Every finding on record at American Homecare Management Corp

The Emergency Preparedness regulations were reviewed as part of the Medicare recertification survey completed on 08/07/2024.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 08/07/2024. The provider had 143 current patients.

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 policy review, record review, and interview, the home health provider failed to provide an initial assessment visit 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 (SOC) date in four of six full records reviewed (Records/Patients #2, #3, and #4). This deficient practice has the potential to affect all patients served by the provider. RECORD/PATIENT #1: Review of the clinical record showed the patient admitted to home health services on 07/16/2024 with a diagnosis of hemiplegia (paralysis of one side of the body) following a cerebral infarction (occurs as a result of disrupted blood flow to the brain due to problems with the blood vessels that supply it). The patient lived at home with his/her caregiver. Review of the referral documentation showed the patient discharged from a skilled nursing facility on 07/02/2024 with orders for home health services. Review of the admission assessment dated, 07/16/2024, showed the entry for "M0104: Date of Referral" to be 07/15/2024. During an interview on 08/06/2024, the administrator stated that he/she could not provide a physician order for a delayed start of care. RECORD/PATIENT #3: Review of the clinical record showed the patient admitted to home health services on 06/24/2024 with a diagnosis of unilateral primary osteoarthritis of the right hip (chronic condition affecting the joints). The patient lived in an assisted living facility. Review of the admission assessment dated, 06/24/2024. showed the entry for "M0104: Date of Referral" to be 06/20/2024 (four days prior to the admission assessment). During an interview on 08/06/2024, the administrator stated that he/she would expect the admission assessments to be completed within 48 hours of the referral. RECORD/PATIENT #4: Review of the clinical record showed the patient admitted to home health services on 07/02/2024 with a diagnosis of urinary tract infection. The patient lived at home with a caregiver. Review of the referral documentation showed the patient discharge from the hospital on 06/27/2024 with orders for home health services. Review of the admission assessment dated, 07/02/2024. showed the entry for "M0104: Date of Referral" to be 07/01/2024. During an interview on 08/06/2024, the administrator stated that he/she could not provide a physician order for a delayed start of care. Review of the provider' Start of Care (SOC) Policy revised 09/14/2022, showed in part: - In order for the patient to be "timely" at SOC, the patient must be admitted on the specified ordered date, or within 48 hours of the most updated referral information received by the agency, or within 48 hours of the facility discharge date. RECORD/PATIENT #2: Review of the clinical record showed the patient admitted to home health services on 06/28/2024 with diagnosis which included bladder cancer, pneumonia (an infection in the lungs), and insomnia (a condition of difficulty falling and/ or remaining asleep). The patient lived at home alone. Review of the referral documentation showed the patient discharge from the hospital on 06/25/2024 with orders for home health services. Review of a Coordination Note Report dated 06/27/2024, showed a verbal order dated 06/25/2024 for the patient's Start Of Care (SOC), During an interview on 08/06/2024, at 9:15 AM, the administrator stated that he/she could not provide a physician order for a delayed start of care. RECORD/PATIENT #5: Review of the clinical record showed the patient admitted to home health services on 06/05/2024 with diagnosis which included dementia ( the loss of cognitive functions which affects thinking, remembering, and reasoning), and hypertension (abnormally elevated blood pressure) .The patient lived at home with a caregiver. Review of the referral documentation showed the patient discharge from the hospital on 06/05/2024, and a physician order dated 6/10/2024 to begin home health services . During an interview on 08/06/2024, at 9:15 AM, the administrator stated that he/she could not provide a physician order for a delayed start of care.

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, observation, and interview, the home health provider failed to ensure an accurate and updated medication profile was included in the patient record in three of three home visits conducted (Records/Patients #1, #2, and #3). This deficient practice has the potential to affect all patients served by the provider. Review of the provider's Medication Reconciliation and Drug Regimen Review Policy revised 11/05/2019, showed in part: - Medication reconciliation is the process of maintaining an accurate list of all medications the patient is taking including the name, dosage, frequency, indication, and route and comparing the list to the actual bottle /containers, etc. that are in the patient's home. - The drug regimen review is completed on the Start Of Care (SOC) / Resumption Of Care (ROC). Medication reconciliation is completed by the clinician as often as needed to meet the patient's needs - Updating of the medication profile is completed on every visit by every licensed clinician. RECORD/PATIENT #2 : Review of the clinical record showed the patient admitted to home health services on 06/28/2024 with diagnosis which included bladder cancer, pneumonia (an infection in the lungs), and insomnia (a condition of difficulty falling and/ or remaining asleep). The patient lived at home alone. Review of the document titled, "Client Medication Report," dated 08/05/2024, showed the patient was prescribed : -Melatonin (used to treat insomnia) 3 mg tablet. Take two tablets at bedtime; and -Oxycodone (an opioid pain reliever) 5 mg tablet. Take one tablet every 6 hours as needed for pain. Observation on 08/05/2024 at 11:20 AM, during the patient's home visit, showed the patient no longer took these medications. During an interview on 08/05/2024 at 11:20 AM, the patient stated he/she, "didn't take the Melatonin since leaving the hospital because it didn't work". Additionally, the patient stated he/she, "didn't take the Oxycodone 5 mg anymore", but currently took Oxycodone 5 mg with Acetaminophen 325 mg for pain. During an interview on 08/05/2024 at 11:40 AM, Licensed Practical Nurse (LPN) A stated the patient's medication discrepancies should be identified, and the medication list revised during each visit to show the patient's current medication. During an interview on 08/06/2024 at 9:15 AM, the administrator stated staff should reconcile and resolve any discrepancies with patient's medications / medication list during each visit. RECORD/PATIENT #1: Review of the clinical record showed the patient admitted to home health services on 07/16/2024 with a diagnosis of hemiplegia (paralysis of one side of the body) following a cerebral infarction (occurs as a result of disrupted blood flow to the brain due to problems with the blood vessels that supply it). The patient lived at home with his/her caregiver. Review of the document titled, "Client Medication Report," dated 08/05/2024, showed the patient was using: -Lidocaine 4% topical pain relief patch. Place patch on affected area in the morning, remove in the evening; -Melatonin (used to treat insomnia) 5 milligram (mg) tablet. Take one tablet at bedtime; -Phenylephrine-guaifenesin (used to treat runny nose or congestion) 5mg-15mg-100mg/5 milliliter (mL) oral liquid. Take 10 mL four times daily as needed; -Senna plus (used to treat constipation) 8.6 mg-50mg tablet. Take one tablet daily; and -Voltaren arthritis pain 1% topical gel. Apply to affected area every 8 hours as needed for pain. Observation on 08/05/2024 at 11:00 AM, during the patient's home visit, showed the patient no longer took these medications. RECORD/PATIENT #3: Review of the clinical record showed the patient admitted to home health services on 06/24/2024 with a diagnosis of unilateral primary osteoarthritis of the right hip (chronic condition affecting the joints). The patient lived in an assisted living facility. Review of the document titled, "Client Medication Report," dated 08/05/2024, showed the patient was taking the following medications: -Cholecalciferol (vitamin D3) 50 micrograms (mcg) capsule. Take one capsule every morning; -Levothyroxine (used to treat an underactive thyroid gland) 137 mcg tablet. Take one tablet daily; -Melatonin 5 mg capsule. Take one capsule at bedtime as needed for insomnia; -Memantine (used to treat dementia) 10 mg tablet. Take one tablet at bedtime; -Ondansetron (used to treat nausea) 4 mg tablet. Take one tablet as needed daily; and -Senna 8.6 mg capsule. Take two capsules as needed every 12 hours. Review of the assisted living facility's medication list showed the patient was taking the following: -Cholecalciferol 50 mcg tablet. Give 1.5 tablet by mouth in the morning; -Levothyroxine 150 mcg tablet. Give one tablet by mouth in the morning; -Memantine 10 mg oral tablet. Take one in the morning and at bedtime; -Ondansetron 4 mg oral tablet. Take one tablet by mouth every 6 hours as needed for nausea; -Senna 8.6 mg tablet. Give two tablets by mouth every 12 hours as needed for constipation; and -Tylenol oral tablet. Give 1000 mg by mouth every eight hours as needed for pain. This medication was not on the provider's medication list. The assisted living facility medication profile failed to contain the order for melatonin.

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 policy review, record review, and interview, the home health provider failed to ensure all orders were included in the plan of care (POC) in one of six full records reviewed (Record/Patient #1). This deficient practice has the potential to affect all patients served by the provider. Findings included: RECORD/PATIENT #1: Review of the clinical record showed the patient admitted to home health services on 07/16/2024 with a diagnosis of hemiplegia (paralysis of one side of the body) following a cerebral infarction (occurs as a result of disrupted blood flow to the brain due to problems with the blood vessels that supply it). The patient lived at home with his/her caregiver. Review of the document titled, "Home Health Certification and Plan of Care," dated 07/24/2024-09/13/2024, showed a visit frequency order for physical therapy effective 07/16/2024 one time a week for nine weeks. Review of all visit notes showed the following: -The skilled nurse (SN) made a visit on 07/16/2024; -The SN made a visit on 07/23/2024; -The SN made a visit on 08/01/2024; -The occupational therapist (OT) made a visit on 07/22/2024; and -The OT made a visit on 08/05/2024. The POC failed to contain visit frequencies for these disciplines. During an interview on 08/06/2024 at 11:45 am, the clinical manager stated that there was a glitch in the computer system and the frequencies for SN and OT services did not pull over from the calendar. Review of the provider's Plan Of Care (POC) policy revised 9/2022 showed in part: - The patient or caregiver will be provided a copy of the POC and/or other form of written instructions outlining visit schedule, disciplines and frequency of visits. - Treatments and/or therapy services to be administered by home health agency staff and personnel acting on behalf of the agency. - Updated written information as the POC changes.- The home health agency will notify the physician/allowed practitioner, patient, patient representative (if any) and caregiver if changes are identified in the patient's condition and obtain physician orders to add or change the current patient POC. The clinician or clinical manager will communicate with all physicians/allowed practitioners involved in the POC as indicated throughout the course of patient care. - Care will be planned to ensure effective utilization of services and resources including the total number of visits/hours appropriate to the care required and ordered.

The Emergency Preparedness regulations were reviewed as part of the Medicare certification survey completed on 01/05/2022. During the survey it was determined Kindred At Home 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 Kindred At Home was completed on 01/05/2022. The agency had 82 current patients at the parent office located in Columbia, Missouri and 102 current patients at the branch office located at 980 Executive Drive, Osage Beach, Missouri. A COVID-19 Focused Infection Control Survey was completed in conjunction with the survey and no deficiencies were identified related to the Focused Infection Control Survey.

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 policy review, record review, and interview, the agency failed to conduct the initial assessment of the patient within 48 hours of the referral to home care, or 48 hours after the patient's return home, or on the physician ordered start of care date in four (Records/Patients #2, #3, #4 and #5) of five full records reviewed. This deficient practice has the potential to affect all patients served by the agency. Review of the agency's policy titled, "Initial and Comprehensive Assessment," dated 06/2021, showed, in part: - All patients receiving skilled services must have an initial on-site professional assessment; and - The assessment must be completed on or before start of care and within 48 hours from the date of referral or facility discharge (whichever is later), unless otherwise ordered by Primary Care Provider (PCP). RECORD/PATIENT #2 The patient was admitted to the agency on 11/15/2021, with in part, the diagnoses of a displaced fracture of the olecranon process (broken elbow that is out of alignment), chronic diastolic congestive heart failure (the heart can’t pump an adequate amount of blood throughout the body or has to pump with increased pressure), uncomplicated alcohol dependence, and history of a left hip fracture. Further review of the clinical record showed: - A referral from [named skilled nursing rehab facility] dated “11/9/21”; - The referral cover sheet with D/C (discharge) home “11/12”; - An agency client coordination note report, unsigned by the physician, dated 11/09/2021, with a projected DC date of 11/12/2021 and SOC (start of care) 11/15/2021; - The OASIS admission (Outcome and Assessment Information Set), (a standardized assessment form), with a visit date of 11/15/2021 (three days after the referral); - The OASIS admission visit note report was listed as visit number 1; - OASIS item M0102 date of physician-ordered start of care 11/12/2021; and - The clinical record failed to show a physician’s order for the late start. During an interview on 01/04/2022 at 4:45 PM, the administrator stated the late SOC was due to a combination of staffing issues and patient refusal. RECORD/PATIENT #3: Review of the referral information, dated 12/17/2021, showed, in part: - Home health services with Kindred At Home; - Opening discipline: Skilled nursing; and - Additional discipline: Physical therapy (PT) and Occupational therapy (OT). Review of the clinical record showed, in part: - Coordination note dated 12/17/2021 showed, in part: * Referral received from the facility, projected DC (discharge) date of 12/21/2021 with HH (home health) orders for SN/PT/OT (skilled nursing/physical therapy/occupational therapy) and the following physician's name was provided; * 12/17/2021: “Community care was told SOC might be 12/22/2021 or 12/23/2021 due to staffing, community care put auth [authorization] for 12/22/2021;” * 12/23/2021: “Mrs [as written by staff member] called patient to inquire about when they would like SOC scheduled. Patient told Mrs that they had so much going and had really been enjoying time with family since being DC’ed [discharged]. Mrs let patient know that if (he/she) wasn’t interested in doing therapy, (he/she) always had the option of coming back to it later. Patient said (he/she) might have to do that since every time something comes up;” * “Office rescheduled for 12/28/2021 in case patient changes mind after holidays;” - Skilled nurse completed SOC visit on 12/28/2021 at 10:06 AM; - Coordination note dated 01/01/2022 showed: * Verbal order SOC: Physician ordered SOC date approved for 12/28/2021; and * Updates to timely initiation of care (M0102/M0104): M0102 answered with a date of 12/28/2021, and M0104 date was left blank (M0102 oasis question for date of physician ordered start of care and M0104 oasis question regarding date the referral was received). During an interview on 01/04/2022 at 4:45 PM, the administrator stated the late SOC was due to a combination of staffing issues and patient refusal. RECORD/PATIENT #4: Review of the clinical record showed, in part: - Referral dated 10/08/2021, for home health services with Kindred at Home; - Skilled referral for Physical therapy; and - SOC date on 10/16/2021. During an interview on 01/04/2022 at 4:40 PM, the administrator stated that staffing was an issue and that upon accepting referrals, late SOC was discussed with referring facility. No other documentation was provided. RECORD/PATIENT #5: The patient was admitted to the agency on 11/01/2021, with in part, unspecified dementia without behavioral disturbance, unspecified atrial fibrillation (an irregular, often rapid heart rate that causes poor blood flow), chronic pain, long term use of anticoagulants (medication to thin blood), and history of falling. Further review of the clinical record showed: - A referral fax cover sheet from [named medical clinic] dated 10-21-2021; - A Kindred at Home, Home Health referral form with a referral date of 10-21-2021; - The Kindred at Home referral dated 10-21-2021 and signed by the referring nurse practitioner, had a spot “(We will see your patient within 48 hours unless a physician-ordered start of care date is included here:)” that was left blank; - A client coordination note report dated 10/29/2021, unsigned by the physician, with PCP notified once again of patient request SOC date and is agreeable to new date (no date was documented); - The OASIS admission showed a visit date of 11/01/2021 (eleven days after the referral); - The OASIS admission visit note report was listed as visit number 1; - OASIS item M0102 date of physician-ordered start of care/resumption of care known? NA- No specific SOC date ordered by the physician; - OASIS item M0104 date of referral showed “11/1/2021”; and - The clinical record failed to show a physician’s order for the late start. During an interview on 01/04/2022 at 4:45 PM, the administrator stated the late SOC was due to a combination of staffing issues and patient refusal.

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 ensure an accurate medication review and/or update of the patient medications was completed in three (Records/Patients #1, #2, and #3) of three home visit observations. This deficient practice has the potential to affect the accurate administration of medications to all the agency’s patients. Review of the agency’s policy titled, “03-05: Initial and Comprehensive Assessments”, dated last revised: 06/2021, showed in part: - At the initial assessment and each subsequent assessment, prescription, over-the-counter drugs, and herbal preparations the patient is taking will be evaluated for possible adverse reactions, allergies, contraindications, and significant effects; - Review will include: * Viewing bottles and labels of drugs the patient has; *Asking about over-the-counter medications the patient is taking (including herbal preparations); and * Asking the patient when and how medications and herbal preparations are taken and potential side effects. - Therapists and social workers will examine and transcribe information from the bottles of medication the patient is taking. - All medications will be evaluated for adverse events, duplication of medication therapy, contraindications, and other medication effects; - Therapists may perform this review when permitted by the state practice act; - When not permitted by the state practice act, the medication list will be sent to the clinical manager, pharmacist, or designee to review the medications for contraindications, duplicative therapy, non-compliance, and side effects/adverse reactions with reports to the PCP (primary care provider) as appropriate; - Agency staff will contact the PCP as appropriate regarding any possible changes in medications after hospitalizations or PCP office visits; - Medications will be entered in the EMR (electronic medical record) and will be updated as the agency becomes aware of changes in prescribed medications; - Drugs prescribed by the PCP will be entered on the POC (Plan of care); and - If the agency is administering the drugs, specific orders for administration and/or teaching patient/caregiver or family administration of the medications will be included in the plan of care. RECORD/PATIENT #1: The patient was admitted to the agency on 12/08/2021, with in part, the diagnoses of displaced fracture of base of neck of right femur (unaligned right hip fracture), laceration without foreign body, left lower leg, subsequent encounter (left hip surgical incision), pressure-induced deep tissue damage of left heel, unspecified dementia without behavioral disturbance, unspecified systolic congestive heart failure (the heart can’t pump an adequate amount of blood throughout the body or has to pump with increased pressure) and history of falling. Review of the updated medication profile provided to the surveyor by the administrator showed the following: - Acetaminophen 325 Mg (milligram) tablet-oral (by mouth), How much to take- 1 tablet, When to take-as needed every 4 hours-take only as needed, Reason to take-pain, Notes- not to exceed 3,000mg in 24 hours from all sources of acetaminophen; - Aspirin low dose 81 Mg tablet, delayed release-oral, How much to take- 1 tablet, When to take-daily, Reason to take- heart; - Calcium carbonate 600 Mg Calcium (1,500mg) tablet- oral, How much to take-1 tablet, When to take-daily, Reason to take-supplement; - Furosemide 40Mg tablet-oral, How much to take- 1 tablet, When to take- 2 times daily, Reason to take- CHF (congestive heart failure); - Multivitamin 50 plus tablet-oral, How much to take- 1 tablet, When to take- daily, Reason to take- supplement; and - Potassium chloride ER (extended release) 20 mEq (milliequivalent) tablet, oral, How much to take- 1 tablet, When to take-daily, Reason to take- CHF. During the home visit observation on 01/04/2022 at 11:10 AM with RN A: - No med reconciliation was conducted by the nurse performing the visit. During an interview with the patient’s caregivers during the home visit observation, the caregivers stated that: - The nurse never asked about the medications; and - The medications never change so they don’t ask. During chart review on 01/04/2022 at 2:50 PM with the agency administrator, in the presence of the Director of Operations and the lead surveyor, the administrator was informed that during the home visit observation, the nurse never questioned the patient regarding current medication regimen or if there were any changes. No further information was provided. RECORD/PATIENT #2: The patient was admitted to the agency on 11/15/2021, with in part, the diagnoses of a displaced fracture of the olecranon process (broken elbow that is out of alignment), chronic diastolic congestive heart failure (the heart can’t pump an adequate amount of blood throughout the body or has to pump with increased pressure), uncomplicated alcohol dependence, and history of a left hip fracture. Review of the updated medication profile provided to the surveyor by the administrator showed the following: - Acetaminophen 500 Mg (milligram) tablet-oral (by mouth), How much to take- 1-2 tablet, When to take-as needed every 6 hours-take only as needed, Reason to take-pain, Notes- not to exceed 3,000mg in 24 hours from all sources of acetaminophen; - Alendronate 70 Mg tablet-oral, How much to take-1 tablet, When to take-weekly, Reason to take- osteoporosis (a condition which makes bones become brittle and weak), Notes- Take on Wednesday before eating. Drink full glass of water. Do not lie down 30 minutes after taking; - Dilt-XR (Diltiazem) 120, 1mg capsule, extended release-oral, How much to take-1 capsule, When to take-daily, Reason to take-blood pressure; - Ondansetron 4 Mg disintegrating tablet-oral, How much to take-1 tablet, When to take- as needed every 6 hours-take only as needed, Reason to take- nausea/vomiting; - Potassium chloride Er 20 Meq (milliequivalents) tablet, extended release – oral, When to take- daily, Reason to take- supplements; - Pravastatin 40 Mg tablet-oral, How much to take- 1 tablet, When to take- daily, Reason to take- hyperlipidemia (elevate lipid levels); - Ropinirole 0.25 Mg tablet-oral, How much to take- 1 tablet, When to take- bedtime, Reason to take- Parkinson (a disorder of the central nervous system that affects movement, often including tremors); - Ropinirole 3 Mg tablet-oral, How much to take- 1 tablet, When to take- every pm (evening), Reason to take- Parkinson; and - Zoloft 100 Mg tablet-oral, How much to take- 1 tablet, When to take- daily, Reason to take-mood. During the home visit observation on 01/04/2022 at 9:02 AM with RN B: - No med reconciliation was conducted by the nurse performing the visit; - The surveyor reviewed the medication list the caregiver was utilizing to fill the medication planner and observed the medication bottles; - The caregiver’s list failed to include the acetaminophen or the ondansetron. During an interview with RN B during the home visit observation he/she stated that: - He/she uses the referral paperwork discharge med list once approved by the physician and puts it in the home; - He/she tries to add new meds to that list; and - It should be checked every time we come. During an interview with the patient’s caregiver during the home visit observation, he/she stated that: - He/she filled the medication planner; - That he/she used their own medication list and not one supplied by the agency; and - The acetaminophen and ondansetron have been used as needed. During chart review on 01/04/2022 at 2:50 PM with the agency administrator, in the presence of the Director of Operations and the lead surveyor, the administrator was informed that during the home visit observation the nurse never questioned the patient regarding current medication regimen or if there were any changes. No further information was provided. RECORD/PATIENT #3: Review of the plan of care, dated 12/28/2021 through 02/25/2022, showed, in part: - Sodium Chloride 0.9% injection syringe, flush peg tube (a tube that allows nutrition, fluids, and/or medications to be put directly in the stomach) with 1 syringe daily; and - No dosage amount for how many milliliters to flush with from each syringe. Review of the referral records showed, in part: - Sodium chloride 0.9% injection syringe 5ml (milliliter), use one syringe for wound irrigation as directed by provider for irrigating wound. During a home visit on 01/04/2022 at 10:30 AM, the patient’s caregiver flushed the peg tube with 0.9% sodium chloride flush syringe with a total of 10mls in the syringe. During chart review on 01/04/2022 at 2:15 PM, the administrator reported that the dosage should be included on the medication profile.

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, clinical record review, and interview, the agency failed to ensure that each patient's written individualized plan of care (POC) included all required elements in one (Record/Patient #3) of five full records reviewed. This deficient practice has the potential to affect all patients served by the agency. Review of the agency's policy dated 06/2021 titled, "Care Planning," showed, in part: - The plan of care/Plan of Treatment may serve as the care-planning document; - The individualized plan of care (POC) must include: * All pertinent diagnoses; * All medications and treatments; * Patient and caregiver education and training to facilitate timely discharge; and - The patient or caregiver will be provided a copy of the POC and/or other form of written instructions outlining: * Patient medication schedule/instructions, to include medication name, dosage, frequency, and which medications will be administered by HHA (home health agency) associates and personnel acting on behalf of the HHA; * Treatments and/or therapy services to be administered by HHA associates and personnel acting on behalf of the HHA; and * Pertinent instructions related to the patient’s care and treatment that the HHA will provide specific to the patient’s care need. RECORD/PATIENT #3: Review of the plan of care dated 12/28/2021 through 02/25/2022, showed, in part: - Diagnosis included hypertensive heart disease with heart failure (heart problems that occur because of high blood pressure that is present over a long time), unspecified systolic congestive heart failure (the heart does not pump efficiently and does not contract the way it should between heartbeats), atherosclerosis heart disease of native coronary artery (blood vessels that carry oxygen and nutrients from your heart to the rest of your body become thick and stiff), alcohol abuse (habitual misuse of alcohol), chronic obstructive pulmonary disease (chronic inflammatory lung disease that causes narrowing of the airway from the lungs), spinal stenosis (narrowing of the spinal canal), nonrheumatic mitral valve disorder (a condition in which your hearts valve doesn’t close tightly, allowing blood to flow backward in your heart), major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest), long term use of anticoagulants (use of blood thinners over a long period of time), long term use of opiate analgesics (use of pain medications over a long period of time), presence of cardiac pacemaker (medical device the generates electrical impulses delivered by electrodes to cause the heart muscle chambers to contract and therefore pump blood), personal history of other venous thrombosis and embolism (blood clots), dependence of wheelchair, and history of falling; - The POC did not include diagnosis for perforated bowel (hole or tear in the bowel) that required surgical intervention, surgical incision, peg tube (a tube that allows nutrition, fluids, and/or medications to be put directly in the stomach), and/or wound; - POC noted, skilled nurse performed/taught incision/suture site care to abdominal incision. Cleansed with theraworx foam pad, applied aquacel ag (antimicrobial absorbent dressing) to incision, applied skin prep around (skin protectant solution) periwound (tissue that surrounds the wound), covered with gauze, secured with medipore tape (soft cloth tape) using clean/aseptic technique. Changed dressing 2x/week and prn (as needed) for soiling /dislodgement. May use equivalent products. Once taught, patient/caregiver to perform on day’s skilled nurse is not in home; - POC noted, skilled nurse performed/taught wound care to peg tube. Cleansed with wound cleanser, dried completely, covered with drainage sponge, secured with tape using clean/aseptic technique. Change dressing every day and prn for soiling/dislodgement. May use equivalent products. Once taught, patient/caregiver to perform on day’s skilled nurse is not in home; and - Durable medical equipment (DME) and supplies: wheelchair, alginate/hydrofiber (moisture absorbent) dressing, gauze, skin protectant, tape, and cleanser. During chart review with the administrator and the director of operations on 01/04/2022 at 2:15 PM, the surveyor discussed the diagnoses missing from the POC. The administrator reviewed the diagnoses and acknowledged that they were missing from the plan of care.

Promptly alert relevant physician of changes CFR(s): 484.60(c)(1) The HHA must promptly alert the relevant physician(s) or allowed practitioner(s) to any changes in the patient's condition or needs that suggest that outcomes are not being achieved and/or that the plan of care should be altered. This ELEMENT is not met as evidenced by: Based on policy review, record review, and interview, the agency failed to promptly alert the physician to changes in the patient's condition that may suggest a need to alter the plan of care (POC) in one (Record/Patient #3) of five full records reviewed. This deficient practice has the potential to affect all patients served by the agency. Review of the agency's policy titled, "Coordination of Care," dated 06/2021, showed, in part: - Interdisciplinary personnel, internal and external to the company, must maintain close communication to ensure the patient receives coordinated complimentary care that meets their needs and supports the objectives identified in the plan of care; and - Communication with the patient’s physician/allowed practitioner must occur regarding the patient’s progress or lack of progress toward established goals, significant changes in condition, identification of new problems, and coordination of orders from any consulting physician/allowed practitioner. RECORD/PATIENT #3: Review of the plan of care (POC), dated, 12/28/2021 through 02/25/2022, showed, in part: - The patient was referred by physician to home health services with perforated bowel; - Skilled nursing to provide/instruct regarding interventions to monitor and mitigate pain; and - Licensed professional to report when pain is greater than 7 on a pain scale of 0-10 (0 being no pain and 10 being the worst pain). Review of start of care (SOC) visit note dated 12/28/2021, showed, in part: - The patient reported pain in both arms and both legs, at a level of 8; - Pain is described as aching, shooting, numbness, sharp, stabbing, tingling and chronic in nature; - Frequency of pain interfering with patient’s activity or movement is all the time; - Will notify was documented next to physician contacted, in the comments section of vital sign alert; and - No documentation of physician being notified of patient reporting pain rated at a level of 8. During an interview on 01/04/2022 at 4:50 PM, the administrator reported issues with staff forgetting to call the physician to report pain after completing the visit.

Patient medication schedule/instructions CFR(s): 484.60(e)(2) Patient medication schedule/instructions, including: medication name, dosage and frequency and which medications will be administered by HHA personnel and personnel acting on behalf of the HHA. This ELEMENT is not met as evidenced by: Based on policy review, home visit observation, and interview, the agency failed to ensure staff provided the patient and/or caregiver with a copy of written instructions outlining the patient’s medication schedule/instruction, including the medication name, dosage and frequency in one (Record/Patient #2) of three home visit observations. This deficient practice has the potential to adversely affect the knowledge of self-care and agency expectations in all the patients served by the agency. Review of the agency’s policy titled, “03-11; Care Planning,” dated annual policy review: “06/2021”, showed in part, the following: - Each patient must receive an individualized written POC (plan of care) including any revisions or additions; - The individualized POC must include all medications and treatments; - The patient or caregiver will be provided a copy of the POC and/or other form of written instructions outlining the patient medication schedule/instructions, to include medication name, dosage, frequency and which medications will be administered by HHA (home health agency) associates and personnel acting on behalf of the HHA; and - The written information should be updated as the POC changes. RECORD/PATIENT #2 The patient was admitted to the agency on 11/15/2021, with in part, the diagnoses of a displaced fracture of the olecranon process (broken elbow that is out of alignment), chronic diastolic congestive heart failure (the heart can’t pump an adequate amount of blood throughout the body or has to pump with increased pressure), uncomplicated alcohol dependence, and history of a left hip fracture. During a home visit observation on 01/04/2022 at 9:02 AM with RN B, the surveyor observed the home folder. The folder failed to contain a medication list. During an interview with RN B during the home visit observation he/she stated that: - He/she uses the referral paperwork discharge medication list once approved by the physician and puts it in the home; - He/she tries to add new medications to that list; - It should be checked every time they come; and - "To be honest, I didn’t look for it on my last visit". During an interview with the patient’s caregiver during the home visit observation, he/she stated that: - He/she filled the medication planner; - That he/she used their own medication list and not one supplied by the agency.

Treatments and therapy services CFR(s): 484.60(e)(3) Any treatments to be administered by HHA personnel and personnel acting on behalf of the HHA, including therapy services. This ELEMENT is not met as evidenced by: Based on policy review, record review, home visit observation, and interview, the agency failed to provide the patient/caregiver with a copy of written instructions of any treatments being administered by the agency and personnel acting on behalf of the HHA (home health agency) in one (Record/Patient #1) of three home visit observations. This deficient practice has the potential to adversely affect the patient/caregiver’s knowledge of self-care and agency expectations in all patients served by the agency. Review of the agency’s policy titled, “03-11; Care Planning,” dated annual policy review: 06/2021, showed in part, the following: - Each patient must receive an individualized written POC (plan of care) including any revisions or additions; - The individualized POC must specify care and services to meet the patient-specific needs as identified in the comprehensive assessment including identification of the responsible disciplines and measurable outcomes the HHA (home health agency) anticipates will occur as a result of implementing and coordinating the POC; - The individualized POC must include all medications and treatments; - The patient or caregiver will be provided a copy of the POC and/or other form of written instructions outlining treatments and/or therapy services to be administered by HHA associates and personnel acting on behalf of the HHA; and - The pertinent instruction related to the patient’s care and treatments that the HHA will provide specific to the patient’s care need. RECORD/PATIENT #1: The patient was admitted to the agency on 12/08/2021, with in part, the diagnoses of displaced fracture of base of neck of right femur (unaligned right hip fracture), laceration without foreign body, left lower leg, subsequent encounter (left hip surgical incision), pressure-induced deep tissue damage of left heel, unspecified dementia without behavioral disturbance, unspecified systolic congestive heart failure (the heart can’t pump an adequate amount of blood throughout the body or has to pump with increased pressure) and history of falling. Review of a physician’s order dated 12/17/2021, showed in part: - Order type: Add on discipline; - Skilled nurse to perform/teach incision/suture site care to right heel; - Cleanse with soap and water, apply Puracol, cover with Mepilex, secure with tape or Ace bandage using clean/aseptic technique; - Change dressing every 1-3 days and prn (as needed) soiling/dislodgement; - May use equivalent products; and - Once taught, patient/caregiver to perform on days skilled nurse is not in home. During a home visit observation on 01/04/2022 at 11:10 AM with RN A, the surveyor observed the patient’s home admission packet. There was a typed form with in part, the following: - “Check dressing to L heel QD”; - “Dry and intact PW S redness, heat, induration, no c/o pain to site”; - “1x topical once daily for heel wound”; - “Change dressing to L heel Q 3-7 day and prn c weekly general skin check due”; and - “Change top. Once ea week for wound.” During an interview with the two live-in caregivers during the home visit observation they stated the following: - No written wound care instructions were left in the home; and - The nurse only provided verbal and demonstration of wound care to be provided to left heel wound. During an interview with the agency administrator on 01/04/2022 at 2:50 PM, in the presence of the Director of Operations and the lead surveyor, the administrator stated that he/she would expect wound care instructions in an understandable language to be left in the patient’s home.