There are  8 surveys for this facility. Please select a date to view the survey results.

Policies reviewed and education provided by the administrator to the DON and staff regarding requirements addressing 601.31(b) Plan of Treatment. The plan of treatment developed in consultation with the agency staff covers all pertinent diagnoses, including: mental status, types of services and equipment required, frequency of visits, prognosis, rehabilitation potential, functional limitations, activities permitted, nutritional requirements, medications and treatments, any safety measures to protect against injury, instructions for timely discharge or referral, and any other appropriate items. (Examples: Laboratory procedures and any contra-indications or precautions to be observed). If a physician refers a patient under a plan of treatment which cannot be completed until after an evaluation visit, the physician is consulted to approve additions or modifications to the original plan. Orders for therapy services include the specific procedures and modalities to be used and the amount, frequency, and duration. The therapist and other agency personnel participate in developing the plan of treatment. The medication list is collectively maintained in the clinical record. The plan of care will demonstrate the patient's current medication regimen, and additions and/or modifications will be identified in clinical notes, progress notes, summary reports, or communication notes. Agency staff will check all medicines a patient may be taking to identify possible ineffective drug therapy of adverse reactions, significant side effects, drug allergies, and contraindicated medication, and will promptly report any problems to the physician...The medication profiles must be updated at least every sixty (60) days and whenever there is a change in the medication regime.

Staff were educated on and reviewed agency policy 2.54 Medication Profile and policy 2.21 Physician's plan of treatment. In addition reviewed procedure for Clinical Documentation Guidelines for Medicare Reimbursement. Staff verbalized understanding of education.

CR #1, Start of Care: 12/1/2021, Home Health Certification and Plan of Care period 6/4/2022 through 8/2/2022 updated to contain related information in the section titled "Rehabilitation Potential and Discharge Plan."

CR #2, Start of Care: 2/22/2022. Home Health Certification and Plan of Care period through 6/22/2022 through 8/20/2022 updated to contain related information in the section titled "Rehabilitation Potential and Discharge Plan."

CR #3, Start of Care: 4/1/2022. Home Health Certification and Plan of Care period through 5/27/2022 through 7/25/2022 updated to contain related information in the section titled "Rehabilitation Potential and Discharge Plan."

CR #4, Start of Care: 12/7/2021. Home Health Certification and Plan of Care period through 6/5/2022 through 8/3/2022, updated to contain related information in the section titled "Rehabilitation Potential and Discharge Plan." The hours for the rest of the month from 7/9/22 to present, scheduled as eleven (11) hours and have been verified. In addition updated medications to reflect corrected information as follows:

1. Levalbuterol 0.63mg/3ml. 1 vial as needed, inhalation.
2. Artificial Tears 2 drops. place 2 drops in left eye every hour times 10 days. Discontinued 3/9/2022.
3. Omeprazole 2mg/ml. 20 mg (10 ml) give half hour to 1 hour before other medications. G-Tube
4. Fluticasone Propionate 50 mcg. 1 spray each nostril twice a day. Via nares
5. Mometasone Furoate 0.1%. Thin layer as needed every Sunday, Tuesday, and Thursday at bedtime. Topically to affected skin
6. Mupirocin 2%. External thin layer twice per day with trach (tracheostomy) care times 7 days trach stoma site. Discontinued 12/14/2021.
7. Levalbuterol Tartrate (Xopenex) 45mcg/act. 2 puffs inhalation via MDI every 4 hours as needed. Inhalation.

CR #6, Start of Care: 10/15/2020. Discharge Date: 5/11/2022. Home Health Certification and Plan of Care period 4/8/2022 through 6/7/2022 updated to contain related information in the section titled "Rehabilitation Potential and Discharge Plan."

The Administrator/DON is responsible for compliance.

The Administrator or DON will audit 100% of all clinical records, for evidence of 601.31(b) Plan of Treatment. The plan of treatment developed in consultation with the agency staff covers all pertinent diagnoses, including mental status, types of services and equipment required, frequency of visits, prognosis, rehabilitation potential, functional limitations, activities permitted, nutritional requirements, medications and treatments, any safety measures to protect against injury, instructions for timely discharge or referral, and any other appropriate items. (Examples: Laboratory procedures and any contra-indications or precautions to be observed). The medication profiles must be updated at least every sixty (60) days and whenever there is a change in the medication regime. Target threshold is 100% within 2 months.
Then, 100% of all clinical records will continue to be audited, and 10% of active staff files will be audited monthly to ensure compliance. The manager will report findings quarterly QAPI Committee and additional action plans will be implemented as appropriate.

Policies reviewed and education provided by the administrator to the DON and staff regarding requirements addressing 601.31(d) Conformance With Physician's Orders. All prescription and nonprescription (over-the-counter) drugs, devices, medications and treatments, shall be administered by agency staff in accordance with the written orders of the physician. Prescription drugs and devices shall be prescribed by a licensed physician. Only licensed pharmacists shall dispense drugs and devices. Licensed physicians may dispense drugs and devices to the patients who are in their care. 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 within 7 days obtain the physician's counter-signature. Agency staff shall check all medicines a patient may be taking to identify possible ineffective drug therapy or adverse reactions, significant side effects, drug allergies, and contraindicated medication, and shall promptly report any problems to the physician.

Staff were educated on agency policy 2.28 Patient Notification of changes and documentation of missed visits along with notification to provider of missed visits.

CR #2, Start of Care: 2/22/2022. Home Health Certification and Plan of Care Certification period reviewed 6/22/2022 through 8/20/2022, contained orders for skilled nursing (SN) twenty (20) hours per day with twelve (12) hours flex time. Missed visit notes completed regarding missing hours on the following dates:
6/24/2022 - missing three (3) hours 7/15/2022 - missing three (3) hours
Physician was notified of the missed hours.

Home Health Certification and Plan of Care Certification also contained an order for "Physical Therapy (PT) and Occupational Therapy (OT) eval and treat(evaluate and treat)" Record did not contain any documentation of PT or OT visits and did not contain any documentation of any PT or OT evaluations. Missed visit
documentation submitted with documentation that the physician was notified of the missed hours. Record updated regarding discontinuation order for PT and OT.

CR#3, Start of Care: 4/1/2022. Home Health Certification and Plan of Care Certification period reviewed 5/27/2022 through 7/25/2022 contained orders for skilled nursing (SN) twenty-four (24) hours per day, seven (7) days per week.

A review of visit documentation for June 2022 and July 2022, revealed the following:
June:
6/1 - missing 4 hours 6/2 - missing 7.5 hours 6/4 - missing 3.5 hours
6/5 - 12 hours scheduled, not verified.
Missing additional 12 hours.
6/6 - 13 hours scheduled, not verified. Missing additional 2 hours.
6/7 - 9 hours scheduled, not verified. Missing additional 5 hours.
6/8 - 9 hours scheduled, not verified. Missing additional 2 hours.
6/9 - missing 3.5 hours 6/10 - missing 3.5 hours 6/12 - missing 5 hours 6/13 - missing 4.5 hours 6/16 - missing 2.5 hours 6/17 - missing 2.5 hours
6/19 - 8 hours scheduled, not verified. 6/20 - missing 4.5 hours
6/23 - missing 2.5 hours 6/24 - missing 2.5 hours 6/28 - missing 2.5 hours 6/30 - missing 2.5 hours For July:
7/9 - missing 7 hours
7/16 - missing 11 hours
7/17 - 12 hours scheduled, not verified.
Missed visit documentation submitted for the missing hours with notification to physician of the missed hours.

CR#6, Start of Care: 10/15/2020. Discharge Date; 5/11/2022. Home Health Certification and Plan of Care Certification period reviewed 4/8/2022 through 6/6/2022 contained orders for SN eight (8) hours a day, seven (7) days a week.

A review of visit documentation for April 2022 and May 2022 missed visit notes submitted for missing hours on the follow dates: 4/8/2022 - missing 4 hours 4/22/2022 - missing 5 hours, 4/24/2022 - missing 3.5 hours 5/8/2022 - missing 1 hour. Documentation updated indicating that the physician was notified of the missed hours.

The Administrator or DON will audit 100% of all clinical records, for evidence of
601.31(d) Conformance With Physician's Orders. All prescription and nonprescription (over-the-counter) drugs, devices, medications and treatments, shall be administered by agency staff in accordance with the written orders of the physician. Prescription drugs and devices shall be prescribed by a licensed physician. Only licensed pharmacists shall dispense drugs and devices. Licensed physicians may dispense drugs and devices to the patients who are in their care. 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 within 7 days obtain the physician's counter-signature. Agency staff shall check all medicines a patient may be taking to identify possible ineffective drug therapy or adverse reactions, significant side effects, drug allergies, and contraindicated medication, and shall promptly report any problems to the physician. If order not signed and dated within 7 days of order, subsequent documentation must be present to demonstrate effort to resend for signature. Provider will be notified of missed visits and note will be place on patient chart. Target threshold is 100% within 2 months.
Then, 100% of all clinical records will continue to be audited, and 10% of active staff files will be audited monthly to ensure compliance. The manager will report findings quarterly QAPI Committee and additional action plans will be implemented as appropriate.

Policies reviewed and education provided by the administrator to the DON and staff regarding requirements addressing 601.36(a) Maintenance and Content of Record. A clinical record is maintained in accordance with accepted professional standards and contains:
i. pertinent past and current findings,
ii. plan of treatment,
iii. appropriate identifying information,
iv. name of physician,
v. drug, dietary, treatment and activity orders,
vi. signed and dated clinical progress notes (clinical notes are written the day service is rendered and incorporated no less often than weekly),
vii. copies of summary reports sent to the physician, and
a discharge summary.

Staff were educated on and reviewed agency policy 2.25 Physician Responsibilities, reviewing written reports to physicians policy and procedure that addresses summary to be sent to physician every 60 days. Staff verbalized understanding.

CR #1, Start of Care: 12/1/2021. Home Health Certification and Plan of Care period reviewed: 6/4/2022 through 8/2/2022. Sixty (60) day summary dated 6/1/2022 updated to contain any documentation of a summary of condition for skilled nursing and faxed to physician.

CR #2, Start of Care: 2/22/2022. Home Health Certification and Plan of Care period reviewed: 6/22/2022 through 8/20/2022. Sixty (60) day summary dated 6/22/2022 updated to contain any documentation of a summary of condition for skilled nursing and faxed to physician.

CR #3, Start of Care: 4/1/2022. Home Health Certification and Plan of Care period reviewed: 5/27/2022 through 7/25/2022. Sixty (60) day summary dated 7/25/2022 updated to contain any documentation of a summary of condition for skilled nursing and faxed to physician.

CR #4, Start of Care: 12/7/2021. Home Health Certification and Plan of Care period reviewed: 6/5/2022 through 8/3/2022. Sixty (60) day summary dated 6/7/2022 updated to contain any documentation of a summary of condition for skilled nursing and faxed to physician.

The Administrator/DON is responsible for compliance.

The Administrator or DON will audit 100% of all clinical records, for evidence of 601.36(a) Maintenance and Content of Record. A clinical record is maintained in accordance with accepted professional standards and contains: pertinent past and current findings, plan of treatment, appropriate identifying information, name of physician, drug, dietary, treatment and activity orders, signed and dated clinical progress notes (clinical notes are written the day service is rendered and incorporated no less often than weekly), copies of summary reports sent to the physician, and a discharge summary. 60 day summary to be completed by each discipline with progress and faxed to physician. Target threshold is 100% within 2 months.
Then, 100% of all clinical records will continue to be audited, and 10% of active staff files will be audited monthly to ensure compliance. The manager will report findings quarterly QAPI Committee and additional action plans will be implemented as appropriate.