Beacon Home Health

“Services by skilled professionals CFR(s): 484.75(a) Standard: Provision of services by skilled professionals. Skilled professional services are authorized, delivered, and supervised only by health care professionals who meet the appropriate qualifications specified under §484.115 and who practice according to the HHA’s policies and procedures. This Standard is not met as evidenced by: Based on policy review, medical record review and interview, the agency failed to provide one patient (#8) a licensed occupational therapist out of 3 patients reviewed. The findings included: Medical record review revealed Patient #8 was admitted to the agency on 6/20/23 with diagnoses including Ehlers-Danlos Syndrome and Essential Hypertension. Review of the agency’s policy on Student on Education revised on 5/1/23 revealed “...The personnel of the agency shall retain overall responsibility of providing patient care to all patients with whom a student may interact...Mentor will ensure that the student will work in accordance with all agency policies and procedures whether observing patient care or providing direct patient care...” Medical record review of the Home Health Certification and Plan of Care dated 8/19/23 to 10/17/23 revealed a physician’s order for occupational therapy visits at one time a week for 9 weeks. Review of documentation provided by the agency dated 10/12/23 revealed a non-licensed occupational therapy student completed an occupational therapy visit on 10/4/23 with Patient #8 without direct supervision of her clinical instructor (OT #1). Interview with the Area Administrator on 11/15/23 at 1:00 PM, in the conference room, confirmed a non-licensed occupational therapist student completed a visit to Patient #8 on 10/4/23 without direct supervision of her clinical supervisor.”

“Licensing CFR(s): 484.100(b) (b) Standard: Licensing. The HHA, its branches, and all persons furnishing services to patients must be licensed, certified, or registered, as applicable, in accordance with the state licensing authority as meeting those requirements. This Standard is not met as evidenced by: Based on policy review, medical record review and interview, the agency failed to provide a licensed occupational therapist to one Patient (#8) of 3 patients reviewed. The findings included: Medical record review revealed Patient #8 was admitted to the agency on 6/20/23 with diagnoses including Ehlers-Danlos Syndrome and Essential Hypertension. Medical record review of the Home Health Certification and Plan of Care dated 8/19/23 to 10/17/23 revealed a physician’s order for occupational therapy visits at one time a week for 9 weeks. Review of documentation provided by the agency dated 10/12/23 revealed a non-licensed occupational therapy student provided care on 10/4/23 to Patient #8 without her direct clinical instructor present. Interview with the Area Administrator on 11/15/23 at 1:15 PM confirmed the occupational student therapy student provided care to Patient #8 without the direct clinical instructor in the home.”

“Authentication CFR(s): 484.110(b) Standard: Authentication. All entries must be legible, clear, complete, and appropriately authenticated, dated, and timed. Authentication must include a signature and a title (occupation), or a secured computer entry by a unique identifier, of a primary author who has reviewed and approved the entry. This Standard is not met as evidenced by: Based on medical record review and interview, the agency’s occupational therapist falsified a visit note for 1 patient (#8) of 3 patients reviewed. The findings included: Medical record review revealed Patient #8 was admitted to the agency on 6/20/23 with diagnoses including Ehlers-Danlos Syndrome and Essential Hypertension. Medical record review of the Home Health Certification and Plan of Care dated 8/19/23 to 10/17/23 revealed a physician’s order for occupational therapy visits at 1 time a week for 9 weeks. Review of documentation provided by the agency dated 10/12/23 revealed the non-licensed occupational therapy student completed a visit for Patient #8 on 10/4/23 without the clinical instructor (occupational therapist) in the home. Medical record review of the occupational therapy visit note dated 10/4/23 revealed the note was completed by the clinical instructor (who was not present in the home during the visit) and not the non-licensed occupational therapy student who completed the visit. Interview with the Area Administrator on 11/15/23 at 1:15 PM, in the conference room, confirmed the clinical instructor falsified the note as he did not complete the home visit.”

“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 medical record review and interview, the agency failed to complete the initial visit within 48 hours of the physician’s referral for 1 patient (#4) of 17 patients reviewed. The findings included: Medical record review revealed Patient #4 was admitted to the agency on 9/29/23 with diagnoses including Osteoporosis and Acute Respiratory Failure with Hypoxia. Medical record review of the physician’s referral dated 9/25/23 revealed the physician referred Patient #4 to the agency on 9/25/23 with a requested start of care date of 9/26/23. Medical record review of the initial visit note revealed the initial assessment was not completed until 9/29/23 and not within the 48 hours. Interview with the Area Administrator on 11/15/2023 at 1:35 PM, in the conference room, confirmed the initial assessment was not completed within the 48 hours.”

“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 medical record review and interview, the agency failed to accurately record wound care frequency in the plan of care for 1 patient (#1) of 17 patients reviewed. The findings included: Medical record review revealed the patient was admitted to the agency on 11/9/2023 with diagnoses including Cellulitis of Left Upper Limb and Cutaneous Abscess of Left Upper Limb. Medical record review of the physician’s referral dated 11/7/2023 revealed an order to change the wound care dressings one time a day and as needed. Medical record review of the Home Health Certification and Plan of Care (485) dated 11/9/2023 to 1/7/2024 revealed the wound care dressings were to be changed two times a day. Medical record review of the nurse’s notes dated 11/9/2023 to 11/13/2023 revealed the wound care dressings were changed one time a day. Interview with the Area Administrator on 11/15/2023 at 1:30 PM, in the conference room, confirmed the wound care frequency orders were incorrectly transcribed to the 484 and should have stated the frequency as one time a day.”