Reliance Health Care LLC

“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 interview, personnel record review and document review, the agency failed to provide documented evidence the direct care staff members had signed and completed the training on the agency’s emergency preparedness (EP) plan for 8 of 10 employee files reviewed (Employee 2, 4, 5, 6, 7, 8, 9, and 10). The deficient practice had the potential to affect the direct care staff members’ ability to assist the agency in continuing to provide patient care and address safety needs of the patients, and staff members in protecting themselves in the event of an emergency. Findings include: A review of ten employee files and the agency’s EP binder revealed an annual EP training checklist titled Emergency Preparedness Training and Testing Program at least Annually. The checklist indicated the only sections to be filled-out were the Employee Name, Training/Testing given by, and Date. The topics included the following: - Emergency Preparedness Plan/Cycles - Risk assessment and Planning - Hazard Vulnerability Analysis (HVA) - Policy for Emergency Preparedness Planning - Communication Plan - Incident Command System - Updated Patient Roster - Staff Phone number - Emergency Resources Contact Information - Nevada Division of Emergency Management Contacts - Disaster Information Broadcasting System - Risk Classification of Patients - Triage System – Patient Category - Mitigation Activities - Emergency Preparedness Response Plan and Procedure - Home Health Care Emergency Preparedness Checklist - Log of Patient Needing Assistance During Disaster - Education and Training - Staff Handwritten Paper Medical Record Documentation The checklist for Employee 2, 4, 5, 6, 7, and 8 lacked documented evidence of the employees’ signature or acknowledgment of the training being provided. Employee 9 and 10 had no checklist on file. On 03/29/24 at 10:30 AM, the Human Resources (HR) Staff confirmed the findings. On 03/29/2024 at 10:49 AM, the Clinical Nursing Supervisor revealed being hired on 08/25/2023 and had not completed an EP training. On 03/29/2024 at 1:06 PM, the Administrator indicated the EP training checklist was provided to the six employees on 01/15/2024. The agency’s policy titled Emergency Preparedness and Response Plan dated 07/01/2020, documented the agency would provide initial training, and then training at least every two years thereafter on emergency preparedness policies and procedures to all new and existing staff, contract staff, and volunteers. The agency would maintain documentation of the training.”

“EP Testing Requirements CFR(s): 484.102(d)(2) §416.54(d)(2), §418.113(d)(2), §441.184(d)(2), §460.84(d)(2), §482.15(d)(2), §483.73(d)(2), §483.475(d)(2), §484.102(d)(2), §485.68(d)(2), §485.542(d)(2), §485.625(d)(2), §485.727(d)(2), §485.920(d)(2), §491.12(d)(2), §494.62(d)(2). *[For ASCs at §416.54, CORFs at §485.68, REHs at §485.542, OPO, “Organizations” under §485.727, CMHCs at §485.920, RHCs/FQHCs at §491.12, and ESRD Facilities at §494.62]: (2) Testing. The [facility] must conduct exercises to test the emergency plan annually. The [facility] must do all of the following: (i) Participate in a full-scale exercise that is community-based every 2 years; or (A) When a community-based exercise is not accessible, conduct a facility-based functional exercise every 2 years; or (B) If the [facility] experiences an actual natural or man-made emergency that requires activation of the emergency plan, the [facility] is exempt from engaging in its next required community-based or individual, facility-based functional exercise following the onset of the actual event. (ii) Conduct an additional exercise at least every 2 years, opposite the year the full-scale or functional exercise under paragraph (d)(2)(i) of this section is conducted, that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or individual, facility-based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the [facility’s] response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the [facility’s] emergency plan, as needed. *[For Hospices at 418.113(d):] (2) Testing for hospices that provide care in the patient’s home. The hospice must conduct exercises to test the emergency plan at least annually. The hospice must do the following: (i) Participate in a full-scale exercise that is community based every 2 years; or (A) When a community based exercise is not accessible, conduct an individual facility based functional exercise every 2 years; or (B) If the hospice experiences a natural or man-made emergency that requires activation of the emergency plan, the hospital is exempt from engaging in its next required full scale community-based exercise or individual facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional exercise every 2 years, opposite the year the full-scale or functional exercise under paragraph (d)(2)(i) of this section is conducted, that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or a facility based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (3) Testing for hospices that provide inpatient care directly. The hospice must conduct exercises to test the emergency plan twice per year. The hospice must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual facility-based functional exercise; or (B) If the hospice experiences a natural or man-made emergency that requires activation of the emergency plan, the hospice is exempt from engaging in its next required full-scale community based or facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional annual exercise that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or a facility based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop led by a facilitator that includes a group discussion using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the hospice’s response to and maintain documentation of all drills, tabletop exercises, and emergency events and revise the hospice’s emergency plan, as needed. *[For PRFTs at §441.184(d), Hospitals at §482.15(d), CAHs at §485.625(d):] (2) Testing. The [PRTF, Hospital, CAH] must conduct exercises to test the emergency plan twice per year. The [PRTF, Hospital, CAH] must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise; or (B) If the [PRTF, Hospital, CAH] experiences an actual natural or man-made emergency that requires activation of the emergency plan, the [facility] is exempt from engaging in its next required full-scale community based or individual, facility-based functional exercise following the onset of the emergency event. (ii) Conduct an [additional] annual exercise or and that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or individual, a facility-based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the [facility’s] response to and maintain documentation of all drills, tabletop exercises, and emergency events and revise the [facility’s] emergency plan, as needed. *[For PACE at §460.84(d):] (2) Testing. The PACE organization must conduct exercises to test the emergency plan at least annually. The PACE organization must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise; or (B) If the PACE experiences an actual natural or man-made emergency that requires activation of the emergency plan, the PACE is exempt from engaging in its next required full-scale community based or individual, facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional exercise every 2 years opposite the year the full-scale or functional exercise under paragraph (d)(2)(i) of this section is conducted that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or individual, a facility based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the PACE’s response to and maintain documentation of all drills, tabletop exercises, and emergency events and revise the PACE’s emergency plan, as needed. *[For LTC Facilities at §483.73(d):] (2) The [LTC facility] must conduct exercises to test the emergency plan at least twice per year, including unannounced staff drills using the emergency procedures. The [LTC facility, ICF/IID] must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise. (B) If the [LTC facility] facility experiences an actual natural or man-made emergency that requires activation of the emergency plan, the LTC facility is exempt from engaging its next required a full-scale community-based or individual, facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional annual exercise that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or an individual, facility based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the [LTC facility] facility’s response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the [LTC facility] facility’s emergency plan, as needed. *[For ICF/IIDs at §483.475(d)]: (2) Testing. The ICF/IID must conduct exercises to test the emergency plan at least twice per year. The ICF/IID must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise; or. (B) If the ICF/IID experiences an actual natural or man-made emergency that requires activation of the emergency plan, the ICF/IID is exempt from engaging in its next required full-scale community-based or individual, facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional annual exercise that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or an individual, facility-based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the ICF/IID’s response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the ICF/IID’s emergency plan, as needed. *[For HHAs at §484.102] (d)(2) Testing. The HHA must conduct exercises to test the emergency plan at least annually. The HHA must do the following: (i) Participate in a full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise every 2 years; or. (B) If the HHA experiences an actual natural or man-made emergency that requires activation of the emergency plan, the HHA is exempt from engaging in its next required full-scale community-based or individual, facility based functional exercise following the onset of the emergency event. (ii) Conduct an additional exercise every 2 years, opposite the year the full-scale or functional exercise under paragraph (d)(2)(i) of this section is conducted, that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or an individual, facility-based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the HHA’s response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the HHA’s emergency plan, as needed. *[For OPOs at §486.360] (d)(2) Testing. The OPO must conduct exercises to test the emergency plan. The OPO must do the following: (i) Conduct a paper-based, tabletop exercise or workshop at least annually. A tabletop exercise is led by a facilitator and includes a group discussion, using a narrated, clinically relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. If the OPO experiences an actual natural or man-made emergency that requires activation of the emergency plan, the OPO is exempt from engaging in its next required testing exercise following the onset of the emergency event. (ii) Analyze the OPO’s response to and maintain documentation of all tabletop exercises, and emergency events, and revise the [RNHCI’s and OPO’s] emergency plan, as needed. *[ RNCHIs at §403.748]: (d)(2) Testing. The RNHCI must conduct exercises to test the emergency plan. The RNHCI must do the following: (i) Conduct a paper-based, tabletop exercise at least annually. A tabletop exercise is a group discussion led by a facilitator, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (ii) Analyze the RNHCI’s response to and maintain documentation of all tabletop exercises, and emergency events, and revise the RNHCI’s emergency plan, as needed. This Standard is not met as evidenced by: Based on interview and document review, the agency failed to provide documented evidence exercises to test the emergency plan were conducted at least annually for the year 2022, 2023, and 2024. The deficient practice had the potential for failing to evaluate the effectiveness of the agency’s emergency plan and to assess the staff members’ ability and readiness to respond during an emergency. Findings include: A review of the agency’s Emergency Preparedness (EP) Binders lacked documented evidence of exercises or testing of the agency’s EP Plan for the years 2022, 2023, and 2024. On 03/29/2024 at 1:06 PM, the Administrator confirmed the findings and acknowledged the exercises to test the EP Plan should have been conducted at least annually. The agency’s policy titled Emergency Preparedness and Response Plan dated 07/01/2020, documented the agency would conduct exercises to test the emergency plan at least annually. The agency would do the following: - Participate in a full-scale community-based exercise every two years. - Conduct an additional exercise every two years, opposite the year the full-scale community-based or facility-based functional exercise was conducted.”

“Encoding and transmitting OASIS CFR(s): 484.45(a) Standard: An HHA must encode and electronically transmit each completed OASIS assessment to the CMS system, regarding each beneficiary with respect to which information is required to be transmitted (as determined by the Secretary), within 30 days of completing the assessment of the beneficiary. This Standard is not met as evidenced by: Based on record review and interview, the agency failed to encode and electronically transmit each completed OASIS assessment within 30 days of completing the assessment of the beneficiary for 5 of 12 quarters. Findings include: The pre-survey CMS OASIS submission report revealed the agency failed to submit its OASIS assessments within 30 days at an error rate greater than 10% for the following quarters: 15%+ for quarter 1 of 2021. 21%+ for quarter 4 of 2021. 10%+ for quarter 2 of 2022. 13%+ for quarter 4 of 2022. 10%+ for quarter 3 of 2023. Validation reports were reviewed, confirming the same. On 3/27/2024 in the afternoon, the agency’s OASIS Coordinator confirmed the findings.”

“12 hours inservice every 12 months CFR(s): 484.80(d) Standard: In-service training. A home health aide must receive at least l2 hours of in-service training during each 12-month period. In-service training may occur while an aide is furnishing care to a patient. This Standard is not met as evidenced by: Based on interview, personnel record review and document review, the agency failed to provide documented evidence of the completion of at least 12 hours of in-service training during each 12-month period for 1 of 2 sampled home health aides (Employee 2). The deficient practice had the potential for failing to ensure qualified aides were providing services to the patients. Findings include: Employee 2 was hired on 08/20/2021as Certified Nursing Assistant (CNA)/Home Health Aide (HHA). On 03/29/2024 at 9:48 AM, a review of Employee 2’s personnel record with the Human Resources (HR) Staff revealed there was no documented evidence of the completion of at least 12 hours of in-service training for the year 2022 and 2023. The HR Staff confirmed the findings and revealed the latest 12 hours in-service training completion filed in Employee 2’s personnel record was dated 09/03/2021. The HR Staff acknowledged there should have been a record or tracking of HHA’s in-service training to comply with required 12 hours of in-service training during each 12-month period. The agency’s policy titled Home Health Aide Skilled Competency (undated), indicated the documentation of individual Home Health Aide training and/or competency should be maintained in the Home Health Aide’s personnel file.”

“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 interview and record review, the agency failed to ensure skilled visits were appropriately authenticated, dated and timed for 3 of 7 patients (Patient 1, 3, and 6). The deficient practice had the potential for failing to ensure the care and services were provided to the patients in a timely manner and documented accurately. Patient #6 On 2/27/2024, the agency admitted Patient #6 with chronic obstructive pulmonary disease exacerbation. On 2/27/2024, the plan of care revealed a physician ordered skilled nursing visits twice weekly for three weeks and then weekly. On 3/28/2024, the electronic clinical record lacked documented evidence any skilled nursing visits were documented and entered into the electronic clinical record. Route sheets were requested and provided as evidence the skilled nursing visits were conducted but not yet entered into the electronic clinical record. On 3/29/2024, the electronic clinical record contained documentation of all the required skilled nursing visits. On 3/29/2024 at 4:00 PM, the Licensed Practical Nurse (LPN) assigned the visits, indicated the visits were all electronically entered on 3/28/2024. The above visits, although all entered on 3/28/2024, were all digitally signed on the respective scheduled visit dates preceding 3/28/2024. The software data was retrieved confirming the issue. On 4/02/2024 in the morning, the OASIS Coordinator indicated the digitalized signature automatically defaulted to the scheduled visit date when the clinician signed off on the visit, even if signing days or weeks later. The software allowed clinicians to digitalize their signature for late entries, but clinicians chose not to utilize the function. Hence all signatures on signed documents defaulted to scheduled visit dates for date and time, even though signatures were entered days or weeks later. The agency did not have a policy addressing late entries to the electronic clinical record and appropriately authenticating those entries. Findings include: Patient 1 (P1) P1 was admitted on 12/11/2023, with diagnoses including diabetes mellitus II uncontrolled and dystonia. P1’s current recertification period was from 02/09/2024 to 04/08/2024. On 03/28/2024 at 12:30 PM, a review of P1’s electronic medical record (EMR) revealed there were no Skilled Nursing Visit notes completed and entered for the week of 03/10/2024 to 03/16/2024 and 03/17/2024 to 03/23/2024. The Clinical Nursing Supervisor was shown P1’s visit calendar from the EMR and confirmed there were no SN visit notes completed for the said two weeks. The Clinical Nursing Supervisor revealed a Licensed Practical Nurse (LPN) performed SN visit on 03/16/2024 and 03/23/2024, and the notes should have been completed and entered into P1’s EMR on 03/18/2024 and 03/25/2024, respectively. On 03/29/2024, a follow-up review of P1’s EMR revealed there were SN Visit notes entered into the patient’s EMR for 03/16/2024 and 03/23/2024 SN visits. The LPN (Licensed Practical Nurse) – Skilled Nursing Visit notes dated 03/16/2024, indicated the document was digitally signed by the LPN on 03/16/2024. The Work Log (documentation history) of the LPN – Skilled Nursing Visit notes documented the name of the LPN as the user (author) and the notes were submitted with signature on 03/28/2024 at 6:41 PM. The LPN – Skilled Nursing Visit notes dated 03/23/2024, indicated the document was digitally signed by the LPN on 03/23/2024. The Work Log of the LPN – Skilled Nursing Visit notes documented the name of the LPN as the user and the notes were submitted with signature on 03/28/2024 at 6:50 PM. Patient 3 (P3) P3 was admitted on 07/14/2023, with diagnoses including Parkinson’s disease and physical debility. P3’s current recertification period was from 03/10/2024 to 05/08/2024. On 03/28/2024 at 1:28 PM, a review of P3’s EMR revealed there were no SN visit notes completed and entered for the week of 03/10/2024 to 03/16/2024 and 03/17/2024 to 03/23/2024. The Clinical Nursing Supervisor was shown P3’s visit calendar from the EMR and confirmed there were no SN visit notes completed for the said two weeks. The Clinical Nursing Supervisor acknowledged the completion and submission of the SN visit notes for P3 were overdue. On 03/29/2024, a follow-up review of P3’s EMR revealed there were SN Visit notes entered into the patient’s EMR for 03/12/2024, 03/15/2024, 03/17/2024, and 03/19/2024 SN visits. The LPN – Skilled Nursing Visit notes dated 03/12/2024, indicated the document was digitally signed by the LPN on 03/12/2024. The Work Log of the LPN – Skilled Nursing Visit notes documented the name of the LPN as the user and the notes were submitted with signature on 03/28/2024 at 5:52 PM. The LPN – Skilled Nursing Visit notes dated 03/15/2024, indicated the document was digitally signed by the LPN on 03/15/2024. The Work Log of the LPN – Skilled Nursing Visit notes documented the name of the LPN as the user and the notes were submitted with signature on 03/28/2024 at 5:56 PM. The LPN – Skilled Nursing Visit notes dated 03/17/2024, indicated the document was digitally signed by the LPN on 03/17/2024. The Work Log of the LPN – Skilled Nursing Visit notes documented the name of the LPN as the user and the notes were submitted with signature on 03/28/2024 at 6:05 PM. The LPN – Skilled Nursing Visit notes dated 03/19/2024, indicated the document was digitally signed by the LPN on 03/19/2024. The Work Log of the LPN – Skilled Nursing Visit notes documented the name of the LPN as the user and the notes were submitted with signature on 03/28/2024 at 6:16 PM. On 03/29/2024 at 3:52 PM, the LPN confirmed the LPN – Skilled Nursing Visit notes for P1 and P3 mentioned above were all started, completed, submitted, and digitally signed on 03/28/2024 as documented in the Work Log for each visit notes. The LPN revealed the date which appeared opposite the digital signature was the actual visit date and not the date when the LPN signed the document. The LPN acknowledged the date on the LPN’s digital signature should have been corrected to reflect the actual date when the visit notes were completed, submitted, and signed.”

“Protection of records CFR(s): 484.110(d) Standard: Protection of records. The clinical record, its contents, and the information contained therein must be safeguarded against loss or unauthorized use. The HHA must be in compliance with the rules regarding protected health information set out at 45 CFR parts 160 and 164. This Standard is not met as evidenced by: Based on record review, interview and policy review, the agency failed to ensure it safeguarded patient information from loss or unauthorized use. The deficient practice placed the patient and the agency at risk for unauthorized release of medical or patient information. Findings include: Patient #6 On 2/27/2024, the agency admitted Patient #6 with chronic obstructive pulmonary disease exacerbation. On 2/27/2024, the plan of care revealed a physician ordered skilled nursing visits twice weekly for three weeks and then weekly. On 3/28/2024, the electronic clinical record lacked documented evidence any skilled nursing visits were documented and entered into the electronic clinical record. Route sheets were requested and provided as evidence the skilled nursing visits were conducted but not yet entered into the electronic clinical record. On 3/29/2024, the electronic clinical record contained documentation of all the required skilled nursing visits. On 3/29/2024 at 4:00 PM: The Licensed Practical Nurse (LPN) assigned the visits, indicated the visits were all electronically entered on 3/28/2024. The LPN was asked how assessment information could be remembered when entering a half dozen visits simultaneously into the electronic clinical record. For instance, if anything stood out like edema on one visit compared to other visits. The LPN indicated pictures would be taken of a particular issue to help differentiate one visit from another. It would be documented on paper, and then any photos would be deleted. The LPN used a personal phone for the pictures. On 4/02/2024 at 11:50 AM, the OASIS Coordinator indicated the agency used a wound care contractor at times, and the contractor sent a fax description with images obtained of patient wounds. Presumably, the contractor used its own electronic devices to document wounds and wound progress. The agency’s employees were not allowed to use electronic devices to document patient assessments. There were no other policies governing the use of electronic devices owned by clinicians, the agency or contractors. The Section III.1. of Reporting, Documentation and Photographic Documentation of Wounds and Wound Treatment policy revealed photographs of a patient’s wounds were not to be taken by clinicians, either using electronic equipment provided by the agency or the clinicians’ personal photographic devices.”

“Social Worker CFR(s): 484.115(m) Standard: Social worker. A person who has a master’s or doctoral degree from a school of social work accredited by the Council on Social Work Education, and has 1 year of social work experience in a health care setting. This Standard is not met as evidenced by: Based on interview, personnel record review and document review, the agency failed to ensure the social worker (Employee 7) hired to provide the medical social services, obtained a master’s or doctoral degree in social work. The deficient practice had the potential for the patients not receiving the required social services per the physician’s orders from a qualified staff. Findings include: Employee 7 was hired on 07/02/2005 as a Social Worker. Employee 7’s Job Description documented the following: - Subject: Medical Social Worker (MSW) - Job Description: An individual who possessed a master’s degree in social work who, in collaboration with the multidisciplinary team, had input in the development of the plan of treatment for those patients requiring social work intervention. - Position requirements included Master of Social Work degree from a school of social work accredited by the Council on Social Work Education. The term “Master” was crossed out and superimposed by the acronym “BSW” (Bachelor of Social Work). - Employee 7 signed the Job Description on 07/01/2005. Employee 7’s personnel record lacked documented evidence of a master’s degree or doctoral degree in social work. The agency’s list of active employees did not include any other Social Worker aside from Employee 7. On 03/29/2024 at 10:55 AM, the Human Resources (HR) Staff confirmed the findings and explained the need to contact Employee 7 to confirm if the employee had a master’s degree. On 03/29/2024 at 12:57 PM, Employee 7 confirmed being a Licensed Social Worker but did not obtain a master’s degree in social work. On 04/02/2024 in the morning, the HR staff provided a copy of the most recent visit performed by Employee 7. The visit calendar documented Employee 7 completed an MSW evaluation for Patient 8 on 01/26/2024. The MSW Evaluation dated 01/26/2024, documented the following signatures: - Digitally signed by Employee 7 (with the name of Employee 7 and MSW after the name) - Handwritten signature of the physician The agency’s policy titled Social Worker/Assistant – Job Duties and Responsibilities (undated), documented medical social services, when provided, should be given by a qualified Social Worker or a qualified Social Worker Assistant under the supervision of a qualified Social Worker.”

“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, interview, record review and document review, the agency failed to ensure the comprehensive assessment included an accurate patient medication record and listed all the medications the patient was taking for 3 of 7 sampled patients (Patient 1, 5, and 7). The deficient practice had the potential for failing to provide an effective medication management for the patients. Patient #5 On 3/31/2023, the agency admitted Patient #5 with chronic obstructive pulmonary disease acute exacerbation. On 8/04/2023, a physician ordered Megestrol 40 milligrams daily and Quetiapine 20 milligrams nightly. On 8/25/2023, a physician ordered Vitamin B12 1000 milligrams injection monthly. On 9/01/2023, a physician ordered Rocephin 1 Gram intravenous daily x 5 days and Normal Saline intravenous infusion at 80 milliliters per hour. On 9/08/2023, the agency discharged the patient to Hospice care. The medication profile lacked documented evidence of the inclusion of Megestrol, Quetiapine, Vitamin B12, Rocephin and Normal Saline. On 3/29/2024 in the late afternoon, the clinical supervisor confirmed the findings. Patient #7 On 10/28/2023, the agency admitted Patient #7 with acute hypoxic respiratory failure and oxygen dependence. On 10/28/2023, the plan of care listed oxygen supplies as part of the durable medical equipment the patient required. On 11/01/2023, a physician ordered Furosemide 40 milligrams daily. On 11/19/2023, the agency discharged the patient. The medication profile lacked documented evidence of the inclusion of Oxygen and Furosemide. On 3/29/2024 in the late afternoon, the clinical supervisor confirmed the findings. Findings include: The agency’s policy titled Medication Reconciliation (undated), documented the agency would reconcile patient’s medications at the time of admission and on an ongoing basis in order to recognize any potential adverse effects and drug interactions. Medications ordered while the patient was receiving care would be associated to the medication list/profile. The medication list/profile would be updated with each new or changed medication. The patient’s medication list in the home would also be updated. Patient 1 (P1) P1 was admitted on 12/11/2023, with diagnoses including diabetes mellitus II uncontrolled and dystonia. The physician’s order dated 12/15/2023, documented Baclofen 10 milligram (mg) take one tablet by mouth once daily as needed (PRN) for muscle spasms. P1’s current recertification period was from 02/09/2024 to 04/08/2024. The Patient Medication Record dated 02/09/2024, documented Lidocaine External 5% one patch transdermal 12 hours on, 12 hours off. The Patient Medication Record did not include Baclofen 10 mg ordered by the patient’s primary physician on 12/15/2023. On 03/27/2024 at 2:12 PM, during a home visit with P1, a reconciliation of the patient’s medications was conducted with the patient’s caregiver. A copy of the Patient Medication Record dated 02/09/2024 was maintained in P1’s home health folder. The patient’s home medications included Baclofen 10 mg. The label of the medication documented the dispense date was 01/04/2024. The caregiver confirmed the observation and indicated the patient had been taking Baclofen 10 mg as needed. During the home visit, the Home Health Aide (HHA), caregiver, and P1 confirmed Lidocaine Patch was not applied to the patient. P1 and the caregiver revealed the Lidocaine Patch was applied to the patient as needed and not scheduled or daily. P1 indicated the Lidocaine Patch had not been applied to the patient since last week. On 03/27/2024 at 4:02 PM, the Clinical Nursing Supervisor explained P1’s comprehensive assessment included the Patient Medication Record dated 02/09/2024. The Clinical Nursing Supervisor indicated the Patient Medication Record should have included all the medications the patient was taking at the time of the comprehensive assessment and an accurate physician’s order. The Clinical Nursing Supervisor acknowledged P1’s Baclofen 10 mg was ordered by the patient’s primary physician on 12/15/2023, and should have been included in the Patient Medication Record. The Clinical Nursing Supervisor revealed P1’s Lidocaine Patch was ordered PRN and not scheduled. The nurse should have documented the accurate physician’s order in the Patient Medication Record.”

“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 observation, interview, record review and document review, the agency failed to ensure the individualized plan of care included all medications the patients were receiving for 3 of 7 sampled patients (Patient 1, 5, and 7). The deficient practice had the potential for failing to provide an effective medication management for the patients. Patient #5 On 3/31/2023, the agency admitted Patient #5 with chronic obstructive pulmonary disease acute exacerbation. On 8/04/2023, a physician ordered Megestrol 40 milligrams daily and Quetiapine 20 milligrams nightly. On 8/25/2023, a physician ordered Vitamin B12 1000 milligrams injection monthly. On 9/01/2023, a physician ordered Rocephin 1 Gram intravenous daily x 5 days and Normal Saline intravenous infusion at 80 milliliters per hour. On 9/08/2023, the agency discharged the patient to Hospice care. The plan of care lacked documented evidence of the inclusion of Megestrol, Quetiapine, Vitamin B12, Rocephin and Normal Saline. On 3/29/2024 in the late afternoon, the clinical supervisor confirmed the findings. Patient #7 On 10/28/2023, the agency admitted Patient #7 with acute hypoxic respiratory failure and oxygen dependence. On 10/28/2023, the plan of care listed oxygen supplies as part of the durable medical equipment the patient required. On 11/01/2023, a physician ordered Furosemide 40 milligrams daily. On 11/19/2023, the agency discharged the patient. The plan of care lacked documented evidence of the inclusion of Oxygen and Furosemide. On 3/29/2024 in the late afternoon, the clinical supervisor confirmed the findings. Findings include: The agency’s policy titled Medication Reconciliation (undated), documented the agency would reconcile patient’s medications at the time of admission and on an ongoing basis in order to recognize any potential adverse effects and drug interactions. Medications ordered while the patient was receiving care would be associated to the medication list/profile. The medication list/profile would be updated with each new or changed medication. The patient’s medication list in the home would also be updated. Patient 1 (P1) P1 was admitted on 12/11/2023, with diagnoses including diabetes mellitus II uncontrolled and dystonia. P1’s current recertification period was from 02/09/2024 to 04/08/2024. On 03/27/2024, the Clinical Nursing Supervisor provided a copy of the patient’s Home Health Certification and Plan of Care prior to home visit. The Clinical Nursing Supervisor revealed the copy was the latest plan of care for P1 and included all the medications the patient was currently receiving. On 03/27/2024 at 2:12 PM, during a home visit with P1, a reconciliation of the patient’s medications was conducted with the patient’s caregiver. The patient’s home medications included the following: - Baclofen 10 milligram (mg). The label of the medication documented the dispense date was 01/04/2024. - Carbidopa/Levodopa 25 mg-100 mg. The label of the medication documented the dispense date was 02/23/2024. The caregiver confirmed the observation and indicated the patient had been taking Baclofen 10 mg as needed and Carbidopa/Levodopa 25 mg-100 mg three times a day (TID). P1’s latest plan of care did not include the above-named medications. On 03/27/2024 at 4:02 PM, the Clinical Nursing Supervisor explained the nurses were expected to reconcile a patient’s home medications with the latest plan of care every home visit. The plan of care should have included all the medications the patient was receiving and ordered by the physicians. The Clinical Nursing Supervisor acknowledged P1’s Baclofen 10 mg was ordered by the patient’s primary physician on 12/15/2023 and should have been included in the patient’s plan of care. The Clinical Nursing Supervisor explained not being aware of a physician’s order for P1’s Carbidopa/Levodopa 25 mg-100 mg. On 03/28/2024 at 12:58 PM, the Clinical Nursing Supervisor provided a copy of the following physician’s orders for P1: - The physician’s order dated 12/15/2023, documented Baclofen 10 mg, take one tablet by mouth once daily as needed (PRN) for muscle spasms. - The physician’s order dated 02/23/2024, documented Carbidopa/Levodopa 25 mg-100 mg, one tablet by mouth TID for Parkinsonism and dystonia. The Clinical Nursing Supervisor revealed calling the patient’s dispensing pharmacy to obtain copies of the physician’s orders. The Clinical Nursing Supervisor indicated P1’s neurologist prescribed Carbidopa/Levodopa 25 mg-100 mg., but was not communicated to the agency. The Clinical Nursing Supervisor acknowledged the nurses should have reconciled the patient’s medications every home visit and informed the Clinical Nursing Supervisor for any discrepancy. The Clinical Nursing Supervisor confirmed Baclofen 10 mg and Carbidopa/Levodopa 25 mg-100 mg should have been included in P1’s latest plan of care.”

“All orders recorded in plan of care CFR(s): 484.60(a)(3) All patient care orders, including verbal orders, must be recorded in the plan of care. This Element is not met as evidenced by: Based on observation, interview, record review and document review, the agency failed to ensure all physician’s orders for the patients’ medications were recorded in the individualized plan of care for 3 of 7 sampled patients (Patient 1, 5, and 7). The deficient practice had the potential for failing to provide an effective medication management for the patients. Patient #5 On 3/31/2023, the agency admitted Patient #5 with chronic obstructive pulmonary disease acute exacerbation. On 8/04/2023, a physician ordered Megestrol 40 milligrams daily and Quetiapine 20 milligrams nightly. On 8/25/2023, a physician ordered a CBC (complete blood count), CMP (comprehensive metabolic panel), UA (urinalysis) and a Vitamin B12 1000 milligrams injection monthly. On 8/31/2023, a physician ordered a podiatrist consult. On 9/01/2023, a physician ordered a CBC, CMP, Lactic Acid, stat chest x-ray and Rocephin 1 Gram intravenous daily x 5 days and Normal Saline intravenous infusion at 80 milliliters per hour. On 9/08/2023, the agency discharged the patient to Hospice care. The plan of care lacked documented evidence of the inclusion of the above orders. On 3/29/2024 in the late afternoon, the clinical supervisor confirmed the findings. Patient #7 On 10/28/2023, the agency admitted Patient #7 with acute hypoxic respiratory failure and oxygen dependence. On 10/28/2023, the plan of care listed oxygen supplies as part of the durable medical equipment the patient required. On 10/29/2023, a physician ordered CBC, Quantiferon and to hold Aspirin for a week. On 11/01/2023, a physician ordered Furosemide 40 milligrams daily, a chest x-ray and a weekly weight. On 11/19/2023, the agency discharged the patient. The plan of care lacked documented evidence of the inclusion of the above orders. On 3/29/2024 in the late afternoon, the clinical supervisor confirmed the findings. Findings include: The agency’s policy titled Medication Reconciliation (undated), documented the agency would reconcile patient’s medications at the time of admission and on an ongoing basis in order to recognize any potential adverse effects and drug interactions. Medications ordered while the patient was receiving care would be associated to the medication list/profile. The medication list/profile would be updated with each new or changed medication. The patient’s medication list in the home would also be updated. Patient 1 (P1) P1 was admitted on 12/11/2023, with diagnoses including diabetes mellitus II uncontrolled and dystonia. P1’s current recertification period was from 02/09/2024 to 04/08/2024. On 03/27/2024, the Clinical Nursing Supervisor provided a copy of the patient’s Home Health Certification and Plan of Care prior to home visit. The Clinical Nursing Supervisor revealed the copy was the latest plan of care for P1 and included all the patient’s ordered medications. On 03/27/2024 at 2:12 PM, during a home visit with P1, a reconciliation of the patient’s medications was conducted with the patient’s caregiver. The patient’s home medications included the following: - Baclofen 10 milligram (mg). The label of the medication documented the dispense date was 01/04/2024. - Carbidopa/Levodopa 25 mg-100 mg. The label of the medication documented the dispense date was 02/23/2024. The caregiver confirmed the observation and indicated the patient had been taking Baclofen 10 mg as needed and Carbidopa/Levodopa 25 mg-100 mg three times a day (TID). P1’s latest plan of care did not include the above-named medications. On 03/27/2024 at 4:02 PM, the Clinical Nursing Supervisor explained the nurses were expected to reconcile a patient’s home medications with the latest plan of care every home visit. The plan of care should have included all the medications the patient was receiving and ordered by the physicians. The Clinical Nursing Supervisor acknowledged P1’s Baclofen 10 mg was ordered by the patient’s primary physician on 12/15/2023 and should have been included in the patient’s plan of care. The Clinical Nursing Supervisor explained not being aware of a physician’s order for P1’s Carbidopa/Levodopa 25 mg-100 mg. On 03/28/2024 at 12:58 PM, the Clinical Nursing Supervisor provided a copy of the following physician’s orders for P1: - The physician’s order dated 12/15/2023, documented Baclofen 10 mg, take one tablet by mouth once daily as needed (PRN) for muscle spasms. - The physician’s order dated 02/23/2024, documented Carbidopa/Levodopa 25 mg-100 mg, one tablet by mouth TID for Parkinsonism and dystonia. The Clinical Nursing Supervisor revealed calling the patient’s dispensing pharmacy to obtain copies of the physician’s orders. The Clinical Nursing Supervisor indicated P1’s neurologist prescribed Carbidopa/Levodopa 25 mg-100 mg, but was not communicated to the agency. The Clinical Nursing Supervisor acknowledged the nurses should have reconciled the patient’s medications every home visit and informed the Clinical Nursing Supervisor for any discrepancy. The Clinical Nursing Supervisor confirmed Baclofen 10 mg and Carbidopa/Levodopa 25 mg-100 mg should have been included in P1’s latest plan of care.”

“Only as ordered by a physician CFR(s): 484.60(b)(1) Drugs, services, and treatments are administered only as ordered by a physician or allowed practitioner. This Element is not met as evidenced by: Based on record review and interview, the agency failed to ensure services were administered in accordance with physician orders for 1 of 7 patients (Patient #5). The deficient practice placed patients at risk for not receiving needed services. Findings include: Patient #5 On 3/31/2023, the agency admitted Patient #5 with chronic obstructive pulmonary disease acute exacerbation. On 8/31/2023, a physician ordered a podiatrist consult. On 9/01/2023, a physician ordered a Lactic Acid blood test. On 9/08/2023, the agency discharged the patient to Hospice care. On 3/29/2024, the clinical record lacked documented evidence the podiatry consult was referred, and at 11:11 AM, the lab confirmed the Lactic Acid test was not processed. On 3/29/2024 in the late afternoon, the clinical supervisor confirmed the findings.”

“Integrate all orders CFR(s): 484.60(d)(2) Integrate orders from all physicians or allowed practitioners involved in the plan of care to assure the coordination of all services and interventions provided to the patient. This Element is not met as evidenced by: Based on observation, interview, record review and document review, the agency failed to ensure all physician’s orders for a patient’s medications were coordinated and integrated for 1 of 7 sampled patients (Patient 1). The deficient practice had the potential for failing to provide well-coordinated services and interventions from all physicians involved in the patient’s plan of care. Findings include: Patient 1 (P1) P1 was admitted on 12/11/2023, with diagnoses including diabetes mellitus II uncontrolled and dystonia. P1’s current recertification period was from 02/09/2024 to 04/08/2024. On 03/27/2024, the Clinical Nursing Supervisor provided a copy of the patient’s Home Health Certification and Plan of Care prior to home visit. The Clinical Nursing Supervisor revealed the copy was the latest plan of care for P1 and included all the patient’s ordered medications. On 03/27/2024 at 2:12 PM, during a home visit with P1, a reconciliation of the patient’s medications was conducted with the patient’s caregiver. The patient’s home medications included the following: - Baclofen 10 milligram (mg). The label of the medication documented the dispense date was 01/04/2024. - Carbidopa/Levodopa 25 mg-100 mg. The label of the medication documented the dispense date was 02/23/2024. The caregiver confirmed the observation and indicated the patient had been taking Baclofen 10 mg as needed and Carbidopa/Levodopa 25 mg-100 mg three times a day (TID). P1’s latest plan of care did not include the above-named medications. On 03/27/2024 at 4:02 PM, the Clinical Nursing Supervisor explained the nurses were expected to reconcile a patient’s home medications with the latest plan of care every home visit. The plan of care should have included all the medications the patient was receiving and ordered by the physicians. The Clinical Nursing Supervisor acknowledged P1’s Baclofen 10 mg was ordered by the patient’s primary physician on 12/15/2023, and should have been included in the patient’s plan of care. The Clinical Nursing Supervisor explained not being aware of a physician’s order for P1’s Carbidopa/Levodopa 25 mg-100 mg. On 03/28/2024 at 12:58 PM, the Clinical Nursing Supervisor provided a copy of the following physician’s orders for P1: - The physician’s order dated 12/15/2023, documented Baclofen 10 mg take one tablet by mouth once daily as needed (PRN) for muscle spasms. - The physician’s order dated 02/23/2024, documented Carbidopa/Levodopa 25 mg-100 mg one tablet by mouth TID for Parkinsonism and dystonia. The Clinical Nursing Supervisor revealed calling the patient’s dispensing pharmacy to obtain copies of the physician’s orders. The Clinical Nursing Supervisor indicated P1’s neurologist prescribed Carbidopa/Levodopa 25 mg-100 mg but was not communicated to the agency. The Clinical Nursing Supervisor acknowledged the nurses should have reconciled the patient’s medications every home visit and informed the Clinical Nursing Supervisor for any discrepancy. The Clinical Nursing Supervisor confirmed Baclofen 10 mg and Carbidopa/Levodopa 25 mg-100 mg should have been included in P1’s latest plan of care. The Clinical Nursing Supervisor explained being responsible for integrating the orders from all physicians involved in the patient’s plan of care. The nurses were expected to communicate with the Clinical Nursing Supervisor for all new orders identified during home visits such as prescribed medications. The agency’s policy titled Medication Reconciliation (undated), documented the agency would reconcile patient’s medications at the time of admission and on an ongoing basis in order to recognize any potential adverse effects and drug interactions. Medications ordered while the patient was receiving care would be associated to the medication list/profile. The medication list/profile would be updated with each new or changed medication. The patient’s medication list in the home would also be updated.”

“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 clinicians provided services as ordered in the plan of care for 3 of 7 patients (Patient #2, #5 and #7). The deficient practice placed the patients at risk for not receiving services as ordered. Findings include: Patient #2 On 7/19/2023, the agency admitted Patient #2 with essential hypertension. The agency continuously recertified the patient through the present. The certification period dated 1/15/2024 to 3/14/2024 was reviewed. The plan of care revealed to report systolic blood pressure > 140 to the physician. Two skilled nursing visits were ordered and conducted for the week of 2/11/2024 to 2/17/2024. On 2/13/2024, a licensed practical nurse conducted a skilled nursing visit and documented a systolic blood pressure of 142 on the patient’s left arm while the patient sat. The clinical record lacked documented evidence the physician was contacted per order. Patient #5 On 3/31/2023, the agency admitted Patient #5 with uncontrolled hypertension. The agency continuously recertified the patient through September 2023. The certification period dated 7/29/2023 to 9/26/2023 was reviewed. The plan of care revealed to report systolic blood pressure > 140 to the physician. Home health aide visits were ordered and conducted weekly. Physical therapy visits were ordered twice weekly for three weeks. On 8/02/2024, a home health aide conducted a skilled visit and documented a systolic blood pressure of 163. On 8/04/2023, a home health aide conducted a skilled visit and documented a systolic blood pressure of 144. On 8/05/2023, a physical therapy assistant conducted a skilled visit and documented systolic blood pressures of 144 and 145. On 8/09/2023, a home health aide conducted a skilled visit and documented a systolic blood pressure of 147. On 8/25/2023, a home health aide conducted a skilled visit and documented a systolic blood pressure of 141. The clinical record lacked documented evidence the physician was contacted per order in each case. Patient #7 On 10/28/2023, the agency admitted Patient #7 with uncontrolled hypertension. The certification period dated 10/28/2023 to 12/26/2023 was reviewed. The plan of care revealed to report diastolic blood pressure > 90 to the physician. Physical therapy visits were ordered and conducted twice weekly for the week of 11/12/2023 to 12/26/2023. On 11/14/2023, a physical therapy assistant conducted a skilled visit and documented a diastolic blood pressure of 96. On 3/29/2024 in the late afternoon, the clinical supervisor confirmed the findings. The clinical record lacked documented evidence the physician was contacted per order. On 3/29/2024 in the afternoon, the clinical supervisor confirmed the above findings.”

“Preparing clinical notes CFR(s): 484.75(b)(6) Preparing clinical notes; This Element is not met as evidenced by: Based on interview, record review and document review, the agency failed to ensure the clinicians’ visit notes were completed and entered into the electronic medical record system within the prescribed period for 5 of 7 sampled patients (Patient 1, 3, 4, 5, and 6). The deficient practice had the potential for failing to monitor the patients’ actual condition and provide interventions to the patients in a timely manner. Patient #5 On 3/31/2023, the agency admitted Patient #5 with chronic obstructive pulmonary disease acute exacerbation. On 9/01/2023, a physician ordered a Lactic Acid blood test, Rocephin 1 Gram intravenous daily x 5 days and Normal Saline intravenous infusion at 80 milliliters per hour. The clinical record showed skilled nursing visits were only ordered and conducted weekly and lacked documented evidence any of the above orders were carried out during the care episode, which concluded 9/8/2023. On 3/29/2023 in the late morning, the Administrator revealed the physician administered the intravenous Rocephin directly to the patient daily, but did not document it. On 3/29/2023 at 11:11 AM, a customer coordinator for the lab first indicated there was no discernible reason the Lactic Acid was not processed. The Administrator later provided a message indicating the lab failed to receive the tube from the mobile phlebotomist, but failed to communicate with the coordinator the patient needed a redraw. The clinical record lacked documented evidence the agency followed up with the lab when Lactic Acid results were not provided. On 3/29/2024 in the late afternoon, the clinical supervisor confirmed the findings. Patient #6 On 2/27/2024, the agency admitted Patient #6 with chronic obstructive pulmonary disease exacerbation. On 2/27/2024, the plan of care revealed a physician ordered skilled nursing visits twice weekly for three weeks and then weekly. On 3/28/2024, the electronic clinical record lacked documented evidence any skilled nursing visits were documented and entered into the electronic clinical record. Routes sheets were requested and provided as evidence the skilled nursing visits were conducted but not yet entered into the electronic clinical record. On 3/29/2024, the electronic clinical record contained documentation of all the required skilled nursing visits. On 3/29/2024 at 4:00 PM, the Licensed Practical Nurse assigned the visits, indicated the visits were all electronically entered on 3/28/2024. Findings include: The agency’s policy titled Clinical Notes/Documentation (undated), documented all skilled services by nursing, therapy or social services would be documented in the clinical record. All documentation was to be completed the day the service was rendered and incorporated into the clinical record within seven days after the care had been provided. The agency’s policy titled Submission of Notes (undated), documented all visit notes must be submitted every seven days to the electronic medical record system. All staff members were required to submit notes every week or every Monday. Patient 1 (P1) P1 was admitted on 12/11/2023, with diagnoses including diabetes mellitus II uncontrolled and dystonia. P1’s current recertification period was from 02/09/2024 to 04/08/2024. P1’s plan of care for the current recertification period included the skilled nursing (SN) frequency of visits as ordered by the physician. The SN frequency of visits starting 02/09/2024 was once weekly for one week, two times per week for two weeks, and once weekly for six weeks. On 03/28/2024 at 12:30 PM, a review of P1’s electronic medical record (EMR) revealed there were no SN visit notes completed and entered for the week of 03/10/2024 to 03/16/2024 and 03/17/2024 to 03/23/2024. The Clinical Nursing Supervisor was shown with P1’s visit calendar from the EMR and confirmed there were no SN visit notes completed for the said two weeks. The Clinical Nursing Supervisor revealed a Licensed Practical Nurse (LPN) performed SN visit on 03/16/2024 and 03/23/2024 and the notes should have been completed and entered into P1’s EMR on 03/18/2024 and 03/25/2024, respectively. The Clinical Nursing Supervisor indicated the clinicians such as the nurses, therapists, and social worker were expected to complete and enter their visit notes in the patient’s EMR every Monday of the following week after the visit had been made. Patient 3 (P3) P3 was admitted on 07/14/2023, with diagnoses including Parkinson’s disease and physical debility. P3’s current recertification period was from 03/10/2024 to 05/08/2024. P3’s plan of care for the current recertification period included the SN and physical therapy frequency of visits as ordered by the physician. The SN frequency of visits starting 03/10/2024 was two times per week for two weeks and once weekly for seven weeks. The physical therapy frequency of visits starting 03/10/2024 was two times per week for three weeks. On 03/28/2024 at 1:28 PM, a review of P3’s EMR revealed there were no SN and physical therapy assistant (PTA) visit notes completed and entered for the following period: - From 03/10/2024 to 03/16/2024: No SN visit notes for 03/11/2024 and 03/14/2024. - From 03/17/2024 to 03/23/2024: No SN visit notes for 03/18/2024 and 03/21/2024. No PTA visit notes for 03/21/2024. The Clinical Nursing Supervisor was shown with P3’s visit calendar from the EMR and confirmed there were no SN and PTA visit notes completed for the said two weeks. The Clinical Nursing Supervisor acknowledged the completion and submission of the SN and PTA visit notes for P3 were overdue. Patient 4 (P4) P4 was admitted on 01/05/2024, with diagnoses including chronic obstructive pulmonary disease and impaired mobility. P4’s current recertification period was from 03/05/2024 to 05/03/2024. P4’s plan of care for the current recertification period included the SN and physical therapy frequency of visits as ordered by the physician. The SN frequency of visits starting 03/05/2024 was once weekly for one week, two times per week for two weeks, and once weekly for six weeks. The physical therapy frequency of visits starting 03/05/2024 was two times per week for three weeks. On 03/28/2024 at 3:57 PM, a review of P4’s EMR revealed there were no SN and physical therapy visit notes completed and entered for 03/20/2024 and 03/22/2024, respectively. The Clinical Nursing Supervisor was shown with P4’s visit calendar from the EMR and confirmed there were no SN and physical therapy visit notes completed on the said dates. The Clinical Nursing Supervisor acknowledged the SN and physical therapy visit notes should have been completed and entered into P4’s EMR by 03/25/2024.”

“Onsite supervisory visit every 14 days CFR(s): 484.80(h)(1)(i) (1)(i) If home health aide services are provided to a patient who is receiving skilled nursing, physical or occupational therapy, or speech language pathology services— (A) A registered nurse or other appropriate skilled professional who is familiar with the patient, the patient’s plan of care, and the written patient care instructions described in paragraph (g) of this section, must complete a supervisory assessment of the aide services being provided no less frequently than every 14 days; and (B) The home health aide does not need to be present during the supervisory assessment described in paragraph (h)(1)(i)(A) of this section. This Element is not met as evidenced by: Based on interview, record review and document review, the agency failed to ensure a supervisory visit for a certified nursing assistant (CNA)/home health aide (HHA) was performed every 14 days for 2 of 7 sampled patients (Patient 1 and 3). The deficient practice had the potential for failing to assess the competence and the quality of services provided by the HHA in a timely manner. Findings include: Patient 1 (P1) P1 was admitted on 12/11/2023, with diagnoses including diabetes mellitus II uncontrolled and dystonia. P1’s current recertification period was from 02/09/2024 to 04/08/2024. P1’s orders and treatments dated 02/09/2024, documented the following frequency of visits: - Skilled Nursing (SN) once weekly for one week, two times per week for two weeks, and once weekly for six weeks. - CNA/HHA once weekly for nine weeks. The physician’s order dated 03/14/2024, documented to increase the CNA visits to two times per week for three weeks. P1’s medical record documented CNA visits were completed on 03/19/2024 and 03/22/2024. P1’s medical record documented a CNA Supervisory Visit was conducted on 03/04/2024. P1’s medical record lacked documented evidence a CNA Supervisory Visit was completed for the week of 03/17/2024 to 03/23/2024, or 14 days after. A screenshot of P1’s visit calendar documented a CNA Supervisory Visit was scheduled on 03/18/2024 and assigned to a Registered Nurse (RN). The status column of the visit calendar indicated “Not Started”. On 03/28/2024 at 12:30 PM, the Clinical Nursing Supervisor was shown P1’s visit calendar from the electronic medical record (EMR) and confirmed a CNA Supervisory Visit should have been done on 03/18/2024 as scheduled in the visit calendar. The Clinical Nursing Supervisor explained the status “Not Started” meant the documentation of the visit had not been entered or started. The Clinical Nursing Supervisor indicated the clinicians such as the nurses, therapists, and social worker were expected to complete and enter their visit notes in the patient’s EMR every Monday of the following week after the visit had been made. On 03/29/2024, during a follow-up review of P1’s EMR, a CNA Supervisory Visit was entered into the patient’s EMR which was digitally signed by the RN on 03/19/2024. The Work Log (documentation history) of the CNA Supervisory Visit documented the following status and date/time: - Task Target Date updated on 03/29/2024 at 2:34 PM - Signed Document and Completed on 03/29/2024 at 2:35 PM On 03/29/2024 at 4:07 PM, the Clinical Nursing Supervisor confirmed the CNA Supervisory Visit dated 03/19/2024 was not contained in P1’s EMR during the review on 03/28/2024. The Clinical Nursing Supervisor indicated per the Work Log, the RN completed and signed the document on 03/29/2024 at 2:35 PM. Patient 3 (P3) P3 was admitted on 07/14/2023, with diagnoses including Parkinson’s disease and physical debility. P3’s current recertification period was from 03/10/2024 to 05/08/2024. P3’s orders and treatments dated 03/10/2024, documented the following frequency of visits: - SN two times per week for two weeks, and once weekly for seven weeks. - CNA/HHA once weekly for nine weeks. On 03/28/2024 at 1:48 PM, a review of P3’s EMR with the Clinical Nursing Supervisor revealed a CNA Supervisory Visit was scheduled on 03/14/2024 and 03/28/2024. The CNA Supervisory Visit dated 03/14/2024 contained in P3’s EMR, indicated the following sections of the document were left blank or had no response/entries: - Supervision Date: Start and End Time - Clinician Present at Time of Visit: Yes or No - Notifies client/caregiver of schedule: - Reports for duty as assigned: - Cooperative with client and others: - Courteous toward client and others: - Maintains an open communication with client and others: - Follows client plan of care as instructed: - Demonstrates competency with assigned tasks: - Documents appropriately: - Timely notification to supervisor of client’s needs or changes in condition: - Adheres to organizational policies and procedures: - Complies with infection prevention and control policies and procedures: - Honors patient rights: The CNA Supervisory Visit documented the RN digitally signed the document on 03/14/2024. The Clinical Nursing Supervisor confirmed the findings and acknowledged the RN should have completed the CNA Supervisory Visit dated 03/14/2024. The Clinical Nursing Supervisor explained a CNA Supervisory Visit could not be completed for 03/28/2024 because the assigned RN was in the home health office. On 03/28/2024 at 1:56 PM, the Clinical Nursing Supervisor provided a copy of the CNA Supervisory Visit dated 03/14/2024 but this time the document had been completed with the start and end time of the supervision visit, the clinician was present at time of the visit, and “Excellent” was documented in all other sections of the CNA Supervisory Visit. The Clinical Nursing Supervisor explained not being aware on how it happened. The Clinical Nursing Supervisor confirmed the document was not completely filled-out earlier. A copy of the Work Log of the CNA Supervisory Visit indicated the RN signed and completed the document on 03/28/2024. On 03/28/2024 at 2:04 PM, the Clinical Nursing Supervisor revealed the RN should have performed the supervisory visit every 14 days. The notes or results of the supervisory visit should have been documented in the CNA Supervisory Visit notes. The agency’s policy titled Home Health Aide Services Supervision of Staff dated May 2023, documented when skilled nursing services were being provided to a patient in addition to personal care, the Registered Nurse would make a supervisory visit to the patient’s residence at least every 14 days. The supervisory visit would start from the first day of HHA visit and every 14 days after while the HHA services was being furnished.”

“Primary HHA is responsible for patient care CFR(s): 484.105(e)(3) The primary HHA is responsible for patient care, and must conduct and provide, either directly or under arrangements, all services rendered to patients. This Element is not met as evidenced by: Based on record review, interview, contract review and policy review, the agency failed to ensure a patient received ordered services in a timely manner for 1 of 7 patients (Patient #5). The deficient practice placed the patients at risk for not receiving needed services. Findings include: Patient #5 On 3/31/2023, the agency admitted Patient #5 with chronic obstructive pulmonary disease acute exacerbation. The agency continuously recertified Patient #5 through September 2023. The recertification period of 7/29/2023 to 9/26/2023 was reviewed. On 8/31/2023, a physician ordered a podiatrist consult. The clinical record lacked documented evidence the consult was completed or the referral was sent. On 9/01/2023, a physician ordered a CBC (complete blood count), CMP (comprehensive metabolic panel), Lactic Acid and stat chest x-ray. The clinical record contained documented evidence the labs were not drawn until 9/7/2023. The clinical record lacked documented evidence of a Lactic Acid result and any documentation of follow-up with the labs or what happened. On 3/29/2024 in the late morning, the Physician Consultant indicated the lactic acid was ordered to identify sepsis, but it was not unacceptable to wait six days for a blood draw for results. On 3/29/2024 in the early afternoon, the Clinical Supervisor indicated 1-2 days was expected for routine lab orders. On 3/29/2024 at 11:11 AM, the lab’s customer coordinator indicated no billing codes were provided with the original orders, which created a two day delay. The lab customer coordinator also indicated the Lactic Acid was not processed because the lab did not receive a tube and it was not redrawn. None of this information was known or documented prior to the inquiry. The lab contract lacked documented evidence of a time frame for fulfilling ordered requests, but the lab customer coordinator indicated labs were typically done in 1-2 days. An apology message was sent to the agency as a result of the inquiry. On 9/2/2023, the stat chest x-ray in the order referenced above on 9/1/2023 was completed. According to the radiology contract provided, a stat x-ray was defined as occurring between 7 PM and 7 AM, 7 days weekly and routine radiology was defined as 7 AM to 7 PM, with an 8 hour response time. The stat chest x-ray was completed a day after ordering, revealing multifocal pneumonia bilaterally. On 9/08/2023, the agency discharged the patient to Hospice care, and the patient expired on 9/10/2023. According to the Clinical Supervisor, the agency lacked documented evidence of clinical expectations in policy form.”