should be out there to see the patients within 48 hours.” P-2: The patient’s start of care was 7/31/24 with diagnoses that included Ischemic Right Lower Leg Ulcer and Diabetes Mellitus. During the record review on 8/27/24 at 10:00 a.m., it was noted that the referral for home care/Physician’s order dated 7/29/24 ordered SN, Occupational Therapy (OT) and PT services to be provided. At the time of this review, Occupational Therapy services had not been provided. Additionally, there was no documented evidence that the patient had refused the ordered services or any other rationale as to why the ordered service had not been provided. These findings were reviewed with and acknowledged by Adm #1 during an interview on 8/28/24 at 3:50 p.m.”

“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 record review and interview, the agency failed to ensure the medical record contained all physical therapy visit notes1 of 7 (P-7) records reviewed, resulting in a lack of information for the physician and all agency staff caring for this patient. Findings include: P-7: This patient was admitted to home care services on 7/15/24 with diagnoses of a recent fall resulting in a fracture of the right humerus, history of falls, and chronic pain. During record review on 8/27/24, it was noted that the 7/15/24 plan of care ordered weekly physical therapy services. The physical therapy assistant documented a visit on 8/14/24. The next visit on 8/21/24 was blank of information. An interview was conducted with the administrator (Adm#1) on 8/27/24 at 1:45 p.m. Adm#1 explained that all documentation is due within 7 days. On 8/29/24 at 10:30 a.m., the clinical record was reviewed with Adm#1 who acknowledged that the 8/21/24 physical therapy visit note remained blank of information.”

“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, policy review, and interview, the agency failed to ensure a copy of the patient’s discharge summary was received by the physician within 5 days of discharge in 1 of 7 records reviewed (P-3) resulting in the physician not having information regarding the patient’s condition at discharge, the patient outcomes in meeting the goals in the plan of care, and the discharge instructions provided to the family. Findings include: **Agency Policy: “Discharge Summary” revised February 2024. The policy states, “A discharge summary form will be completed by the Skilled Nurse, Medical Social Worker, and/or Therapist. A Discharge Summary will be sent within 5 business days of patient discharge to the primary care practitioner or other health care professional who will be responsible for providing care and services to the patient.” P-3: The Start of Care (SOC) was dated 3/14//24. The Plan of Care (POC) for the certification period 3-14-24 to 5-6-24 identified diagnoses of Congestive Heart Failure (CHF), Anemia, Diabetes type 2 (DM2), Hypertension (HTN), and muscle weakness. The patient was discharged from the agency on May 6, 2024. The Administrator and Clinical Manager were asked during an interview on August 29, 2024, if the physician had been notified and if the physician had received a copy of the Discharge Summary within 5 days of the discharge? The Administrator and Clinical Manager stated, we usually fax a copy of the discharge summary to the physician upon discharge. When asked if they had a copy of the fax receipt, the Clinical Manager stated, “we don’t keep copies of the faxed receipts.” The agency failed to ensure the ordering physician had received a copy of the discharge summary to ensure provision of care and services after the patient was discharged from the agency. These findings were reviewed and acknowledged during an interview with the Administrator and Clinical Manager on August 29, 2024, at 1:00 p.m.”