Diversified Home Health Care

“Authentication CFR(s): 484.110(b) Standard: Authentication. All entries must be legible, clear, complete, and appropriately authenticated, dated, and timed. Authentication must include a signature and a title (occupation), or a secured computer entry by a unique identifier, of a primary author who has reviewed and approved the entry. This Standard is not met as evidenced by: Based on record review and interview, the agency failed to ensure all entries into the clinical record were appropriately authenticated by the clinician who signed the entry in 1 (P-5) of 5 sample records reviewed resulting in duplicate assessment entries and potentially inaccurate patient information. Findings include: P-5: This 71-year-old was admitted to the agency on 1/22/22 with diagnoses including recent left knee replacement surgery; osteoarthritis of left knee; and unspecified pain. The medical record was reviewed on 7/31/24. During review, the following documentation, including all grammatical and spelling errors, was found in both the comprehensive assessment under section “Musculoskeletal Assessment” signed by the RN on 1/22/22 and in the PT evaluation under section “Assessment” signed by the PT on 1/27/22: “Patient was discharged from the hospital on the same day (01/19/2022). Patient has has increase in pain level to 7/10 on Left Knee follwoing surgery. Patient is allowed to put weight as tolerated on left L/E. Patient presents with impaired balance and coordination in standing due to weakness of Quadriceps, Hip Flexors, Hip Abductor and stiffness of back extensors muscles. Pain and stiffness in Left Knee causes difficulty in walking and standing up for extended period of time and performing ADLs. Patient is complaining of increase pain level and tiredness while walking and performing any activity. Patient has low endurance level and unsteady gait pattern with discontinuous steps and unequal weight bearing on B-Feet. Patient has decreased hip and Knee Flexion/Extension and decreased ground clearance. Patient has acquired kyphotic posture with rounded shoulders, and generalized muscle weakness affecting B-U/E and B-L/E and is at high risk for falls. Patient requires assistance in performing ADLs and IADLs. Patient lives with her friends in single family house and receives assistance from her friends. Patient requires to ambulate for 150 feet independently to get around in the house.” [sic]. During interview with the Administrator (Staff A) on 8/1/24 at 12:15 p.m., Staff A was queried to how both assessments could have the exact same information considering the assessments were signed by different staff members 5 days apart. Staff A stated that some assessment data provided by the referral source during the agency intake process was being auto populated on the comprehensive assessment to show need for home care. Staff A was queried to where this data was being auto populated on the comprehensive assessment and PT evaluation. Staff A stated that the data should only be auto populated in demographic areas, not in assessment areas. Staff A was queried to whether the assessment information was gathered by the agency clinician who signed the assessments (RN on 1/22/22 and PT on 1/27/22), or from the facility in which the patient was received (prior to admission to the home care agency), Staff A was not able to provide the answer.”

“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 status based on past medical history and history of events leading to current home care needs in 2 (P-2, 3) of 5 records reviewed, resulting in incomplete and inaccurate clinical information to aide in determining the needs of the patient. Findings include: P-2: This 44-year-old patient was admitted to this agency on 10/26/23 with the diagnosis of left shoulder pain and stiffness. During record review on 7/30/24, it was noted on the Outcomes and Assessment Information Set (OASIS) dated 10/26/23 under “Prior Level of Functioning” (baseline prior to admission) that the patient was fully dependent on others for bed mobility, transfers, sitting and standing balance, and ambulation (walking). Upon further review of the OASIS form under current performance of the above functions, it stated the patient required stand by assist for all bed mobility, 25% assistance for transfers, and 50% assistance to ambulate 20 feet with a walker. This information is conflicting as it appears that the patient was functioning significantly better at the evaluation than how he was at his baseline and may not need home care services. The Administrator (Staff A) was questioned regarding this information during an interview on 7/31/24 at 2:00 PM. Staff A stated the patient “told them” that’s what his status was prior to admission, however, she acknowledged the information was conflicting and should have been clarified in the evaluation as it does not show a clear picture of the patient in order to set appropriate goals for treatment. Staff A acknowledged the findings. P-3: This 77-year-old patient was admitted to this agency on 8/28/21 with the diagnosis of a sacral decubitus ulcer (wound on the tailbone) and muscle weakness. During record review on 7/30/24, it was noted on the OASIS dated 8/28/21 that the patient “Lives alone around the clock.” The OASIS also noted under “Potential Risk for Infection Assessment” that the patient had an “absence of a capable caregiver” for a confounding factor that increased his risk for infection. Upon further review of the record, it was noted the physical therapy evaluation dated 9/8/21 stated the patient lived with “family” and had a “willing caregiver available.” It is unclear who the patient lived with according to the documentation, therefore, the comprehensive assessment does not show a clear picture of the patient. Staff A was questioned regarding this information during an interview on 7/31/24 at 2:00 PM. Staff A stated she remember it was a “confusing situation” with this patient and not knowing who he lived with. Staff A admitted the findings were conflicting and did not show a clear picture of the patient in order to set appropriate goals for treatment. Staff A acknowledged the findings. P-4: This 65-year-old patient was admitted to this agency on 2/17/22 with a primary diagnosis of right hip osteoarthritis. Secondary diagnoses included left hip pain and presence of a left artificial hip joint. According to the narrative on the physical therapy plan of care, the patient had surgery on 2/11/22 for a left total hip replacement (not right). Also, during record review on 7/30/24, it was noted the OASIS dated 2/17/22 stated “No” under question M1340, “Does the patient have a surgical wound?” Staff A was questioned regarding this information during an interview on 7/31/24 at 2:00 PM. Staff A stated she thought P-4 had pian in both hips and need the right hip replaced too, however, Staff A was unable to find evidence of this in the record. Staff A acknowledged the primary diagnosis should have been noted as the left hip since that is what she was referred for following surgery. Staff A did not know why “No” was selected under surgical wound and acknowledged the findings.”

“A review of all current medications CFR(s): 484.55(c)(5) A review of all medications the patient is currently using in order to identify any potential adverse effects and drug reactions, including ineffective drug therapy, significant side effects, significant drug interactions, duplicate drug therapy, and noncompliance with drug therapy. This Element is not met as evidenced by: Based on record review and interview, the agency failed to ensure clinicians included a review of all medications during the comprehensive assessment in order to identify any potential adverse effects and drug reactions in 1 (P-5) of 5 sample records reviewed potentially resulting in unknown side effects, drug interactions, duplication of therapies, and poor patient outcomes. Findings include: Agency policy titled “Medication Reconciliation”, Revised February 2024, was reviewed on 7/31/24. On page 1., it stated “The Agency will reconcile patient’s medications at the time of admission and on an ongoing basis in order to identify any potential adverse effects and drug reactions including ineffective drug therapy, significant side effects, significant drug reactions, duplicate drug therapy… Any concerns or discrepancies will be reconciled by a RN with the patient’s physician/practitioner… Discrepancies include duplications, omissions, changes, contraindicated or unclear information…” [sic]. P-5: This 71-year-old was admitted to the agency on 1/22/22 with diagnoses including recent left knee replacement surgery; osteoarthritis of left knee; and unspecified pain. The medical record was reviewed on 7/31/24. During review, it was noted that the comprehensive assessment was completed by the nurse on 1/22/22 and included documentation in the section “(M2001) Drug Regimen Review” indicating that a complete drug regimen review to identify potentially clinically significant medication issues was completed and no issues were found. During review of the patient medications, it was noted that the patient’s medication list contained duplications of two nonsteroidal anti-inflammatory pain relief medications (Meloxicam and Aspirin), and three additional medications for pain (Oxycodone, Tramadol, and Acetaminophen). During interview with the Administrator (Staff A) on 7/31/24 at 3:41 p.m., Staff A stated that the agency prints the medication interactions and duplications, reviews any discrepancies with the physician, and a copy is left in the medical record. Staff A stated that she recalled duplications with the medication list for this patient but was unable to locate the report in the medical record or show evidence that duplicate therapies were reconciled with the patient’s physician.”

“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 individualized, patient-specific measurable outcomes and goals in 3 (P-1, 3, 5) of 5 sample records reviewed potentially resulting in the lack of care that is specific to the patient’s individual needs and difficulty determining progress toward goals for care. Findings include: P-1: This 68-year-old patient was admitted to this agency on 3/12/24 with the diagnosis of an encounter for surgical aftercare following surgery on the digestive system (wound care for non-healing surgical wounds on his abdomen). During record review on 7/30/24, it was determined the plan of care (dated 3/12/24) did not contain any measurable, objective goals regarding wound size and healing. P-3: This 77-year-old patient was admitted to this agency on 8/28/21 with the diagnosis of a sacral decubitus ulcer (wound on the tailbone) and muscle weakness. During record review on 7/30/24, it was determined the plan of care (dated 8/28/21) did not contain any measurable, objective goals regarding wound size or healing. The Administrator (Staff A) acknowledged the finding during an interview on 7/30/24 at 2:00 PM. P-5: This 71-year-old was admitted to the agency on 1/22/22 with diagnoses including recent left knee replacement surgery; osteoarthritis of left knee; and unspecified pain. The medical record was reviewed on 7/31/24. During review of the plan of care dated 1/22/22, the following examples of Skilled Nursing goals for care were noted: Patient will achieve optimal wound healing without further signs/symptoms of infection or complications by end of episode; Patient will have optimal bowel evacuation throughout episode of care; Patient/caregiver will be able to verbalize signs of type of infection to report and demonstrate proper infection precautions by 2/10/22. It was unclear how these goals were specific to this patient or how they would be measured in terms that would enable nursing staff to accurately perform an objective evaluation of the patient’s progress toward the goals. This finding was reviewed and acknowledged on 8/1/24 during interview at 12:15 p.m. with the Administrator, Staff A.”

“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-3 and P-5) of 5 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 71-year-old was admitted to the agency on 1/22/22 with diagnoses including recent left knee replacement surgery; osteoarthritis of left knee; and unspecified pain. The medical record was reviewed on 7/31/24. During review of the physician referral dated 1/19/22, it was noted that the patient had a “silver surgical knee dressing” on the left knee that was to remain in place until removed by the physician on 1/26/22 and, had a pain pump to be removed by the patient within “3-4 days” after surgery. During review of the comprehensive assessment dated 1/22/22, it was noted that the Registered Nurse (RN) documented under the section “Pain Status”, that the patient had a “pain pump” inserted in the left upper thigh and that the patient would be removing the pain pump per physician orders on the scheduled date of 1/23/22. The following was noted when reviewing the RN visit notes: there was no RN visit on 1/23/22. The RN visit on 1/24/22 did not include documentation of whether the pain pump in the upper left thigh had been removed, what the patient’s response to the removal of the pain pump was, or the condition of the skin to the left upper thigh after removal. It was unclear from the RN documentation if the patient removed the pain pump as ordered. Also during review of the comprehensive assessment dated 1/22/22, the RN documented under the section “Wound Care Flowsheet”, that the first dressing change to the left knee would be completed by the provider. During review of the plan of care dated 1/22/22, a skilled nursing physician order was included and stated, “Per physician orders, care of incision is as follows: Remove dressing on 1/26/2022.” The following was noted when reviewing the RN visit notes: the RN did not make a visit on 1/26/22. On 1/27/22, the RN made a visit and did not document if removal of the silver surgical dressing to the left knee had been completed and did not have any updated wound orders (if it had not been completed). It was unclear whether the silver surgical dressing to the left knee was removed as ordered. These findings were reviewed and acknowledged on 8/1/24 during interview at 12:15 p.m. with the Administrator, Staff A. Staff A agreed that treatments, services, and responses to interventions regarding the pain pump and the silver surgical left knee dressing were not documented in the medical record. P-3: This 77-year-old patient was admitted to this agency on 8/28/21 with the diagnosis of a sacral decubitus ulcer (wound on the tailbone) and muscle weakness. On 7/30/24, the treatment period from 8/28/21 to 10/26/21 was reviewed. Upon review of the skilled nursing notes for the wound care, it was determined that 14 of 17 skilled nursing daily notes (dated 9/7/21, 9/9/21, 9/11/21, 9/14/21, 9/16/21, 9/21/21, 9/25/21, 9/27/21, 9/29/21, 10/5/21, 10/15/21, 10/18/21, 10/21/21, and 10/25/21) had the following documented in the section under “Response to Care/Progress Toward Goals/Plan for Next Visit”: “Patient verbalized understanding of instruction on turning q2 to 3 hours and weight shifting q2-3 hours while sitting o prevent pressure on sacral area. Patient verbalized understanding of SN instruction to remind Dialysis technician to change his Dialysis port dressing as per protocol. Pt verbalized understanding when to call SN or PCP with S&S of infection and pain greater than 7/10 Pt verbalized understanding of the reason he in on Clindamycin 100 mg for prophylaxis to prevent infection and the need to stop use of mineral, iron while taking this medication without physician prescribed” [sic] The Administrator (Staff A) was queried regarding the identical documentation in 14 notes during an interview on 7/31/24 at 2:00 PM. Staff A stated that part carries through from the previous note and was not changed on the dates in questions. Staff A acknowledged the findings.”

“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 1 (P-3) of 5 discharged records reviewed, resulting in a lack of information communicated to ensure continuity of care for all patient’s discharged from this agency. Findings include: **Policy titled “Discharge Summary” (revised February 2024) stated, “2. 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: This 77-year-old patient was admitted to this agency on 8/28/21 with the diagnosis of a sacral decubitus ulcer (wound on the tailbone) and muscle weakness. During record review on 7/30/24, it was determined the discharge summary was written on 12/23/21. According to the fax confirmation sheet, the discharge summary was not sent to the doctor until 1/15/22 – 23 day after the discharge summary was written. The Administrator (Staff A) was unable to provide evidence of a fax sent informing the doctor of the discharge prior to this date and acknowledged the findings during an interview on 7/31/24 at 2:00 PM.”