Every finding on record at Ardent Home Health Care Agency Corp

A Recertification and Emergency Preparedness survey was conducted by Healthcare Management Solutions, LLC on behalf of Nevada Department of Health and Human Services. An unannounced on-site Recertification Survey at the above-named Home Health Agency (HHA) from 01/29/25 to 01/31/25 resulted in the following findings respective to the Emergency Preparedness Program Condition of Participation under 42 CFR 484.102.

Plan Based on All Hazards Risk Assessment CFR(s): 484.102(a)(1)-(2) §403.748(a)(1)-(2), §416.54(a)(1)-(2), §418.113(a)(1)-(2), §441.184(a)(1)-(2), §460.84(a)(1)-(2), §482.15(a)(1)-(2), §483.73(a)(1)-(2), §483.475(a)(1)-(2), §484.102(a)(1)-(2), §485.68(a)(1)-(2), §485.542(a)(1)-(2), §485.625(a)(1)-(2), §485.727(a)(1)-(2), §485.920(a)(1)-(2), §486.360(a)(1)-(2), §491.12(a)(1)-(2), §494.62(a)(1)-(2) [(a) Emergency Plan. The [facility] must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least every 2 years. The plan must do the following:] (1) Be based on and include a documented, facility-based and community-based risk assessment, utilizing an all-hazards approach.* (2) Include strategies for addressing emergency events identified by the risk assessment. * [For Hospices at §418.113(a):] Emergency Plan. The Hospice must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least every 2 years. The plan must do the following: (1) Be based on and include a documented, facility-based and community-based risk assessment, utilizing an all-hazards approach. (2) Include strategies for addressing emergency events identified by the risk assessment, including the management of the consequences of power failures, natural disasters, and other emergencies that would affect the hospice's ability to provide care. *[For LTC facilities at §483.73(a):] Emergency Plan. The LTC facility must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least annually. The plan must do the following: (1) Be based on and include a documented, facility-based and community-based risk assessment, utilizing an all-hazards approach, including missing residents. (2) Include strategies for addressing emergency events identified by the risk assessment. *[For ICF/IIDs at §483.475(a):] Emergency Plan. The ICF/IID must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least every 2 years. The plan must do the following: (1) Be based on and include a documented, facility-based and community-based risk assessment, utilizing an all-hazards approach, including missing clients. (2) Include strategies for addressing emergency events identified by the risk assessment. This STANDARD is not met as evidenced by: Based on interview and review of the facility's Emergency Preparedness Plan (EPP), the agency failed to ensure the EPP policies were based on an all hazards-based facility and/or community risk assessment. This failure had the potential to affect the current 43 patients receiving care provided by the agency as well as all agency staff. Findings include: Review of the facility's EPP on 01/31/25 at 4:00 PM with the Administrator, revealed the EPP policies were not developed on an all hazards-based facility and/or community risk assessment. During an interview with the Administrator on 01/31/25 at 4:15 PM, he confirmed there was no hazard risk assessment in the EPP.

A Recertification and Emergency Preparedness Survey was conducted by Healthcare Management Solutions, LLC on behalf of Nevada Department of Health and Human Services. An unannounced on-site Recertification survey conducted at the above-named Home Health Agency (HHA) facility from 01/29/25 through 01/31/25 resulted in a finding of substantial compliance respective to the applicable Condition of Participation (CoP) under 42 CFR 484 Subparts A through C with the following standard-level deficiencies listed below.

Encoding and transmitting OASIS CFR(s): 484.45(a) Standard: An HHA must encode and electronically transmit each completed OASIS assessment to the CMS system, regarding each beneficiary with respect to which information is required to be transmitted (as determined by the Secretary), within 30 days of completing the assessment of the beneficiary. This STANDARD is not met as evidenced by: Based on record review and interview, the Home Health Agency (HHA) failed to ensure the timely submission of OASIS (Outcome and Assessment Information Set) to IQIES (Internet Quality and Improvement and Evaluation System). The failure had the potential to affect all 43 patients receiving services from the HHA who require evaluation and care. Findings include: The facility's OASIS submission data for calendar year 2024 was reviewed and revealed two out of a total of 383 assessments were coded as being transmitted to IQIES more than 30 days late during that time period. This resulted in an error code of -3330 (late submission) for 0.32% of all assessments submitted in the 2024 calendar year. During an interview on 01/31/25 at 1:00 PM, the Administrator stated the staff member who was responsible for the data transmission was not available for interview, but stated had transmitted data when the staff member was not available. The Administrator was not able to say why the agency's OASIS data was transmitted late.

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 observation, record review, and interview, the Home Health Agency (HHA) failed to ensure the Registered Nurse (RN) conducted a medication reconciliation during homecare visits for one of five sampled patients (Patient (P) 2) reviewed for medication reconciliation. This deficient practice had the potential to affect all 43 patients receiving services from the HHA. Findings include: Observation during a homecare visit performed by Certified Nursing Assistant (CNA)1 on 01/30/25 at 2:00 PM revealed that P2's Medication List, found in P2's electronic medical record (EMR), did not accurately reflect the medications being administered to the patient in his/her group home. Medications observed in P2's home, and reflected as being given in the patient's home Medication Administration Record (MAR) included Loperamide (an antidiarrheal medication) 4 milligrams (MG) with each loose stool not to exceed 16 MG in 24 hours, Pantoprazole (an acid reducing medication) 40 MG twice daily, Alprazolam (an antianxiety medication) 0.25 MG twice daily as needed, and Risperdal (an antipsychotic medication) 1 MG daily. Review of the HHA's Patient Medication Profile, found in the EMR and dated 01/04/25 through 03/04/25, revealed orders that did not indicate the Loperamide, and indicated P2 was to receive Pantoprazole 40 MG once daily, Alprazolam 0.25 MG three times daily as needed, and Risperdal 1 MG twice daily. The medications administered in the home did not match the orders - in the HHA's EMR. During an interview on 01/30/24 at 2:30 PM, P2's group home caregiver confirmed P2's current prescribed medications and confirmed P2 was being given the medications indicated on the group home MAR routinely per physician's order. During an interview on 01/30/25 at 3:15 PM, the Director of Nursing (DON) confirmed P2 was receiving routine skilled nursing visits and indicated that medications were expected to be reconciled by the nurse at every visit. The DON indicated the expectation was that the medications being administered to residents in their homes would match the HHA's medication order set.

This Statement of Deficiencies was generated as a result of an Emergency Preparedness survey conducted in conjunction with a Medicare recertification survey conducted at your facility on March 15, 2022 through March 17, 2022, in accordance with 42 Code of Federal Regulations (CFR) and the State Operations Manual (SOM), Appendix Z- Emergency Preparedness for All Provider and Certified Supplier Types. The findings and conclusions of any investigation by the Division of Public and Behavioral Health shall not be construed as prohibiting any criminal or civil investigations, actions or other claims for relief that may be available to any party under applicable federal, state, or local laws. The following deficiencies were identified:

Develop EP Plan, Review and Update Annually CFR(s): 484.102(a) §403.748(a), §416.54(a), §418.113(a), §441.184(a), §460.84(a), §482.15(a), §483.73(a), §483.475(a), §484.102(a), §485.68(a), §485.625(a), §485.727(a), §485.920(a), §486.360(a), §491.12(a), §494.62(a). The [facility] must comply with all applicable Federal, State and local emergency preparedness requirements. The [facility] must develop establish and maintain a comprehensive emergency preparedness program that meets the requirements of this section. The emergency preparedness program must include, but not be limited to, the following elements: (a) Emergency Plan. The [facility] must develop and maintain an emergency preparedness plan that must be [reviewed], and updated at least every 2 years. The plan must do all of the following: * [For hospitals at §482.15 and CAHs at §485.625(a):] Emergency Plan. The [hospital or CAH] must comply with all applicable Federal, State, and local emergency preparedness requirements. The [hospital or CAH] must develop and maintain a comprehensive emergency preparedness program that meets the requirements of this section, utilizing an all-hazards approach. * [For LTC Facilities at §483.73(a):] Emergency Plan. The LTC facility must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least annually. * [For ESRD Facilities at §494.62(a):] Emergency Plan. The ESRD facility must develop and maintain an emergency preparedness plan that must be [evaluated], and updated at least every 2 years. . This STANDARD is not met as evidenced by: Based on interview and record review the agency failed to ensure their emergency preparedness plan was reviewed and updated at least every 2 years. Findings include: The facility's Emergency Operations Plan and Policies documented the agency maintained an emergency preparedness plan and policies were reviewed and updated every 2 years. There was no documented evidence the agency had reviewed and updated their emergency preparedness plan and policies every 2 years. On 3-16-2022, the facility Administrator verbalized the Emergency Preparedness plan had not been reviewed or updated every 2 years.

EP Training Program CFR(s): 484.102(d)(1) §403.748(d)(1), §416.54(d)(1), §418.113(d)(1), §441.184(d)(1), §460.84(d)(1), §482.15(d)(1), §483.73(d)(1), §483.475(d)(1), §484.102(d)(1), §485.68(d)(1), §485.625(d)(1), §485.727(d)(1), §485.920(d)(1), §486.360(d)(1), §491.12(d)(1). *[For RNCHIs at §403.748, ASCs at §416.54, Hospitals at §482.15, ICF/IIDs at §483.475, HHAs at §484.102, "Organizations" under §485.727, OPOs at §486.360, RHC/FQHCs at §491.12:] (1) Training program. The [facility] must do all of the following: (i) Initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles. (ii) Provide emergency preparedness training at least every 2 years. (iii) Maintain documentation of all emergency preparedness training. (iv) Demonstrate staff knowledge of emergency procedures. (v) If the emergency preparedness policies and procedures are significantly updated, the [facility] must conduct training on the updated policies and procedures. *[For Hospices at §418.113(d):] (1) Training. The hospice must do all of the following: (i) Initial training in emergency preparedness policies and procedures to all new and existing hospice employees, and individuals providing services under arrangement, consistent with their expected roles. (ii) Demonstrate staff knowledge of emergency procedures. (iii) Provide emergency preparedness training at least every 2 years. (iv) Periodically review and rehearse its emergency preparedness plan with hospice employees (including nonemployee staff), with special emphasis placed on carrying out the procedures necessary to protect patients and others. (v) Maintain documentation of all emergency preparedness training. (vi) If the emergency preparedness policies and procedures are significantly updated, the hospice must conduct training on the updated policies and procedures. *[For PRTFs at §441.184(d):] (1) Training program. The PRTF must do all of the following: (i) Initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles. (ii) After initial training, provide emergency preparedness training every 2 years. (iii) Demonstrate staff knowledge of emergency procedures. (iv) Maintain documentation of all emergency preparedness training. (v) If the emergency preparedness policies and procedures are significantly updated, the PRTF must conduct training on the updated policies and procedures. *[For PACE at §460.84(d):] (1) The PACE organization must do all of the following: (i) Initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing on-site services under arrangement, contractors, participants, and volunteers, consistent with their expected roles. (ii) Provide emergency preparedness training at least every 2 years. (iii) Demonstrate staff knowledge of emergency procedures, including informing participants of what to do, where to go, and whom to contact in case of an emergency. (iv) Maintain documentation of all training. (v) If the emergency preparedness policies and procedures are significantly updated, the PACE must conduct training on the updated policies and procedures. *[For LTC Facilities at §483.73(d):] (1) Training Program. The LTC facility must do all of the following: (i) Initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected role. (ii) Provide emergency preparedness training at least annually. (iii) Maintain documentation of all emergency preparedness training. (iv) Demonstrate staff knowledge of emergency procedures. *[For CORFs at §485.68(d):](1) Training. The CORF must do all of the following: (i) Provide initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles. (ii) Provide emergency preparedness training at least every 2 years. (iii) Maintain documentation of the training. (iv) Demonstrate staff knowledge of emergency procedures. All new personnel must be oriented and assigned specific responsibilities regarding the CORF's emergency plan within 2 weeks of their first workday. The training program must include instruction in the location and use of alarm systems and signals and firefighting equipment. (v) If the emergency preparedness policies and procedures are significantly updated, the CORF must conduct training on the updated policies and procedures. *[For CAHs at §485.625(d):] (1) Training program. The CAH must do all of the following: (i) Initial training in emergency preparedness policies and procedures, including prompt reporting and extinguishing of fires, protection, and where necessary, evacuation of patients, personnel, and guests, fire prevention, and cooperation with firefighting and disaster authorities, to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles. (ii) Provide emergency preparedness training at least every 2 years. (iii) Maintain documentation of the training. (iv) Demonstrate staff knowledge of emergency procedures. (v) If the emergency preparedness policies and procedures are significantly updated, the CAH must conduct training on the updated policies and procedures. *[For CMHCs at §485.920(d):] (1) Training. The CMHC must provide initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles, and maintain documentation of the training. The CMHC must demonstrate staff knowledge of emergency procedures. Thereafter, the CMHC must provide emergency preparedness training at least every 2 years. This STANDARD is not met as evidenced by: Based on interview, record review and document the agency failed to ensure all new and existing staff members received emergency preparedness training initially and every 2 years. Findings include: The facility's Emergency Operations Plan training Program documented the agency will provide initial training for Emergency Preparedness (EP) to all new staff and for existing staff every 2 years. On 3-15-2022 at 2:10 PM, during a telephone interview, a staff member verbalized had started with the agency as a contracted staff member in May 2020. The staff member revealed had only received generalized orientation training from the agency. Review of the agency's EP training records revealed there was no documented evidence the staff member had received EP training from the agency. On 3-16-2022 in the morning, during the review of the agency's EP training records with the Administrator, there was no documentation the staff members had received EP training every 2 years in accordance with their policy. On 3-16-2022, the facility Administrator and Director of Nursing (DON) both verbalized all staff including contracted staff were to receive initial EP training and repeated every 2 years. On 3-16-2022 at 11:00 AM, a review of the EP training records with DON for new employees hired from 2018 through 2021 revealed the records lacked documented evidence the new employees had received initial EP training. From 2018 through 2021 the agency hired 24 new employee's. During this time frame there was no documented evidence 16 new employees had received the initial EP training and six new employee's had not received their initial EP training within the 3 month probation period. On 3-16-2022 at 12:40 PM, the Administrator verbalized the initial EP training should be completed within the three month probation period.

This Statement of Deficiencies was generated as a result of the Medicare Recertification Survey conducted at your agency from March 15-17, 2022, in accordance with 42 CFR (Code of Federal Regulations) Part 484 - Home Health Services. The active census was 42 patients. Seven clinical records were reviewed. Three home visits were conducted. The investigation of regulatory compliance for COVID-19 Vaccination of Facility Staff included: - Review of Infection Control Surveillance plans. - Review of Vaccination policies including staff members vaccination status, exemptions, (medical and non-medical), temporary delays for vaccinations, additional precautions for unvaccinated staff, contingency plans for unvaccinated staff and additional precautions to prevent the spread of Covid -19. Review of the facility's Healthcare Worker Vaccination policies and facility documentation revealed the facility was at 100% compliance with Healthcare Worker vaccination requirements. The findings and conclusions of any investigation by the Division of Public and Behavioral Health shall not be construed as prohibiting any criminal or civil investigation, actions or other claims for relief that may be available to any party under applicable federal, state, or local laws. The following regulatory deficiencies were identified:

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 record review, observation, interview and policy review, the agency failed to maintain accurate medication profiles for 2 of 7 patients (Patient #4 and #6). Findings include: Patient #4 On 2/19/2022, the agency admitted Patient #4 with Parkinson's Disease. On 3/16/2022, a home visit was conducted with Patient #4, and the medication profile the agency provided was reviewed with the patient. The following anomalies were identified with the family member regarding the medications listed. Carbidopa-Levodopa tablets/frequency listed as one tablet three times daily, but the label showed two tablets twice daily. Gabapentin listed as one tablet three times daily, but the label showed one tablet four times daily. Memantine, Timolol and Latanoprost were listed, but the patient was no longer taking them. During the visit, prescription level Ammonium Lactate Cream 12% was observed in the bathroom which the aide and family member indicated was used by the patient. It was not listed on either the medication profile or the plan of care. Patient #6 On 11/13/2021, the agency admitted Patient #6 with hypertension. On 3/15/2022, a home visit was conducted with Patient #6, and the medication profile the agency provided was reviewed with the patient. Pantoprazole 40 milligrams daily was listed on the profile dated 1/10/2022, but Patient #6 indicated the medication was stopped a while back. On 3/15/2022 after the home visit, the Registered Nurse obtained an order changing the medication from daily to daily as needed. Section 10 under Medication Administration of the Clinical Documentation policy provided revealed the medication profile shall be reviewed by a Registered Nurse every 60 days and updated whenever there is a change or discontinuation in medication.

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 record review, interview and policy review, the agency failed to ensure physician orders were recorded in the plan of care for 1 of 7 patients (Patient #2). Findings include: Patient #2 On 2/07/2022, the agency admitted Patient #2 with unspecified open wound of the right lower leg. From 2/07/2022 through 3/15/2022, a certified physician assistant (PA-C) provided orders and performed wound care weekly. The PA-C documented each visit which was divided into sections of wound care, wound care orders, wound cleaning and dressing orders, a history of present illness, physical exam, assessment, plan and medication review. The packet was then collectively faxed to the agency's office and then uploaded to the documents section of the electronic clinical record. Skilled nurses were ordered twice weekly to perform wound care in the home. Skilled nursing visits were documented directly in the electronic clinical record, including wound care. The following anomalies related to all of the PA-C and skilled nursing visit documentation was identified after reviewing the clinical record: The plan of care lacked documented evidence of the following: Either, the wound clinic or provider(s) who would provide wound care and wound care orders or the numerous wound care changes endorsed in the PA-C's faxed documentation in the form of dated and signed individual provider orders. The PA-C's faxed documentation lacked evidence of an order to measure the wound. The PA-C documented weekly measurements which showed the wound was larger than what skilled nurses documented. Ultimately, the PA-C's measurements showed the wound increased in size from admission to the present, including debridement. The plan of care lacked documented evidence of an order to measure the wound; however, the skilled nursing visits documented to measure and record the wound weekly, yet each measurement documented was exactly the same from admission to the present: 4.8 centimeters x 5 centimeters x 0.1 centimeters. The agency lacked documented evidence of a policy instructing providers and skilled nurses to measure wounds. In some cases, the PA-C applied wound care product (med-honey) which was not ordered for skilled nurses to use. In other instances, the PA-C indicated generic or equivalent products could be used, making it difficult to hold skilled nurses and the agency accountable. Calcium Alginate was identified as ordered early in the care episode, but the skilled nursing visits lacked documented evidence Calcium Alginate was applied. As of 3/09/2022, Silvadene was identified as ordered by the PA-C, yet the skilled nursing visits continued to document a combination of Silvadene and Xeroform. The PA-C changed the treatment performed in the PA-C visit and for skilled nurses frequently throughout the care episode that it was difficult to evaluate any treatment change and correlate with progress. On 3/16-17/2022 in the afternoon, the agency's Clinical Director indicated the PA-C and the skilled nurse were unavailable for interview. The Clinical Director acknowledged and confirmed the issues identified as they related to coordination of care. Section 2 of the Plan Of Care policy revealed the plan of care shall be completed in full to include medications, treatments and procedures.

Conformance with physician orders CFR(s): 484.60(b) Standard: Conformance with physician or allowed practitioner orders. This STANDARD is not met as evidenced by: Based on record review, interview and policy review, the agency failed to ensure skilled nurses documented monitoring blood glucose for 2 of 7 patients (Patient #3 and #5). Findings include: Patient #3 On 2/23/2022, the agency admitted Patient #3 with urinary tract infection and diabetes mellitus II. On 2/23/2022, the plan of care showed a physician ordered skilled nursing visits twice the first week and then weekly thereafter. On 2/23/2022, the plan of care showed nurses were to perform blood glucose monitoring every visit and as needed. All the skilled nursing visits completed at the time of the inspection lacked documented evidence of blood glucose monitoring either performed by a nurse or the patient. Patient #5 On 9/26/2020, the agency admitted Patient #5 with stage v chronic kidney disease and diabetes mellitus II and then recertified the patient for a succession of care episodes thereafter. On 9/26/2020, the plan of care showed a physician ordered skilled nursing visits once the first week, twice the second week and then weekly thereafter. On 9/26/2020, the plan of care showed nurses were to perform blood glucose monitoring every visit and as needed. On 3/30/2021, a skilled nursing visit lacked documented evidence of blood glucose monitoring. On 3/17/2022 in the late morning, the Clinical Director indicated the agency did not have a state lab license, so patients had to monitor their own blood glucose. The Clinical Director agreed blood glucose monitoring should include a blood glucose level, teaching documentation and whether or not the patient or patient's caregiver in the home performed the blood glucose check. The Plan of Care policy revealed the plan of care was based on a comprehensive assessment and information provided by the client/family and health team members. Planning for care was a dynamic process that addressed the care, treatment and services to be provided.

Coordination of Care CFR(s): 484.60(d) Standard: Coordination of care. The HHA must: This STANDARD is not met as evidenced by: Based on record review, interview and policy review, the agency failed to ensure PA-C documentation involving wound care coincided with skilled nursing documentation in a manner which demonstrated orders were clearly identified and followed, and a wound was clearly assessed and re-evaluated during each clinician's visit for 1 of 7 patients (Patient #2). Findings include: Patient #2 On 2/07/2022, the agency admitted Patient #2 with unspecified open wound of the right lower leg. From 2/07/2022 through 3/15/2022, a certified physician assistant (PA-C) provided orders and performed wound care weekly. The PA-C documented each visit which was divided into sections of wound care, wound care orders, wound cleaning and dressing orders, a history of present illness, physical exam, assessment, plan and medication review. The packet was then collectively faxed to the agency's office and then uploaded to the documents section of the electronic clinical record. Skilled nurses were ordered twice weekly to perform wound care in the home. Skilled nursing visits were documented directly in the electronic clinical record, including wound care. The following anomalies related to all of the PA-C and skilled nursing visit documentation was identified after reviewing the clinical record: The plan of care lacked documented evidence of the following: Either the wound clinic or provider(s) who would provide wound care and wound care orders, or the numerous wound care changes endorsed in the PA-C's faxed documentation in the form of dated and signed individual provider orders. The PA-C's faxed documentation lacked evidence of an order to measure the wound. The PA-C documented weekly measurements which showed the wound was larger than what skilled nurses documented. Ultimately, the PA-C's measurements showed the wound increased in size from admission to the present, including debridement. The plan of care lacked documented evidence of an order to measure the wound; however, the skilled nursing visits documented to measure and record the wound weekly, yet each measurement documented was exactly the same from admission to the present: 4.8 centimeters x 5 centimeters x 0.1 centimeters. The agency lacked documented evidence of a policy instructing providers and skilled nurses to measure wounds. Due to the repetitious manner the PA-C documented each visit, it was difficult to compare what was ordered at the visits for skilled nurses to what the skilled nurses documented using on their visits. In some cases, the PA-C applied wound care product (med-honey) which was not ordered for skilled nurses to use. In other instances, the PA-C indicated generic or equivalent products could be used. Calcium Alginate was identified as ordered early in the care episode, but the skilled nursing visits lacked documented evidence Calcium Alginate was applied. As of 3/09/2022, Silvadene was identified as ordered by the PA-C, yet the skilled nursing visits continued to document a combination of Silvadene and Xeroform. The PA-C changed the treatment performed in the PA-C visit and for skilled nurses frequently throughout the care episode which created difficulty in evaluating any treatment change and correlate the changes with wound healing progress. On 3/16-17/2022 in the afternoon, the agency's Clinical Director indicated the PA-C and the skilled nurse were unavailable for interview. The Clinical Director acknowledged and confirmed the issues raised as they related to coordination of care.

Integrate all services CFR(s): 484.60(d)(3) Integrate services, whether services are provided directly or under arrangement, to assure the identification of patient needs and factors that could affect patient safety and treatment effectiveness and the coordination of care provided by all disciplines. This ELEMENT is not met as evidenced by: Based on observation, interview and record review, the agency failed to ensure timely follow-through regarding an adjustable bed for Patient #4. Findings include: On 2/19/2022, the agency admitted Patient #4 with Parkinson's Disease. On 3/16/2022 in the afternoon, a home visit was conducted with a home health aide for Patient #4. During the home visit, Patient #4 was observed walking with a slow shuffling gait. In talking with the spouse, it was identified during the visit Patient #4 slept on the couch because of the difference in height between the patient's bed and the couch. Patient #4 could not get in and out of the bed due to frailty. An adjustable bed was discussed a while back, but they were unable to verbalize the current status of obtaining an adjustable bed. On 2/22/2022, a communication note documented the agency received notice from an Advanced Practice Registered Nurse (APRN) an adjustable bed was requested the prior week. The clinical record lacked documented evidence of a physician order for an adjustable bed. On 3/17/2022 in the late morning, the Assistant Clinical Director was asked to follow-up with the situation and provide a status report. The following was received: On 2/16/2022, the APRN faxed an order for a hospital bed to a durable medical equipment provider (DMEP). On 2/21/2022, the DMEP requested clinical justification documentation for the bed from the APRN. On 3/03/2022, a skilled nurse documented the provider's office would follow-up with the requested hospital bed in a skilled nursing visit note. On 3/17/2022 at the time of the exit, the agency lacked documented evidence the APRN responded to the DMEP or the agency. During the on site inspection, the agency was unable to resolve the issue.

Available during all operating hours CFR(s): 484.105(b)(3) The administrator or a pre-designated person is available during all operating hours. This ELEMENT is not met as evidenced by: Based on observation and interview, the agency failed to ensure it was available by phone. Findings include: On 3/16/ 2022, a home visit with physical therapy was scheduled with Patient #7 at 10:00 AM. At 9:55 AM, the agency's office was contacted regarding the whereabouts of the therapist. The message received was the agency's phone number was disconnected. The agency's phone number was verified as the same on the plan of care provided. At 9:56 AM, the bureau's office was contacted. The bureau's administrative assistant contacted the agency with the same phone number and received the same message. After looking up the the agency in the bureau's records, a secondary number was utilized finally providing contact with the agency after the 10:00 AM appointment. The secondary number was not provided to patients. On 3/16/2022 in the afternoon, the Assistant Clinical Director indicated forgetting to activate the number from the answering service.