Every finding on record at Advance Medical Services, Inc

The Emergency Preparedness regulations were reviewed as part of the Medicare recertification survey completed on 09/25/2024. During the survey it was determined the home health provider is in compliance with the requirements of 42 CFR 484.102 Condition of Participation: Emergency Preparedness for Home Health Providers.

A partial extended survey for Medicare recertification for the home health provider was completed on 09/25/2024. The provider had 1 (one) current patient.

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 policy review, record review, and interview, the home health provider failed to ensure the patient’s physician(s) were notified of missed visits in two of five full records reviewed (Records/Patients #1 and #2). This deficient practice has the potential to affect the coordination of care for all the provider’s patients. Findings included: Review of the provider’s undated policy titled, “Notification to Physician Regarding Missed Visits,” showed in part, “a missed visit which cannot be rescheduled shall be documented and communicated to the physician.” RECORD/PATIENT #1: Review of the clinical record showed the patient was admitted to home health services on 05/12/2022. Review of the plan of care dated 08/29/2024 showed the patient’s primary diagnosis for care was spastic quadriplegic cerebral palsy (spasticity, or stiff and tight muscles, in all four limbs). The patient had a secondary diagnosis of type 2 diabetes mellitus (a group of diseases that results in too much sugar in the blood). The patient resided alone in their own home with intermittent assistance from an in-home services provider. Review of the plan of care dated 06/30/2024 to 08/28/2024 showed the document contained a nursing frequency order of four times per month for two months, and three as needed visits for catheter leaks, and malfunctions. Review of the nursing visit documentation showed the nurse visited the patient on 07/11/2024 and 07/25/2024. The clinical record failed to contain documentation of physician notification of the two missed visits ordered for the month of July 2024. During an interview on 09/25/2024 at 10:32 AM the administrator stated that they would expect the physician to be notified of missed visits, and they were unable to provide documentation of physician notification of the two missed visits in July of 2024. RECORD/PATIENT #2: Review of the clinical record showed the patient was admitted to home health services on 03/30/2023 with a primary diagnosis of hemiplegia (paralysis affecting one side of the body) following a cerebral infarction (stroke) affecting the right, dominant side. Review of the plan of care dated 03/30/2023 to 05/28/2023 showed an order for physical therapy to visit the patient two times per week for four weeks. Review of the clinical documentation showed the physical therapy assistant documented a missed visit on 05/06/2023. The clinical record failed to contain documentation that the physician was notified of the missed visit. During an interview on 09/25/2024 at 10:33 AM, the administrator stated that they would expect the physician to be notified of missed visits, and they were unable to provide documentation of physician notification of the missed visit dated 05/06/2023.

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 policy review, record review and interview, the home health provider failed to ensure that clinicians developed a plan of care that contained patient-specific interventions with measurable outcomes and goals in one of five full records reviewed (Record/Patient #1). This deficient practice has the potential to affect the development of individualized plans of care for all the provider’s patients. Findings included: Review of the provider’s undated policy titled, “Care Plans,” showed that the care plan shall include, but not be limited to: - Reasonable, measurable, and realistic goals as determined by the assessment and client expectations; and - A list of specific interventions with plans for implementation. RECORD/PATIENT #1: Review of the clinical record showed the patient was admitted to home health services on 05/12/2022. Review of the plan of care dated 08/29/2024 showed the patient’s primary diagnosis for care was spastic quadriplegic cerebral palsy (spasticity, or stiff and tight muscles, in all four limbs). The patient had a secondary diagnosis of type 2 diabetes mellitus (a group of diseases that results in too much sugar in the blood). The patient resided alone in their own home with intermittent assistance from an in-home services provider. Review of the comprehensive nursing assessment dated 06/28/2024 showed: - The patient needed help with managing medications; - A non-skilled nurse filled the medication planner; and - A medication reconciliation had been performed. Review of the plans of care, dated 06/30/2024 to 08/28/2024 and 08/29/2024 to 10/27/2024, showed the documents failed to contain orders, interventions, and/or goals for the coordination of medication management with the in-home services provider. During a home visit, on 09/24/2024 at 10:10 AM, the patient stated that they had many changes to their diabetic management regimen, they were weaning off multiple medications, and beginning new medications. The patient reported that the non-skilled nurse from the in-home provider prefilled their medication planner weekly and managed their medications. During an interview with the clinical manager on 09/24/2024 at 09:50 AM, the clinical manager stated that the non-skilled nurse from the in-home service provider prefilled the patient’s medication planner weekly and managed the patient’s medications. During an interview on 09/24/2024 at 1:23 PM, the administrator provided this writer with a medication profile from the in-home service provider last updated 11/20/2023. During an interview on 09/25/2024 at 10:32 AM the administrator stated that; - They would expect coordination of care with the non-skilled nurse working for the in-home services provider to be included in the plan of care, and - The clinical record failed to contain documentation of coordination of care with the in-home services provider.

Discharge and transfer summaries CFR(s): 484.110(a)(6)(i-iii) (i) A completed discharge summary that is sent to the primary care practitioner or other health care professional who will be responsible for providing care and services to the patient after discharge from the HHA (if any) within 5 business days of the patient's discharge; or (ii) A completed transfer summary that is sent within 2 business days of a planned transfer, if the patient's care will be immediately continued in a health care facility; or (iii) A completed transfer summary that is sent within 2 business days of becoming aware of an unplanned transfer, if the patient is still receiving care in a health care facility at the time when the HHA becomes aware of the transfer. This ELEMENT is not met as evidenced by: Based on policy review, record review, and interview, the home health provider failed to provide a discharge summary to the primary care physician after discharge within five business days of the patient’s discharge, in one of six discharge records reviewed (Record/Patient #5). The home health provider failed to provide a completed transfer summary to the health care facility providing care to the patient within 2 (two) days of becoming aware of the transfer in two of six full records reviewed (Records/Patients #2 and #3). This deficient practice has the potential to adversely affect the post discharge care of all patients served by the provider. Findings included: Review of the provider’s undated policy titled, "Client Discharge Process," showed in part, the following: - Agency staff will complete a discharge summary; and - A copy of the discharge summary is mailed to the physician upon request (The policy failed to include that the discharge summary will be sent to the physician within 5 days of discharge from services). RECORD/PATIENT #5: Review of the clinical record showed that the patient was admitted for home health services on 06/20/2023 with a primary diagnosis of cervical disc disorder at C5-C6 level with radiculopathy (a disease process marked by nerve compression that results in radiating pain, muscle weakness and/or numbness down the arm). Review of the discharge OASIS (Outcome and Assessment Information Set; a standardized data collection tool) showed a discharge date of 08/16/2023 and was completed by the PT (physical therapist). Review of the discharge summary showed it was completed by the PT on 08/27/2023 (eleven days after discharge). During an interview on 09/25/2024 at 10:55 AM, the clinical manager stated that: - The discharge summary was completed late; and - It (discharge summary) should have been completed and sent to the physician within 5 days. Review of the provider’s undated policy titled, “Client Transfer,” showed that: - A transfer summary shall be completed by the registered nurse/therapist; and - The original transfer summary form shall be sent to the new provider or facility, and a copy shall be retained for the client’s chart. RECORD/PATIENT #2: Review of the clinical record showed the patient was admitted to home health services on 03/30/2023 with a primary diagnosis of hemiplegia following a cerebral infarction affecting the right, dominant, side (a stroke affecting the right side). Review of a communication note dated 05/08/2023 showed that the patient had developed swelling on both lower extremities over the weekend and was taken to the hospital. The patient was admitted to acute, inpatient care and the patient planned to be into inpatient rehabilitation upon discharge from the hospital. Review of the document titled, “Home Health Transfer Summary,” dated 05/0/9/2024 showed the document failed to contain evidence that the transfer summary was sent to the receiving facility. During an interview on 09/25/2024 at 10:33 AM the administrator stated they were unable to provide evidence that the transfer summary had been sent to the receiving facility. RECORD/PATIENT #3: Review of the document titled, “Home Health Transfer Summary,” dated 11/15/2023 showed that: - The patient went to the emergency room because he/she was so weak, was diagnosed with a urinary tract infection, and was admitted to the hospital to receive intravenous antibiotics; and - The document failed to contain documentation of: * The name of the receiving facility; and * Evidence that the transfer summary had been sent to the receiving facility. During an interview on 09/25/2024 at 10:34 AM the administrator stated they were unable to provide evidence that the transfer summary had been sent to the receiving facility.

The Emergency Preparedness regulations were reviewed as part of the Medicare certification survey completed on 01/12/2022. During the survey it was determined Advance Medical Services, INC is in compliance with the requirements of 42 CFR 484.102 Condition of Participation: Emergency Preparedness for Home Health Agencies.

A partial extended survey for Medicare certification for Advance Medical Services, INC was completed on 01/12/2022. The agency had 5 current patients. A COVID-19 Focused Infection Control survey was completed on 01/12/2022. No deficiencies were identified related to the Infection Control survey.

Participate in care CFR(s): 484.50(c)(4)(i,ii,iii,iv,v,vi,vii,viii) Participate in, be informed about, and consent or refuse care in advance of and during treatment, where appropriate, with respect to-- (i) Completion of all assessments; (ii) The care to be furnished, based on the comprehensive assessment; (iii) Establishing and revising the plan of care; (iv) The disciplines that will furnish the care; (v) The frequency of visits; (vi) Expected outcomes of care, including patient-identified goals, and anticipated risks and benefits; (vii) Any factors that could impact treatment effectiveness; and (viii) Any changes in the care to be furnished. This ELEMENT is not met as evidenced by: Based on review of the agency's current patient rights information, record review, home visit observation and interview, the agency failed to provide one (Patient #1) of three home visit observations the right to participate in, be informed about, and consent to or refuse care, in advance of and during treatment. This deficient practice has the potential to affect the rights of all agency patients. Findings included: The alternate administrator provided an admission packet for review on 01/10/2022. The patient has the right to participate in, be informed about, and consent or refuse care in advance of and during treatment, where appropriate. RECORD/PATIENT #1: Review of the medical record showed the following: - Diagnosis included, but not limited to, paranoid schizophrenia (severe mental health condition that can involve delusions and paranoia) and major depressive disorder; - There was no advanced directive and the patient had a surrogate (a substitute health-care decision-maker who consents or refuses to consenet to some or all medical treatments for the patient who lacks decision making capacity); - A physician order dated 12/03/2021 showed Arista ER (long-acting injectable atypical antipsychotic) 1064 milligrams (mg) was received from the pharmacy and the medication will be administered on the next skilled visit; and - The skilled visit note dated 12/08/2021 showed the patient was started on Aristada ER 1064 mg, 3.9 milliliter intramuscularly every 60 days due to decompensation in his/her mental health (there was no education documented). During the home visit observation on 01/11/2022 beginning at 9:00 AM showed: - Reviewed the patient’s medication; and - Started to review Aristada with the patient and licensed practical nurse (LPN) A stood behind the patient and shook his/her head no. During an interview on 01/11/2022 at 10:00 AM, LPN A stated the reason he/she was shaking his/her head no when asking about the patient’s Aristada was that the patient did not know he/she was taking the Aristada and he/she would refuse the medication if he/she knew what it was. There was no physician order not to tell the patient he/she was receiving the Aristada and it was not on the plan of care.

Payment from federally funded programs CFR(s): 484.50(c)(7)(i, ii, iii, iv) Be advised, orally and in writing, of- (i) The extent to which payment for HHA services may be expected from Medicare, Medicaid, or any other federally-funded or federal aid program known to the HHA, (ii) The charges for services that may not be covered by Medicare, Medicaid, or any other federally-funded or federal aid program known to the HHA, (iii) The charges the individual may have to pay before care is initiated; and (iv) Any changes in the information provided in accordance with paragraph (c)(7) of this section when they occur. The HHA must advise the patient and representative (if any), of these changes as soon as possible, in advance of the next home health visit. The HHA must comply with the patient notice requirements at 42 CFR 411.408(d)(2) and 42 CFR 411.408(f). This ELEMENT is not met as evidenced by: Based on review of the agency's current patient rights information, and interview, the agency failed to update the written notice of patient rights to be advised, orally and writing, of financial liability changes as soon as possible, in advance of the next home health visit of charges for services that may not be covered by Medicare, Medicaid, or any other Federally-funded or Federal aid program known to the home health agency, and the charges the individual may have to pay before care is initiated. This deficient practice has the potential to affect the knowledge and comprehension of the rights and responsibilities of all agency patients. Findings included: The alternate administrator provided an admission packet for review on 01/10/2022. The agency notice of patient rights and other information given to a patient during the initial visit contained no written information regarding the patient's right to be advised, orally and writing, of financial liability changes as soon as possible, in advance of the next home health visit of charges for services that may not be covered by Medicare, Medicaid, or any other Federally-funded or Federal aid program known to the home health agency, and the charges the individual may have to pay before care is initiated. The findings were reviewed with the alternate administrator on 01/10/2022 at 3:05 PM. He/she thought the patient rights were current. No additional information was provided.

Contact info Federal/State-funded entities CFR(s): 484.50(c)(10)(i,ii,iii,iv,v) Be advised of the names, addresses, and telephone numbers of the following Federally-funded and state-funded entities that serve the area where the patient resides: (i) Agency on Aging (ii) Center for Independent Living (iii) Protection and Advocacy Agency, (iv) Aging and Disability Resource Center; and (v) Quality Improvement Organization. This ELEMENT is not met as evidenced by: Based on policy review, review of the agency's current patient rights information, and interview, the agency failed to update the written notice of patient rights to include that the patient and representative (if any) be advised of the name, addresses, and telephone number of the following Federally funded and state funded entities that serve the area where the patient resides to include the current Quality Improvement Organization. This deficient practice has the potential to affect the knowledge and comprehension of the rights and responsibilities of all agency patients. Findings included: The alternate administrator provided an admission packet for review on 01/10/2022. The agency notice of patient rights and other information given to a patient during the initial visit showed the Quality Improvement Organization was TMF Health Quality Institute. The findings were reviewed with the alternate administrator on 01/10/2022 at 3:05 PM. He/she was not aware the Quality Improvement Organization was Livanta LLC. No additional information was provided.

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 clinical record review and interview, the agency failed to have a registered nurse (RN) complete the initial assessment of the patient within 48 hours of the referral to home care, or on the physician ordered start of care date in, but not limited to, two (Records/Patients #2 and #4) of five full records reviewed. This deficient practice has the potential to affect the immediate needs of all the agency's patients. RECORD/PATIENT #4: Review of the clinical record showed the patient was admitted to the agency on 12/9/2021 for surgical aftercare of an abdominal hernia (a bulging of an organ or tissue through an abnormal opening) repair. The patient lives alone in his/her own home. Review of the hospital referral notes, dated 12/06/2021, showed a referral to home health with an ordered start of care date of 12/07/2021. Review of the clinical record showed: - A separate referral printed on the agency’s letterhead dated 12/08/2021; - An unsigned physicians order dated 12/09/2021 stating that the clinical manager called with the referral on 12/07/2021; and - A comprehensive assessment with a start of care date of 12/09/2021. The agency failed to conduct an initial assessment visit on the physician’s ordered start of care date of 12/07/2021. During an interview on 01/12/2021, the alternate administrator stated that the agency didn’t always get the hospital referrals on the day they are printed by the hospital case manager. He/she stated that they didn’t receive the referral until 12/07/2021 but he/she did not have any documentation to explain why the initial assessment wasn’t performed on the physician ordered start of care date. Findings included: RECORD/PATIENT #2: Review of a fax dated “12/28/2021 at 12:22 PM” showed an internists follow up visit note dated 11/29/21 and orders for physical therapy and skilled nursing. Review of the clinical record showed: - The Start of care (SOC) assessment form dated 12/09/2021 and digitally signed by the registered nurse (RN) showed: *The physician ordered start of care date was not applicable; there was no specific start of care date ordered by the physician; *Date of referral was 12/08/2021; - Review of a face sheet showed a start of care date 12/09/21; - Review of a physician order dated 12/09/2021 at 12:00 PM showed on “12/07/2021 at 10:00 AM” the patient called the agency verbalizing his/her need for physical therapy; -There was no start of care assessment until 10 days after the referral; and - The clinical record failed to include documentation/communication the physician changed the start of care date from 11/29/2021 to 12/09/2021. During an interview on 01/12/2022 at 9:57 PM, the alternate administrator stated he/she might not have the physician's face to face before the patient admission to home health services to show when the start of care was ordered and he/she will clarify the discrepancies with the physician and write an 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 policy review, record review, home visit observation, and interview, the agency failed to review all of the patient's current medications to maintain an accurate/updated medication profile in, but not limited to, two (Records/Patients #1 and #2) of two home visit observations. This deficient practice has the potential to affect all patients served by the agency. Findings included: Review of the agency’s undated policy titled, "Drug Regimen Review Policy," showed, in part, the following: - The drug regimen includes a review of all medications a patient is currently using, including prescribed and over the counter and administered by any route; - Drug regimen review- 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 reactions, duplicate drug therapy, and noncompliance with drug therapy; - Completion of a drug regimen review at the beginning of the care episode; includes medication name, dose, frequency and route of administration. Medications administered only with a physician order, dated, and signed; - Physician contact and follow-up if medication issues are identified at start of care/resumption of care; and - Physician contact and follow-up each time significant medication issues are identified throughout the care episode. RECORD/PATIENT #1: During the patient's home visit observation on 01/11/2022 beginning at 9:00 AM, showed the following discrepancies with the agency's current medication profile: -The medication profile showed an order for losartan hydrochlorothiazide (anti-hypertensive) one tablet daily (there was no dosage). The patient stated that he/she took losartan hydrochlorothiazide 150 milligrams (mg)/25 mg once a day. The patient’s prescription bottle showed losartan hydrochlorothiazide 100 mg/25 mg one tablet daily; and - The patient stated he/she uses mesalamine (used to treat mild to moderate ulcerative colitis) as needed. The prescription showed mesalamine 1000 mg for rectal use as needed, fill date 01/22/2021. The medication list did not include mesalamine. RECORD/PATIENT #2: During the patient’s home visit observation on 01/11/2022 beginning at 1:00 PM, showed the medication profile showed D3 5000 international units (IU) (vitamin) one tablet daily and Women’s vitamin one tablet daily. The patient stated he/she stopped taking D3 and woman’s vitamin because they seem not to work. During an interview on 01/11/2022 at 12:45 PM, the alternate administrator stated staff ask the patient to bring out all of his/her medications and write all the medications down. He/she would expect the medications to be checked every visit for discrepancies.

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 policy review, record review, and interview, the agency failed to include all the elements of an individualized plan of care in, but not limited to, two (Records/Patients #1 and #3) of five full records reviewed. This deficient practice has the potential to affect all patients served by the agency. Findings included: Review of the agency's undated policy titled, "Plan of Care," showed the plan of care shall include: - All pertinent diagnoses, principle and secondary; - Functional limitations and precautions; - Medications, treatments, and procedures; - Any safety measures to protect against injury; and - Instructions to the client/caregiver, as applicable. RECORD/PATIENT #3: Review of the clinical record showed the patient was admitted to the agency for simple chronic bronchitis, falls from his/her bed and end stage renal (kidney) disease on 11/15/2021. The patient lives in his/her own home with his/her daughter and attends dialysis three days a week. Review of the comprehensive assessment, dated 11/15/2021, showed the patient has an AV (arteriovenous) graft/fistula (a form of vascular access that is created by connecting a vein to an artery to be used for hemodialysis treatments) in the right arm. The record also showed the patient only has an index finger and thumb on the right hand due to a previous occlusion (blockage) of a dialysis graft/fistula. The occupational therapist evaluation, dated 11/29/2021, showed the patient has impaired fine motor coordination due to the finger amputations on the right hand. The agency’s plan of care failed to include specific interventions and precautions for the patient’s AV graft and failed to include specific interventions to address the limitations related to the patient’s right finger amputations. During an interview on 11/11/2021, the alternate administrator stated that he/she would expect the plan of care to be individualized and contain interventions and precautions specific to the patient’s conditions. RECORD/PATIENT #1: Review of the physician’s home visit note dated 11/09/2021 showed: - History of urinary retention and monitor; - Congestive heart failure (occurs when the heart muscle doesn’t pump blood as well as it should), minimal edema and monitor; - Hypertension, for being non-compliant, and blood pressure is not too bad today at 150 (systolic)/80 (diastolic) (normal blood pressure systolic pressure less than 120 and diastolic pressure of less than 80); ; - Osteoarthritis/arthritis pain: Continue Tylenol and Ibuprofen 800 mg and continue to monitor kidney function and may need to decrease non-steroidal medication dose in future; and - Constipation, continue Linzess (used to treat irritable bowel syndrome with constipation and chronic constipation) daily and miralax and mesalamine (nonsteroidal anti-inflammatory drug) suppository as needed. The comprehensive assessment dated 11/12/2021 at 12:30 PM showed: - Patient’s blood pressure was 176//91; - The patient displayed bizarre behavior and stated he/she was certain people were monitoring his/her whereabouts. People were moving about his/her apartment and he/she had a “chips” in his/her body and knew exactly where the “chips” were; - Requires assistance and some direction in specific situations (for example, on all tasks involving shifting of attention) or consistently requires low stimulus environment due to distractibility; - Diabetic; and - Pain less than daily. Review of the plan of care (POC) dated 11/12/2021 through 01/10/2022 showed: - Diagnoses included: Type 2 diabetes mellitus (chronic condition that affects the way the body processes blood sugar), chest pain, paranoid schizophrenia (severe mental health condition that can involve delusions and paranoia), heart failure, hypertension, and major depressive disorder; - Notify physician of systolic blood pressure greater than 170 and less than 90 and diastolic blood pressure greater than 100 and less than 50 (the POC was not signed by the physician and there was no verbal order for the parameters); - The POC did not include how often to check the blood glucose; - The POC did not include the medication mesalamine; - The POC did not include specific interventions for monitoring and education of heart failure, constipation, pain and urinary retention; and - The plan of care did not include specific individualized interventions and education of paranoid schizophrenia. During an interview on 01/11/2022 at 10:00 AM, LPN A stated: - He/she knew the "tricks" to use that helped the patient with his/her paranoid schizophrenia; - He/she does not update the plan of care; - He/she calls the office if the plan of care needs to be updated; - He/she was unaware the patient used mesalamine for constipation; and - He/she checked the patient’s blood sugar every visit. During an interview on 01/12/2022 at 9:57 AM, the alternate administrator said the computer generates the vital sign parameters and the physician signs the plan of care. He/she expects staff to provide services as indicated in the plan of care. No further information was provided.

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 policy review, record review, and interview, the agency failed to ensure that services ordered by the physician are provided as indicated in the plan of care in, but not limited to, two (Records/Patients #4 and #5) of five full records reviewed. This deficient practice has the potential to affect all patients served by the agency. Findings included: Review of the undated agency's policy titled, "Physicians Orders," showed all medications and treatments, that are part of the client's plan of care, must be ordered by the physician. Review of the undated agency's policy titled, "Plan of Care," showed that the plan of care: - Provides guidelines for agency staff to meet the patient's specific identified needs; - Must include the type, frequency, and duration of all visits/services; and - Must include all medications, treatments, and procedures. Review of the undated agency policy titled, "Policy & Procedure Jackson Pratt," showed the registered nurse or licensed practical nurse should: - Monitor and document the appearance of the drain insertion site every visit; - Measure the drainage by holding the container at eye level; - Note the amount, color, and consistency of the drainage; and - Document the assessment findings each visit. RECORD/PATIENT #4: Review of the clinical record showed the patient was admitted to the agency on 12/09/2021 for surgical aftercare of an abdominal hernia (a bulging of an organ or tissue through an abnormal opening) repair. The patient lives alone in his/her own home. Review of the plan of care, dated 12/09/2021, showed the skilled nurse is to: - Assess abdominal surgical incision each visit; - Assess the sites of the right and left Jackson-Pratt (a type of surgical drainage system) each visit; and - The skilled nurse is to perform one visit a week for nine weeks. Review of the comprehensive nursing assessment, dated 12/09/2021, showed the licensed nurse failed to assess the amount, color, and consistency of the drainage in the Jackson-Pratt drains. Review of the skilled nurse note, dated 12/16/2021, showed the licensed nures failed to assess the amount and consistency of the drainage in the Jackson-Pratt drains. Review of the clinical record showed: - An initial visit was completed on 12/09/2021; - A skilled nurse visit was completed on 12/16/2021; - An order, dated 12/23/2021, stated that the patient states she just wants to rest; - The agency failed to document a nursing visit for the week of 01/02/2022 through 01/08/2022; and - The agency failed to notify the physician of the missed visit. RECORD/PATIENT #5: Review of the clinical record showed the patient was admitted on 11/02/2021 with diagnoses of hemiplegia (paralysis of one side of the body) following a cerebral infarct (stroke) and a cutaneous abscess (a localized collection of pus in the skin) of the right hand. He/she lives alone in his/her own home and was discharged on 11/30/2021. Review of the plan of care, dated 11/02/2021, showed the skilled nurse is to assess the patient's right middle finger cutaneous abscess each visit. Review of the skilled nursing notes dated 11/08/2021, showed the licensed nurse failed to assess the patient's right middle finger abscess. During an interview on 01/12/2022, the alternate administrator stated he/she would expect the agency clinicians to follow the physician's orders as written in the plan of care.

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 employee files and interview, the agency failed to ensure they employ qualified personnel by failing to verify professional licenses on, but not limited to, one (OT B) of three employee records reviewed. This deficient practice has the potential to affect all patients served by the agency. Findings included: Review of the personnel file for Occupational Therapist (OT) B showed a copy of the Missouri professional occupational therapy license with an expiration date of 06/30/2021. During an interview on 01/11/2022, the alternate administrator stated that the clinician usually sends in a copy of their license renewal. He/she also stated that he/she checks the employee's licensure on their annual evaluation date and he/she has a notification on his/her phone that sends an alert when the employee's evaluation is due. The alternate administrator stated that he/she would expect the licenses of the agency's professional staff to be checked at the time of expiration to ensure that the clinician renewed their license. The alternate administrator stated that he/she would have to come up with a better system to ensure licenses were checked.