Elara Caring Xxi

“Names and Contact Information CFR(s): 484.102(c)(1) §403.748(c)(1), §416.54(c)(1), §418.113(c)(1), §441.184(c)(1), §460.84(c)(1), §482.15(c)(1), §483.73(c)(1), §483.475(c)(1), §484.102(c)(1), §485.68(c)(1), §485.542(c)(1), §485.625(c)(1), §485.727(c)(1), §485.920(c)(1), §486.360(c)(1), §491.12(c)(1), §494.62(c)(1). [(c) The [facility must develop and maintain an emergency preparedness communication plan that complies with Federal, State and local laws and must be reviewed and updated at least every 2 years [annually for LTC facilities]. The communication plan must include all of the following:] (1) Names and contact information for the following: (i) Staff. (ii) Entities providing services under arrangement. (iii) Patients’ physicians (iv) Other [facilities]. (v) Volunteers. *[For Hospitals at §482.15(c) and CAHs at §485.625(c)] The communication plan must include all of the following: (1) Names and contact information for the following: (i) Staff. (ii) Entities providing services under arrangement. (iii) Patients’ physicians (iv) Other [hospitals and CAHs]. (v) Volunteers. *[For RNHCIs at §403.748(c):] The communication plan must include all of the following: (1) Names and contact information for the following: (i) Staff. (ii) Entities providing services under arrangement. (iii) Next of kin, guardian, or custodian. (iv) Other RNHCIs. (v) Volunteers. *[For ASCs at §416.45(c):] The communication plan must include all of the following: (1) Names and contact information for the following: (i) Staff. (ii) Entities providing services under arrangement. (iii) Patients’ physicians. (iv) Volunteers. *[For Hospices at §418.113(c):] The communication plan must include all of the following: (1) Names and contact information for the following: (i) Hospice employees. (ii) Entities providing services under arrangement. (iii) Patients’ physicians. (iv) Other hospices. *[For HHAs at §484.102(c):] The communication plan must include all of the following: (1) Names and contact information for the following: (i) Staff. (ii) Entities providing services under arrangement. (iii) Patients’ physicians. (iv) Volunteers. *[For OPOs at §486.360(c):] The communication plan must include all of the following: (2) Names and contact information for the following: (i) Staff. (ii) Entities providing services under arrangement. (iii) Volunteers. (iv) Other OPOs. (v) Transplant and donor hospitals in the OPO’s Donation Service Area (DSA). This Standard is not met as evidenced by: Based on record review and interview, the agency failed to ensure an Emergency Preparedness Communication Plan included updated required information related to the staff contact information for the agency for all patients and staff. Findings: A review of emergency preparedness records showed no updated Emergency Preparedness Communication Plan which included current staff contact information for the agency. On 07/10/24 at 11:15 a.m., Staff A stated the Emergency Preparedness Communication Plan was not updated to include contact information for current staff of the agency.”

“Performance improvement projects CFR(s): 484.65(d)(1)(2) Standard: Performance improvement projects. Beginning July 13, 2018 HHAs must conduct performance improvement projects. (1) The number and scope of distinct improvement projects conducted annually must reflect the scope, complexity, and past performance of the HHA’s services and operations. (2) The HHA must document the quality improvement projects undertaken, the reasons for conducting these projects, and the measurable progress achieved on these projects. This Standard is not met as evidenced by: Based on record review and interview, the agency failed to ensure: The initiation and review of a PIP through their QAPI Program for 06/09/22 to 02/21/23 and; PIP documentation included baseline and goal percentages to measure performance for a designated project from 02/23/23 to 04/05/23 for all patients and employees. Findings: A review of QAPI Program documents showed no initiation and review of a PIP through their QAPI Program for 06/09/22 to 02/21/23 and PIP documentation from 02/23/23 to 04/05/23 included baseline and goal percentages to measure performance. On 07/10/24 at 11:20 a.m., Staff A stated the agency had no QAPI records which showed initiation and review of a PIP through their QAPI Program for 06/09/22 to 02/21/23 and PIP documentation for a designated project for 02/23/23 to 04/05/23 showed no baseline and goal percentages to measure performance.”

“Plan of care must include the following CFR(s): 484.60(a)(2)(i-xvi) The individualized plan of care must include the following: (i) All pertinent diagnoses; (ii) The patient’s mental, psychosocial, and cognitive status; (iii) The types of services, supplies, and equipment required; (iv) The frequency and duration of visits to be made; (v) Prognosis; (vi) Rehabilitation potential; (vii) Functional limitations; (viii) Activities permitted; (ix) Nutritional requirements; (x) All medications and treatments; (xi) Safety measures to protect against injury; (xii) A description of the patient’s risk for emergency department visits and hospital re-admission, and all necessary interventions to address the underlying risk factors. (xiii) Patient and caregiver education and training to facilitate timely discharge; (xiv) Patient-specific interventions and education; measurable outcomes and goals identified by the HHA and the patient; (xv) Information related to any advanced directives; and (xvi) Any additional items the HHA or physician or allowed practitioner may choose to include. This Element is not met as evidenced by: Based on record review and interview, the agency failed to ensure individualized patient POCs included SN catheter treatment/interventions or last changed/treatment due date for three (Patients #6, 7 and #12) of 13 patients. Findings: Patient #6 A review of the POC dated 05/12/24 to 07/10/24 showed orders for a SN to perform monthly catheter changes using a 16 French/10 milliliter catheter. POC documentation showed no SN catheter treatment intervention last changed or change due date. Documentation showed SN visits were conducted 05/22/24 and on 06/21/24 and showed no physician notifications and no changes in orders. On 07/10/24 at 11:50 a.m., Staff A stated the POC for patient #6 had no catheter treatment intervention last changed or change due date related to suprapubic urinary catheter management. Patient #7 A review of the POC dated 05/16/24 to 08/14/24 showed orders for a SN to perform monthly catheter changes using an 18 French/10 milliliter catheter. POC documentation showed no SN catheter treatment intervention last changed or change due date. Documentation showed SN visits were conducted 06/18/24 and on 07/02/24 and showed no physician notification and no changes in orders. On 07/10/24 at 11:54 a.m., Staff A stated the POC for patient #6 had no catheter treatment intervention last changed or change due date related to indwelling urinary catheter management. Patient #12 A review of the POC dated 04/26/24 to 06/24/24 showed orders for a SN to perform monthly catheter changes using a 22 French/30 milliliter catheter. POC documentation showed no SN catheter treatment intervention last changed or change due date. Documentation showed SN visits were conducted 04/29/24, 05/02/24, 05/06/24, 05/09/24, 05/13/24, 05/16/24, 05/20/24, 05/23/24, 05/27/24, 05/28/24, 05/30/24, 06/03/24, 06/06/24, 06/11/24, 06/13/24, 06/17/24 and on 06/20/24 and showed no physician notification and no changes in orders. On 07/10/24 at 12:10 p.m., Staff A stated the POC for patient #12 had no catheter treatment intervention last changed or change due date related to indwelling urinary catheter management.”

“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 physician ordered wound site care and dressing materials for one (Patient #1) of 13 patients. Findings: Patient #1 A review of the POC dated 05/07/24 to 07/05/24 showed no orders for SN to assess and perform wound site care to identified wound site to the right foot. A SN visit note dated 06/13/24 documented an identified wound site to the right foot, SN cleansed the wound site, applied antibiotic ointment, and covered it with a dry dressing. Documentation showed no physician notification and no changes in orders. A later physician’s order dated 06/21/24 (7 days from the date wound site was identified) documented wound site care to the right foot as: cleanse with normal saline, apply antibiotic ointment and cover with dry dressing weekly. On 07/10/24 at 11:39 a.m., Staff A stated the POC for patient #1 did not include wound site care to the right foot until 06/21/24.”

“Communication with all physicians CFR(s): 484.60(d)(1) Assure communication with all physicians or allowed practitioners involved in the plan of care. This Element is not met as evidenced by: Based on record review and interview, the agency failed to ensure care was coordinated between the agency and physician for one (Patient #5) of 13 patients. Findings: Patient #5 A plan of care dated 05/24/24 to 07/22/24 documented diagnoses of Diabetes Mellitus Type II with foot ulcer. Documentation showed orders for SN visit frequency of one time a week for eight weeks for SN to perform assessment and monitoring of health conditions and to perform wound site care every visit. Documentation for week of 05/26/24 to 06/01/24 showed a missed visit on 05/31/24 (no visit conducted, one visit ordered), week of 06/02/24 to 06/08/24 one visit missed on 06/07/24 (no visit conducted, one visit ordered), week of 06/09/24 to 06/15/24 showed a missed visit on 06/14/24 (no visit conducted, one visit ordered). week of 06/16/24 to 06/29/24 showed a missed visit on 06/28/24 (no visit conducted; one visit ordered). Documentation showed missed visits were auto faxed to the physician but showed no follow up communication to the physician that the missed visit frequency continued over a five-week period. Documentation showed no physician provider notifications or coordination of care communications related to changes in the patient’s condition, continued missed SN visits and no changes in orders. On 07/10/24 at 11:48 a.m., Staff A stated the agency did not notify the physician of changes in the patient’s condition and showed no follow up communication to the physician that the missed visit frequency continued over a five-week period.”

“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: 1. SN conducted visit frequency as ordered on the POC for three (Patients #3, 7 and #8) of 13 patients and; 2. SN conducted wound site care ordered on the POCs for one (Patient #7) of 13 patients. Findings: Patient #3 A review of the POC dated 06/20/24 to 08/08/24 showed orders for SN visit frequency one time a week for nine weeks. Documentation showed during the weeks of 06/30/24 to 07/06/24 a SN visit was missed on 06/30/24 (one visit ordered, no visit conducted). Documentation showed no patient/caregiver refusal of care, physician notification or change in orders. On 07/10/24 at 11:46 a.m., Staff A stated SN should have conducted SN visit as ordered in the POC. Patient #7 A review of the POC dated 05/16/24 to 07/14/24 showed orders for SN visit frequency two times a week for eight weeks, then one time a week for one week for SN to assess, instruct caregiver and perform wound site care to buttock: cleanse with Dakins solution, apply Blast X and iodine and cover with Exudry dressing every day. Documentation showed during the weeks of 06/16/24 to 06/22/24 SN visits were conducted on 06/16/24 [SOC] and 06/18/24. SN visit note documentation on 06/18/24 showed no documentation of performed wound care and during the week of 06/30/24 to 07/06/24 a SN visit was conducted on 07/02/24 (two visits ordered, one visit conducted). Documentation showed no patient/caregiver refusal of care, physician notification or change in orders. On 07/10/24 at 11:54 a.m., Staff A stated SN should have conducted SN visits as ordered in the POC and wound site care should be documented in the SN visit notes. Patient #8 A review of the POC dated 06/21/24 to 08/19/24 showed orders for SN visit frequency one time a week for one week, three times a week for eight weeks, then one time a week for one week. Documentation showed during the weeks of 06/30/24 to 07/06/24 a SN visit was conducted on 07/01/24 and 07/05/24 (three visits ordered, two visits conducted). Documentation showed no patient/caregiver refusal of care, physician notification or change in orders. On 07/10/24 at 11:57 a.m., Staff A stated SN should have conducted SN visit as ordered in the POC.”

“Participate in the HHA’s QAPI program; CFR(s): 484.75(b)(8) Participation in the HHA’s QAPI program; and This Element is not met as evidenced by: Based on a record review and interview, the agency failed to ensure multi-disciplined skilled professional staff were available to participate and provide input into the agency’s QAPI program for all patients and employees. Findings: A review of administrative records showed no multi-disciplined skilled professional staff participation in QAPI activities for calendar years 2022 and 2023 and 01/01/24 to 06/05/24. On 07/10/24 at 11:20 a.m., Staff A stated documentation showed no multi-disciplined skilled professional staff participation in ongoing QAPI program activities for the agency for calendar years 2022 and 2023 and 01/01/24 to 06/05/24.”

“Interventions and patient response CFR(s): 484.110(a)(2) All interventions, including medication administration, treatments, and services, and responses to those interventions; This Element is not met as evidenced by: Based on record review and interview, the agency failed to ensure skilled professional service visit note documentation was completed within 24 hours (agency timeline requirements) for two (Patients #2 and #6) of 13 patients. Findings: Patient #2 A review of the POC dated 05/14/24 to 07/12/24 showed orders for SN visit frequency one time a week for nine weeks and an occupational therapy visit frequency of one time a week, two times a week for three weeks, then one time a week. Documentation showed SN visit dated 06/12/24 was completed/submitted on 06/16/24 (4 days from the date of the visit) and showed an OT visit note dated 05/17/24 was completed on 05/20/24 (3 days from the date of the visit). Documentation showed no coordination of care or communication of why visit notes were not completed and submitted within 24 hours of the visits. Patient #6 A review of the POC dated 05/12/24 to 07/10/24 showed orders for SN visit frequency of one time a week for one week, one time every four weeks for four weeks, then one time every three weeks for three weeks. Documentation showed SN visit dated 05/22/24 was completed/submitted on 05/27/24 (five days from the date of the visit). Documentation showed no coordination of care or communication of why visit notes were not completed and submitted within 24 hours of the visits. On 07/10/24 at 11:30 a.m., Staff A stated all non-oasis patient visit documentation is due within 24 hours of the visit per agency policy.”

“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 reviews and interview, the agency failed to ensure a completed transfer/discharge summary was provided for three (Patients #10, 12 and #13) of 13 patients. Findings: Patient #10 A review of the clinical record documented discharge from the agency on 04/13/24 to hospice services. Documentation showed no discharge summary was provided to the hospice service provider. On 07/10/24 at 12:00 p.m., Staff A stated clinical record documentation showed no discharge summary was provided to the hospice service provider for patient #10. Patient #12 A review of the clinical record documented transfer to inpatient hospital services on 06/24/24. Documentation showed no transfer summary was provided to the inpatient hospital service provider. On 07/10/24 at 12:06 p.m., Staff A stated clinical record documentation showed no transfer summary was provided to the inpatient hospital service provider for patient #12. Patient #13 A review of the clinical record documented discharge from the agency on 06/25/24 to hospice services. Documentation showed no discharge summary was provided to the hospice service provider. On 07/10/24 at 12:10 p.m., Staff A stated clinical record documentation showed no discharge summary was provided to the hospice service provider for patient #13.”