Grove Park Pharmacy Home Care, LLC

“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 Home Health Agency (HHA) failed to complete the initial assessment visit 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 for three of seven patient records reviewed, Patients #3 and #6. Findings: Review of Patient #3’s record on 7/16/24 at 1:18 PM revealed Patient #3 was admitted to the Home Health Agency (HHA) on 5/29/24 with a diagnosis of Diabetes (elevated blood sugar levels). The referral was dated 5/21/24 and faxed to the HHA on 5/23/24. The initial assessment was completed on 5/29/24 (six days after the referral was received). There was no documentation in the record indicating a reason for the delay in care. In an interview with the Clinical Director (CD) on 7/17/24 at 10:46 AM, she/he reviewed Patient #3’s record and confirmed the findings stating, “No, she does not have a communication note in there for the delay or an order.” Review of Patient #6’s record on 7/16/24 at 12:07 PM revealed Patient #6 was admitted to the HHA on 3/12/24 with a diagnosis of Peripheral Vascular Disease (PVD). The referral for HHA services was dated 3/5/24. The initial assessment was completed on 3/12/24 (seven days after the referral date). There was no documentation in the record indicating a reason for the delay in care. In an interview with the CD on 7/17/24 at 9:18 AM, she/he reviewed Patient #6’s record and confirmed the findings. Review of the HHA policy titled, “ADMISSION CRITERIA AND PROCESS” on 7/17/24 revealed, “...Home Care staff shall make the initial home visit within the time requested by the referral source or as ordered by the physician or per the patient/family requested date...goal is to admit patients within 48 hours after the referral/order...”.”

“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 observation, interview and record review, the home health agency staff failed to provide and update the current medication list for 1 of 2 applicable patient records reviewed. (Patient #7). Findings include: Home observation on 07/16/24 from 10:40 AM to 11:40 AM showed Patient #7’s hospice medication list with inaccuracies. Patient #7 stated taking Lasix 20 mg (milligrams) tablet by mouth once a day, Potassium 99 meq (milliequivalent) tablet by mouth once a day, Zinc 50 mg by mouth once a day at bedtime and Calcium Chews 650 mg 1 chew by mouth once a day of which none were listed on the home health agency medication list. During an interview on 7/17/24 at 10:15 AM, the Clinical Director verified the 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 interview and record review, the home health agency failed to include re-hospitalization risk assessments and parameters for glucose reporting in the Plan of Care (POC) for 6 out of 7 patients (Patient #1, #2, #3, #5, #6 and #7). Findings: Review of Patient # 1’s record on 7/15/24 at 1:19 PM revealed Patient #1 was admitted to the Home Health Agency (HHA) on 5/30/24 with a diagnosis of a fractured pelvis. The plan of care dated 5/30/24 to 7/28/24 did not include documentation of the risk for re-hospitalization. In an interview with the Clinical Director (CD) on 7/17/24 at 9:25 AM she/he reviewed Patient #1’s record and plan of care and confirmed the findings. Review of Patient #3’s record on 7/16/24 at 1:18 PM revealed Patient #3 was admitted to the HHA on 5/29/24 with a diagnosis of Diabetes (elevated blood sugar). The plan of care dated 5/29/24 to 7/27/24 did not include documentation of the risk for re-hospitalization. Additionally, review of the nursing visit notes dated 5/29/24, 6/7/24, 6/10/24, 6/20/24, 6/26/24 and 7/2/24 revealed Patient #3’s blood sugars were monitored each nursing visit and ranged from 100 to 309. There was nothing in the plan of care indicating parameters for blood sugar levels to be reported to the physician. In an interview with the CD on 7/17/24, she/he reviewed Patient #3’s record and confirmed the findings and confirmed the plan of care should include blood sugar parameters indicating when to notify the physician. Review of Patient #4’s record on 7/16/24 at 2:41 PM revealed Patient #4 was admitted to the HHA on 5/29/24 with a diagnosis of Diabetes with a foot ulcer (wound). Review of the nursing visit notes dated 5/30/24, 6/3/24, 6/7/24, 6/10/24, 6/14/24, 6/19/24, 6/26/24, 7/3/24, and 7/10/24 revealed Patient #4’s blood sugars were monitored each nursing visit and ranged from 80 to 200. Review of the plan of care for the period 5/29/24 to 7/27/24 revealed there was no indication of parameters for blood sugar levels to be reported to the physician. In an interview with the CD on 7/17/24 at 10:07 AM, she/he reviewed Patient #4’s record and confirmed the findings. Review of Patient #6’s record on 7/16/24 at 12:07 PM revealed Patient #6 was admitted to the HHA on 3/12/24 with a diagnosis of Peripheral Vascular Disease (PVD) and Diabetes. Review of the plan of care dated 3/12/24 to 5/10/24 revealed no documented risk for re-hospitalization. Additionally, review of the nursing visit notes dated 3/21/24, 3/25/24, and 3/28/24 revealed Patient #6’s blood sugars were monitored each nursing visit. Review of the plan of care for the period 3/12/24 to 5/10/24 revealed no parameters for blood sugar levels to be reported to the physician. In an interview with the CD on 7/17/24 at 9:21 AM, she/he reviewed Patient #6’s record and confirmed the findings. Findings include Review of Patient # 2’s record on 07/16/24 at 1:40 PM revealed Patient #2 was admitted to the HHA on 07/09/24 with a diagnosis of spinal stenosis, lumbar region without neurogenic claud. The POC dated 07/09/24 to 09/06/24 did not include documentation of the risk for re-hospitalization. During an interview on 07/17/24 at 9:25 AM Clinical Director reviewed Patient #2’s record and plan of care and confirmed the findings. Review of Patient # 5’s record on 07/15/24 at 1:40 PM revealed Patient #2 was admitted to the HHA on 05/22/23 with a diagnosis of Encounter for change or removal of surgical wound dressing. The POC dated 05/22/23 to 07/20/23 did not include documentation of the risk for re-hospitalization. During an interview on 07/17/24 at 1:35 PM, Clinical Director reviewed Patient #5’s record and plan of care and confirmed the findings. Review of Patient # 7’s record on 07/16/24 at 2:03PM revealed Patient #7 was admitted to the HHA on 05/31/24 with a diagnosis of Unspecified fracture of fourth lumbar vertebra, sequela. The POC dated 05/31/24 to 07/29/24 did not include documentation of the risk for re-hospitalization. During an interview on 07/17/24 at 10:15 AM, Clinical Director reviewed Patient #7’s record and plan of care and confirmed the findings. Findings include Review of Patient # 2’s record on 07/16/24 at 1:40 PM revealed Patient #2 was admitted to the HHA on 07/09/24 with a diagnosis of spinal stenosis, lumbar region without neurogenic claud. The POC dated 07/09/24 to 09/06/24 did not include documentation of the risk for re-hospitalization. During an interview on 07/17/24 at 9:25 AM Clinical Director reviewed Patient #2’s record and plan of care and confirmed the findings. Review of Patient # 5’s record on 07/15/24 at 1:40 PM revealed Patient #2 was admitted to the HHA on 05/22/23 with a diagnosis of Encounter for change or removal of surgical wound dressing. The POC dated 05/22/23 to 07/20/23 did not include documentation of the risk for re-hospitalization. During an interview on 07/17/24 at 1:35 PM, Clinical Director reviewed Patient #5’s record and plan of care and confirmed the findings.”

“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 record review and interview, the Home Health Agency (HHA) failed to ensure physician’s orders were documented in the clinical record for two of seven patient records reviewed, Patients #1 and #3. Findings include: Review of Patient #1’s record on 7/15/24 at 1:19 PM revealed Patient #1 was admitted to the HHA on 5/30/24 with a diagnosis of a fractured pelvis. The nursing visit note dated 7/9/24 indicated, “...Labs...Blood test obtained...Visit Narrative...RN TO HOME FOR...LAB DRAW...LABS OBTAINED...”. The nursing visit note dated 7/17/24 indicated, “...Visit Narrative...RN TO HOME FOR...lab draw...”. Review of the plan of care dated 5/30/24 to 7/28/24 and review of the physician’s orders revealed no physician’s order for labs to be drawn for Patient #1. In an interview with the Clinical Director (CD) on 7/17/24 at 10:36 AM, she/he reviewed Patient #1’s record and confirmed the findings stating, “I don’t see an order.” Review of Patient #3’s record on 7/16/24 at 1:18 PM revealed Patient #3 was admitted to the HHA on 5/29/24 with a diagnosis of Diabetes (elevated blood sugar levels). Review of the nursing visit notes dated 5/29/24, 6/10/24, 6/20/24 and 6/26/24 revealed the nurse performed wound care to Patient #3’s left foot wound. Review of the plan of care dated 5/29/24 to 7/27/24 and the physician’s orders revealed no physician’s order for wound care to Patient #3’s left foot wound. Review of the HHA policy titled, “HOME HEALTH PLAN OF CARE” on 7/17/24 revealed, “...All home care services are furnished under a physician’s order, based on the patient’s plan of care...”.”

“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 Home Health Agency (HHA) failed to ensure services were only provided as ordered by a physician or allowed practitioner for two of seven records reviewed for physician’s orders, (Patient #5 and Patient #6). Findings: Review of Patient #6’s record on 7/16/24 at 12:07 PM revealed Patient #6 was admitted to the HHA on 3/12/24 with a diagnosis of Peripheral Vascular Disease (PVD) and Diabetes (elevated blood sugar levels). The plan of care dated 3/12/24 to 5/10/24 indicated, “...Orders for Disciplines and Treatment...SN [Skilled Nurse] Frequency...1w9 [one time a week for nine weeks]...Effective Date...3/12/24.” Review of the nursing visit notes revealed a nurse made a PRN visit on 3/28/24. There was no physician’s order for any PRN (as needed nursing visits) and no documentation indicating why the PRN visit was done. In an interview with the CD on 7/17/24 at 9:20 AM, she/he reviewed Patient #6’s record and confirmed the findings. Review of the HHA’s policy titled, “PHYSICIANS ORDERS” on 7/17/24 revealed, “...All home care services are provided in accordance with physician orders...” Review of Patient #5’s medical record on 7/15/24 at 12:07 PM revealed Patient #5 was admitted to the HHA on 05/22/23 with a diagnosis of Encounter for change or removal of surgical wound dressing. The plan of care dated 05/22/23 to 07/20/23 reports Skilled Nurse (SN) schedule 3 visits every week for 9 weeks with 5 visits Pro Re Nata (PRN) starting 05/22/24. Physician orders dated 07/03/23 reports SN schedule decreased to 2 visits a week for 2 weeks starting 07/05/23. SN visits are documented on 07/10/23, 07/13/23 and 07/14/23. There are no orders for the visit on 07/14/23. During an interview on 07/17/24 at 1:35 PM, Clinical Director reviewed Patient #5’s record and plan of care and confirmed the findings.”

“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 observation, record review and interview, the Home Health Agency (HHA) failed to ensure Skilled Nursing (SN), Physical Therapy (PT) and Occupational Therapy (OT) provided services as indicated in the plan of care and physician referral for two of seven patient records reviewed, (Patient #2 and Patient #4). Review of Patient #4’s record on 7/16/24 at 2:41 PM revealed Patient #4 was admitted to the Home Health Agency (HHA) on 5/29/24 with a diagnosis of Diabetes (elevated blood sugar levels) with a foot ulcer (wound). The plan of care dated 5/29/24 to 7/27/24 indicated, “..Orders for Discipline and Treatment...Notify Physician of vital sign parameters out of range...Systolic BP (blood pressure; SBP) Greater Than (>) 160...” Review of the nursing visit notes revealed on 6/19/24 Patient #4’s SBP was 168 and on 6/26/24 his/her SBP was 162. There was no documented evidence the physician was notified Patient #4’s SBP was greater than 160. In an interview with the Clinical Director (CD) on 7/17/24 at 10:07 AM, she/he reviewed Patient #4’s record and confirmed the findings. Findings included Review of Patient #2’s medical record on 07/16/24 at 1:40 PM showed referral orders for OT evaluation. There is no documentation in the medical record for why OT assessment was not completed. PT visit schedule on the POC is 2 visits a week for 4 weeks starting 05/31/24, there are no documented PT visits the week of 05/31/24. During an interview on 07/17/24 at 10:35 AM, Clinical director stated that the home health does not have an OT. Clinical director stated that there should have been documentation in the chart that the physician and patient were both notified and that the PT should have clarified the visit schedule to start the week of 06/02/24.”

“Onsite supervisory visit every 14 days CFR(s): 484.80(h)(1)(i) (1)(i) If home health aide services are provided to a patient who is receiving skilled nursing, physical or occupational therapy, or speech language pathology services— (A) A registered nurse or other appropriate skilled professional who is familiar with the patient, the patient’s plan of care, and the written patient care instructions described in paragraph (g) of this section, must complete a supervisory assessment of the aide services being provided no less frequently than every 14 days; and (B) The home health aide does not need to be present during the supervisory assessment described in paragraph (h)(1)(i)(A) of this section. This Element is not met as evidenced by: Based on record review and interview, the Home Health Agency (HHA) failed to complete a supervisory assessment of the aide services being provided no less frequently than every 14 days for one of one patient records reviewed receiving aide services, Patient #1. Findings include: On 7/16/24 at 9:35 AM a home visit by Aide #1 to Patient #1 was observed. Patient #1 stated the HHA Aide visited her/him two times every week. Review of Patient #1’s record on 7/16/24 at 1:19 PM revealed the HHA Aide visited on 5/7/24, 5/14/24, 7/5/24, 7/9/24 and 7/12/24. There was no documented evidence the HHA Aide services were supervised. In an interview with the Clinical Director (CD) on 7/17/24 at 10:44 AM, she/he reviewed Patient #1’s record and confirmed the findings. Review of the HHA policy titled, “HOME HEALTH AIDE SERVICES” on 7/17/24 revealed, “...Supervision of In-Home Aides...a supervisory visit is made to the home of all patients at the following minimums...At least every fourteen (14) days and more frequently if indicated by the patient’s condition...”.”

“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 Home Health Agency (HHA) failed to ensure laboratory results from blood draws by the HHA Nurse were in the patients clinical record for one of one patients reviewed for laboratory tests, Patient #1. Findings include: Review of Patient #1’s record on 7/15/24 at 1:19 PM revealed Patient #1 was admitted to the HHA on 5/30/24 with a diagnosis of a fractured pelvis. Review of the nursing visit notes revealed the HHA Nurse drew blood for laboratory analysis on 7/9/24 and 7/17/24. There was no documentation in the record of the laboratory results. In an interview with the Clinical Director (CD) on 7/17/24 at 10:40 AM, she/he reviewed Patient #1’s record and confirmed the findings.”