Elara Caring V

“RN performs assessment CFR(s): 484.55(a)(1) A registered nurse must conduct an initial assessment visit to determine the immediate care and support needs of the patient; and, for Medicare patients, to determine eligibility for the Medicare home health benefit, including homebound status. The initial assessment visit must be held either within 48 hours of referral, or within 48 hours of the patient’s return home, or on the physician or allowed practitioner - ordered start of care date. This Element is not met as evidenced by: Based on record review and interview, the agency failed to ensure a SOC assessment was conducted within 48 hours of referral for one (Patient #12) of 14 patients. Findings: Patient #12 A review of the clinical record showed the agency received referral information on 12/20/24 and the SOC assessment occurred on 12/24/24 (4 days later). Documentation showed no physician notification of a delay in SOC and no change in orders. On 04/23/24 at 2:15 p.m., Staff B stated the SOC assessment should have been conducted within 48 hours of referral and the physician should have been notified for orders of a different SOC date.”

“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 POC included a SN intervention goal for one (Patient #9) of 14 patients. Findings: Patient #9 A review of the POC dated 02/12/25 to 04/12/25 showed orders for SN to monitor the patient’s weight via virtual video monitoring daily for two times a week for one week, effective 04/06/25. Documentation showed no weight monitoring SN intervention goals. Documentation showed no physician notifications and no change in orders. On 04/23/25 at 1:52 p.m., Staff B stated the POC documentation should have included a SN intervention goal for the patient.”

“Communication with all physicians CFR(s): 484.60(d)(1) Standard: Coordination of Care. The HHA must: (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 five (Patients #4, 5, 10, 11 and #12) of 14 patients. Findings: Patient #4 A review of the POC dated 03/07/25 to 05/05/25 showed a diagnosis of polyarthritis. Documentation showed SN to assess, monitor and teach blood glucose management and report to the physician blood glucose levels less than 70 or greater than 265 every visit. A SN visit dated 03/20/25 stated the patient had no glucometer to monitor blood glucose levels and patient fell out of bed hitting her head. Documentation showed the SN note was auto faxed to the physician by the EMR system on 03/21/25. SN visits dated 03/27/25 stated the patient had no glucometer to monitor blood glucose levels and went to an emergency department for medical evaluation twice during the week between SN visits. Documentation showed the SN note was not auto faxed to the physician by the EMR system, no follow up physician communications, no coordination of care notes regarding the patient having no glucometer to monitor blood glucose levels, falling out of bed hitting her head, or visiting the emergency department twice during the week. On 04/23/25 at 1:20 p.m., Staff B stated the SN should have communicated the patient had no glucometer to monitor blood glucose levels, fell out of bed hitting her head and had gone to the emergency department for medical evaluation twice during the week between SN visits. Patient #5 A review of the POC dated 03/06/25 to 05/04/25 showed a diagnosis of hypertension. Documentation showed orders for SN to assess, monitor and teach blood glucose management and report to the physician blood glucose levels less than 70 or greater than 265 every visit. SN visits dated 03/11/25 and 03/18/25 stated the patient would not monitor blood glucose levels outside of the SN visits. Documentation showed the SN notes were not auto faxed to the physician by the EMR system and showed no follow up physician communications or coordination of care notes regarding the patient not monitoring blood glucose levels. On 04/23/25 at 1:30 p.m., Staff B stated the SN should have communicated the patient was refusing to monitor blood glucose levels. Patient #10 A review of the POC dated 12/01/24 to 01/29/25 showed a diagnosis of Alzheimer’s disease. The POC showed orders for SN to assess, monitor, teach weight and blood pressure management and report to the physician weight reporting parameters of less than 145 pounds and greater than 150 pounds and blood pressure less than 80/50 and greater than 180/100. A SN visits dated 01/23/25 showed a reading of 142 with no notification to the physician. A SN visit dated 01/27/25 (to discharge from agency services) showed a blood pressure reading of 146/103. Documentation showed the blood pressure reading of 146/103 was auto faxed to the physician by the EMR system on 01/27/25 (day of agency discharge). Documentation showed no follow up physician communications or coordination of care notes regarding weight loss and elevated blood pressure reading. On 04/23/25 at 1:57 p.m., Staff B stated the SN should have communicated the patient’s weight loss and elevated blood pressure prior to discharge from agency services with the physician. Patient #11 A review of the POC dated 01/14/25 to 03/14/25 showed a diagnosis of after care for joint replacement. A SN visit dated 02/12/25 showed the patient complained of diarrhea, vomiting and weakness. Documentation showed no physician notification. During a SN visit dated 02/25/25, documentation showed the patient stated he was unable to drink fluids and continued to complain of vomiting and weakness. Documentation showed no physician notification, no coordination of care notes regarding the complaints of vomiting and weakness, and no changes in orders. Clinical documentation showed the patient was admitted to inpatient hospital services on 02/26/25. On 04/23/25 at 2:05 p.m., Staff B stated the SN should have communicated the patient’s continued complaints of diarrhea, vomiting and weaknesses with the physician. Patient #12 A review of the POC dated 12/24/24 to 02/21/25 showed a diagnosis of Diabetes mellitus Type II with a foot ulcer. Documentation showed orders for SN to assess, monitor and teach blood glucose management and report to the physician blood glucose levels less than 70 or greater than 300 every visit. A SN visit dated 12/26/24 showed a glucose level of 420 and verification the SN note was auto faxed to the physician by the EMR system on 12/27/24. A SN visit dated 12/28/24 showed a glucose level of 377 and verification he SN note was auto faxed to the physician by the EMR system on 12/31/24. A SN visit dated 01/24/25 showed a glucose level of 379 and the patient was out of insulin (diabetic medication). Documentation showed no physician notification by the SN or by auto faxed to the physician from the EMR system. Clinical documentation showed the patient was admitted to inpatient hospital services on 01/28/25 for cellulitis and wound infection with no follow up physician communications or coordination of care notes regarding patient’s elevated blood glucose level and lack of insulin. On 04/23/25 at 2:15 p.m., Staff B stated the SN should have communicated the elevated blood glucose levels and reported the patient was out of insulin.”

“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 interviews, the agency failed to ensure transfer/discharge summaries were provided to receiving service providers within two days of notification of transfer/discharge for three (Patients #10, 12 and #14) of 14 patients. Findings: Patient #10 A review of the clinical record showed discharge from the agency on 01/27/25 to hospice provider services. Documentation showed no transfer summary was provided to the receiving hospice service provider. On 04/23/25 at 1:52 p.m., Staff B stated no discharge summary was sent to the receiving hospice service. Patient #12 A review of the clinical record showed transfer from the agency on 01/28/25 to inpatient hospital provider services. Documentation showed a transfer summary was provided to the receiving inpatient hospital service provider on 02/04/25 (6 days from the patient transfer). On 04/23/25 at 2:15 p.m., Staff B stated the transfer summary was sent to the receiving provider six days after the patient transferred to inpatient hospital service provider. Patient #14 A review of the clinical record showed transfer from the agency on 01/28/25 to inpatient hospital provider services. Documentation showed a transfer summary was provided to the receiving inpatient hospital service provider on 02/07/25 (9 days from the patient transfer). On 04/23/25 at 2:25 p.m., Staff B stated the transfer summary was sent to the receiving provider nine days after the patient transferred to inpatient hospital service provider.”