Always Best Care Cleveland South

“Participate in care CFR(s): 484.50(c)(4)(i,ii,iii,iv,v,vi,vii,viii) Participate in, be informed about, and consent or refuse care in advance of and during treatment, where appropriate, with respect to-- (i) Completion of all assessments; (ii) The care to be furnished, based on the comprehensive assessment; (iii) Establishing and revising the plan of care; (iv) The disciplines that will furnish the care; (v) The frequency of visits; (vi) Expected outcomes of care, including patient-identified goals, and anticipated risks and benefits; (vii) Any factors that could impact treatment effectiveness; and (viii) Any changes in the care to be furnished. This Element is not met as evidenced by: Based on document review, medical record review, policy review and staff interview, the agency failed to ensure the patient had the right to consent or refuse care in advance of and during treatment, where appropriate for two of three patients reviewed (Patient #2 and 3). The census was 551. Findings include: Review of the agency policy titled. “Informed Consent/Refusal of Treatment.” revised 11/2022, revealed the agency will obtain written consent for care during the admission process. Review of the undated agency directive titled, “Admission Consents,” revealed all admission consents need a signature. If a patient is unable to sign because of physical limitations or because of decreased cognition, the responsible party must sign the admission consent. If a verbal consent is obtained at the start of care, the admission consent will then need to be sent out to the responsible party for a signature. 1. Review of the medical record for Patient #3 revealed the patient was admitted to the agency on 12/01/23. Physical therapy (PT) and occupational therapy (OT) completed evaluations on 12/01/23 and the registered nurse (RN) completed the comprehensive assessment on 12/02/23. Review of consents revealed the family member/Power of Attorney gave verbal consent to the RN on 12/02/23 due to the patient being unable to sign due to impaired cognition. Interview on 01/23/24 at 11:28 AM with Staff H confirmed the PT was supposed to get the consents signed on the first visit, 12/01/23, but did not. Interview on 01/23/24 at 1:02 PM with Staff A confirmed the consents needed to be signed on the first day of service. Review of the consent tracking log revealed the consents for Patient #3 were mailed 12/04/23 to the POA, with no received date. Interview on 01/23/24 at 12:24 PM with Staff A confirmed the consents were mailed seven weeks ago with no follow up. 2. Review of the complaint log for 2024 revealed a complaint dated 01/17/24 from Patient #2’s family who was upset they were not notified of the services Patient #2 had been receiving (SN, PT and OT). The Director of Nursing (DON) spoke to the registered nurse (RN) on 01/17/24 regarding getting consents on admission and notifying the family of the start of care. The therapists and skilled nursing will update the family of Patient #2’s progress. Review of the consents signed by Patient #2 on 12/15/23 revealed Patient #2 had dementia and revealed documentation Patient #2 had a Health Care Power of Attorney with the contact information documented in the patient’s record Interview on 01/22/24 at 9:22 AM with Staff A revealed the nurse thought Patient #2 was alert and oriented because they answered all questions appropriately. The nurse had the patient sign the consents on admission and didn’t think the HCPOA was needed. This deficiency represents non-compliance investigated under Substantial Allegation 103567.”

“Visit schedule CFR(s): 484.60(e)(1) Visit schedule, including frequency of visits by HHA personnel and personnel acting on behalf of the HHA. This Element is not met as evidenced by: Based on record review, policy review, and patient and staff interview, the agency failed to ensure that the patient and/or caregiver were provided with a Visit schedule, including frequency of visits by HHA personnel and personnel acting on behalf of the HHA for two of three patients reviewed (Patient #3 and #5). The census was 551. Findings include: Review of the agency policy titled, “Care Planning Process” revised 05/2023, revealed the agency shall provide the patient and caregiver with a copy of written instructions outlining the visit schedule to include the day of the week and frequency of visits by personnel. Interview on 01/22/24 at 10:03 AM with Staff A revealed if physical therapy (PT), occupational therapy (OT) or speech therapy (ST) were the only services ordered they would do an initial assessment and determine the frequency and duration of visits for that discipline. The therapy visits were determined by the therapy assessment and patient needs. The nurse would determine the number and frequency of skilled nursing visits, if needed, based on the nursing assessment and patient needs. The registered nurse (RN), Staff B, who admitted Patient #3 was reached by phone, on 01/22/24 at 4:10 PM and stated she did not give the patients specific days of the visits just the frequency like twice a week. The skilled nurses got their schedule at 4:30 PM the night before, from the agency. The nurses called the patients the night before the visit to let them know they were coming the next day. A calendar was in the folder, but the visits may not be on the same days. They just told the patients the frequency of visits. Interview on 01/23/24 at 2:00 PM with the ST revealed they could not remember seeing the agency folder at Patient #3’s home and did not write the visits on the calendar. Interview on 01/23/24 at 1:55 PM with Staff A revealed it was the expectation the frequency and duration of visits for all services were to be placed on a calendar that was left in the patient’s home. 2. Interview on 01/24/24 at 2:06 PM with Patient #5 revealed the PT and OT did not use a calendar to indicate when their visits would be. They just called the night before. This deficiency represents non-compliance investigated under Substantial Allegation 103567.”