Helping Hand Nurse, LLC

“Care planning, coordination, quality of care CFR(s): 484.60 Condition of participation: Care planning, coordination of services, and quality of care. Patients are accepted for treatment on the reasonable expectation that an HHA can meet the patient’s medical, nursing, rehabilitative, and social needs in his or her place of residence. Each patient must receive an individualized written plan of care, including any revisions or additions. The individualized plan of care must specify the care and services necessary to meet the patient-specific needs as identified in the comprehensive assessment, including identification of the responsible discipline(s), and the measurable outcomes that the HHA anticipates will occur as a result of implementing and coordinating the plan of care. The individualized plan of care must also specify the patient and caregiver education and training. Services must be furnished in accordance with accepted standards of practice. This Condition is not met as evidenced by: Based on reviews of policies/procedures, medical records (MR), and interview with the agency administrator the agency failed to ensure the plan of care contained patient specific measurable outcomes and goals established and periodically reviewed by the physician for nine (9) of nine (9) records reviewed. MR #1-#9.; failed to ensure documentation showing periodic review of the plan of care fornine (9) of nine (9) records reviewed. MR #1-#9 (G0572), the agency failed to ensure the plan of care contained the following information: (iii) The types of services, supplies, and equipment required; (iv) The frequency and duration of visits to be made for seven (7) of seven (7) records reviewed. MR#1-7. (G0574), the agency failed to ensure the plan of care contained All patient care orders, including verbal orders for one (1) of nine (9) records reviewed. MR#2. (G0576); failed to ensure the physician authenticated verbal orders in accordance with the state law and regulations for three (3) of nine (9) records reviewed. MR#2, MR#6 and MR#8 (G0584); failed to ensure the plan of care was reviewed and revised by the physician as frequently as the patient’s condition or needs required but not less frequently that once every sixty (60) days for eight (8) of nine (9) records reviewed. MR #1-#6 & MR#8-#9. (G0588); Findings include: Cross reference: 484.60(a) Tag 572 Plan of Care 484.60 (a)(1) Tag G572 Each patient must receive the home health services that are written in an individualized plan of care that identifies patient-specified measurable outcomes and goals... 484.60(a)(2) (iii-xvi) Tag G574 individual plan of care must include the following: 484.60(a)(3) Tag G576 All patient care orders, including verbal orders, must be recorded in the plan of care. 484.60(c) (2) Tag G592 plan of care must reflect current information from patient’s updated comprehensive assessment... 484.60(c)Tag G586 Review and revision of the plan of care 484.60(c)(1) Tag G588 Reviewed, revised by physician every sixty (60) days Tag G588 The cumulative effect of these systemic problems resulted in the Home Health Agency’s inability to plan, coordinate and provide quality care.”

“Development of EP Policies and Procedures CFR(s): 484.102(b) §403.748(b), §416.54(b), §418.113(b), §441.184(b), §460.84(b), §482.15(b), §483.73(b), §483.475(b), §484.102(b), §485.68(b), §485.542(b), §485.625(b), §485.727(b), §485.920(b), §486.360(b), §491.12(b), §494.62(b). (b) Policies and procedures. [Facilities] must develop and implement emergency preparedness policies and procedures, based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, and the communication plan at paragraph (c) of this section. The policies and procedures must be reviewed and updated at least every 2 years. *[For LTC facilities at §483.73(b):] Policies and procedures. The LTC facility must develop and implement emergency preparedness policies and procedures, based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, and the communication plan at paragraph (c) of this section. The policies and procedures must be reviewed and updated at least annually. *Additional Requirements for PACE and ESRD Facilities: *[For PACE at §460.84(b):] Policies and procedures. The PACE organization must develop and implement emergency preparedness policies and procedures, based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, and the communication plan at paragraph (c) of this section. The policies and procedures must address management of medical and nonmedical emergencies, including, but not limited to: Fire; equipment, power, or water failure; care-related emergencies; and natural disasters likely to threaten the health or safety of the participants, staff, or the public. The policies and procedures must be reviewed and updated at least every 2 years. *[For ESRD Facilities at §494.62(b):] Policies and procedures. The dialysis facility must develop and implement emergency preparedness policies and procedures, based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, and the communication plan at paragraph (c) of this section. The policies and procedures must be reviewed and updated at least every 2 years. These emergencies include, but are not limited to, fire, equipment or power failures, care-related emergencies, water supply interruption, and natural disasters likely to occur in the facility’s geographic area. This Standard is not met as evidenced by: Based on review of emergency preparedness plan, and interview with the Agency Administrator, the agency failed to ensure the policies and procedures were established for the review and updating of the emergency preparedness plan as necessary for one (1) of one (1) plan reviewed. Review of the emergency plan was completed April 9, 2024, between approximately 10:00 am and 12:30 pm revealed: No established policies and procedures for the review of the emergency plan to be completed at least every two (2) years. Review of the emergency preparedness assessment complete April 9, 2024, between approximately 10:00 am and 12:30 pm revealed: “Helping Hand Nurse Emergency Preparedness assessment was completed: 06/1/2019 and updated: 01/31/2024. No documentation to show policies or procedures. No documentation to show the assessment was completed for years: 2021, 2023. Interview w with Agency Administrator completed April 11, 2024, at approximately 1:00 pm confirmed the above findings.”

“HHA- Procedures for Follow up Staff/Pts. CFR(s): 484.102(b)(3) §484.102(b)(3) Condition of Participation: [(b) Policies and procedures. The HHA must develop and implement emergency preparedness policies and procedures, based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, and the communication plan at paragraph (c) of this section. The policies and procedures must be reviewed and updated at least every 2 years. At a minimum, the policies and procedures must address the following:] (3) The procedures to follow up with on-duty staff and patients to determine services that are needed, in the event that there is an interruption in services during or due to an emergency. The HHA must inform State and local officials of any on-duty staff or patients that they are unable to contact. This Standard is not met as evidenced by: Based on review of emergency preparedness plan, and interview with the Agency Administrator, the agency failed to ensure the policies and procedures were established for the review and updating of the emergency preparedness plan at least every two (2) years as necessary for one (1) of one (1) plan reviewed. EP #1. Findings include: Review of the emergency plan was completed April 9, 2024, between approximately 10:00 am and 12:30 pm revealed: No established policies and procedures for the review of the emergency plan to be completed at least every two (2) years. Review of EP#1, completed April 9, 2024, between approximately 10:00 am and 12:30 pm revealed: “Helping Hand Nurse Emergency Preparedness assessment was completed: 06/1/2019 and updated: 01/31/2024. No documentation to show policies or procedures. No documentation to show the assessment was completed for years: 2021, 2023. Interview w with Agency Administrator completed April 11, 2024, at approximately 1:00 pm confirmed the above findings.”

“Policies/Procedures for Medical Documentation CFR(s): 484.102(b)(4) §403.748(b)(5), §416.54(b)(4), §418.113(b)(3), §441.184(b)(5), §460.84(b)(6), §482.15(b)(5), §483.73(b)(5), §483.475(b)(5), §484.102(b)(4), §485.68(b)(3), §485.542(b)(5), §485.625(b)(5), §485.727(b)(3), §485.920(b)(4), §486.360(b)(2), §491.12(b)(3), §494.62(b)(4). [(b) Policies and procedures. The [facilities] must develop and implement emergency preparedness policies and procedures, based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, and the communication plan at paragraph (c) of this section. The policies and procedures must be reviewed and updated at least every 2 years [annually for LTC facilities]. At a minimum, the policies and procedures must address the following:] [(5) or (3),(4),(6)] A system of medical documentation that preserves patient information, protects confidentiality of patient information, and secures and maintains availability of records. *[For RNHCIs at §403.748(b) and REHs at §485.542(b):] Policies and procedures. (5) A system of care documentation that does the following: (i) Preserves patient information. (ii) Protects confidentiality of patient information. (iii) Secures and maintains the availability of records. *[For OPOs at §486.360(b):] Policies and procedures. (2) A system of medical documentation that preserves potential and actual donor information, protects confidentiality of potential and actual donor information, and secures and maintains the availability of records. This Standard is not met as evidenced by: Based on review of policies/procedures, emergency preparedness plan (EP) and interview with the agency administrator the agency failed to ensure that policies/procedures were established for that preserves patient information, protects confidentiality of patient information, and secures and maintains availability of records for one (1) of one (1) plan reviewed. EP #1 Findings Include: Review of emergency management plan completed on April 9, 2024, between approximately 10:00 am and 10:30 am revealed: Review of the emergency plan was completed April 9, 2024, between approximately 10:00 am and 12:30 pm revealed: No established policies and procedures for the review of the emergency plan to be completed at least every two (2) years. Review of EP#1 complete April 9, 2024, between approximately 10:00 am and 12:30 pm revealed: “Helping Hand Nurse Emergency Preparedness assessment was completed: 06/1/2019 and updated: 01/31/2024. No documentation to show policies or procedures. No documentation to show the assessment was completed for years: 2021, 2023.”

“Policies/Procedures-Volunteers and Staffing CFR(s): 484.102(b)(5) §403.748(b)(6), §416.54(b)(5), §418.113(b)(4), §441.184(b)(6), §460.84(b)(7), §482.15(b)(6), §483.73(b)(6), §483.475(b)(6), §484.102(b)(5), §485.68(b)(4), §485.542(b)(6), §485.625(b)(6), §485.727(b)(4), §485.920(b)(5), §491.12(b)(4), §494.62(b)(5). [(b) Policies and procedures. The [facilities] must develop and implement emergency preparedness policies and procedures, based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, and the communication plan at paragraph (c) of this section. The policies and procedures must be reviewed and updated at least every 2 years [annually for LTC facilities]. At a minimum, the policies and procedures must address the following:] (6) [or (4), (5), or (7) as noted above] The use of volunteers in an emergency or other emergency staffing strategies, including the process and role for integration of State and Federally designated health care professionals to address surge needs during an emergency. *[For RNHCIs at §403.748(b):] Policies and procedures. (6) The use of volunteers in an emergency and other emergency staffing strategies to address surge needs during an emergency. *[For Hospice at §418.113(b):] Policies and procedures. (4) The use of hospice employees in an emergency and other emergency staffing strategies, including the process and role for integration of State and Federally designated health care professionals to address surge needs during an emergency. This Standard is not met as evidenced by: Based on review of the emergency preparedness plan and interview with agency Administrator the agency failed to ensure establishment of policies and procedures addressing the utilization of volunteers for one (1) of one (1) plan reviewed. EP#1. Findings Include: Review of the emergency plan was completed April 9, 2024, between approximately 10:00 am and 12:30 pm revealed: No established policies and procedures for the review of the emergency plan to be completed at least every two (2) years. Review of EP#1 complete April 9, 2024, between approximately 10:00 am and 12:30 pm revealed: “Helping Hand Nurse Emergency Preparedness assessment was completed: 06/1/2019 and updated: 01/31/2024. No documentation to show policies or procedures. No documentation to show the assessment was completed for years: 2021, 2023. Interview w with Agency Administrator completed April 11, 2024, at approximately 1:00 pm confirmed the above findings.”

“Accuracy of encoded OASIS data CFR(s): 484.45(b) Standard: The encoded OASIS data must accurately reflect the patient’s status at the time of assessment. This Standard is not met as evidenced by: Based on review of medical records (MR) and an interview with the agency administrator, the agency failed to ensure transmission of OASIS data for current certification period for three (3) of nine (9) records reviewed. MR #5, MR #8 and MR#9. Findings include: Policy: Request made for policy on April 10, 2024, between 9am am and 1:00 pm, none provided. Reviews of medical records (MR) completed April 9, 2024, between approximately 12:30 pm and 3:00 pm and again on April 10, 2024, between approximately 9:00 am and 1:00 pm revealed the following: MR#5, SOC:12/12/20; certification period reviewed: 3/26/24-5/24/24; Diagnoses included: Essential hypertension (condition causing high blood pressure), Type two (2) diabetes mellitus without complications (condition causing high blood sugar); Idiopathic gout, right wrist (condition causing swelling), Hyperlipidemia, unspecified (low levels of blood cholesterol), Long term use of anticoagulants ( condition affecting how the blood clots), Difficulty in walking, not elsewhere classified (condition affecting ambulation). Home Health plan of care & certification showed no patient specific measurable outcomes and goals pertaining to essential hypertension, type two (2) diabetes mellitus, Idiopathic gout, right wrist, Hyperlipidemia, Long term use of anticoagulants, or Difficulty in walking. No documentation showing an oasis for the current certification period. . MR#8, SOC: 6/2/21; certification period reviewed: 3/18/24-5/16/24; Diagnoses included: Radiculopathy, lumbar region ( Nerve pain in lower back), Radiculopathy, site unspecified (Nerve pain), Essential Hypertension (condition of high blood pressure), Chronic pain syndrome ( condition of long-term pain). Home Health plan of care & certification showed no patient specific measurable outcomes and goals pertaining to Radiculopathy, , Radiculopathy, Essential Hypertension, or Chronic pain syndrome. No documentation showing an oasis for the current certification period. MR#9, SOC:1/19/23; certification period reviewed: 3/14/24-5/12/24; Diagnoses included: Spastic quadriplegic (condition affecting ability to move all limbs), Neuromuscular dysfunction of bladder, unspecified (condition affecting bladder control);Essential hypertension (condition causing high blood pressure), Hyperlipidemia, unspecified (low levels of blood cholesterol), Prediabetes (condition affecting blood sugar levels), Bed confinement status (bedridden). Home Health plan of care & certification showed no patient specific measurable outcomes and goals pertaining to Spastic quadriplegic, Neuromuscular dysfunction of bladder; essential hypertension, hyperlipidemia, prediabetes, Bed confinement status. No documentation showing any coordination of services. No documentation showing an oasis for the current certification period. Interview with agency administrator completed on April 11, 2024, at approximately 2:00 pm confirmed the above findings.”

“Plan of care CFR(s): 484.60(a)(1) Each patient must receive the home health services that are written in an individualized plan of care that identifies patient-specific measurable outcomes and goals, and which is established, periodically reviewed, and signed by a doctor of medicine, osteopathy, or podiatry acting within the scope of his or her state license, certification, or registration. If a physician or allowed practitioner refers a patient under a plan of care that cannot be completed until after an evaluation visit, the physician or allowed practitioner is consulted to approve additions or modifications to the original plan. This Standard is not met as evidenced by: Based on review of policy/procedure, medical records (MR) and an interview with the agency administrator, the agency failed to ensure the plan of care contained patient specific measurable outcomes and goals established and periodically reviewed by the physician for nine (9) of nine (9) records reviewed. MR #1-#9 ; failed to ensure documentation showing periodic review of the plan of care for nine (9) of nine (9) records reviewed. MR #1-#9 MR#4, SOC:12/1/19; certification period reviewed: 3/09/24-5/07/24; Diagnoses included: Gastro-esophageal reflux (condition stomach contents backs up into esophagus), Unspecified chronic resp. disease origin in the perinatal period (condition affecting the lungs and/or airways); Feeding difficulties, unspecified (condition affecting oral intake). Home Health plan of care & certification showed no patient specific measurable outcomes and goals pertaining to gastro-esophageal reflux, Unspecified chronic resp. disease origin in the perinatal period, or Feeding difficulties, unspecified. No documentation showing any coordination of services. MR#5, SOC:12/12/20; certification period reviewed: 3/26/24-5/24/24; Diagnoses included: Essential hypertension (condition causing high blood pressure), Type two (2) diabetes mellitus without complications (condition causing high blood sugar); Idiopathic gout, right wrist (condition causing swelling), Hyperlipidemia, unspecified (low levels of blood cholesterol), Long term use of anticoagulants ( condition affecting how the blood clots), Difficulty in walking, not elsewhere classified (condition affecting ambulation). Home Health plan of care & certification showed no patient specific measurable outcomes and goals pertaining to essential hypertension, type two (2) diabetes mellitus, Idiopathic gout, right wrist, Hyperlipidemia, Long term use of anticoagulants, or Difficulty in walking. No documentation showing any coordination of services. MR#6, SOC: 1/24/22; certification period reviewed: 5/19/23 to 7/17/23; Diagnosis included: Salmonella sepsis (infection), Pain in right hip (Pain) Chronic obstructive pulmonary disease, unspecified (Condition affection lungs), Hypertensive heart & chronic kidney dis w heart failure and stg 1-4 unspecified kidney disease (condition affecting the heart and kidneys), Heart failure (condition affecting the heart). Home Health plan of care & certification showed no patient specific measurable outcomes and goals pertaining to Salmonella sepsis, Pain in right hip, Chronic obstructive pulmonary disease, Hypertensive heart & chronic kidney dis w heart failure and stg 1-4 unspecified kidney disease. No documentation showing any coordination of services. MR#7, SOC:727/23; certification period reviewed: 7/27/23-9/24/23; Diagnoses included: Displaced bicondylar fracture of left tibia, init (condition of broken leg bone), unsp fracture of shaft of left fibula, init for clos fx (condition of broken leg bone); unspecified fracture of shaft of left tibia, init for clos fracture (condition of broken leg). Home Health plan of care & certification showed no patient specific measurable outcomes and goals pertaining to Displaced bicondylar fracture of left tibia, unspecified fracture of shaft of left fibula, init for clos fx, or unspecified fracture of shaft of left tibia, init. for clos fracture. No documentation showing any coordination of services. MR#8, SOC: 6/2/21; certification period reviewed: 3/18/24-5/16/24; Diagnoses included: Radiculopathy, lumbar region ( Nerve pain in lower back), Radiculopathy, site unspecified (Nerve pain), Essential Hypertension (condition of high blood pressure), Chronic pain syndrome ( condition of long-term pain). Home Health plan of care & certification showed no patient specific measurable outcomes and goals pertaining to Radiculopathy, , Radiculopathy, Essential Hypertension, or Chronic pain syndrome. No documentation showing any coordination of services. MR#9, SOC:1/19/23; certification period reviewed: 3/14/24-5/12/24; Diagnoses included: Spastic quadriplegic (condition affecting ability to move all limbs), Neuromuscular dysfunction of bladder, unspecified (condition affecting bladder control);Essential hypertension (condition causing high blood pressure), Hyperlipidemia, unspecified (low levels of blood cholesterol), Prediabetes (condition affecting blood sugar levels), Bed confinement status (bedridden). Home Health plan of care & certification showed no patient specific measurable outcomes and goals pertaining to Spastic quadriplegic, Neuromuscular dysfunction of bladder; essential hypertension, hyperlipidemia, prediabetes, Bed confinement status. No documentation showing any coordination of services. Findings include: Review of policies/procedures completed April 10, 2024, at between approximately 11:30 am and 2:30 pm revealed the following. Policy #2019: Care Planning and coordination, section: Procedure: bullet point #6,” The case Manager/clinical supervisor is responsible for overseeing the care planning process to ensure the plan is appropriate and realistic.”. Reviews of medical records (MR) completed April 9, 2024, between approximately 12:30 pm and 3:00 pm and again on April 10, 2024, between approximately 9:00 am and 1:00 pm revealed the following: MR #1, start of care (SOC): 9/14/23, certification period reviewed: 3/12/24-5/10/24; Diagnoses included: encounter for change or removal of surgical wound dressing, encounter for surgical after following surgery on the digestive system, chronic atrial fibrillation (fluttering of heart atria), Hypertensive chronic kidney disease and chronic kidney disease. Home Health plan of care & certification showed no goals pertaining to atrial fibrillation, chronic kidney disease or hypertension. No documentation showing any coordination of services. MR#2, SOC: 6/1/23; certification period reviewed: 3/27/24-5/25/24; Diagnoses included: Fibromyalgia (condition causing chronic fatigue), atherosclerotic heart disease of native coronary artery (clogging of arteries within the heart muscle); Chronic obstructive pulmonary disease (COPD), Hypocalcemia (low levels of blood calcium), Home Health plan & certification showed no goals pertaining to COPD, atherosclerosis of coronary arteries, or hypocalcemia. No documentation showing any coordination of services. MR#3, SOC:5/12/22; certification period reviewed: 1/2/24-3/1/24: Diagnoses included: Multiple sclerosis (damages the protective cover around nerves called myelin in your central nervous system. It can cause muscle weakness, vision changes, numbness and memory issues. While there isn’t a cure, treatment options can help you manage symptoms and slow disease progression), neuromuscular dysfunction of bladder (Neurogenic bladder is a bladder malfunction caused by an injury or disorder of the brain, spinal cord, or nerves), Diabetes. Home Health plan & certification showed no goals pertaining to MS, neuromuscular dysfunction or Diabetes. No documentation showing any coordination of services. Interview with agency administrator completed on April 11, 2024, at approximately 2:00 pm confirmed the above findings.”

“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 review of policies and procedures, medical records (MR) and interview with the Agency Administrator the agency failed to ensure the plan of care contained the following information: (iii) The types of services, supplies, and equipment required; (iv) The frequency and duration of visits to be made for seven (7) of nine (9) records reviewed. MR#1-5, MR#7, &MR#9 Findings include: Review of policies/procedures completed April 10, 2024, at between approximately 11:30 am and 2:30 pm revealed the following. Policy #2019: Care Planning and coordination does not include types of services and frequency and duration of visits to be made by specific disciplines. Reviews of medical records (MR) completed April 9, 2024, between approximately 12:30 pm and 3:00 pm and again on April 10, 2024, between approximately 9:00 am and 1:00 pm revealed the following: MR #1, start of care (SOC): 9/14/23, certification period reviewed: 3/12/24-5/10/24; Diagnoses included: encounter for change or removal of surgical wound dressing, encounter for surgical after following surgery on the digestive system, chronic atrial fibrillation (fluttering of heart atria), Hypertensive chronic kidney disease and chronic kidney disease. Physician’s Orders: “Skilled nursing frequency and duration every other day” effective 1/12/2024. No documentation showing change in Skilled nursing orders for new certification period. No physician orders for SN to complete PEG tube changes or wound care. MR#2, SOC: 6/1/23; certification period reviewed: 3/27/24-5/25/24; Diagnoses included: Fibromyalgia (condition causing chronic fatigue), atherosclerotic heart disease of native coronary artery (clogging of arteries within the heart muscle); Chronic obstructive pulmonary disease (COPD), Hypocalcemia (low levels of blood calcium), Physicians orders: “PT to assess and eval and treat effective:6/1/2023”, No documentation of orders for frequency and duration. MR#3, SOC:5/12/22; certification period reviewed: 1/2/24-3/1/24: Diagnoses included: Multiple sclerosis (damages the protective cover around nerves called myelin in your central nervous system. It can cause muscle weakness, vision changes, numbness and memory issues. While there isn’t a cure, treatment options can help you manage symptoms and slow disease progression), neuromuscular dysfunction of bladder (Neurogenic bladder is a bladder malfunction caused by an injury or disorder of the brain, spinal cord, or nerves), Diabetes. Physician orders,” ST (Speech Therapy) to assess/eval and treat effective 7/1/2023, Skilled nursing 7x9 (seven times a week for nine weeks), PT to asses/eval and treat effective 7/1/23. OT to assess/eval and treat effective 7/1/23, Home health aide 7xweek (seven days per week). Interview with agency administrator completed on April 11, 2024, at approximately 2:00 pm confirmed the above findings. MR#4, SOC:12/1/19; certification period reviewed: 3/09/24-5/07/24; Diagnoses included: Gastro-esophageal reflux (condition stomach contents backs up into esophagus), Unsp. chronic resp. disease origin in the perinatal period (condition affecting the lungs and/or airways); Feeding difficulties, unspecified (condition affecting oral intake) Physicians orders: “16 hours of skilled nursing service daily effective:11/15/2022”, No documentation of orders for frequency and duration. MR#5, SOC:12/12/20; certification period reviewed: 3/26/24-5/24/24; Diagnoses included: Essential hypertension (condition causing high blood pressure), Type two (2) diabetes mellitus without complications (condition causing high blood sugar); Idiopathic gout, right wrist (condition causing swelling), Hyperlipidemia, unspecified (low levels of blood cholesterol), Long term use of anticoagulants ( condition affecting how the blood clots), Difficulty in walking, not elsewhere classified (condition affecting ambulation) Physicians orders: “Skilled nursing frequency and duration 2w9, effective :9/28/2023, Skill nursing to assess and eval.., PT to assess/eval and treat eff:09/20/23, HHA 24/7:effective 9/28/23” No documentation of orders for frequency and duration. MR#7, SOC:727/23; certification period reviewed: 7/27/23-9/24/23; Diagnoses included: Displaced bicondylar fracture of left tibia, init (condition of broken leg bone), unsp fracture of shaft of left fibula, init for clos fx (condition of broken leg bone); unsp fracture of shaft of left tibia, init for clos fx (condition of broken leg) Physicians orders: “empty”, No documentation of orders for frequency and duration. MR#9, SOC:1/19/23; certification period reviewed: 3/14/24-5/12/24; Diagnoses included: Spastic quadriplegic (condition affecting ability to move all limbs), Neuromuscular dysfunction of bladder, unspecified (condition affecting bladder control);Essential hypertension (condition causing high blood pressure), Hyperlipidemia, unspecified (low levels of blood cholesterol), Prediabetes (condition affecting blood sugar levels), Bed confinement status (bedridden),” Physicians orders: “ Skilled nursing frequency and duration daily :effective 11/15/23” HHA orders, “frequency and duration: provide /assist with personal care and assistance with ADL’s :effective 9/16/23 “ No documentation of orders for frequency and duration.”

“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 review of policies and procedures, medical records (MR) and interview with the Agency Administrator the agency failed to ensure the plan of care contained All patient care orders, including verbal orders for one (1) of nine(9) records reviewed. MR#2. Findings include: Review of policies/procedures completed April 10, 2024, at between approximately 11:30 am and 2:30 pm revealed the following. No policy outlining procedure for verbal orders. Reviews of medical records (MR) completed April 9, 2024, between approximately 12:30 pm and 3:00 pm and again on April 10, 2024, between approximately 9:00 am and 1:00 pm revealed the following: MR#2, SOC: 6/1/23; certification period reviewed: 3/27/24-5/25/24; Diagnoses included: Fibromyalgia (condition causing chronic fatigue), atherosclerotic heart disease of native coronary artery (clogging of arteries within the heart muscle); Chronic obstructive pulmonary disease (COPD), Hypocalcemia (low levels of blood calcium), Physicians orders: “PT to assess and eval and treat effective:6/1/2023”. verbal physician order dated 5/31/23, “PT 2w9 (two times per week for nine weeks effective 5/31/23). Home health plan & certification did not show this order. Interview with agency administrator completed on April 11, 2024, at approximately 2:00 pm confirmed the above findings.”

“Verbal orders CFR(s): 484.60(b)(3)(4) (3) Verbal orders must be accepted only by personnel authorized to do so by applicable state laws and regulations and by the HHA’s internal policies. (4) When services are provided on the basis of a physician or allowed practitioner’s verbal orders, a nurse acting in accordance with state licensure requirements, or other qualified practitioner responsible for furnishing or supervising the ordered services, in accordance with state law and the HHA’s policies, must document the orders in the patient’s clinical record, and sign, date, and time the orders. Verbal orders must be authenticated and dated by the physician or allowed pracitioner in accordance with applicable state laws and regulations, as well as the HHA’s internal policies. This Element is not met as evidenced by: Based on review of state license regulations, medical records (MR) and interview with agency Administrator the agency failed to ensure the physician authenticated verbal orders in accordance with the state law and regulations for three (3) of nine (9) records reviewed. MR#2, MR#6 and MR#8 Findings include: Review of PA Code, Title 28, Health and Safety, Part IV, Health Facilities, Subpart G, Chapter 601, Home Health Care Agencies completed April 11,2024, at approximately 2:30pm revealed; section 601.31(d),”The licensed nurse or other individual, who is authorized by appropriate statutes and the State Boards in the Bureau of Professional and Occupational Affairs, shall immediately record and sign oral orders and obtain the physician’s countersignature within 7 days”. Reviews of medical records (MR) completed April 9, 2024, between approximately 12:30 pm and 3:00 pm and again on April 10, 2024, between approximately 9:00 am and 1:00 pm revealed the following: MR#2, SOC: 6/1/23; certification period reviewed: 3/27/24-5/25/24; Diagnoses included: Fibromyalgia (condition causing chronic fatigue), atherosclerotic heart disease of native coronary artery (clogging of arteries within the heart muscle); Chronic obstructive pulmonary disease (COPD), Hypocalcemia (low levels of blood calcium) contained a verbal order dated 05/31/2023,”PT2w9 (physical therapy two (2) times per week for nine (9) weeks)”. The physician signature was not obtained until 8/9/2023. Seventy-three (73) days from the time the verbal order was taken by the clinician until it was authenticated by the physician. Interview with agency administrator completed on April 11, 2024, at approximately 2:00 pm confirmed the above findings. MR#6, SOC: 1/24/22; certification period reviewed: 5/19/23 to 7/17/23; Diagnosis included: Salmonella sepsis (infection), Pain in right hip (Pain) Chronic obstructive pulmonary disease, unspecified (Condition affection lungs), Hypertensive heart & chronic kidney dis w heart failure and stg 1-4 unsp kidney disease (condition affecting the heart and kidneys), Heart failure (condition affecting the heart) contained a verbal order for certification 5/19/23 to 7/17/23, “skilled nursing frequency and duration 2w9.” The physician signature was not obtained until 7/18/2023. Sixty (60) days from the time the verbal order was taken by the clinician until it was authenticated by the physician. MR#8, SOC: 6/2/21; certification period reviewed: 3/18/24-5/16/24; Diagnoses included: Radiculopathy, lumbar region ( Nerve pain in lower back), Radiculopathy, site unspecified (Nerve pain), Essential Hypertension (condition of high blood pressure), Chronic pain syndrome ( condition of long-term pain) contained a verbal order for certification 1/23//23 to 3/23/23, “PT3wk (physical therapy three (3) times per week).” The physician signature was not obtained until 8/3/2023. One hundred ninety two (192) days from the time the verbal order was taken by the clinician until it was authenticated by the physician.”

“Reviewed, revised by physician every 60 days CFR(s): 484.60(c)(1) The individualized plan of care must be reviewed and revised by the physician or allowed practitioner who is responsible for the home health plan of care and the HHA as frequently as the patient’s condition or needs require, but no less frequently than once every 60 days, beginning with the start of care date. This Element is not met as evidenced by: Based on review of policy/procedure, medical records (MR) and an interview with the agency administrator, the agency failed to ensure the plan of care was reviewed and revised by the physician as frequently as the patient’s condition or needs required but not less frequently that once every sixty (60) days for eight (8) of nine (9) records reviewed. MR #1-#6 & MR#8-#9. Findings include: Review of policies/procedures completed April 10, 2024, at between approximately 11:30 am and 2:30 pm revealed the following. Policy #2019: Care Planning and coordination, section: Procedure: bullet point #8,” The plan of care is reviewed, updated and/or modified at least every two (2) weeks and more often if necessary ...”. Reviews of medical records (MR) completed April 9, 2024, between approximately 12:30 pm and 3:00 pm and again on April 10, 2024, between approximately 9:00 am and 1:00 pm revealed the following: MR #1, start of care (SOC): 9/14/23, certification period reviewed: 3/12/24-5/10/24; Diagnoses included: encounter for change or removal of surgical wound dressing, encounter for surgical after following surgery on the digestive system, chronic atrial fibrillation (fluttering of heart atria), Hypertensive chronic kidney disease and chronic kidney disease. Home Health plan of care & certification showed no goals pertaining to atrial fibrillation, chronic kidney disease or hypertension. No documentation the plan of care was updated every two (2) weeks. MR#2, SOC: 6/1/23; certification period reviewed: 3/27/24-5/25/24; Diagnoses included: Fibromyalgia (condition causing chronic fatigue), atherosclerotic heart disease of native coronary artery (clogging of arteries within the heart muscle); Chronic obstructive pulmonary disease (COPD), Hypocalcemia (low levels of blood calcium), Home Health plan & certification showed no goals pertaining to COPD, atherosclerosis of coronary arteries, or hypocalcemia. No documentation the plan of care was updated every two (2) weeks. MR#3, SOC:5/12/22; certification period reviewed: 1/2/24-3/1/24: Diagnoses included: Multiple sclerosis (damages the protective cover around nerves called myelin in your central nervous system. It can cause muscle weakness, vision changes, numbness and memory issues. While there isn’t a cure, treatment options can help you manage symptoms and slow disease progression), neuromuscular dysfunction of bladder (Neurogenic bladder is a bladder malfunction caused by an injury or disorder of the brain, spinal cord, or nerves), Diabetes. Home Health plan & certification showed no goals pertaining to MS, neuromuscular dysfunction or Diabetes. No documentation the plan of care was updated every two (2) weeks. Interview with agency administrator completed on April 11, 2024, at approximately 2:00 pm confirmed the above findings. MR#4, SOC:12/1/19; certification period reviewed: 3/09/24-5/07/24; Diagnoses included: Gastro-esophageal reflux (condition stomach contents backs up into esophagus), Unsp. chronic resp. disease origin in the perinatal period (condition affecting the lungs and/or airways); Feeding difficulties, unspecified (condition affecting oral intake). No documentation the plan of care was updated every two (2) weeks. MR#5, SOC:12/12/20; certification period reviewed: 3/26/24-5/24/24; Diagnoses included: Essential hypertension (condition causing high blood pressure), Type two (2) diabetes mellitus without complications (condition causing high blood sugar); Idiopathic gout, right wrist (condition causing swelling), Hyperlipidemia, unspecified (low levels of blood cholesterol), Long term use of anticoagulants ( condition affecting how the blood clots), Difficulty in walking, not elsewhere classified (condition affecting ambulation). No documentation the plan of care was updated every two (2) weeks. MR#6, SOC: 1/24/22; certification period reviewed: 5/19/23 to 7/17/23; Diagnosis included: Salmonella sepsis (infection), Pain in right hip (Pain) Chronic obstructive pulmonary disease, unspecified (Condition affection lungs), Hypertensive heart & chronic kidney dis w heart failure and stg 1-4 unsp kidney disease (condition affecting the heart and kidneys), Heart failure (condition affecting the heart).No documentation the plan of care was updated every two (2) weeks. MR#8, SOC: 6/2/21; certification period reviewed: 3/18/24-5/16/24; Diagnoses included: Radiculopathy, lumbar region ( Nerve pain in lower back), Radiculopathy, site unspecified (Nerve pain), Essential Hypertension (condition of high blood pressure), Chronic pain syndrome ( condition of long-term pain). No documentation the plan of care was updated every two (2) weeks. MR#9, SOC:1/19/23; certification period reviewed: 3/14/24-5/12/24; Diagnoses included: Spastic quadriplegic (condition affecting ability to move all limbs), Neuromuscular dysfunction of bladder, unspecified (condition affecting bladder control);Essential hypertension (condition causing high blood pressure), Hyperlipidemia, unspecified (low levels of blood cholesterol), Prediabetes (condition affecting blood sugar levels), Bed confinement status (bedridden).No documentation the plan of care was updated every two (2) weeks.”

“Ensure that HHA employs qualified personnel CFR(s): 484.105(b)(1)(iv) (iv) Ensure that the HHA employs qualified personnel, including assuring the development of personnel qualifications and policies. This Element is not met as evidenced by: Based on review of policies and procedures, personnel files (PF), and an interview with the agency administrator the agency failed to ensure files contained required information including but not limited to job descriptions, FBI clearances, performance evaluations and completed orientation documentation for four (4) of four (4) files reviewed. PF #1-#4. Findings include: Review of policy: Orientation Program, completed on April 10, 2024, at approximately 12:15 pm revealed: Purpose: “To provide an organization-wide effective and systemic orientation program for all newly hired staff…”. Policy: bullet point #3, “Department orientation and appropriate job training is provided to anyone new to a department and includes content not covered during general orientation as well as content that is covered during general orientation as well as content that is unique to the role of the new, transferred or cross-trained employee”. Procedure: bullet point #1, “Staff members sign their named on an orientation sign-in sheet for each day of general orientation attended”. Review of personnel files completed on April 9, 2024at approximately 10:15 am revealed: PF #1, date of hire (DOH): 3/30/2015 did not contain documentation of a general orientation, completed competencies or an annual evaluation for years: 2016, 2017, 2018, 2019, 2020, 2021, 2022, and 2023. PF#2, DOH: 6/14/2012, contained an orientation checklist that was incomplete, missing dates for specific tasks. PF #3, DOH: 5/15/2023, did not contain a job description. PF #4, DOH: 2/7/2023, did not contain documentation of a FBI criminal background check, a general orientation or completed competencies. Interview with agency administrator completed on April 11, 2024, at approximately 2:00 pm confirmed the above findings.”

“Ensures qualified pre-designated person CFR(s): 484.105(b)(2) When the administrator is not available, a qualified, pre-designated person, who is authorized in writing by the administrator and the governing body, assumes the same responsibilities and obligations as the administrator. The pre-designated person may be the clinical manager as described in paragraph (c) of this section. This Element is not met as evidenced by: Based on review of policy/procedures, governing body meeting minutes and interview with agency administrator the agency failed to ensure documentation of appointment of alternate individual to act on behalf of the administrator in writing for one (1) of one (1) meeting minutes reviewed. GB 2024. Findings include: A request for policy regarding specification of Governing Body meetings and need to appoint an alternate to the administrator was made on April 9, 2024, at approximately 10:00 am. No policy received. A review of the Governing body meeting minutes was completed April 10, 2024, at approximately 9:30 am revealing: GB #2024 held a meeting on:2/23/24, “Appointment of New Administrator: The administrator indicated her desire to take a back seat… She shared her recommendation for Patience O. to become the new administrator at the beginning of the new quarter… The Board unanimously agreed and appointed P. O. as the administrator starting April 1, 2024. No additional documentation showing the appointment of an alternate administrator in writing. An interview with the Administrator completed April 11, 2024, at approximately 2:30 pm confirmed the above findings.”