Capital Home Health Care

“Care planning, coordination, quality of care CFR(s): 484.60 Condition of participation: Care planning, coordination of services, and quality of care. Patients are accepted for treatment on the reasonable expectation that an HHA can meet the patient’s medical, nursing, rehabilitative, and social needs in his or her place of residence. Each patient must receive an individualized written plan of care, including any revisions or additions. The individualized plan of care must specify the care and services necessary to meet the patient-specific needs as identified in the comprehensive assessment, including identification of the responsible discipline(s), and the measurable outcomes that the HHA anticipates will occur as a result of implementing and coordinating the plan of care. The individualized plan of care must also specify the patient and caregiver education and training. Services must be furnished in accordance with accepted standards of practice. This Condition is not met as evidenced by: Based on record review and interview, it was determined the Agency failed to ensure the plan of care included objectively measurable and individualized goals in 4 (P-1, 2, 3, and 5) of 4 records reviewed with skilled nursing and/or physical therapy services ordered, resulting in a potential for failure to measure progress toward achievement of desired outcomes (See G 572); failed to ensure the plan of care included pertinent monitoring, interventions, and treatments in 1 (P-4) of 1 record requiring wound care, resulting in a high potential for a poor outcome (See G 574); failed to ensure that treatment/interventions were provided only in accordance with physician’s orders for 1 (P-4) of 1 record requiring wound care, resulting in the potential for the provision of unsafe, unauthorized care and unmet care needs (See G 580); and failed to coordinate patient care needs in 1 (P-5) of 1 record with a significant change in condition, out of a total sample of 7 records reviewed (See G 608). The cumulative effect of these systemic problems resulted in the Agency’s inability to ensure the provision of quality health care in a safe environment for the Condition of Participation 42 CFR §484.60 Care Planning, Coordination, Quality of Care.”

“EP Testing Requirements CFR(s): 484.102(d)(2) §416.54(d)(2), §418.113(d)(2), §441.184(d)(2), §460.84(d)(2), §482.15(d)(2), §483.73(d)(2), §483.475(d)(2), §484.102(d)(2), §485.68(d)(2), §485.542(d)(2), §485.625(d)(2), §485.727(d)(2), §485.920(d)(2), §491.12(d)(2), §494.62(d)(2). *[For ASCs at §416.54, CORFs at §485.68, REHs at §485.542, OPO, “Organizations” under §485.727, CMHCs at §485.920, RHCs/FQHCs at §491.12, and ESRD Facilities at §494.62]: (2) Testing. The [facility] must conduct exercises to test the emergency plan annually. The [facility] must do all of the following: (i) Participate in a full-scale exercise that is community-based every 2 years; or (A) When a community-based exercise is not accessible, conduct a facility-based functional exercise every 2 years; or (B) If the [facility] experiences an actual natural or man-made emergency that requires activation of the emergency plan, the [facility] is exempt from engaging in its next required community-based or individual, facility-based functional exercise following the onset of the actual event. (ii) Conduct an additional exercise at least every 2 years, opposite the year the full-scale or functional exercise under paragraph (d)(2)(i) of this section is conducted, that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or individual, facility-based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the [facility’s] response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the [facility’s] emergency plan, as needed. *[For Hospices at 418.113(d):] (2) Testing for hospices that provide care in the patient’s home. The hospice must conduct exercises to test the emergency plan at least annually. The hospice must do the following: (i) Participate in a full-scale exercise that is community based every 2 years; or (A) When a community based exercise is not accessible, conduct an individual facility based functional exercise every 2 years; or (B) If the hospice experiences a natural or man-made emergency that requires activation of the emergency plan, the hospital is exempt from engaging in its next required full scale community-based exercise or individual facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional exercise every 2 years, opposite the year the full-scale or functional exercise under paragraph (d)(2)(i) of this section is conducted, that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or a facility based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (3) Testing for hospices that provide inpatient care directly. The hospice must conduct exercises to test the emergency plan twice per year. The hospice must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual facility-based functional exercise; or (B) If the hospice experiences a natural or man-made emergency that requires activation of the emergency plan, the hospice is exempt from engaging in its next required full-scale community based or facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional annual exercise that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or a facility based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop led by a facilitator that includes a group discussion using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the hospice’s response to and maintain documentation of all drills, tabletop exercises, and emergency events and revise the hospice’s emergency plan, as needed. *[For PRFTs at §441.184(d), Hospitals at §482.15(d), CAHs at §485.625(d):] (2) Testing. The [PRTF, Hospital, CAH] must conduct exercises to test the emergency plan twice per year. The [PRTF, Hospital, CAH] must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise; or (B) If the [PRTF, Hospital, CAH] experiences an actual natural or man-made emergency that requires activation of the emergency plan, the [facility] is exempt from engaging in its next required full-scale community based or individual, facility-based functional exercise following the onset of the emergency event. (ii) Conduct an [additional] annual exercise or and that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or individual, a facility-based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the [facility’s] response to and maintain documentation of all drills, tabletop exercises, and emergency events and revise the [facility’s] emergency plan, as needed. *[For PACE at §460.84(d):] (2) Testing. The PACE organization must conduct exercises to test the emergency plan at least annually. The PACE organization must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise; or (B) If the PACE experiences an actual natural or man-made emergency that requires activation of the emergency plan, the PACE is exempt from engaging in its next required full-scale community based or individual, facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional exercise every 2 years opposite the year the full-scale or functional exercise under paragraph (d)(2)(i) of this section is conducted that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or individual, a facility based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the PACE’s response to and maintain documentation of all drills, tabletop exercises, and emergency events and revise the PACE’s emergency plan, as needed. *[For LTC Facilities at §483.73(d):] (2) The [LTC facility] must conduct exercises to test the emergency plan at least twice per year, including unannounced staff drills using the emergency procedures. The [LTC facility, ICF/IID] must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise. (B) If the [LTC facility] facility experiences an actual natural or man-made emergency that requires activation of the emergency plan, the LTC facility is exempt from engaging its next required a full-scale community-based or individual, facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional annual exercise that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or an individual, facility based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the [LTC facility] facility’s response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the [LTC facility] facility’s emergency plan, as needed. *[For ICF/IIDs at §483.475(d)]: (2) Testing. The ICF/IID must conduct exercises to test the emergency plan at least twice per year. The ICF/IID must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise; or. (B) If the ICF/IID experiences an actual natural or man-made emergency that requires activation of the emergency plan, the ICF/IID is exempt from engaging in its next required full-scale community-based or individual, facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional annual exercise that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or an individual, facility-based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the ICF/IID’s response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the ICF/IID’s emergency plan, as needed. *[For HHAs at §484.102] (d)(2) Testing. The HHA must conduct exercises to test the emergency plan at least annually. The HHA must do the following: (i) Participate in a full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise every 2 years; or. (B) If the HHA experiences an actual natural or man-made emergency that requires activation of the emergency plan, the HHA is exempt from engaging in its next required full-scale community-based or individual, facility based functional exercise following the onset of the emergency event. (ii) Conduct an additional exercise every 2 years, opposite the year the full-scale or functional exercise under paragraph (d)(2)(i) of this section is conducted, that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or an individual, facility-based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the HHA’s response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the HHA’s emergency plan, as needed. *[For OPOs at §486.360] (d)(2) Testing. The OPO must conduct exercises to test the emergency plan. The OPO must do the following: (i) Conduct a paper-based, tabletop exercise or workshop at least annually. A tabletop exercise is led by a facilitator and includes a group discussion, using a narrated, clinically relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. If the OPO experiences an actual natural or man-made emergency that requires activation of the emergency plan, the OPO is exempt from engaging in its next required testing exercise following the onset of the emergency event. (ii) Analyze the OPO’s response to and maintain documentation of all tabletop exercises, and emergency events, and revise the [RNHCI’s and OPO’s] emergency plan, as needed. *[ RNCHIs at §403.748]: (d)(2) Testing. The RNHCI must conduct exercises to test the emergency plan. The RNHCI must do the following: (i) Conduct a paper-based, tabletop exercise at least annually. A tabletop exercise is a group discussion led by a facilitator, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (ii) Analyze the RNHCI’s response to and maintain documentation of all tabletop exercises, and emergency events, and revise the RNHCI’s emergency plan, as needed. This Standard is not met as evidenced by: Based on record review and interview, the Agency failed to provide documentation that it had conducted exercises to test its emergency plan annually, by way of a tabletop and community based full-scale exercise required every two years, and failed to conduct an additional exercise at least every two years opposite the year of the full-scale exercise, resulting in the potential for patients and staff not to be properly prepared in the event of an actual emergency. Findings include: On 4/23/24 at 10:50AM., review of the Agency’s Emergency Preparedness (EP) binder found no evidence the Agency’s staff had conducted the required full-scale community-based exercise every two years. Additionally, no evidence was noted of an additional testing exercise scheduled every two years opposite of the full-scale exercise noted above. No documentation of an actual emergency or event that could be substituted for an exercise was evidenced. The Agency had documented attempts to schedule and attend a community-based exercise on 3/23/2024, 1/12/2024, 10/17/2023, 4/3/2023, 1/22/2023, and 10/4/2022. However, no actual Agency staff participation was evidenced in any of the required testing/drills noted above since at least 9/14/2020. The above findings were reviewed with and acknowledged by the Administrator (Staff A) and Clinical Manager (Staff B) during an interview on 4/23/2024 at 11:35 AM.”

“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, it was determined that the Agency failed to ensure the Plan of Care (POC) included objectively measurable and individualized goals in 4 (P-1, 2, 3, 5) of 4 records reviewed with skilled nursing ordered out of a total of 7 records reviewed, resulting in a potential for failure to measure progress toward achievement of desired outcomes. Findings include: P-5: This patient was admitted to the Agency on 6/2/2022, with diagnoses which included congestive heart failure, chronic obstructive pulmonary disease, and hypertensive heart disease. On 4/23/24, record review of P-5’s POC noted all goals (12 of 12) by skilled nursing (SN) failed to be measurable. Subsequently, no numerical data that could be tracked and trended to ascertain progress made concerning goals (or lack of) was found in the medical record. Examples are, “Patient and caregiver will be able to identify fall risk factors; Patient will demonstrate proper use of assistive devices, Patient will receive safe and effective personal care during this episode of care.” The above findings were reviewed with and acknowledged by the Administrator (Staff A) and Clinical Manager (Staff B) during an interview on 4/24/2024 at 9:45 AM. The Agency failed to follow its policy referenced here. Agency Policy: “Care Plans” (undated) pg. 1 stated, “The Care Plan shall include, but not be limited to: Patient specific interventions and education, measurable outcomes and goals that are identified...” **Agency Policy: Care Plans: The policy states, “The Care Plan shall include...measurable outcomes and goals that are identified by the patient, representative...Indicators for measuring goal achievement and identified time frames.” P-1: The Start of Care was dated 10/15/2022. The Plan of Care for the certification period 10/15/22 to 12/13/22 identified diagnoses of Malignant Neoplasm of the bladder, Urinary Tract Infection (UTI), Sciatica, Diabetes Type 2 (DM2), and Chronic Kidney Disease (CKD). Upon review of the Plan of Care, it was noted the goals were not objectively measurable to determine the patient’s progress toward obtaining the goals. Examples included: “Patient able verbalize fall/safety precautions by 10/15/22 {sic}; Patient able verbalize all new/changed Rx, purpose, S/E & compliance with Rx by 10/15/22 {sic}; Patient able verbalize ER preparedness & plan, infection control measures, hand washing, universal, diabetic, & corona virus precautions, disposal sharps by 10/15/22” {sic}. These goals are not objectively measurable to determine the patient’s progress towards achieving the goals. P-2: The Start of Care was dated 2/28/2022. The Plan of Care (POC) for the Certification Period 2/28/2022 to 4/28/2022 identified diagnoses of Fracture of neck; Hypertensive Chronic Kidney Disease, Restless legs Syndrome, Radiculopathy of cervical region. The patient was receiving Skilled Nursing and Physical Therapy Services. Upon review of the Plan of Care, it was noted the goals on the POC were not objectively measurable to determine the patient’s progress towards achieving the goals. Examples include: “Understand recent diagnosis, avoid stress and anxiety, medication management, vs to be stable, coping skills need to be addressed r/t high anxiety.” {sic}; Patient will be able to verbalize need to have Advance Care Planning documents to ensure wishes are carried out by end of certification” {sic}. These goals are not objectively measurable to determine the patient’s progress toward achieving the goals. P-3: The Start of Care was dated 6/1/2022. The Plan of Care for the Certification Period 6/1/2022 to 7/30/2022 identified diagnoses of Chorea, Drug induced secondary Parkinsonism and dyskinesia, Repeated Falls, Dysarthria and Anarthria. Dysphagia, Epilepsy, Orofacial Dystonia, and Depression. This patient was receiving Physical Therapy (PT) and Speech Therapy (ST) services. Upon review of the Plan of Care it was noted the goals were not objectively measurable to determine the patient’s progress towards achieving the goals. Examples included: “Patient will demonstrate understanding of individual emergency preparedness plan by cert period {sic}; Patient will demonstrate compliance with home exercise program and improvement to functional mobility and objective data for within time-period {sic}.” These goals are not objectively measurable to determine the patient’s progress towards achieving the goals. These findings were reviewed with and acknowledged by the Administrator (Staff A) and Clinical Manager (Staff B) during an interview on 4/24/2024 at 1:00 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 that the initial comprehensive assessment visit was conducted within 48 hours of the date of referral for 3 records (P-2, P-3, and P-7) from a total of 7 records reviewed, resulting in the potential for decline in the patient’s health status and poor clinical outcomes. Findings include: P-7: This patient’s start of care (SOC) date was 9/26/23, with diagnoses of poly-osteoarthritis-unspecified, chronic obstructive pulmonary disease, and chronic pain. The patient received Physical Therapy (PT) for the lone service provided. On 4/23/24, record review noted a physician face-to-face document dated 9/14/2023. Further review found no evidence of a referral for home care in the medical record. Subsequently, the Agency failed to document authentication that the SOC visit occurred within 48 hours of the referral. An explanation or communication note of why the referral for home care was missing was not found in the medical record. The above findings were reviewed with and acknowledged by the Administrator (Staff A) and Clinical Manager (Staff B) during an interview on 4/24/2024 at 10:02 AM. **Agency Policy: Admission Policy: The policy states, “Initial assessment Visit: A home visit is made by the RN or PT within 24-48 hours of the referral or according to physician orders and patient/family wishes.” P-2: The Start of Care was dated 2/28/2022. The Plan of Care (POC) for the Certification Period 2/28/2022 to 4/28/2022 identified diagnoses of Fracture of neck; Hypertensive Chronic Kidney Disease, Restless legs Syndrome, Radiculopathy of cervical region. The patient was receiving Skilled Nursing and Physical Therapy Services. Upon review of the record, it was noted the referral for home care was dated 2/25/2022. A face-to-face document was completed on 2/23/22. This patient was discharged from an in-patient facility on 2/23/22. Further review of the record failed to reveal that the patient had requested a later Start of Care date. There was no explanation found in the record explaining why the Start of Care had occurred greater than 48 hours of the referral or inpatient date of discharge of 2/23/22. P-3: The Start of Care was dated 6/1/2022. The Plan of Care for the Certification Period 6/1/2022 to 7/30/2022 identified diagnoses of Chorea, Drug induced secondary Parkinsonism, Dyskinesia, Repeated Falls, Dysarthria and Anarthria. Dysphagia, Epilepsy, Orofacial Dystonia, and Depression. Upon review of the record, it was noted a referral for Home Health Care services was dated 5/13/23, however, the Start of Care Assessment occurred on 6/1/22, 18 days after the referral. There was no documentation or physician’s order found in the record that provided evidence of why the Start of Care occurred 19 days after the referral date. These findings were reviewed with and acknowledged by the Administrator (Staff A) and Clinical Manager (Staff B) during an interview on 4/24/2024 at 1:00 p.m.”

“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 (POC) included appropriate safety measures, pertinent diabetic monitoring, and wound care treatments/interventions in 1 (P-4) of 3 records reviewed with skilled nursing services, out of a total sample of 7 records reviewed, resulting in the high potential for poor clinical outcomes. Findings include: P-4: This patient was admitted to the Agency on 1/2/2024, with diagnoses which included cerebral infarction (brain stroke) affecting right dominant side, type-2 diabetes with neuropathy, pressure ulcer of right heel-unstageable, and long-term use of insulin. On 4/23/24, record review of this therapy only case (Physical Therapy/PT) noted the following significant findings concerning P-4’s initial comprehensive assessment. P-4’s morning blood sugar or fasting on 1/2/24 was 171 (normal range: 70-100 mg./dl.) Under “Integumentary” (skin) assessment, PT documented a pressure ulcer with the highest range of skin breakdown, “F1-Unstageable-Deep tissue injury.” Patient was also noted as being in “Poor” condition, “Urinary and Fecal Incontinence”, alert to self only with right-sided weakness, and “Patient bedbound and requires 2 persons and Hoyer lift to get patient into a chair to sit-per wife has difficulty finding persons to assist.” (sic) Further review of the patient’s POC revealed the following concerns. The safety parameters to notify the physician regarding fasting blood sugars were greater than 380 mg./dl. and a pain level of greater than 9, or a level 10 (highest pain level possible). Both levels are considered unacceptably high according to standards of professional practice. Further, no evidence was found in the POC to record and monitor blood sugar levels throughout the certification episode. In addition, no orders for monitoring, interventions and treatments were found in the POC concerning P-4’s unstageable right heel wound throughout the certification episode. Subsequently, no clinical assessments, interventions or treatments were documented in 27 of 27 home visit opportunities by PT spanning from 1/5/24 through 4/4/24 for both the patient’s diabetes and right-heel wound. The combination of the following factors placed P-4 in a high-risk potential for a poor clinical outcome: 1) Insulin dependent diabetic with neuropathy (nerve damage), 2) Significant unstageable wound status of the lower extremity, 3) Poor bed mobility to exacerbate skin breakdown, 4) Incontinence of bowel and bladder further encouraging skin breakdown with infection, and 4) severe confusion (oriented to self only) limiting communication of patient needs. The above findings were reviewed with and acknowledged by the Administrator (Staff A) and Clinical Manager (Staff B) during an interview on 4/24/2024 at 9:28 AM. Both were noted this did not meet Agency expectations or its policy referenced below. Agency Policy: “Care Plans” (undated) pg. 1 stated, “Each client will have a care plan on file that outline care and services necessary to meet the patient specific needs identified in the comprehensive assessment, addresses their identified needs and the agency’s plan to respond to those needs.””

“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 ensure services were provided only as ordered by the physician in 1 (P-4) of 1 record reviewed requiring wound care, out of a total sample of 7 records reviewed, resulting in the potential to negatively affect all 11 patients serviced by this Agency in the last 12 months. Findings include: P-4: This patient was admitted to the Agency on 1/2/2024, with diagnoses which included cerebral infarction (brain stroke) affecting right dominant side, type-2 diabetes with neuropathy, pressure ulcer of right heel-unstageable, and long-term use of insulin. On 4/23/24, record review of this therapy only case (Physical Therapy/PT) noted the initial comprehensive assessment documentation under “Integumentary” (skin), that P-4 had a pressure ulcer with the highest degree of uncertainty regarding skin breakdown, “F1-Unstageable-Deep tissue injury.” The patient had no previous wound care orders noted in the clinical record. However, PT (Staff C) documented under “Treatment Performed” the following: “Unstageable - cleanse with betadine daily and PRN (as needed).” Additional review found no order or evidence that this treatment was authenticated or approved by a physician in the medical record. The above findings were reviewed with and acknowledged by the Administrator (Staff A) and Clinical Manager (Staff B) during an interview on 4/24/2024 at 9:33 AM. Both were noted this did not meet Agency expectations and any treatments furnished needed a physician’s order first.”

“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 document review and interview, the Agency failed to ensure the physician was notified of changes in the patient’s condition in 1 (P-5) of 3 records reviewed with skilled nursing (SN) services, from a total sample of 7 records reviewed, resulting in the potential for a poor clinical outcome. Findings include: P-5: This patient was admitted to the Agency on 6/2/2022, with diagnoses which included congestive heart failure (CHF), chronic obstructive pulmonary disease, and hypertensive heart disease. On 4/23/24, record review of a SN visit noted dated 6/6/2022 revealed the following documentation. Under “Cardiovascular” SN documented, “No problems identified” with no edema (swelling) noted anywhere on P-5. No weight or limb circumference was documented in the visit note. Pt was noted having dyspnea (difficulty in breathing) walking greater than 20 feet, non-productive cough, and an oxygen saturation level of 98% on room air. On 6/9/2022, SN’s OASIS (Outcome and Assessment Information Set) discharge note documented P-5’s condition had significantly changed given the patient’s CHF history. Under “Cardiac Assessment”, SN documented bilateral lower edema was now 2+ pitting (pressing on the swollen area creating an indentation lasting under 15 seconds before returning to its previous state. This indicates fluid overload, a complication often associated with CHF. Under “Respiratory Status”, SN documented P-5 had dyspnea, non-productive cough with nebulizer use, shortness of breath while ambulating. The “Vital Signs” section was left blank by SN, therefor no clinical findings were made available to ascertain if the patient was within baseline or not. Under “Care Coordination” SN documented “Other: agency” with the “Physician” left blank. SN documented the reason for discharge was “pt (patient) is with different agency.” No evidence was found in the medical record indicating SN had passed on the findings above to the Physician or other agency. These findings were reviewed with and acknowledged by the Administrator (Staff A) and Clinical Manager (Staff B) during an interview on 4/24/2024 at 9:45 AM. The Agency failed to adhere to its policy referenced below. Agency Policy: “Subject Case Management/Coordination of Care” (undated) pg. 1 stated, “The communication between the disciplines, physicians, other health care professionals... shall be documented in the patient medical record... To assure the clients receive appropriate services to meet their needs.””

“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 provide services as ordered in the plan of care in 1 of 7 records reviewed (P-1) out of a total of 7 records reviewed, resulting in the possibility of poor outcomes. Findings included: P-1: The Start of Care was dated 10/15/2022. The Plan of Care for the certification period 10/15/22 to 12/13/22 identified diagnoses of Malignant Neoplasm of the bladder, Urinary Tract Infection (UTI), Sciatica, Diabetes Type 2 (DM2), and Chronic Kidney Disease (CKD). This patient was receiving Skilled Nursing and Physical Therapy services. The order for frequency of visits for Physical Therapy services was 2 times a week for 6 weeks. Upon review of the record, it was noted documentation for the following 2 missed visits: “On 11/17/22-missed visit due to no answer to phone call; On 11/21/2022-missed visit due to no answer to phone call. There was no documentation found in the record that indicated the visits were rescheduled, or that the physician was notified of the missed visits. The agency failed to provide services as ordered on the Plan of Care. These findings were reviewed with and acknowledged by the Administrator (Staff A) and Clinical Manager (Staff B) during an interview on 4/24/2024 at 1:00 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, it was determined that the Agency failed to ensure the clinical record was complete, including assessments, communication notes and discharge summary for 1 (P-7) of 3 records reviewed with therapy only cases, from a total sample of 7 records reviewed, resulting in an incomplete record that failed to provide any information concerning the patient after admission, and the potential for unmet care needs. Findings include: P-7: This patient’s start of care (SOC) date was 9/26/23, with diagnoses of poly-osteoarthritis-unspecified, chronic obstructive pulmonary disease, and chronic pain. During record review on 4/23/24, it was noted the medical record for P-7 contained a physician face to face evaluation on 9/14/2023, a SOC comprehensive assessment (9/26/23), and a Plan of Care (9/26/23). There were no clinical findings, communication notes or transfer/discharge summary which explained what happened to P-7 after 9/26/23. The above findings were reviewed with and acknowledged by the Administrator (Staff A) and the Chief Financial Officer/Physical Therapist (Staff C) during an interview on 4/24/2024 at 9:35 AM. Staff C stated he should have documented the reason (transfer to hospital with no return) which would explain why P-7’s clinical record was incomplete.”

“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 a discharge summary was complete, provided the patient’s health status at the time of discharge, progress toward goals, and forwarded to the physician within 5 days of discharge in 6 (P-2, P-3, P-4, P-5, P-6, P-7) of 7 closed records; and failed to ensure a transfer summary was sent to the physician/receiving facility within 2 business days of the patient’s transfer for 1 (P-1) of 1 record in which the patient was transferred to an inpatient facility, resulting in the physician/receiving facility not having knowledge of the patient’s health status at the time of transfer, and the physician not having a clear picture of the patient’s status at the time of discharge, resulting in the potential for unidentified continuing health care concerns and unmet care needs. Findings include: P-4: This patient was admitted to the Agency on 1/4/2024, with diagnoses which included cerebral infarction (brain stroke) affecting right dominant side, type-2 diabetes with neuropathy, pressure ulcer of right heel-unstageable, and long-term use of insulin. On 4/23/24, record review of this Physical Therapy (PT) only case noted P-4 was discharged on 4/8/24. Review of the discharge (DC) summary revealed a failure to include any clinical findings concerning P-4’s diabetes and right heel wound. No blood sugar recordings or right heel wound measurements, interventions, or treatments were found in the DC summary. In addition, no evidence was found this incomplete DC summary was sent to the physician for review. The above findings were reviewed with and acknowledged by the Administrator (Staff A) and Clinical Manager (Staff B) during an interview on 4/24/2024 at 9:28 AM. P-5: This patient was admitted to the Agency on 6/2/2022, with diagnoses which included congestive heart failure, chronic obstructive pulmonary disease, and hypertensive heart disease. On 4/23/24, record review noted P-5 had a significant change in condition (SCIC) from 6/6/22 through 6/9/22 (discharged to another agency). The SCIC concerned exacerbation (worsening) of heart failure symptoms. However, this information was not found on the DC summary (dated 6/9/22). Further, no evidence was found that a DC summary was sent to the physician for review. The above findings were reviewed with and acknowledged by the Administrator (Staff A) and Clinical Manager (Staff B) during an interview on 4/24/2024 at 9:40 AM. P-6: The patient’s start of care (SOC) date was 6/3/2021, with diagnoses which included bilateral osteoarthritis of knee, chronic kidney disease, and peripheral vascular disease. On 4/23/24, record review found no documented evidence a DC summary (dated 7/12/21) was sent to the physician for review. The above findings were reviewed with and acknowledged by the Administrator (Staff A) and Clinical Manager (Staff B) during an interview on 4/24/2024 at 9:48 AM. P-7: This patient’s start of care (SOC) date was 9/26/23, with diagnoses of poly-osteoarthritis-unspecified, chronic obstructive pulmonary disease, and chronic pain. On 4/23/24, record review found no documented evidence of a DC summary. Subsequently, evidence that a DC summary was sent to the physician for review was not found. The above findings were reviewed with and acknowledged by the Administrator (Staff A) and Clinical Manager (Staff B) during an interview on 4/24/2024 at 9:58 AM. Both agreed the findings for P-4 through P-7 failed to meet Agency expectations and its policy referenced below. Agency Policy: “Discharge Policy and Summary” (undated) pg. 1 stated, “In all cases, a discharge summary will be completed by all disciplines... Sent to MD... with 5 days of discharge.” **Discharge Policy & Summary: The policy states, “In all cases a discharge OASIS and Summary will be completed by all disciplines with exception of Home Health aide. When a client is discharged from the agency a discharge summary and/or OASIS form shall be completed by the last discipline on the case. A copy of the discharge summary will be sent to physician upon request by fax, mail or e-mail for electronic medical records if applicable. The discharge summary shall include, but not limited to: Admission and discharge dates; Services provided; Diagnoses; Status upon admission; Status at time of discharge; reason for discharge; Transfer information; if applicable, unmet needs, referrals made, instructions provided for family; current medication list/profile/interactions if applicable; if goals were met and if not met, reasons why; Initial problem/s; Action taken; Patient response to treatment. The disciplines will assure that the treatment goals and client outcomes have been met. If unmet needs are present, the disciplines will assure that appropriate referrals are made to agencies/organizations/institutions to meet continuing needs (with client consent) ...A Complete copy to physician by writing in physicians’ name, date notified, and checks off how they were notified. Sent to MD & hospital facility within 5 days discharge & documented. P-1: The Start of Care was dated 8/25/22. The Plan of Care for the certification period 8/25/22 to 8/30/22 identified diagnoses of Malignant Neoplasm of the bladder, Urinary Tract Infection (UTI), Sciatica, Diabetes Type 2 (DM2), and Chronic Kidney Disease (CKD). The patient was experienced a significant change in condition (SCIC) on 8/30/22 and was transferred to a hospital. The record included both a Transfer Summary and a Discharge from the agency on 8/30/2022 due to fall resulting in an inpatient hospitalization. Upon review of the record, there was no indication that the physician was notified of the Transfer to the hospital, or that the transfer Summary was sent within 2 business days to the physician and receiving hospital. In addition, this patient was admitted again to this agency on 10/15/2022. The Plan of Care for the certification period 10/15/2022 through 12/13/2022 identified diagnoses of intervertebral disc degeneration of lumbar region, Urinary Tract Infection (UTI), Sciatica, Type 2 Diabetes (DM2), Bladder Cancer, and Chronic Kidney Disease (CKD). Upon review of the record, it was noted the discharge summary dated 11/26/2022 failed to include information regarding the patient’s health status at the time of discharge, progress towards goals, and evidence that the discharge summary was forwarded to the physician within 5 days of discharge from the agency. P-2: The Start of Care was dated 4/1/2022. The Plan of Care for the certification period 4/1/2022 to 4/8/2022 identified diagnosis of Dehydration, Chronic Kidney Disease (CKD), Hypertension, muscle Weakness, Vertigo, and history of falls. Upon review of the record, it was noted the discharge summary dated 11/26/2022 failed to include information regarding the patient’s health status at the time of discharge, progress towards goals, and evidence that the discharge summary was forwarded to the physician within 5 days of discharge from the agency. P-3: The Start of Care was dated 6/1/2022. The Plan of Care for the Certification Period 6/1/2022 to 7/30/2022 identified diagnoses of Chorea, Drug induced secondary Parkinsonism and dyskinesia, Repeated Falls, Dysarthria and Anarthria. Dysphagia, Epilepsy, Orofacial Dystonia, and Depression. This patient was receiving Physical Therapy (PT) and Speech Therapy (ST) services. Upon review of record, it was noted the discharge summary dated, 6/24/2022, failed to include information regarding the patient’s health status at the time of discharge, progress towards goals, and evidence that the discharge summary was forwarded to the physician within 5 days of discharge from the agency. These findings were reviewed with and acknowledged by the Administrator (Staff A) and Clinical Manager (Staff B) during an interview on 4/24/2024 at 1:00 p.m. **Discharge Policy & Summary: The policy states, “In all cases a discharge OASIS and Summary will be completed by all disciplines with exception of Home Health aide. When a client is discharged from the agency a discharge summary and/or OASIS form shall be completed by the last discipline on the case. A copy of the discharge summary will be sent to physician upon request by fax, mail or e-mail for electronic medical records if applicable. The discharge summary shall include, but not limited to: Admission and discharge dates; Services provided; Diagnoses; Status upon admission; Status at time of discharge; reason for discharge; Transfer information; if applicable, unmet needs, referrals made, instructions provided for family; current medication list/profile/interactions if applicable; if goals were met and if not met, reasons why; Initial problem/s; Action taken; Patient response to treatment. The disciplines will assure that the treatment goals and client outcomes have been met. If unmet needs are present, the disciplines will assure that appropriate referrals are made to agencies/organizations/institutions to meet continuing needs (with client consent) ...A Complete copy to physician by writing in physicians’ name, date notified, and checks off how they were notified. Sent to MD & hospital facility within 5 days discharge & documented. P-1: The Start of Care was dated 8/25/22. The Plan of Care for the certification period 8/25/22 to 8/30/22 identified diagnoses of Malignant Neoplasm of the bladder, Urinary Tract Infection (UTI), Sciatica, Diabetes Type 2 (DM2), and Chronic Kidney Disease (CKD). The patient was experienced a significant change in condition (SCIC) on 8/30/22 and was transferred to a hospital. The record included both a Transfer Summary and a Discharge from the agency on 8/30/2022 due to fall resulting in an inpatient hospitalization. Upon review of the record, there was no indication that the physician was notified of the Transfer to the hospital, or that the transfer Summary was sent within 2 business days to the physician and receiving hospital. In addition, this patient was admitted again to this agency on 10/15/2022. The Plan of Care for the certification period 10/15/2022 through 12/13/2022 identified diagnoses of intervertebral disc degeneration of lumbar region, Urinary Tract Infection (UTI), Sciatica, Type 2 Diabetes (DM2), Bladder Cancer, and Chronic Kidney Disease (CKD). Upon review of the record, it was noted the discharge summary dated 11/26/2022 failed to include information regarding the patient’s health status at the time of discharge, progress towards goals, and evidence that the discharge summary was forwarded to the physician within 5 days of discharge from the agency. P-2: The Start of Care was dated 4/1/2022. The Plan of Care for the certification period 4/1/2022 to 4/8/2022 identified diagnosis of Dehydration, Chronic Kidney Disease (CKD), Hypertension, muscle Weakness, Vertigo, and history of falls. Upon review of the record, it was noted the discharge summary dated 11/26/2022 failed to include information regarding the patient’s health status at the time of discharge, progress towards goals, and evidence that the discharge summary was forwarded to the physician within 5 days of discharge from the agency. P-3: The Start of Care was dated 6/1/2022. The Plan of Care for the Certification Period 6/1/2022 to 7/30/2022 identified diagnoses of Chorea, Drug induced secondary Parkinsonism and dyskinesia, Repeated Falls, Dysarthria and Anarthria. Dysphagia, Epilepsy, Orofacial Dystonia, and Depression. This patient was receiving Physical Therapy (PT) and Speech Therapy (ST) services. Upon review of record, it was noted the discharge summary dated, 6/24/2022, failed to include information regarding the patient’s health status at the time of discharge, progress towards goals, and evidence that the discharge summary was forwarded to the physician within 5 days of discharge from the agency. These findings were reviewed with and acknowledged by the Administrator (Staff A) and Clinical Manager (Staff B) during an interview on 4/24/2024 at 1:00 p.m. P-4: This patient was admitted to the Agency on 1/4/2024, with diagnoses which included cerebral infarction (brain stroke) affecting right dominant side, type-2 diabetes with neuropathy, pressure ulcer of right heel-unstageable, and long-term use of insulin. On 4/23/24, record review of this Physical Therapy (PT) only case noted P-4 was discharged on 4/8/24. Review of the discharge (DC) summary revealed a failure to include any clinical findings concerning P-4’s diabetes and right heel wound. No blood sugar recordings or right heel wound measurements, interventions, or treatments were found in the DC summary. In addition, no evidence was found this incomplete DC summary was sent to the physician for review. The above findings were reviewed with and acknowledged by the Administrator (Staff A) and Clinical Manager (Staff B) during an interview on 4/24/2024 at 9:28 AM. P-5: This patient was admitted to the Agency on 6/2/2022, with diagnoses which included congestive heart failure, chronic obstructive pulmonary disease, and hypertensive heart disease. On 4/23/24, record review noted P-5 had a significant change in condition (SCIC) from 6/6/22 through 6/9/22 (discharged to another agency). The SCIC concerned exacerbation (worsening) of heart failure symptoms. However, this information was not found on the DC summary (dated 6/9/22). Further, no evidence was found that a DC summary was sent to the physician for review. The above findings were reviewed with and acknowledged by the Administrator (Staff A) and Clinical Manager (Staff B) during an interview on 4/24/2024 at 9:40 AM. P-6: The patient’s start of care (SOC) date was 6/3/2021, with diagnoses which included bilateral osteoarthritis of knee, chronic kidney disease, and peripheral vascular disease. On 4/23/24, record review found no documented evidence a DC summary (dated 7/12/21) was sent to the physician for review. The above findings were reviewed with and acknowledged by the Administrator (Staff A) and Clinical Manager (Staff B) during an interview on 4/24/2024 at 9:48 AM. P-7: This patient’s start of care (SOC) date was 9/26/23, with diagnoses of poly-osteoarthritis-unspecified, chronic obstructive pulmonary disease, and chronic pain. On 4/23/24, record review found no documented evidence of a DC summary. Subsequently, evidence that a DC summary was sent to the physician for review was not found. The above findings were reviewed with and acknowledged by the Administrator (Staff A) and Clinical Manager (Staff B) during an interview on 4/24/2024 at 9:58 AM. Both agreed the findings for P-4 through P-7 failed to meet Agency expectations and its policy referenced below. Agency Policy: “Discharge Policy and Summary” (undated) pg. 1 stated, “In all cases, a discharge summary will be completed by all disciplines... Sent to MD... with 5 days of discharge.””