Elara Caring Xx

“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 01/19/24 at 2:00 p.m., Staff B stated the Emergency Preparedness Communication Plan was not updated to include contact information for current staff of the agency.”

“Patient/payer will no longer pay for services CFR(s): 484.50(d)(2) The patient or payer will no longer pay for the services provided by the HHA; This Element is not met as evidenced by: Based on record review and interview, the agency failed to ensure advance beneficiary notice and/or HHCOC notice prior to discharge from agency services were provided to two (Patients #12 and 15) of 17 patients. Findings: Patient #12 A review of the clinical record showed no advance notice of discharge or home health change of care notice prior to discharge from the agency on 11/06/23 for non-compliance. On 01/19/24 at 2:35 p.m., Staff B stated there was no ABN or HHCOC notices in the clinical record for patient #12 prior to being discharged from the agency for non-compliance. Patient #15 A review of the clinical record showed no advance notice of discharge or home health change of care notice prior to discharge from the agency on 11/12/23 for non-compliance. On 01/19/24 at 2:35 p.m., Staff B stated there was no ABN or HHCOC notices in the clinical record for patient #15 prior to being discharged from the agency for non-compliance.”

“Patient refuses services CFR(s): 484.50(d)(4) The patient refuses services, or elects to be transferred or discharged; This Element is not met as evidenced by: Based on record review and interview the agency failed to: 1. Educate the patient on potential health outcomes related to refusal of and/or missed visits prior to the patient’s discharge from HHA services for noncompliance and; 2. Notify the physician of the patient’s continued refusal of and/or missed visits prior to the patient’s discharge from HHA services for noncompliance for two (Patients #12 and 15) of 17 patients. Findings: Patient #12 A review of a POC for 09/10/23 to 11/08/23 showed a SN visit frequency of one time a week for nine weeks. A review of visit notes showed missed SN visits on 09/22/23, 09/25/23, 09/28/23, 10/09/23 and on 10/19/23. Documentation showed no communication or education attempts to the patient for potential health outcomes related to refusal of and/or missed SN visits and no documentation of follow up communications to the physician of the patient’s continued refusal of and/or missed SN visits prior to the patient’s discharge from HHA services for noncompliance. On 01/19/24 at 2:43 p.m., Staff B stated documentation showed no: 1. Attempts to educate the patient of potential health outcomes related to refusal of and/or missed SN visits and; 2. No physician notification of the patient’s continued refusal of and/or missed SN visits prior to the patient’s discharge from HHA services for noncompliance. Patient #15 A review of a POC for 10/04/23 to 12/02/23 showed a SN visit frequency of one time a week for eight weeks. A review of visit notes showed missed SN visits on 10/26/23, 10/31/23, 11/14/23, 11/22/23, 11/24/23 and on 11/25/23. Documentation showed no communication or education attempts to the patient for potential health outcomes related to refusal of and/or missed SN visits and no documentation of follow up communications to the physician of the patient’s continued refusal of and/or missed SN visits prior to the patient’s discharge from HHA services for noncompliance. On 01/19/24 at 2:55 p.m., Staff B stated documentation showed no: 1. Attempts to educate the patient of potential health outcomes related to refusal of and/or missed SN visits and; 2. No physician notification of the patient’s continued refusal of and/or missed SN visits prior to the patient’s discharge from HHA services for noncompliance.”

“A review of all current medications CFR(s): 484.55(c)(5) A review of all medications the patient is currently using in order to identify any potential adverse effects and drug reactions, including ineffective drug therapy, significant side effects, significant drug interactions, duplicate drug therapy, and noncompliance with drug therapy. This Element is not met as evidenced by: Based on record review and interview, the agency failed to ensure medication regimen changes were updated on the medication profile for one (Patient #5) of 17 patients. Findings: Patient #5 A review of the plan of care dated 11/27/23 to 01/25/24 documented a principal diagnosis of laceration to left lower leg. A physician’s order dated 12/20/23 documented Bactrim DS (an antibiotic) twice daily times for five days, Keflex (an antibiotic) 500 milligrams three times a day for five days for infection. A review of the clinical record showed no update to the medication profile for the medication Bactrim DS and Keflex and showed no review for potential/adverse effects, drug reactions, side effects, interactions and duplicate drug therapy On 01/19/24 at 2:20 p.m., Staff B stated the medication profile for Patient #5 should have been added to the medication profile and reviewed for potential/adverse effects, drug reactions, side effects, interactions and duplicate drug therapy.”

“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 #4) of 17 patients. Findings: Patient #4 A review of a plan of care dated 12/18/23 to 02/15/24 documented a primary diagnosis of stage 2 pressure ulcer and secondary diagnosis of hypertension and chronic kidney disease with heart failure and showed a physician reporting parameter of weight gain of 2 pounds in day or 5 pounds in one week. Documentation showed an SN visit note dated 12/21/23 showed a weight of 265 pounds, the vital sign alert was auto-faxed to the physician with no follow up; an SN visit note dated on 12/29/23 showed a weight of 265 pounds, the vital sign alert was auto-faxed to the physician with no follow up; a SN visit note dated 01/03/24 showed a weight of 268 pounds, the vital sign alert was auto-faxed to the physician with no follow up; and an SN visit note dated on 01/09/24 showed a weight of 270 pounds, the vital sign alert was auto-faxed to the physician with no follow up. Documentation showed no direct physician coordination of care communications as follow up to the changes in the patient’s weight status, no changes in orders and the patient was admitted to inpatient hospital services for exacerbation of congestive heart failure.. On 01/19/24 at 2:15 p.m., Staff B stated the weight gain vital sign alerts for patient #5 that were auto-faxed by the computer system should have had follow up coordination of care communications to ensure the physician was aware of the patient’s change in weight status.”

“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 four (Patients #1, 4, 10 and #12) of 17 patients and; 2. SN conducted wound site care ordered on the POCs for one (Patient #4) of 17 patients. Findings: Patient #1 A review of the POC dated 12/16/23 to 02/13/24 showed orders for SN visit frequency one time a week for one week, two times a week for four weeks, then one time a week for five weeks. Documentation showed during the weeks of 12/17/23 to 12/23/23 SN visit was conducted on 12/20/23 (two visit ordered, one visits conducted), 12/24/23 to 12/30/23 (two visit ordered, no visits conducted), 12/31/23 to 01/06/24 SN visit was conducted on 01/06/23 (two visit ordered, one visits conducted). Documentation showed no patient/caregiver refusal of care, physician notification or change in orders. On 01/19/24 at 2:10 p.m., Staff B stated SN should have conducted SN visits as ordered in the POC. Patient #4 A review of the POC dated 12/18/23 to 02/15/24 showed orders for SN visit frequency two times a week for nine weeks for SN to assess, instruct caregiver and perform wound site care to buttock of cleanse with normal saline, apply barrier cream and cover with Optifoam. Documentation showed during the weeks of 12/24/23 to 12/30/23 a SN visit was conducted on 12/29/23 (two visit ordered, one visits conducted) and during SN visits conducted on 12/20/23 and 12/21/23 SN documentation showed no wound site assessment or care to buttock was conducted. Documentation showed no patient/caregiver refusal of care, physician notification or change in orders. On 01/19/24 at 2:15 p.m., Staff B stated SN should have conducted SN visits as ordered in the POC. Patient #10 A review of the POC dated 11/14/23 to 01/12/24 showed orders for SN visit frequency one time a week for nine weeks. Documentation showed during the weeks of 12/17/23 to 12/23/23 (one visit ordered, no visits conducted), 12/24/23 to 12/30/23 (two visit ordered, no visits conducted). Documentation showed no patient/caregiver refusal of care, physician notification or change in orders. On 01/19/24 at 2:25 p.m., Staff B stated SN should have conducted SN visits as ordered in the POC. Patient #12 A review of the POC dated 09/10/23 to 11/08/23 showed orders for SN visit frequency one time a week for nine weeks. Documentation showed during the weeks of 10/08/23 to 10/15/23 (one visit ordered, no visits conducted) and 10/29/23 to 11/04/23 (one visit ordered, no visits conducted). Documentation showed no patient/caregiver refusal of care, physician notification or change in orders. On 01/19/24 at 2:35 p.m., Staff B stated SN should have conducted SN visits 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. On 01/19/24 at 2:00 p.m., Staff B stated documentation showed no evidence of multi-disciplined skilled professional staff participation in ongoing QAPI program activities for the agency for calendar years 2022 and 2023.”

“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 SN visit note documentation was completed within 24 hours (agency timeline requirements) for four (Patients #1, 5, 15 and #16) of 17 patients. Findings: Patient #1 A review of the POC dated 12/16/23 to 02/13/24 showed orders for SN visit frequency one time a week for one week, two times a week for four weeks, then one time a week for five weeks. Documentation showed SN visit dated 01/09/24 was completed/submitted on 01/15/24. Documentation showed no coordination of care or communication of why visit note was not completed and submitted within 24 hours of the visit. On 01/19/24 at 2:10 p.m., Staff B stated non-oasis SN visit documentation for 10/06/23 was not completed within 24 hours of the visit per agency policy Patient #5 A review of the plan of care dated 11/27/23 to 01/25/24 documented a SN visit frequency of two times a week for four weeks, then one time a week for five weeks. Documentation showed SN visit dated 12/22/23 was completed/submitted on 01/04/24. Documentation showed no coordination of care or communication of why visit note was not completed and submitted within 24 hours of the visit. On 01/19/24 at 2:20 p.m., Staff B stated non-oasis SN visit documentation for 10/06/23 was not completed within 24 hours of the visit per agency policy. Patient #15 A review of a POC for 10/04/23 to 12/02/23 showed a SN visit frequency of one time a week for eight weeks. Documentation showed SN visit dated 11/12/23 was completed/submitted on 12/06/23. Documentation showed no coordination of care or communication of why visit note was not completed and submitted within 24 hours of the visit. On 01/19/24 at 2:55 p.m., Staff B stated non-oasis SN visit documentation for 10/06/23 was not completed within 24 hours of the visit per agency policy. Patient #16 A review of the POC dated 10/02/23 to 11/30/23 showed orders for SN visit frequency of one time a week for nine weeks. Documentation showed SN visit dated 10/06/23 was completed/submitted on 10/09/23. Documentation showed no coordination of care or communication of why visit note was not completed and submitted within 24 hours of the visit. On 01/19/24 at 2:58 p.m., Staff B stated non-oasis SN visit documentation for 10/06/23 was not completed 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 two (Patients #14 and #15) of 17 patients. Findings: Patient #14 A review of the clinical record documented discharge from the agency on 08/23/23 for non-compliance. Documentation showed discharge summary was provided to the physician on 09/05/23 (12 days after discharge). On 01/19/24 at 2:40 p.m., Staff B stated discharge summary was sent to the physician 12 days after discharge. Patient #15 A review of the clinical record documented discharge from the agency on 11/12/23 (desk discharge back dated to the date of the last SN visit) for non-compliance. Documentation showed discharge summary was provided to the physician on 12/06/23 (24 days after discharge). On 01/19/24 at 2:55 p.m., Staff B stated discharge summary was sent to the physician 24 days after discharge.”