Delta Home Health Care, LLC

“Develop EP Plan, Review and Update Annually CFR(s): 484.102(a) §403.748(a), §416.54(a), §418.113(a), §441.184(a), §460.84(a), §482.15(a), §483.73(a), §483.475(a), §484.102(a), §485.68(a), §485.542(a), §485.625(a), §485.727(a), §485.920(a), §486.360(a), §491.12(a), §494.62(a). The [facility] must comply with all applicable Federal, State and local emergency preparedness requirements. The [facility] must develop establish and maintain a comprehensive emergency preparedness program that meets the requirements of this section. The emergency preparedness program must include, but not be limited to, the following elements: (a) Emergency Plan. The [facility] must develop and maintain an emergency preparedness plan that must be [reviewed], and updated at least every 2 years. The plan must do all of the following: * [For hospitals at §482.15 and CAHs at §485.625(a):] Emergency Plan. The [hospital or CAH] must comply with all applicable Federal, State, and local emergency preparedness requirements. The [hospital or CAH] must develop and maintain a comprehensive emergency preparedness program that meets the requirements of this section, utilizing an all-hazards approach. * [For LTC Facilities at §483.73(a):] Emergency Plan. The LTC facility must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least annually. * [For ESRD Facilities at §494.62(a):] Emergency Plan. The ESRD facility must develop and maintain an emergency preparedness plan that must be [evaluated], and updated at least every 2 years. . This Standard is not met as evidenced by: Based on record review and interview, the agency failed to review and update the Emergency Preparedness plan at least every two years, resulting in the potential to negatively affect the health and safety of all patients served by this agency in the event of an actual agency or community-based emergency. Findings include: On 5/8/24, the Emergency Preparedness (EP) binder titled Emergency Disaster Plan was reviewed. The Emergency Disaster Management Plan was dated 2018. There was no evidence the plan had been reviewed or updated since 2018. This finding was reviewed and acknowledged by the Administrator (Staff A) during an interview on 5/8/24 at 3:00 p.m.”

“Development of EP Policies and Procedures CFR(s): 484.102(b) §403.748(b), §416.54(b), §418.113(b), §441.184(b), §460.84(b), §482.15(b), §483.73(b), §483.475(b), §484.102(b), §485.68(b), §485.542(b), §485.625(b), §485.727(b), §485.920(b), §486.360(b), §491.12(b), §494.62(b). (b) Policies and procedures. [Facilities] must develop and implement emergency preparedness policies and procedures, based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, and the communication plan at paragraph (c) of this section. The policies and procedures must be reviewed and updated at least every 2 years. *[For LTC facilities at §483.73(b):] Policies and procedures. The LTC facility must develop and implement emergency preparedness policies and procedures, based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, and the communication plan at paragraph (c) of this section. The policies and procedures must be reviewed and updated at least annually. *Additional Requirements for PACE and ESRD Facilities: *[For PACE at §460.84(b):] Policies and procedures. The PACE organization must develop and implement emergency preparedness policies and procedures, based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, and the communication plan at paragraph (c) of this section. The policies and procedures must address management of medical and nonmedical emergencies, including, but not limited to: Fire; equipment, power, or water failure; care-related emergencies; and natural disasters likely to threaten the health or safety of the participants, staff, or the public. The policies and procedures must be reviewed and updated at least every 2 years. *[For ESRD Facilities at §494.62(b):] Policies and procedures. The dialysis facility must develop and implement emergency preparedness policies and procedures, based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, and the communication plan at paragraph (c) of this section. The policies and procedures must be reviewed and updated at least every 2 years. These emergencies include, but are not limited to, fire, equipment or power failures, care-related emergencies, water supply interruption, and natural disasters likely to occur in the facility’s geographic area. This Standard is not met as evidenced by: Based on record review and interview, the agency failed to develop written emergency preparedness policies and procedures that were based on an emergency preparedness plan, risk assessment, and communication plan. Resulting in the agency’s inability to implement appropriate emergency actions. This deficient practice has the potential to negatively affect the health and safety of all patients served by this agency. Findings include: On 5/8/24, the Emergency Preparedness (EP) binder titled Emergency Disaster Plan was reviewed. During the review, it was noted that there was no documented evidence of emergency preparedness policies and procedures that were based on an emergency preparedness plan, a documented risk assessment, and communication plan. This finding was reviewed and acknowledged by the Administrator (Staff A) during an interview on 5/8/24 at 3:00 p.m.”

“Plan of care CFR(s): 484.60(a)(1) Each patient must receive the home health services that are written in an individualized plan of care that identifies patient-specific measurable outcomes and goals, and which is established, periodically reviewed, and signed by a doctor of medicine, osteopathy, or podiatry acting within the scope of his or her state license, certification, or registration. If a physician or allowed practitioner refers a patient under a plan of care that cannot be completed until after an evaluation visit, the physician or allowed practitioner is consulted to approve additions or modifications to the original plan. This Standard is not met as evidenced by: Based on record review and interview, the agency failed to ensure goals written in the plan of care were patient-specific and measurable in 7 (P-1, 2, 3, 4, 5, 6, 7) of 7 records reviewed, resulting in the inability to determine the patient’s progress towards achieving goals and the potential for poor patient outcomes. Findings include: P-1: This 77-year-old patient was admitted to home care on 4/10/24 with diagnoses of type 2 diabetes, hypertension, and paranoid schizophrenia. During record review on 5/6/24, it was noted that the plan of care failed to include measurable nursing goals that are individualized to address patient needs. The plan of care contained the following goals, patient/caregiver will verbalize understanding of pain management, hypertension related interventions and all aspects of associated care and the patient/caregiver will verbalize understanding of 2gm sodium diet as evidenced by compliance with diet plan. There was no evidence of how these goals could be objectively measured to determine progress toward meeting the goals. P-2: This 74-year-old patient was admitted to home care on 1/2/24 with diagnoses of congestive heart failure, unstable angina, and low back pain. During record review on 5/7/24, it was noted that the plan of care failed to include measurable nursing goals that are individualized to address patient needs. The plan of care contained the following goals, Patient/caregiver will verbalize understanding of congestive heart failure, angina, hypertension, osteoarthritis, edema, lumbosacral spondylitis, obesity, asthma, and all aspects of associated care and the patient/caregiver will verbalize understanding of medications as evidenced by recall of action/dose/side effects within cert period. There was no evidence of how these goals could be objectively measured to determine progress toward meeting the goals. P-3: This 97-year-old patient was admitted to home care on 2/14/24 with diagnoses of pancreatic cancer, cerebral infarction, and dysuria. During record review on 5/7/24, it was noted that the plan of care failed to include measurable nursing goals that are individualized to address patient needs. The plan of care contained the following goals, patient/caregiver will verbalize understanding of pain management, hypertension related interventions and all aspects of associated care and the patient/caregiver will verbalize understanding of medications as evidenced by recall of action/dose/side effects within cert period. There was no evidence of how these goals could be objectively measured to determine progress toward meeting the goals. P-4: This 62-year-old patient was admitted to home care on 2/17/24 with diagnoses of type 2 diabetes and fibromyalgia. During record review on 5/7/24, it was noted that the plan of care failed to include measurable nursing goals that are individualized to address patient needs. The plan of care contained the following goals, patient/caregiver will verbalize understanding of diabetes, hypertension, osteoarthritis, edema, obesity, bipolar, GERD (gastrointestinal reflux disease), anxiety, indwelling foley catheter pain management, hypertension related interventions and all aspects of associated care and the patient/caregiver will verbalize understanding of medications as evidenced by recall of action/dose/side effects within cert period. There was no evidence of how these goals could be objectively measured to determine progress toward meeting the goals. These findings were reviewed and acknowledged by the administrator (Staff A) during an interview on 5/9/24 at 10:00 a.m. P-5: This 65-year-old patient was admitted to this home care agency on 5/22/23 with the diagnoses of type 2 diabetes, spinal stenosis, and congestive heart failure. During record review on 5/7/24, it was noted the goals on the plan of care dated 5/22/23 were not measurable or patient specific. Examples on this patient’s plan of care (POC) included: “The patient/caregiver will verbalized understanding of (disease process) pain management, HTN related interventions and all aspects of associated care within cert period of time” [sic] and “The patient will reach maximum functional potential, as evidenced by improved endurance, ADL’s, IADL’s within cert period of time.” P-6: This 71-year-old patient was admitted to this home care agency on 7/24/23 with the diagnoses of chronic obstructive pulmonary disease, hypertension, and osteoarthritis. During record review on 5/8/24, it was noted the goals on the plan of care dated 7/24/23 were not measurable or patient specific. Examples on this patient’s POC included: “The patient’s pain will be controlled and managed at the patient’s own comfort level as verbalized by the patient/caregiver within cert period of time” and “The patient/caregiver will verbalize understanding of medications as evidenced by recall action/dose/side effects within cert period of time.” P-7: This 83-year-old patient was admitted to this home care agency on 4/1/24 with the diagnoses of type 2 diabetes, hypertension, and end stage renal disease. During record review on 5/8/24, it was noted the goals on the plan of care dated 4/1/24 were not measurable or patient specific. Examples on this patient’s POC included: “The patient/caregiver will verbalize understanding of 2 gm sodium diet as evidenced by compliance with diet plan within cert period of time.” It was also determined the goals for P-5, P-6, and P-7 were identical except for the diagnoses listed under the goal for understanding interventions, therefore, these goals are not patient specific. The Administrator (Staff A) acknowledged the findings during an interview on 5/9/24 at 10:30 AM.”

“Home health aide assignments and duties CFR(s): 484.80(g)(1) Standard: Home health aide assignments and duties. Home health aides are assigned to a specific patient by a registered nurse or other appropriate skilled professional, with written patient care instructions for a home health aide prepared by that registered nurse or other appropriate skilled professional (that is, physical therapist, speech-language pathologist, or occupational therapist). This Standard is not met as evidenced by: Based on record review and interview, the agency failed to ensure the registered nurse prepared an aide care plan that contained safety precautions for 1 (P-4) of 1 record reviewed in which aide services were provided, resulting in the potential for unsafe, substandard care and unmet care needs. Findings include: P-4: This 62-year-old patient was admitted to home care on 2/17/24 with diagnoses of type 2 diabetes and fibromyalgia. During record review on 5/7/24, it was noted that the 2/17/24 aide care plan, created by the registered nurse, failed to include special instructions/precautions for diabetes and blood thinner, as Eliquis (a blood thinner) is listed as a medication on the plan of care. This finding was reviewed and acknowledged by the administrator (Staff A) during an interview on 5/9/24 at 10:00 a.m.”

“5 calendar days after start of care CFR(s): 484.55(b)(1) The comprehensive assessment must be completed in a timely manner, consistent with the patient’s immediate needs, but no later than 5 calendar days after the start of care. This Element is not met as evidenced by: Based on record review and interview, the agency failed to ensure the comprehensive assessment was completed within 5 calendar days after the start of care in 1 (P-6) of 7 records reviewed, resulting in the potential for unmet care needs and poor patient outcomes. Findings include: P-6: This 71-year-old patient was admitted to this home care agency on 7/24/23 with the diagnoses of chronic obstructive pulmonary disease, hypertension, and osteoarthritis. During record review on 5/8/24, it was noted the referral (verbal order) ordered services by skilled nursing and physical therapy. The Outcomes and Assessment Information Set (OASIS) that the patient was at risk for falls and was having difficulty with her mobility. Additionally, it was noted under section “M2200 Therapy Need:” on the OASIS that 8 therapy visits were indicated for this patient. Upon further review of the record, it was determined that physical therapy did not evaluate this patient. During an interview with the Administrator (Staff A) on 5/9/24 at 10:30 AM, Staff A was asked for the reason why physical therapy did not evaluate this patient. Staff A stated this patient “always refused”, but she was unable to provide evidence of this being documented in the record. She acknowledged the findings at the time of interview.”

“Health, psychosocial, functional, cognition CFR(s): 484.55(c)(1) The patient’s current health, psychosocial, functional, and cognitive status; This Element is not met as evidenced by: Based on record review and interview, the agency failed to ensure the comprehensive assessment accurately reflected the patient’s current health, psychosocial, functional, and cognitive status in 5 (P-1, 4, 5, 6, 7) of 7 records reviewed, resulting in incomplete clinical information to aide in determining the needs of the patient and creating individualized, patient-specific plans for treatment. Findings include: P-5: This 65-year-old patient was admitted to this home care agency on 5/22/23 with the diagnoses of type 2 diabetes, spinal stenosis, and congestive heart failure. During record review on 5/7/24, it was noted the Outcome and Assessment Information Set (OASIS) dated 5/22/23 reported under the “GG0170 Mobility” section the patient required “Partial/moderate assistance” for most activities – including higher level activities such as walking 150 feet, walking on uneven surfaces, making turns, and going up/down up to 4 stairs. It also reported the patient’s TUG (Timed up and Go) score to be 10 seconds. The TUG is a test timing how long it takes a patient to safely rise from a chair, walk 10 feet, turn around, return to the chair, and sit back down. It is used to assist in determining the patient’s function and risk for falls. According to the Centers for Disease Control and Prevention (CDC), an older adult who takes longer than 12 seconds to complete the test is at risk for falls. Upon further review of the record, it was noted the physical therapy evaluation dated 5/22/23 (the same day), reported the patient could only tolerate 1 to 2 minutes of activity at a time and needed assistance to walk 10 feet at a slow pace and wide base of support due to fear of falling. The information in the record is conflicting, therefore does not provide an accurate representation of the patient’s current health, psychosocial, functional, and cognitive status. P-6: This 71-year-old patient was admitted to this home care agency on 7/24/23 with the diagnoses of chronic obstructive pulmonary disease, hypertension, and osteoarthritis. During record review on 5/8/24, it was noted on the OASIS dated 7/24/23 under the “GG0100 Prior Function: Everyday Activities” that the patient was “Dependent” on others for ambulation (walking) and stairs prior to admission. Upon further review of the OASIS, it was noted under the “GG0170 Mobility” section that the patient was able to perform all activities with “Substantial/maximal assistance” – which is a higher level of function than the patient’s prior level of “Dependent”. Additionally, the goals were set for all mobility activities to be “Supervision or touching assistance” – which is significantly higher than the patient’s baseline. The information in the record is conflicting, therefore does not provide an accurate representation of the patient’s current health, psychosocial, functional, and cognitive status. P-7: This 83-year-old patient was admitted to this home care agency on 4/1/24 with the diagnoses of type 2 diabetes, hypertension, and end stage renal disease. During record review on 5/8/24, it was it was noted the Outcome and Assessment Information Set (OASIS) dated 4/1/24 reported under the “GG0170 Mobility” section that the patient required “Partial/moderate assistance” for all activities - including higher level activities such as walking 150 feet, walking on uneven surfaces, making turns, and going up/down up to 12 stairs. The patient’s TUG test was recorded at 4 seconds. Upon further review of the record, it was noted the physical therapy evaluation dated 4/1/24 indicated this patient was a bilateral amputee who used prosthetics to ambulate. The evaluation also noted the patient was unable to walk at the time of the assessment and needed maximum assistance for bed mobility. The information in the record is conflicting, therefore does not provide an accurate representation of the patient’s current health, psychosocial, functional, and cognitive status. Findings were reviewed with and acknowledged by the Administrator (Staff A) during an interview on 5/9/24 at 10:30 AM. P-1: This 77-year-old patient was admitted to home care on 4/10/24 with diagnoses of type 2 diabetes, hypertension, and paranoid schizophrenia. During record review on 5/6/24, it was noted that the 4/10/24 comprehensive assessment, conducted by the registered nurse, stated there were no cognitive, behavioral, or psychiatric symptoms (M1740) and indicated there were “never” any disrupted behavior symptoms (M1745) while the diagnoses and symptom control (M1021/1023) indicated paranoid schizophrenia and “symptoms poorly controlled.” The comprehensive assessment failed to accurately reflect the patient’s health status on 4/10/24 to assist in developing the patient’s plan of care. P-4: This 62-year-old patient was admitted to home care on 2/17/24 with diagnoses of type 2 diabetes and fibromyalgia. During record review on 5/7/24, it was noted that the 2/17/24 comprehensive assessment, conducted by the registered nurse, stated that the patient is incontinent of urine (M1610) and is experiencing urgency/frequency while the diagnoses and symptom control (M1021/1023) indicated presence of indwelling urethral catheter. The comprehensive assessment failed to accurately reflect the patient’s health status on 2/17/24 to assist in developing the patient’s plan of care. These findings were reviewed and acknowledged by the administrator (Staff A) during an interview on 5/9/24 at 10:00 a.m.”

“Continuing need for home care CFR(s): 484.55(c)(3) The patient’s continuing need for home care; This Element is not met as evidenced by: Based on record review and interview, the agency failed to ensure the comprehensive assessment contained sufficient information to demonstrate the continuing in need for homecare services in 1 (P-6) of 7 records reviewed, resulting in the potential for delivery of unnecessary services. Findings include: P-6: This 71-year-old patient was admitted to this home care agency on 7/24/23 with the diagnoses of chronic obstructive pulmonary disease (COPD), hypertension, and osteoarthritis. During record review on 5/8/24, it was determined the patient received services from 7/24/23 to 9/8/23 and was re-certified to continue services from 9/22/23 to 11/20/23. Upon further review of the record, it was noted the patient received education/training on COPD, fall precautions, hypertension, coronary artery disease, pain, and exercise during the first certification period. It was also noted the patient’s vitals remained stable throughout the episode of care and there were no issues identified regarding the patient not meeting the goals set on the plan of care. Upon review of the comprehensive assessment for the recertification dated 9/18/23, it was noted the goals were the same as the initial comprehensive assessment aside from the addition of “IBS” (irritable bowel syndrome) on one goal. It was also noted the diagnoses were all labeled as “poorly controlled”. Administrator (Staff A) was interviewed on 5/9/24 at 10:30 AM regarding the above findings and the need for continued home care services. Staff A agreed the patient’s symptoms had been well controlled throughout the first episode, however, she wanted to continue the patient’s services due to issues related to anxiety and depression. Staff A admitted she should have documented that. She agreed the information in the recertification does not reflect the patient’s need for continued home care services. Staff A acknowledged the findings.”

“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 skilled professionals provided services as ordered by the physician in the plan of care for 3 (P-2, 4, 6) of 7 records reviewed, resulting in the potential for poor patient outcomes for these patients. Findings include: **Agency Policy – Plan of Care (485) and Physician/NPP Orders (dated 2024). If the agency provides fewer visits than the physician orders, it has altered the plan of care, and the physician must be notified. The Agency must maintain documentation in the clinical record indicating that the physician was notified and is aware of the missed visit. P-2: This 74-year-old patient was admitted to home care on 1/2/24 with diagnoses of congestive heart failure, unstable angina, and low back pain. During record review on 5/7/24, it was noted that physical therapy (PT) was ordered on the plan of care once a week for nine weeks. The PT documented two missed visit notes, 2/8/24 with documentation the physician was notified and on 2/22/24 with no evidence the physician was notified. The administrator (Staff A) was queried on the expectation for missed visits and stated, “the expectation is the staff keep trying to meet frequency until the end of the week.” There was no evidence alternate visit dates were offered. P-4: This 62-year-old patient was admitted to home care on 2/17/24 with diagnoses of type 2 diabetes and fibromyalgia. During record review on 5/7/24, it was noted that skilled nursing was ordered on the plan of care once a week for 8 weeks. There was no evidence of a skilled nursing visit or missed visit note for week 6, week 7, or week 8; and no evidence the physician was notified. The patient was transferred to the hospital on 4/12/24 and discharged from home care services. These findings were reviewed and acknowledged by the administrator (Staff A) during an interview on 5/9/24 at 10:00 a.m. P-6: This 71-year-old patient was admitted to this home care agency on 7/24/23 with the diagnoses of chronic obstructive pulmonary disease, hypertension, and osteoarthritis. During record review on 5/8/24, it was noted the plan of care dated 7/24/23 stated to notify the physician of pulse oximetry numbers below 90%. Pulse oximetry is used to measure the amount of oxygen saturation in a person’s blood. Upon further review of the record, it was noted pulse oximetry measurements were not recorded for the skilled nursing visits on 8/4/23, 8/11/23, 8/18/23, 8/25/23 and 9/8/23. During an interview on 5/9/24 at 10:30 AM, the Administrator (Staff A) was interviewed regarding her expectation of pulse oximetry measurements during skilled nursing visits. Staff A stated she believed this patient’s levels were “under control”, however, agreed that measurements should have been recorded as it was ordered by the physician on the plan of care. Staff A acknowledged the findings.”

“Services provided by HH aide CFR(s): 484.80(g)(2) A home health aide provides services that are: (i) Ordered by the physician or allowed practitioner; (ii) Included in the plan of care; (iii) Permitted to be performed under state law; and (iv) Consistent with the home health aide training. This Element is not met as evidenced by: Based on record review and interview, the agency failed to ensure the aide provided care as instructed for 1 (P-4) of 1 record reviewed in which aide services were provided, resulting in the potential for poor patient outcomes. Findings include: P-4: This 62-year-old patient was admitted to home care on 2/17/24 with diagnoses of type 2 diabetes and fibromyalgia. During record review on 5/7/24, it was noted that the 2/17/24 aide care plan, created by the registered nurse, instructed the aide to provide skin care/check pressure areas every visit and to provide foot care/tepid water soak every visit. The aide (Staff C) documented 5 visits were provided on 2/22/24, 2/29/24, 3/7/24, 3/21/24, and 3/28/24. On all 5 visits, the aide failed to document if skin care and foot care were provided. This finding was reviewed and acknowledged by the administrator (Staff A) during an interview on 5/9/24 at 10:00 a.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 clinical record contained completed assessments and physician orders for 4 (P-2, 3, 4, 7) of 7 records reviewed, resulting in the potential for poor patient outcomes and a lack of information for all agency staff caring for the patient. Findings include: P-7: This 83-year-old patient was admitted to this home care agency on 4/1/24 with the diagnoses of type 2 diabetes, hypertension, and end stage renal disease. During record review on 5/8/24, it was noted there were no visits by skilled nursing the week of 4/7/24. The Administrator (Staff A) was interviewed on 5/9/24 at 10:30 AM regarding the reason for the missed visit. Staff A reported she made a visit to the patient on 4/12/24 according to her calendar, however, she did not complete a note on that day. Staff A acknowledged the findings at the time of interview. **Entrance Interview: During the entrance interview with the administrator (Staff A) on 5/6/24 at 10:35 a.m., Staff A stated notes are to be completed and uploaded into the chart on the Monday of the following week. P-2: This 74-year-old patient was admitted to home care on 1/2/24 with diagnoses of congestive heart failure, unstable angina, and low back pain. The patient was discharged from home care on 2/29/24. During record review on 5/7/24, it was noted that the plan of care ordered home health aide once a week for five weeks. There was no evidence the home health aide had visited the patient. During interview on 5/9/24 at 10:00 a.m., Staff A provided a paper copy of an order from a basket in her office that the patient had refused home health aide services, stating the order hadn’t been uploaded into the electronic medical record. P-3: This 97-year-old patient was admitted to home care on 2/14/24 with diagnoses of pancreatic cancer, cerebral infarction, and dysuria. On 3/25/24, the patient was transferred to hospice services. During record review on 5/7/24, it was noted that the order for home care included skilled nursing, physical therapy (PT), occupational therapy (OT), and home health aide (HHa) services. There was no evidence the patient had been evaluated by PT, OT, or the HHa. During interview on 5/9/24 at 10:00 a.m., Staff A provided a paper copy of an order from a basket in her office that the patient had refused PT, OT, and HHa, stating the order hadn’t been uploaded into the electronic medical record. Additionally, skilled nursing (RN) visit notes from 2/19/24, 2/26/24, 3/4/24, 3/11/24, and 3/18/24 all indicate the RN discussed discharge planning with the physical therapist, when PT was refused. Staff A acknowledged this finding during an interview on 5/9/24 at 10:00 a.m. P-4: This 62-year-old patient was admitted to home care on 2/17/24 with diagnoses of type 2 diabetes and fibromyalgia. On 4/12/24, the patient was transferred to the hospital and discharged from home health services. During record review on 5/7/24, it was noted on the plan of care that physical therapy (PT) was ordered to evaluate and treat. There was no evidence the patient had been evaluated by PT. During interview on 5/9/24 at 10:00 a.m., Staff A provided a paper copy of an order from a basket in her office that the patient had refused physical therapy services, stating the order hadn’t been uploaded into the electronic medical record.”

“Interventions and patient response CFR(s): 484.110(a)(2) All interventions, including medication administration, treatments, and services, and responses to those interventions; This Element is not met as evidenced by: Based on record review and interview, the agency failed to ensure the clinical records contained an accurate representation of all treatments and interventions provided in 2 (P-5, 7) of 7 records reviewed, resulting in the potential for an unclear picture of the patient’s treatment and an incomplete medical record. Findings include: P-5: This 65-year-old patient was admitted to this home care agency on 5/22/23 with the diagnoses of type 2 diabetes, spinal stenosis, and congestive heart failure. During record review on 5/7/24, it was noted the discharge note completed by the physical therapist on 6/27/23 indicated the patient should “Continue with HEP” (home exercise program). The Administrator (Staff A) was asked where to find a record of the HEP in the record during an interview on 5/9/24 at 10:30 AM. Staff A was unable to provide evidence of the HEP being provided to the patient. Staff A reported she was not sure if the clinicians usually put it in the record and acknowledged the findings. P-7: This 83-year-old patient was admitted to this home care agency on 4/1/24 with the diagnoses of type 2 diabetes, hypertension, and end stage renal disease. During record review on 5/8/24, it was noted the physical therapy notes recorded the following exercises under treatment: “Exercise B/L LE muscle strengthening” (bilateral lower extremity) for 10x3 repetitions and “Core muscle strengthening” for 10x3 repetitions. These interventions do not describe which particular exercises were done by this patient; therefore, the record is an inaccurate representation of the patient’s treatment. Findings were reviewed with and acknowledged by Staff A during an interview on 5/9/24 at 10:30 AM.”

“Discharge and transfer summaries CFR(s): 484.110(a)(6)(i-iii) (i) A completed discharge summary that is sent to the primary care practitioner or other health care professional who will be responsible for providing care and services to the patient after discharge from the HHA (if any) within 5 business days of the patient’s discharge; or (ii) A completed transfer summary that is sent within 2 business days of a planned transfer, if the patient’s care will be immediately continued in a health care facility; or (iii) A completed transfer summary that is sent within 2 business days of becoming aware of an unplanned transfer, if the patient is still receiving care in a health care facility at the time when the HHA becomes aware of the transfer. This Element is not met as evidenced by: Based on record review and interview, the agency failed to ensure a completed discharge summary was sent to the primary care physician or other health care professional who will be responsible for providing care to the patient after discharge in 2 (P-5, 7) of 6 discharged records reviewed, resulting in a lack of information communicated to ensure continuity of care for all patients discharged from this agency. Findings include: **Policy titled “Discharge Summary” (dated 2024) stated, “…The physician will notified [sic] regarding discharge and a copy of the Discharge Summary will be sent to the physician within 5 business days of discharge.” P-6: This 71-year-old patient was admitted to this home care agency on 7/24/23 with the diagnoses of chronic obstructive pulmonary disease, hypertension, and osteoarthritis. During record review on 5/8/24, it was determined this patient was discharged from this agency on 11/8/23. There was no evidence in the record that the discharge summary was sent to the physician. P-7: This 83-year-old patient was admitted to this home care agency on 4/1/24 with the diagnoses of type 2 diabetes, hypertension, and end stage renal disease. During record review on 5/8/24, it was determined this patient was discharged from this agency on 4/17/24. There was no evidence in the record that the discharge summary was sent to the physician. The Administrator (Staff A) was interviewed on 5/9/24 at 10:30 regarding how she keeps track of discharge summaries being sent to the physician. Staff A reported “it depends”, however, she was not able to provide evidence of the discharge summaries being sent for these patients. Staff A acknowledged the findings.”