Franklin Home Health Care

“Comprehensive Assessment of Patients CFR(s): 484.55 Condition of participation: Comprehensive assessment of patients. Each patient must receive, and an HHA must provide, a patient-specific, comprehensive assessment. For Medicare beneficiaries, the HHA must verify the patient’s eligibility for the Medicare home health benefit including homebound status, both at the time of the initial assessment visit and at the time of the comprehensive assessment. This Condition is not met as evidenced by: Based on record review and interview, the agency failed to ensure the initial assessment was performed by the registered nurse to determine immediate care and support needs for the patient in 2 (P-1, and P-6) out of 5 sample records reviewed in which nursing and rehab services were ordered on the referral, and failed to ensure the initial assessment was performed within 48 hours of referral in 1 (P-2) of 7 sample records reviewed, potentially resulting in unmet care and support needs for these patients (See G514); failed to ensure the comprehensive assessment accurately reflected the patient’s health and psychosocial status in 1 (P-2) of 7 sample records reviewed resulting in confusing information documented by the home health agency and the potential to delay communication between the patient and home health agency in the event of an emergency (See G528); and, failed to ensure the comprehensive assessment included a review of all medications the patient was currently using in order to identify potential adverse effects and drug reactions in 6 (P-1, P-2, P-3, P-4, P-5, P-6) of 7 sample records reviewed potentially resulting in unidentified significant side effects and/or significant drug interactions for these patients, and the potential for poor patient outcomes (See G536). The cumulative effects of this systemic problem resulted in the Home Health Agency’s inability to ensure the provision of quality health care in a safe environment for the condition of participation of 42 CFR 484.55 Comprehensive Assessment of Patients.”

“Organization and administration of services CFR(s): 484.105 Condition of participation: Organization and administration of services. The HHA must organize, manage, and administer its resources to attain and maintain the highest practicable functional capacity, including providing optimal care to achieve the goals and outcomes identified in the patient’s plan of care, for each patient’s medical, nursing, and rehabilitative needs. The HHA must assure that administrative and supervisory functions are not delegated to another agency or organization, and all services not furnished directly are monitored and controlled. The HHA must set forth, in writing, its organizational structure, including lines of authority, and services furnished. This Condition is not met as evidenced by: Based on record review and interview, the agency failed to ensure clinical manager oversight when coordinating patient care in 1 (P-6) of 5 records reviewed in which nursing services were ordered on the referral resulting in a delay of nursing care and services and the potential for a poor patient outcome (See G962); failed to ensure clinical manager oversight when coordinating referrals for care in 1 (P-1) of 1 sample records reviewed with Occupational Therapy (OT) requested on the referral resulting in lack of referral for OT services and potential patient decline (See G964); failed to ensure clinical manager oversight for assuring the continual assessment of patient needs in 2 (P-4 and P-5) of 5 sampled records reviewed in which both nursing and therapy services were utilized, resulting in a lack of ongoing clinical assessments throughout the episode of care potentially resulting in poor patient outcomes (See G966); and, failed to ensure clinical manager oversight when assuring development, implementation, and updates of the individualized plan of care to include nursing services in 1 (P-6) of 5 sample records reviewed for which nursing services were ordered resulting in no development, no implementation, and no updates to include nursing on the individualized plan of care for this patient, and the potential for a poor patient outcome (See G968). The cumulative effects of this systemic problem resulted in the Home Health Agency’s inability to ensure the provision of quality health care in a safe environment for the condition of participation of 42 CFR 484.105 Organization and administration of services.”

“EP Training Program CFR(s): 484.102(d)(1) §403.748(d)(1), §416.54(d)(1), §418.113(d)(1), §441.184(d)(1), §460.84(d)(1), §482.15(d)(1), §483.73(d)(1), §483.475(d)(1), §484.102(d)(1), §485.68(d)(1), §485.542(d)(1), §485.625(d)(1), §485.727(d)(1), §485.920(d)(1), §486.360(d)(1), §491.12(d)(1). *[For RNCHIs at §403.748, ASCs at §416.54, Hospitals at §482.15, ICF/IIDs at §483.475, HHAs at §484.102, REHs at §485.542, “Organizations” under §485.727, OPOs at §486.360, RHC/FQHCs at §491.12:] (1) Training program. The [facility] must do all of the following: (i) Initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles. (ii) Provide emergency preparedness training at least every 2 years. (iii) Maintain documentation of all emergency preparedness training. (iv) Demonstrate staff knowledge of emergency procedures. (v) If the emergency preparedness policies and procedures are significantly updated, the [facility] must conduct training on the updated policies and procedures. *[For Hospices at §418.113(d):] (1) Training. The hospice must do all of the following: (i) Initial training in emergency preparedness policies and procedures to all new and existing hospice employees, and individuals providing services under arrangement, consistent with their expected roles. (ii) Demonstrate staff knowledge of emergency procedures. (iii) Provide emergency preparedness training at least every 2 years. (iv) Periodically review and rehearse its emergency preparedness plan with hospice employees (including nonemployee staff), with special emphasis placed on carrying out the procedures necessary to protect patients and others. (v) Maintain documentation of all emergency preparedness training. (vi) If the emergency preparedness policies and procedures are significantly updated, the hospice must conduct training on the updated policies and procedures. *[For PRTFs at §441.184(d):] (1) Training program. The PRTF must do all of the following: (i) Initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles. (ii) After initial training, provide emergency preparedness training every 2 years. (iii) Demonstrate staff knowledge of emergency procedures. (iv) Maintain documentation of all emergency preparedness training. (v) If the emergency preparedness policies and procedures are significantly updated, the PRTF must conduct training on the updated policies and procedures. *[For PACE at §460.84(d):] (1) The PACE organization must do all of the following: (i) Initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing on-site services under arrangement, contractors, participants, and volunteers, consistent with their expected roles. (ii) Provide emergency preparedness training at least every 2 years. (iii) Demonstrate staff knowledge of emergency procedures, including informing participants of what to do, where to go, and whom to contact in case of an emergency. (iv) Maintain documentation of all training. (v) If the emergency preparedness policies and procedures are significantly updated, the PACE must conduct training on the updated policies and procedures. *[For LTC Facilities at §483.73(d):] (1) Training Program. The LTC facility must do all of the following: (i) Initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected role. (ii) Provide emergency preparedness training at least annually. (iii) Maintain documentation of all emergency preparedness training. (iv) Demonstrate staff knowledge of emergency procedures. *[For CORFs at §485.68(d):](1) Training. The CORF must do all of the following: (i) Provide initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles. (ii) Provide emergency preparedness training at least every 2 years. (iii) Maintain documentation of the training. (iv) Demonstrate staff knowledge of emergency procedures. All new personnel must be oriented and assigned specific responsibilities regarding the CORF’s emergency plan within 2 weeks of their first workday. The training program must include instruction in the location and use of alarm systems and signals and firefighting equipment. (v) If the emergency preparedness policies and procedures are significantly updated, the CORF must conduct training on the updated policies and procedures. *[For CAHs at §485.625(d):] (1) Training program. The CAH must do all of the following: (i) Initial training in emergency preparedness policies and procedures, including prompt reporting and extinguishing of fires, protection, and where necessary, evacuation of patients, personnel, and guests, fire prevention, and cooperation with firefighting and disaster authorities, to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles. (ii) Provide emergency preparedness training at least every 2 years. (iii) Maintain documentation of the training. (iv) Demonstrate staff knowledge of emergency procedures. (v) If the emergency preparedness policies and procedures are significantly updated, the CAH must conduct training on the updated policies and procedures. *[For CMHCs at §485.920(d):] (1) Training. The CMHC must provide initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles, and maintain documentation of the training. The CMHC must demonstrate staff knowledge of emergency procedures. Thereafter, the CMHC must provide emergency preparedness training at least every 2 years. This Standard is not met as evidenced by: Based on record review and interview, the agency failed to ensure staff were provided with emergency preparedness training at least every 2 years potentially resulting in unprepared staff during an emergency. Findings include: The agency’s Emergency Preparedness (EP) documentation was reviewed on 9/12/24. During review it was noted that there was no documented evidence of staff training for the years of 2024, 2023, and 2022. During interview on 9/12/24 at 12:30 p.m. with the Administrator (Staff A) and the Clinical Manager (Staff B), query was made regarding EP training for staff. Staff B stated that other than orientation training, the agency has not been providing EP training every 2 years.”

“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 the registered nurse accurately prepared clinical notes with appropriately authenticated and dated entries in 1 (P-5) of 5 records reviewed for which nursing services were ordered resulting in contents in the clinical record being inaccurate. Findings include: P-5: This 90-year-old was admitted to the agency on 5/6/24 with diagnoses including type 2 Diabetes; Poly-osteoarthritis (degenerative changes in many joints); and high blood pressure. The medical record was reviewed on 9/11/24. During review of the plan of care (POC) dated 5/6/24 through 7/4/24, it was noted that nursing services were ordered at a frequency of 1 time per week for 4 weeks. The registered nurse (RN) made a visit 1 time a week for the first 2 weeks. On the third week, the nurse documented two visits on 5/24/24 (one routine and one discharge). It was noted the RN documented different clinical data including vital signs on each visit made on 5/24/24. On the routine visit, the RN signed the visit note on 5/24/24. On the discharge visit, the RN dated the visit for 5/24/24 but signed the visit note on 5/31/24. During interview on 9/12/24 at 10:30 a.m. with the Administrator (Staff A) and the Clinical Manager (Staff B), query was made to why the RN visited twice on 5/24/24. Staff B stated that it was most likely that the discharge visit was done on 5/31/24 but that the RN entered the wrong date of care, and this was not caught during quality review of the chart.”

“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 the initial assessment was performed by the registered nurse to determine immediate care and support needs for the patient in 2 (P-1, and P-6) out of 5 sample records reviewed in which nursing and rehab services were ordered on the referral, and failed to ensure the initial assessment was performed by within 48 hours of referral in 1 (P-2) of 7 sample records reviewed, potentially resulting in unmet care and support needs for these patients. Findings include: Agency policy titled “Initial Assessments/Comprehensive Assessments”; Revised February 2024, was reviewed on 9/12/24. On page 2., it stated “5. … A RN, PT or SLP must conduct the initial assessment visit within 48 hours of referral, within 48 hours of the patient’s return home or on the physician/practitioner-ordered start of care date… A patient who requires short term nursing determined at the start of care in addition to ongoing therapy is not considered a therapy-only case, e.g., a one-time visit by a nurse scheduled to remove sutures. Therefore, the RN must do the initial assessment.” P-1: This 81-year-old was admitted to the agency on 9/6/24 with diagnoses including arthritis of multiple joints; Rheumatoid arthritis (long term disorder affecting the joints); and type 2 Diabetes. The medical record was reviewed on 9/11/24. During review, it was noted that the referral was received by the agency on 9/5/24 and signed by the referring physician requesting home health services to include nursing, physical therapy (PT), and occupational therapy. The start of care (SOC) comprehensive assessment was completed on 9/6/24 by PT services. P-2: This 74-year-old was admitted to the agency on 7/18/24 with diagnoses including Chronic Obstructive Pulmonary Disease; type 2 Diabetes; and high blood pressure. The medical record was reviewed on 9/10/24. During review, it was noted that the referral was dated 7/15/24 and was signed by the referring physician requesting home health services to include nursing and PT services. The SOC was completed by the registered nurse (RN) on 7/18/24 (72 hours after referral). P-6: This 86-year-old was admitted to the agency on 5/1/24 with diagnoses including type 2 Diabetes; end stage kidney disease; and Poly-osteoarthritis (degenerative changes in many joints). The medical record was reviewed on 9/11/24. During review, it was noted that the referral was dated 4/29/24 and was signed by the referring physician with request for home health services to include nursing and PT services. The SOC was completed on 5/1/24 by PT services. These findings were reviewed and acknowledged on 9/12/24 during interview at 10:30 a.m. with the Administrator (Staff A) and the Clinical Manager (Staff B).”

“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 health and psychosocial status in 1 (P-2) of 7 sample records reviewed resulting in confusing information documented by the home health agency and the potential to delay communication between the patient and home health agency in the event of an emergency. Findings include: Agency policy titled “Initial Assessments/Comprehensive Assessments”; Revised February 2024, was reviewed on 9/12/24. On page 1., it stated “1. Each patient admitted will receive a comprehensive assessment. The assessment will reflect the patient’ current health status and include information…”; on page 3., it stated “8. Age-specific and gender-specific findings, as appropriate…”; and on page 4., it stated “Psychosocial status… functional capacity within the community is intended to be a screening of the patient’s relationships, living environment, impact on the delivery of services and ability to participate in his/her own care.” P-2: This 74-year-old was admitted to the agency on 7/18/24 with diagnoses including Chronic Obstructive Pulmonary Disease; type 2 Diabetes; and high blood pressure. The medical record was reviewed on 9/10/24. During review of the start of care (SOC) comprehensive assessment on 7/18/24, it was noted that P-2’s gender was documented as “Female”. The SOC also contained the following documentation in the Skilled Intervention” area of the assessment as follows: “Patient stressed she took her… the entire time she… adherence to her… “. The following was also documented in the “Skilled Intervention” section, “… his home with patient and his wife… Informed patient and his wife… Patient and his wife are in agreement… Patient and his wife denied…” It was also noted that the RN instructed the patient to call a completely different home health agency if “he” got admitted to the hospital. It was unclear from the documentation who was being instructed and what the gender of the patient was. This finding was reviewed and acknowledged on 9/12/24 during interview at 10:30 a.m. with the Administrator (Staff A) and the Clinical Manager (Staff B).”

“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 observation, record review, and interview, the agency failed to ensure the comprehensive assessment included a review of all medications the patient was currently using in order to identify potential adverse effects and drug reactions in 6 (P-1, P-2, P-3, P-4, P-5, P-6) of 7 sample records reviewed potentially resulting in unidentified significant side effects and/or significant drug interactions for these patients, and the potential for poor patient outcomes. Findings include: Agency policy titled “Medication Reconciliation”; Revised February 2024, was reviewed on 9/12/24. On page 1., it stated “1. At time of admission, the admitting RN, PT, or SLP will create and document a complete list of medications that patient is taking at home, including dose, strength, route, and frequency… The Agency provides the patient and/or caregiver with written patient medication schedule/instructions, including medication name, dose, strength, route and frequency… In therapy only cases, the therapist submits a list of medications collected during the comprehensive assessment to RN for review, who contacts physician/practitioner if indicated… 2. Medications ordered while the patient is receiving care will be compared to the medication list/profile… The patient’s medication list in the home will also be updated.” P-1: This 81-year-old was admitted to the agency on 9/6/24 with diagnoses including arthritis of multiple joints; Rheumatoid arthritis (long term disorder affecting the joints); and type 2 Diabetes. A joint home visit was conducted on 9/10/24 at 1:15 p.m. with the physical therapy assistant. During the visit, review of the start of care (SOC) binder was conducted with permission of P-1. Within the binder, there was a handwritten form titled “Medication Profile”, dated 9/6/24, which listed all the patient’s current medications at the time of the SOC, and was completed by an agency physical therapist. It was noted that much of the medication information listed was difficult to read (either name, dose/route, and/or frequency). Interview with P-1 was completed during the visit and P-1 stated that she was aware of her medications and her daughter assisted her when needed. Review of the medication profile in the medical record was completed on 9/11/23 (5 days after the SOC). It was noted that the medication profile in the medical record included medications which were titled “Current Medications” but all with a start date of 3/21/24 (date of previous admission to agency). No medications had been entered from the SOC visit on 9/6/24. It was noted there were 20 medications in the medical record profile. Only 2/20 medications in the medical record were also listed on the home medication list as written in the profile. 18/20 were either not on the home list, or the dose and/or frequency was different on the home list than in the medical record profile. The home list also contained 10 other medications which were not listed in the medical record profile. The PT failed to submit the home list collected on 9/6/24 to the home health agency nurse for review, and the nurse failed to review the home medications as agency policy directs. P-2: This 74-year-old was admitted to the agency on 7/18/24 with diagnoses including Chronic Obstructive Pulmonary Disease; type 2 Diabetes; and high blood pressure. The medical record was reviewed on 9/10/24. During review, it was noted on the “Patient Medication Record” signed on 7/19/24 by the registered nurse (RN) who completed the start of care, the RN marked the box “No” for if the physician was contacted regarding medication discrepancies and left the box “No Discrepancies”, (NA), blank. No explanation was given for not contacting the physician. It was also noted the RN marked the box “Yes” that action was taken. Explanation given was that the medication profile was attached for “your review and reconciliation”. There was no evidence in the chart that a review or reconciliation was completed by an agency RN, or that the physician was aware of any potential discrepancies or interactions. P-3: This 81-year-old was admitted to the agency on 5/7/24 with diagnoses including Cerebral Palsy (neurological disorder affecting movement); Epilepsy (neurological disorder characterized by seizure activity in the brain); and high blood pressure. The medical record was reviewed on 9/10/24. During review, it was noted that no “Patient Medication Record” report with signature of RN completing a medication review and reconciliation was found in the medical record. P-4: This 80-year-old was admitted to the agency on 8/24/23 with diagnoses including type 2 Diabetes; osteoarthritis; and high blood pressure. The medical record was reviewed on 9/11/24. During review it was noted that the RN who completed the SOC, signed a “Patient Medication Record” form. The form has 2 sections regarding physician contact and notification and include the questions with answer boxes as follows: “Physician contacted regarding medication discrepancies:” and there are 3 answers that could be marked, “yes”, “no” or “NA” meaning there were no discrepancies found. “Please explain:” “Action taken:” with answers boxes for “yes” or “no” “Please explain:” “Physician notified of severe medication interactions?” And there are 3 answers that could be marked, “yes”, “no” or “NA” meaning no interactions were found. “Please explain:” No information was entered in the areas noted above regarding a medication review or reconciliation. It is unclear if a medication review and reconciliation was completed, if discrepancies were found, if physician contact was necessary, or what actions were taken because of the review. P-5: This 90-year-old was admitted to the agency on 5/6/24 with diagnoses including type 2 Diabetes; Poly-osteoarthritis (degenerative changes in many joints); and high blood pressure. The medical record was reviewed on 9/11/24. During review it was noted that the RN who completed the SOC, signed a “Patient Medication Record” form. The RN marked a box on the form indicating that no medication discrepancies were found but did not indicate if severe medication interactions were found, and if so, if the physician was contacted and any actions taken. It is unclear from the medical record whether a review and reconciliation were completed for this patient’s medications. P-6: This 86-year-old was admitted to the agency on 5/1/24 with diagnoses including type 2 Diabetes; end stage kidney disease; and Poly-osteoarthritis (degenerative changes in many joints). The medical record was reviewed on 9/11/24. During review, it was noted that no “Patient Medication Record” report with signature of RN completing a medication review and reconciliation was found in the medical record. These findings were reviewed and acknowledged on 9/12/24 during interview at 10:30 a.m. with the Administrator (Staff A) and the Clinical Manager (Staff B).”

“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 that were ordered by the physician in the plan of care for 1 (P-2) of 5 sample records reviewed for which nursing services were ordered resulting in this patient not receiving care and services as indicated by the physician and potentially resulting in poor patient outcomes. Findings include: Agency policy titled “Plan of Care- CMS #485 and Physician/Practitioners Orders”; Revised February 2024, was reviewed on 9/12/24. On page 6., it stated “26. … The Agency alerts the physician/practitioner to any changes that suggests a need to alter the plan of care. If the Agency provides fewer visits than the physician/practitioner orders, it has altered the plan of care and the physician/practitioner must be notified…” P-2: This 74-year-old was admitted to the agency on 7/18/24 with diagnoses including Chronic Obstructive Pulmonary Disease; type 2 Diabetes; and high blood pressure. The medical record was reviewed on 9/10/24. During review of the plan of care (POC) physician orders dated 7/18/24 through 9/15/24, it was noted that skilled nursing was ordered with a frequency of 1 time for 1 week, 2 times for 1 week, and then 1 time for 2 weeks (total of 4 weeks of care and 5 visits). During the second week of care (7/21/24- 7/27/24), there were no skilled nursing visits (should have been 2 times for that week). There was no documentation in the medical record which explained the lack of 2 nursing visits as ordered in the second week of care. There was no evidence that the skilled nursing frequency order had been changed since the POC orders. There was no evidence in the medical record that the physician was informed of the change in frequency from what was ordered in the POC. This finding was reviewed and acknowledged on 9/12/24 during interview at 10:30 a.m. with the Administrator (Staff A) and the Clinical Manager (Staff B).”

“Coordinate patient care CFR(s): 484.105(c)(2) Coordinating patient care, This Element is not met as evidenced by: Based on record review and interview, the agency failed to ensure clinical manager oversight when coordinating patient care in 1 (P-6) of 5 records reviewed in which nursing services were ordered on the referral resulting in a delay of nursing care and services and the potential for a poor patient outcome. Findings include: P-6: This 86-year-old was admitted to the agency on 5/1/24 with diagnoses including type 2 Diabetes; end stage kidney disease; and Poly-osteoarthritis (degenerative changes in many joints). The medical record was reviewed on 9/11/24. During review it was noted that the physician referral dated 4/29/24 requested home health services to include nursing and physical therapy (PT). The PT completed the start of care comprehensive assessment on 5/1/24. The plan of care (POC) dated 5/1/24 through 6/29/24 failed to include any nursing services. The registered nurse (RN) made the first nursing visit to the patient on 5/14/24 (13 days after the SOC). It was unclear from the medical record why a delay in nursing services occurred. There were no orders discontinuing nursing services and no evidence that the physician was made aware of the delay in nursing care. During interview on 9/12/24 at 10:30 a.m. with the Administrator (Staff A) and the Clinical Manager (Staff B), no explanation was provided to why there was a delay in nursing care.”

“Coordinate referrals; CFR(s): 484.105(c)(3) Coordinating referrals, This Element is not met as evidenced by: Based on record review and interview, the agency failed to ensure clinical manager oversight when coordinating referrals for care in 1 (P-1) of 1 sample records reviewed with Occupational Therapy (OT) requested on the referral resulting in lack of referral for OT services and potential patient decline. Findings include: P-1: This 81-year-old was admitted to the agency on 9/6/24 with diagnoses including arthritis of multiple joints; Rheumatoid arthritis (long term disorder affecting the joints); and type 2 Diabetes. The medical record was reviewed on 9/11/24. During review, it was noted that the referral received by the agency on 9/5/24 and signed by the referring physician requested home health services to include nursing, physical therapy (PT), and occupational therapy (OT). The plan of care dated 9/6/24 to 11/4/24 did not include orders for OT services and no OT services had been provided at the time of review. There were no notes regarding OT services on the start of care documentation, no evidence the patient refused OT services, and no new physician orders to discontinue OT. During interview on 9/12/24 at 10:30 a.m. with the Administrator (Staff A) and the Clinical Manager (Staff B), query was made to why OT services had not either been offered or started. Staff B stated that it must have been missed as a discipline requested on the referral.”

“Assure patient needs are continually assessed CFR(s): 484.105(c)(4) Assuring that patient needs are continually assessed, and This Element is not met as evidenced by: Based on record review and interview, the agency failed to ensure clinical manager oversight for assuring the continual assessment of patient needs in 2 (P-4 and P-5) of 5 sampled records reviewed in which both nursing and therapy services were utilized, resulting in a lack of ongoing clinical assessments throughout the episode of care potentially resulting in poor patient outcomes. Findings include: P-4: This 80-year-old was admitted to the agency on 8/24/23 with a primary diagnosis type 2 Diabetes and co-morbidities of osteoarthritis and high blood pressure. The medical record was reviewed on 9/11/24. During review, it was noted that the referral was received on 8/24/23 and was signed by the physician requesting physical therapy (PT) services only. The start of care (SOC) was completed on 8/24/23 by a registered nurse (RN). The plan of care (POC) was signed for the period of 8/24/23 through 10/22/23 and included the ordered frequency for RN as 1 time for 1 week (the SOC visit). PT services completed an evaluation on 8/29/23 and included a frequency of 2 times per week for 6 weeks. The PT evaluation did not include type 2 Diabetes as one of the patient’s diagnoses. No other RN visits were made after the initial SOC visit on 8/24/23. Examples of “Goals and Outcomes” on the POC included the following: Patient and caregiver will verbalize an understanding of factors that contribute to shortness of breath by 9/9/23. Patient will be free from signs and symptoms of hypo/hyperglycemia during the episode. The Patient/Caregiver will verbalize understanding of symptoms of cardiac complications and when to call 911 by: 9/8/23. The Patient/Caregiver will be independent with medication management by: 9/9/23. The Patient/Caregiver will be independent with setting up medication boxes by: 9/9/23. The Patient/Caregiver will verbalize understanding of medication regimen, dose, route, frequency, indications, and side effects by: (blank). The PT evaluation did not include any goals, treatments, or orders regarding the diagnosis of type 2 diabetes, cardiac complications, or medication management. PT services made 10 visits over 6 weeks. There were no PT visits that included monitoring of any of the above goals. The patient was discharged on 10/6/23. It is unknown whether the patient was able to verbalize factors contributing to shortness of breath, had any signs/symptoms of hypo/hyperglycemia; verbalized understanding of cardiac symptoms; was independent with medications or medication boxes; or could verbalize medication regime. There was no oversight by the Clinical Manager assuring the patient needs were continually assessed throughout the episode of care. P-5: This 90-year-old was admitted to the agency on 5/6/24 with diagnoses including type 2 Diabetes; Poly-osteoarthritis (degenerative changes in many joints); and high blood pressure. The medical record was reviewed on 9/11/24. During review of the POC dated 5/6/24 through 7/4/24, it was noted that “Goals and Outcomes” for this patient’s care included: Patient’s fasting blood sugar will remain between 65 milligrams/deciliter (mg/dL) and 240 mg/dL during the episode; Patient’s random blood sugar will remain between 70 mg/dL and 250 mg/dL during the episode; Patient’s weight will be maintained between 180 pounds (lbs.) and 182 lbs. during the episode. The RN discharged the patient from services on 5/24/24. PT continued to see the patient until 6/17/24 (4 more weeks). The patient “Goals and Outcomes” were not monitored by PT on any visit during the episode. There was no clinical manager oversight assuring the patient needs were continually assessed throughout the episode of care. These findings were reviewed and acknowledged on 9/12/24 during interview at 10:30 a.m. with the Administrator (Staff A), and the Clinical Manager (Staff B).”

“Assure implementation of plan of care CFR(s): 484.105(c)(5) Assuring the development, implementation, and updates of the individualized plan of care. This Element is not met as evidenced by: Based on record review and interview, the agency failed to ensure clinical manager oversight when assuring development, implementation, and updates of the individualized plan of care to include nursing services in 1 (P-6) of 5 sample records reviewed for which nursing services were ordered on the referral resulting in no development, no implementation, and no updates to include nursing on the individualized plan of care for this patient, and the potential for a poor patient outcomes. Findings include: P-6: This 86-year-old was admitted to the agency on 5/1/24 with diagnoses including type 2 Diabetes; end stage kidney disease; and Poly-osteoarthritis (degenerative changes in many joints). The medical record was reviewed on 9/11/24. During review it was noted that the physician referral dated 4/29/24 requested home health services to include nursing and physical therapy (PT). PT completed the start of care comprehensive assessment on 5/1/24. The registered nurse (RN) made the first nursing visit on 5/14/24 (13 days later). There were no skilled nursing physician orders for care, identified frequency, interventions or goals for care noted on the first nursing visit. The plan of care (POC) dated 5/1/24 through 6/29/24 was not appropriately updated to include nursing frequency, intervention, and goals. The RN made 2 additional visits (5/21/24 and 5/26/24). No discharge was completed by the nurse. It was unclear from the medical record how the RN determined the number of visits to make or when to discontinue making visits to the patient. The patient was not discharged from PT services until 6/6/24 (11 days later). During interview on 9/12/24 at 10:30 a.m. with the Administrator (Staff A) and the Clinical Manager (Staff B), query was made to how nursing frequency was determined, what the goals for RN services was, and how the RN knew when to discontinue making visits to this patient. No explanation was able to be provided.”

“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 sent to the primary care practitioner or other healthcare professional who would be responsible for providing care and services to the patient after discharge within 5 business days in 5 (P-3, P-4, P-5, P-6, P-7) of 6 records reviewed for which discharge from the agency occurred, and failed to ensure a transfer summary was sent to the physician within 2 days of becoming aware of an unplanned transfer 1 (P-2) of 1 record for which a transfer of care occurred during care. These findings could potentially result in lack of continuity of care for these patients. Findings include: Agency policy titled “Transfer/Referral Criteria and Planning”; Revised February 2024, was reviewed on 9/12/24. On page 2., it stated “3. … A written Transfer Summary concerning the Agency’s involvement with the patient… will be completed… 5. The Agency will send all necessary medical information pertaining to the patient’s current course of illness treatment… to the receiving facility or health care practitioner to ensure the safe and effective transition of care.” Agency policy titled “Discharge Summary”; Revised February 2024, was reviewed on 9/12/24. On page 1., it stated “1. A Discharge Summary form will be completed by the Skilled Nurse, Medical Social Worker and/or Therapist… 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…”; on page 2., it stated “12. The Agency will send all necessary medical information pertaining to the patient’s current course of illness treatment… to the receiving facility or health care practitioner to ensure the safe and effective transition of care.” P-2: This 74-year-old was admitted to the agency on 7/18/24 with diagnoses including Chronic Obstructive Pulmonary Disease; type 2 Diabetes; and high blood pressure. The medical record was reviewed on 9/10/24. During review, it was noted that the registered nurse (RN) completed a transfer discharge on 8/11/24. There was no documented evidence in the medical record that a transfer summary was sent to the health care facility where the patient had been admitted. During interview on 9/12/24 at 10:30 a.m. with the Administrator (Staff A) and the Clinical Manager (Staff B), query was made to whether a transfer summary was sent to the health care facility where the patient had been admitted. Staff B stated that they (the agency), did not send this information to the admitting facility. P-3: This 81-year-old was admitted to the agency on 5/7/24 with diagnoses including Cerebral Palsy (neurological disorder affecting movement); Epilepsy (neurological disorder characterized by seizure activity in the brain); and high blood pressure. The medical record was reviewed on 9/10/24. During review, it was noted the patient was discharged from RN care on 5/31/24 and discharged from physical therapy (PT) services on 6/22/24. There was no documented evidence that a discharge summary was sent to the health care practitioner responsible for the care of the patient after discharge. P-4: This 80-year-old was admitted to the agency on 8/24/23 with diagnoses including type 2 Diabetes; osteoarthritis; and high blood pressure. The medical record was reviewed on 9/11/24. During review, it was noted that the patient was discharged from RN care on 5/24/24 and discharged from PT services on 6/17/24. There was no documented evidence that a discharge summary was sent to the health care practitioner responsible for the care of the patient after discharge. P-5: This 90-year-old was admitted to the agency on 5/6/24 with diagnoses including type 2 Diabetes; Poly-osteoarthritis (degenerative changes in many joints); and high blood pressure. The medical record was reviewed on 9/11/24. During review, it was noted that the patient was discharged from RN services on 5/24/24 and PT services on 6/17/24. There was no documented evidence that a discharge summary was sent to the health care practitioner responsible for the care of the patient after discharge. P-6: This 86-year-old was admitted to the agency on 5/1/24 with diagnoses including type 2 Diabetes; end stage kidney disease; and Poly-osteoarthritis (degenerative changes in many joints). The medical record was reviewed on 9/11/24. During review, it was noted that the RN made the last visit on 5/26/24 (no discharge summary completed), and the PT discharged the patient on 6/6/24. There was no documented evidence that a discharge summary was sent to the health care practitioner responsible for the patient after discharge. P-7: This 77-year-old was admitted to the agency on 8/22/23 with diagnoses including chronic atrial fibrillation (abnormal rhythm of the heart); polyneuropathy (disease affecting many nerves); and abnormality when walking. The medical record was reviewed on 9/11/24. During review, it was noted that the RN made one visit (SOC on 8/22/23) and the PT discharged the patient on 9/29/23. There was no documented evidence that a discharge summary was sent to the health care practitioner responsible for the patient after discharge. During interview on 9/12/24 at 10:30 a.m. with Staff A and Staff B, query was made to whether a discharge summary was sent to the health care practitioner after discharge for P-3, P-4, P-5, P-6, or P-7. Staff B stated that although the physician was notified of discharge per each completed discharge visit, the discharge summary was not sent to the health care practitioner.”