Almighty Home Health

“Required items in clinical record CFR(s): 484.110(a)(1) The patient’s current comprehensive assessment, including all of the assessments from the most recent home health admission, clinical notes, plans of care, and physician or allowed practitioner orders; This Element is not met as evidenced by: Based on record review and interview the clinical records for 2 (Patient #1 and Patient #2) of 3 patients who the surveyor made home visits with failed to include all the required items in the clinical record. Clinical notes and home health aide notes were not completed in the records of the clients. Patient records did not reflect the course of care and were incomplete. The lack of documentation could result in a lack of continuity of care. Review of Patient #1’s clinical record on 04/16/2024 revealed a plan of care dated 03/01/2024 to 04/29/24 that ordered skilled nursing visits weekly for 9 weeks and twice weekly visits by a home health aide for 8 weeks. The POC documented Patient #1 had heart disease, lung disease, a history of falling and fractures. Review of the skilled nursing visits revealed weekly visits were scheduled 03/14/2024 to 04/11/2024. Patient #1’s schedule revealed RN A was scheduled for visits dated 03/14/2024, 03/21/2024, 03/28/2024, 04/04/2024, and 04/11/2024. Each of these 5 visits were marked as “Not Started” in the client record. Patient #1’s schedule revealed HHA A was scheduled for visits dated 04/02/2024, 04/04/2024, 04/09/2024, and 04/11/2024. Each of these 4 visits were marked as “Not Started” in the client record. Review of Patient #2’s clinical record on 04/16/2024 revealed a plan of care dated 03/25/2024 to 05/23/24 that ordered skilled nursing visits weekly for 9 weeks and twice weekly visits by a home health aide for 9 weeks. The POC documented Patient #2 had heart and kidney disease, arthritis, hearing loss, a history of falling, and long- term use of blood thinners. Review of the skilled nursing visits revealed weekly visits were scheduled 03/25/2024, 04/04/2024, and 04/11/2024, and that RN A was scheduled for these visits. Each of these 3 visits were marked as “Not Started” in the patient record. During a home visit with Patient #1 and Patient #2 on 04/18/2024 at 10:15 AM, Patient #1 stated RN A came to the home weekly and saw Patient #1 and Patient #2 for more than one year. Patient #1 stated HHA A came twice a week to see Patient #1 for more than one year. The surveyor reviewed vital sign logs found in home folders for Patient #1 and Patient #2 with weekly vital sign entries for March 2024 and April 2024 through 04/18/2024. An interview was conducted with the RN A on 04/18/2024 at 10 AM. The surveyor asked how often the nurse made visits to Patient #1. The nurse stated she sees the patient weekly. The surveyor asked why the electronic client record for Patient #1 did not contain any visit notes for 03/14/24 to 04/11/24 when the surveyor reviewed the clinical record on 04/16/2024. The RN stated: “I was late documenting.” The surveyor asked how often the nurse made visits to Patient #2. The nurse stated she sees the patient weekly. The surveyor asked why the electronic client record for Patient #2 did not contain any visit notes for 03/25/2024 to 04/11/2024 when the surveyor reviewed the clinical record on 04/16/2024. RN A stated: “I did the visits, and I am behind in documentation.” An interview was conducted with the Administrator and DON on 04/18/2024 at 11:38 AM. The surveyor asked how the agency oversaw the documentation of visits. The Administrator stated they did QA weekly and reminded staff if they were behind on documentation. The surveyor asked what was done if the staff did not complete the visits. The Administrator stated they reminded the nurse and did a verbal counseling. The surveyor reviewed the findings for the record reviews and asked about the lack of nursing notes for Patient #1 and Patient #2, and the lack of Home Health Aide notes for Patient #1 in the electronic medical records. The Administrator stated they were aware of the late documentation, and that the patient’s only wanted that “particular nurse” assigned to care for them. The surveyor asked the DON what the policy was for completing documentation of clinical notes. The DON stated 48 hours, and usually they received them within 3-4 days. The DON stated this was only an issue with 1 nurse. The surveyor reviewed and asked about the home health aide notes that were not documented. The DON stated they should have been done. Review of agency policy titled: “IM.9 Timeliness” dated “070121” revealed read in part: Purpose – To establish timeframes for completion and incorporation of paperwork and OASIS into the clinical record … Policy A. Agency will ensure timely provision of care and services to meet the patient’s needs in compliance with all federal and state laws and regulations and standards of practice… Clinical and progress notes are written the day services is rendered. If agency does not have electronic records, the clinical or progress note is submitted to the agency within 24 hours… Review of agency policy titled: “IM.7 Medical Record Content” dated “070121” read in part: Purpose – To ensure a medical record is created for every patient who receives treatment, care or services and is maintained for the primary purpose of providing patient care. The record shall contain sufficient information to identify the patient, support the diagnosis(es), justify treatment, document the course of care and results and facilitate the continuity of patient care…”