Every finding on record at Baptist Health

On 03/16/26 at 1:40 p.m., an entrance conference was conducted with the Agency Representatives. The Agency was informed the purpose of the visit was to conduct a Medicare Recertification Survey for the compliance with the Conditions of Participation for Home Health. On 03/19/26 at 11:00 a.m. an exit conference was conducted with Agency Representatives. Preliminary findings were discussed.

Update of the comprehensive assessment CFR(s): 484.55(d) Standard: Update of the comprehensive assessment. The comprehensive assessment must be updated and revised (including the administration of the OASIS) as frequently as the patient's condition warrants due to a major decline or improvement in the patient's health status, but not less frequently than- This STANDARD is not met as evidenced by: Based on clinical record review and personnel interview, it was determined the agency failed to ensure there was a timely comprehensive assessment completed for a change of condition, including a hospital transfer for 1 (#7) of 17 (#1 -#17) clinical records reviewed. This failed practice had the potential to affect all patients on census in that there was a possibility of a lack of continuity of care. Findings follow: A. Clinical Record #7 with a start of care date of 01/22/26 revealed a patient with a diagnosis of Contusion of left hip, Acute Pain, and Pressure Ulcers. B. The clinical record revealed a change of condition for this patient on 01/23/26 and was transferred to an acute care hospital. The transfer OASIS (Outcome and Assessment Information Set) was not completed for another 10 days, on 02/02/26. C. On 03/18/26 at 2:00 p.m., Personnel #2 and the Agency Director were interviewed and asked to provide any further information. They confirmed the findings and had no further documentation.

Discharge plans communication CFR(s): 484.60(c)(3)(ii) (ii) Any revisions related to plans for the patient's discharge must be communicated to the patient, representative, caregiver, all physicians or allowed practitioner's issuing orders for the HHA plan of care, and the patient's 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). This ELEMENT is not met as evidenced by: Based on clinical record review and personnel interview, it was determined the agency failed to ensure there was evidence of communication with the Hospice agency in order to transition to Hospice services for 1 (#1) and discharge education for a patient and family was provided for 1 (#5) of 5 (#1 - #5) closed records reviewed. This failed practice had the potential to affect all patients on census in that there could be a patient discharged without the appropriate teaching, and referrals for care and services needed for a safe and proper discharge. Findings follow: A. Clinical Record #1 with a start of care date of 01/13/26 revealed a patient with a diagnosis of Diabetes, Cerebrovascular Disease (Stroke) with left hemiplegia. A Speech and Language Pathologist (SLP) visit note dated (Monday) 02/09/26 documented the patient had a change of condition over the weekend. The SLP gave the agency's nurse information on the patient's condition and the request for Hospice referral.There was no evidence the agency coordinated the transfer to the family's chosen hospice services, which included medical records sent to the hospice agency. B. Clinical Record #5 with a start of care date of 06/23/25 revealed a patient with a diagnosis of Hemiplegia and Hemiparesis. A Discharge skilled nurse visit documented a discharge on 07/22/25.On 03/18/26 at 2:00p.m., Personnel #2 was interviewed and stated the Discharge visit on 07/22/25 was a skilled nurse visit and later changed to a discharge visit. There was no communication to the patient and/or family which included teaching and potential referrals which would demonstrate a continuity of care. C. On 03/19/26 at 8:35 a.m., the Agency Director was interviewed, confirmed the findings and did not have any further documentation.

Integrate all orders CFR(s): 484.60(d)(2) Integrate orders from all physicians or allowed practitioners involved in the plan of care to assure the coordination of all services and interventions provided to the patient. This ELEMENT is not met as evidenced by: Based on clinical record review and personnel interview it was determined the agency failed to ensure there was a discharge from agency order from the physician for 1 (#1) of 5 (#1 - #5) clinical records reviewed. This failed practice had the potential to affect all patients on census in that there could be a lack of coordination of care and services without the physician's discharge approval. Findings follow: A. Clinical Record #1 with a start of care date of 01/13/26 revealed a patient with a diagnosis of Cerebrovascular Accident (CVA) (stroke), Left hemiplegia, and aphasia. B. The Patient was discharged to Hospice Services on 02/10/26. C. There was no evidence of a physician's order to demonstrate awareness of this patient's sudden change of condition and family's plan to discharge to hospice services. D. On 03/18/26 at 2:00 p.m., Personnel #2 was interviewed about this patient's change of condition, transition to hospice services, and the discharge records. She confirmed there was no communication between the agency and the patient's physician, as well as with the hospice agency chosen by the family.

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 clinical record review and personnel interview, it was determined the agency failed to ensure there was an accurate medication list for 1 of 1 (#1) clinical record reviewed which involved a patient with medications through a Percutaneous Gastrostomy tube (stomach tube). This failed practice had the potential to affect all clients on census that have a Percutaneous Gastrostomy (PEG) tube. Findings follow: A. Clinical Record #1 with a start of care date of 01/13/26 revealed a patient with a diagnosis of Diabetes, Cerebrovascular Accident (CVA) (stroke), Left Hemiplegia, and aphasia. B. The Home Health Plan of Care dated 01/13/26 documented the patient was NPO (nothing by mouth) and to receive medications through the PEG tube. C. The agency's medication list documented 3 medications which had the instruction to administer "by mouth". D. On 03/17/26 at 1:00 p.m., Personnel #2 was asked to provide any further information regarding the discrepancy on the medication list. On 03/18/26 at 8:45 a.m., the agency Director stated the nurse who entered 2 of the orders validated she entered the order incorrectly. The Agency Director stated the 3rd medication was entered by the Doctor's office but confirmed the agency is responsible for the accuracy of the agency's current medication list.

Development and evaluation of plan of care CFR(s): 484.75(b)(2) Development and evaluation of the plan of care in partnership with the patient, representative (if any), and caregiver(s); This ELEMENT is not met as evidenced by: Based on clinical record review and personnel interview, it was determined the agency failed to ensure there was a complete plan of care for 1 (#13) of 17 (#1 - #17) clinical records reviewed. This failed practice had the potential to affect all patients on census who had an acute injury and/ or evidence of pain. Findings follow: A. Clinical Record #13 with a start of care date of 02/19/26 revealed a patient with hemothorax, multiple rib fractures, and lung contusion. B. The Home Health Plan of Care dated 02/19/26 documented physical and occupational therapy. The medical record revealed the patient had signs of pain. It was documented on 02/25/26, a 5 out of 10 on the pain scale, which indicates moderate pain. C. The Home Health Plan of Care dated 02/19/26 did not include pain management. D. On 03/18/26 at 2:00p.m., the Agency Director was interviewed and asked to provide any further information. On 3/19/26 at 8:40 a.m., she confirmed the findings and was unable to provide further documentation.

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 Clinical Record reviews and staff interviews, it was determined the Agency staff did not provide care in accordance with the written Plan of Care (POC) in 1 (#2) of 17 (#1 - #17) Clinical Records reviewed. This failed practice had the potential to affect the quality of care received by all patients currently on census for a risk of adverse outcomes, potential to affect the attainment of the patient’s individual goals and risk of hospitalizations. A. Review of the Clinical Record with a Start of Care date of 01/02/2026 contained Physician orders for skilled nurse visits 3 times a week for 10 weeks. Review of documentation by the skilled nurse showed 1 skilled nurse visit was made for week 1 (01/02/26 through 01/03/26) and no other skilled nurse visits were made as ordered. B. During an interview on 3/18/26 at 09:15 AM, Agency Representatives were provided with an opportunity to present additional documentation. With no additional documentation presented, Personnel #2 confirmed the Agency staff failed to provide care in accordance with the written Plan of Care and visits should have been scheduled with a different frequency.

Communication with physicians CFR(s): 484.75(b)(7) Communication with all physicians involved in the plan of care and other health care practitioners (as appropriate) related to the current plan of care; This ELEMENT is not met as evidenced by: Based on clinical record review, agency policy and procedures, and personnel interview it was determined the agency failed to ensure the physician was notified of a blood pressure out of parameters for 1 (#14) of 17 (#1 - #17) clinical records reviewed. This failed practice had the potential to affect all clients on census in that the physician would not be given all information so that changes in the plan of care could be revised. Findings follow: A. Clinical Record #14 with a start of care date of 02/20/26 revealed a patient with a diagnosis of Peripheral Vascular Disease and Hypertension. B. On 02/27/26 the patient had a blood pressure of 177/99 and on 03/10/26 the patient had a blood pressure of 164/91. C. A Policy and Procedure titled "Parameters for Reporting" documented, "...Evidence based parameters guide home care clinician decision making. Measurements that fall outside of established parameters are reported to physicians...Systolic BP [blood pressure] ... greater than or equal to 160... Diastolic BP greater than or equal to 90...for 30 minutes or more..." D. There was no evidence that the physician was notified of the elevated blood pressures. E. On 03/18/26 at 9:30 a.m., Personnel #2 was asked about the process for notifying the physician of elevated blood pressures. She stated the current computer system does not alert the skilled nurse of a requirement for notification when the BP is entered so the nurse has to be aware of the agency protocol (Policy and Procedure) and complete that notification. She confirmed the findings and had no further documentation to provide.

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 clinical record review and personnel interview, it was determined the agency failed to ensure there was a discharge summary completed and available to the physician within 5 business days from discharge for 1 (#5) and a transfer summary completed within 2 business days for 1 (#7) of 5 (#1 - #5) closed records reviewed. This failed practice had the potential to affect all clients on census in that there was a possibility for lack of continuity of care at discharge. Findings follow: A. Clinical Record #5 with a start of care date of 06/23/25 revealed a patient with a diagnosis of Hemiplegia and Hemiparesis. A Discharge skilled nurse visit documented a discharge on 07/22/25.On 03/18/26 at 1:20 p.m., Personnel #2 was interviewed and stated the Discharge visit on 07/22/25 was a skilled nurse visit and later changed to a discharge visit. The Discharge Summary was dated 08/13/25.B. Clinical Record #7 with a start of care date of 01/22/26 revealed a patient with a diagnosis of Contusion of left hip, Acute Pain, and Pressure Ulcers. The clinical record revealed a change of condition for this patient on 01/23/26 and was transferred to an acute care hospital. The transfer OASIS (Outcome and Assessment Information Set) was not completed for another 10 days, on 02/02/26. The late transfer OASIS resulted in a late transfer summary. C. On 03/18/26 at 1:45 p.m., Personnel #2 and the Agency Director were interviewed and asked to provide any further information. They confirmed the findings and had no further documentation.

On 3/13/23 at 12:15 PM, an entrance conference was conducted with Agency Representatives. The Agency was informed the purpose of the visit was to conduct a complaint survey for compliance with the Conditions of Participation for Home Health. On 3/23/23 at 3:40 PM an exit conference was conducted with Agency Representatives. Preliminary findings of the survey were discussed. .

Property and person treated with respect CFR(s): 484.50(c)(1) Have his or her property and person treated with respect; This ELEMENT is not met as evidenced by: Based on review of Clinical Records, administrative documentation and Staff interviews, the Agency failed to coordinate and schedule visits and communicate changes for 1 (#18) of 18 (#1-#18) clinical records reviewed. This failed practice affected patient #18 and had the potential to affect all patients on census in that, it inhibited the establishment of trust and therapeutic care relationship between patients and Agency Staff and it had the potential to inhibit patient care goals. A review of Patient #18 Clinical Record revealed the following: A. Review of the Agency's Complaint log revealed a complaint for patient #18. An Agency Document titled “Compliant 242" and dated 2/17/22 showed documentation by the Agency Director, “I called to follow up with [named caregiver] and Caregiver stated that [named patient] was readmitted to Baptist Health Home Health on 02/07/2022 but had no other visits until [named caregiver] called on 02/15/2022. Caregiver stated, 'I followed up with Clinical Manager and she stated that SN [Skilled Nurse] entered her visit string incorrectly causing visits not to be scheduled out timely to patient.'” B. The Agency presented a list of visits which showed a Resumption of Care visit was completed on 02/07/2022. There was no further visits scheduled by the Agency. The Agency SN did not conduct another visit until the patient's caregiver called on 02/15/22 (8 days later) which prompted a SN visit.

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 Clinical Records, Agency Documentation of a complaint, and Staff interviews, the Agency failed to follow through on the treatment and frequency of visits discussed at the ROC (Resumption of Care) reassessment visit for 1 (#18) of 18 (#1-#18) clinical records reviewed and did not communicate the changes to the patient and/or caregiver. This practice affected patient #18 and had the potential to affect all patients on census in that it has the potential to inhibit the establishment of patient investment of agreed upon and identified goals, the frequency of SN visits to help the patient obtain goals and trust between patients and Agency Staff, as well as potentially inhibited the patient care needs. Review of Patient #18 Clinical Record and Staff Interviews revealed the following: A. During an interview with Agency Staff on 3/23/2023 at 3:00 P.M, Agency staff member # 1 reported the SN who went out to ROC the patient told the caregiver a nurse would go out to see the patient three times a week. B. The Agency's list of visits showed a ROC was completed 02/07/2022 but there was no evidence another visit was made until the caregiver called and requested a visit on 02/15/2022, eight days later. c. Agency Document titled “Compliant 242" and dated 2/17/22, showed documentation by Agency staff member #1, “I called to follow up with caregiver [for Patient #18] and stated [named patient] was readmitted to Baptist Health Home Health on 02/07/2022 but had no other visits until [caregiver] called on 02/15/2022. I followed up with Clinical Manager and she stated that SN entered her visit string incorrectly causing visits not to be scheduled out timely to patient.” D. During an interview with Agency staff on 3/23/23 at 3:00 P.M., Agency staff member #1 confirmed the agency failed to schedule any further visits for Patient #18 due to the Agency "SN entered her visit string incorrectly [in the EMR system] causing visits not to be scheduled out timely to patient.” Agency staff member #1 verified Patient #18 should have had more visits scheduled after the SN visit on 2/7/22 for ROC. Agency staff #1 verified the incorrect scheduling of visits were not found by the Agency staff until Patient #18 caregiver called the Agency to question if more SN visits would be made for Patient #18.

Treatment or care CFR(s): 484.50(e)(1)(i)(A) (i)(A) Treatment or care that is (or fails to be) furnished, is furnished inconsistently, or is furnished inappropriately; and This ELEMENT is not met as evidenced by: Based on Clinical Record Review and Staff interviews, it was determined the Agency Staff failed to provide patient care or reinforce teaching to 1 (#18) of 18 (#1- #18) clinical records reviewed. This lack of appropriate and consistent care had the potential to affect all patients on census in that it could potentially inhibit achievement of patient care goals, positive outcomes, worsening of patients conditions and potential rehospitalization. Review of Patient #18 Clinical Record and Agency staff interviews revealed the following: A. Document titled “Home Health Certification And Plan of Care” with certification period of 01/13/2022 through 03/13/2022 lists a Principle Diagnosis of “Encounter for adjustment and management of vascular device” (PICC or Peripherally Inserted Central Catheter- a long tube that is inserted into a vein and guided into a larger vein close to the heart) that was being utilized to administer antibiotics (medication used to treat an infection). B. There was no evidence of further visits for Patient #18 to ascertain Patient's Caregiver was proficient in administering the medication and care of the PICC line until 5 days later on 1/18/2022 after the SOC visit on 1/13/2022. A review of a document titled “SN Extended Home Visit” dated 01/18/2022 revealed documentation of “IV dressing changed." There was no evidence of Caregiver teaching on safe PICC use and care as evidenced by further documentation, "No leur-lock (lacking a necessary piece of the PICC line for safe home infusions of medications.) IV site noted to have dark purple bruising around puncture, skin around site sensitive and raw.” C. On 03/23/2023 at 3:00 PM, Agency Staff #2 stated, “Nurses usually go back out the next day after start of care to reinforce patient and caregiver teaching about PICC, the nurse who did patient #18's Start of Care was new to home health nursing.” D. A Document titled “Telephone Encounter” and dated 01/21/2022 showed, “The patient called in the middle of the night complaining of sob (shortness of breath). SN advised patient go to ER [Emergency Room]." further documentation revealed, "patient was not wanting to do that.” There was no evidence the Agency followed up about the on-call encounter. E. SN Visit Note dated 01/22/2022, documented “Midline (PICC) discontinued via sterile technique.” There was no reference of the call the patient made the night before, no instruction to the patient #18 or their caregiver about what to do should another episode of shortness of breath occur, no education regarding other symptoms for which to be aware and no weight was recorded to show if significant weight gain had occurred as evidence that Patient #18 could be at risk for cardiac issues. F. Agency Complaint documentation showed “Patient went into the hospital on 1/23/2022 with acute pulmonary edema (a build up of fluid in the lungs), heart failure (a condition in which the heart doesn’t pump enough blood for needs of the body.), hypertensive emergency, history of lymphoma (cancer of lymph system).” The Agency Complaint document showed "Patient was discharged [from named hospital] on 2/3/2022." Complaint document showed Caregiver stated Patient #18 was "readmitted to [Baptist Health Home Health] on 2/7/2022." There was no evidence patient #18 received further visits until the patient's caregiver called the Agency on 2/15/2022 to ask when the SN would be coming to visit the patient again. G. A document titled, "Complaint 242" showed, "[Patient #18] was readmitted to Baptist Health Home Health on 2/07/22." There was no evidence patient #18 had other visits until [named caregiver] called on 02/15/2022.” Documentation showed the reason no further visits had been made, "the Caregiver was instructed that due to the SN entering the Visit string incorrectly causing visits not to be scheduled out timely to patient.” H. Document titled "SN OASIS Resumption of Care," showed the ROC did not occur until 5 days after discharge from hospital on 02/07/2022 which was 3 days past the 48 hour timeframe.

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 clinical record review and staff interviews, the Agency failed ensure a Skilled Nurse (SN) conducted a timely and accurate Drug Regimen Review (DRR - review of medication regimen related to potential adverse effects, drug reactions, significant side effects or significant drug interactions) to include all current and added medication the patient was taking in 2(#13 and #18) of 18 (#1 - #18) clinical records reviewed. This deficient practice posed a risk of potential harm for all patients on census by inhibiting the Skilled Nurse (SN) and Physician's ability to make informed decisions regarding the patient's medication regimen related to potential adverse effects, drug reactions, significant side effects or significant drug interactions. Review of Clinical Record #13 revealed the following: A. Document titled "Telephone Encounter" dated 2/9/23 showed SN message left with Patient's Physician regarding patient's symptoms of Urinary Tract Infection (UTI). Patient was prescribed an antibiotic, Ciprofloxacin HCI, (drug used to treat an infection of the urinary tract). B. Document titled "Outpatient Medications on the Plan of Care" showed no evidence that the Ciprofloxacin HCL was added to the medication and reviewed for potential adverse effects, drug reactions, significant side effects or significant drug interactions. 2. Review of Clinical Record #18 revealed the following: Document titled “Home Care Visit” dated 02/07/2022, revealed SN documentation “Patient has new home O2 (oxygen) and is currently using her nasal cannula (a tube that blows oxygen into the nostrils).” There is no evidence oxygen was added to the medication profile and reviewed against all other medications the patient was taking for potential adverse effects, drug reactions, significant side effects or significant drug interaction. 3. During an interview with Agency Staff on 3/23/2023 at 3:10 P.M. Agency staff #2 verified the Ciprofloxacin HCL and the O2 was not on the Medications on the medications list and therefore not reviewed for potential adverse effects, drug reactions, significant side effects of significant drug interactions.

Within 48 hours of the patient's return CFR(s): 484.55(d)(2) Within 48 hours of the patient's return to the home from a hospital admission of 24 hours or more for any reason other than diagnostic tests, or on physician or allowed practitioner - ordered resumption date; This ELEMENT is not met as evidenced by: Based on Clinical Record review and staff interview, it was determined Agency Staff failed to conduct a required timely comprehensive reassessment within 48 hours of discharge from the hospital in 1 (#18) of 18 (#1-#18) Clinical Records reviewed. This failed practice has the potential to affect all patients on census in that every patient who undergoes any changes in their healthcare status require a reevaluation to assure the individualized Plan of Care is appropriate to the patient’s health needs as changes occur. 1. A review of clinical record #18 revealed the following: A. Document titled "SN OASIS Transfer" dated 1/31/23 showed Patient #18 was admitted to the hospital on 1/23/22. B. Document titled "SN OASIS Resumption of Care" dated 2/7/23 showed Patient #18 was discharged on 2/2/22. The SN failed to complete the resumption of care comprehensive re-assessment until the 5th day, after discharge from the hospital. There was no evidence the Physician was notified of the delayed re-assessment of Patient #18.

Care planning, coordination, quality of care CFR(s): 484.60 Condition of participation: Care planning, coordination of services, and quality of care. Patients are accepted for treatment on the reasonable expectation that an HHA can meet the patient's medical, nursing, rehabilitative, and social needs in his or her place of residence. Each patient must receive an individualized written plan of care, including any revisions or additions. The individualized plan of care must specify the care and services necessary to meet the patient-specific needs as identified in the comprehensive assessment, including identification of the responsible discipline(s), and the measurable outcomes that the HHA anticipates will occur as a result of implementing and coordinating the plan of care. The individualized plan of care must also specify the patient and caregiver education and training. Services must be furnished in accordance with accepted standards of practice. This CONDITION is not met as evidenced by: Based upon Clinical Record review, Staff Interviews, Complaint log/individual complaint, frequency of visits scheduled, and care provided, the Agency failed to meet the reasonable expectation in care with 2 (#3 and #18) of 18 (#1-#18) clinical records reviewed. This failed practice, if not corrected has the potential to impact all patients on census in that patients trust that the Agency will meet their nursing needs in their place of residence and failure to do so may lead to delayed goal attainment, longer episodes of home health, disease/condition exacerbation and possible rehospitalization. 1. The Agency failed to coordinate care delivery to meet the patients needs. Refer to G 608 for details related to lack of coordination of care. 2. The Agency failed to ensure that a written visit schedule was provided to the patient based on the most current Plan of Care. Refer to G614 for details regarding a written schedule provided to the patient 3. The Agency failed to coordinate care delivery to meet the Patient's needs. Refer to G608 for details related to lack of coordination of care. 4. The Agency failed to ensure that a written visit schedule was provided to the patient based on the most current Plan of Care. Refer to G614 for details regarding a written schedule provided to the patient.

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 Clinical Record review and Agency staff interviews, the Skilled Nurse (SN) failed to ensure the patients Plan of Care (POC) included the required elements of patient specific interventions, education, measurable outcomes, and goals identified by the Home Health Agency skilled assessment of the patient in 1 (#18) of 18 (#1 - #18) Clinical Records reviewed. This deficient practice had the potential to result in harm for all patients on census by inhibiting the SN and Physicians ability to make informed decisions regarding the patient specific interventions and goals. 1. Review of clinical record #18 revealed the following: A. Document titled “Home Health Certification and Plan of Care” with a Certification period from 01/13/2022 through 03/13/2022, contained treatment orders for a PICC line (a line inserted intraveniously for infusion medications). The PICC line was used for infusions of antibiotics to treat the relevant diagnosis of Sepsis (a serious infection in the blood stream and other organs). There was no evidence interventions, goals, or teaching related to the Sepsis diagnosis were included in the POC. B. The POC included an order/treatment for pain and for the SN to assess pain on a 0-10 scale, with 0 being no pain and 10 being the greatest pain. There was no evidence that patient specific parameters, goals or acceptable level of pain or any indication as to when the physician was to be notified of the patient's pain within the POC. 2. G0574 is a repeat deficient practice found on the previous survey completed 11/22/19.

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 Clinical Record review and staff interview, it was determined the Agency did not follow Attending Physician orders for Speech Therapy (ST) that was ordered in the Plan of Care in 1 (#3) of 18 (#1 - #18) Clinical Records reviewed. This deficient practice had the potential to prevent the Physician and ST from evaluating the improvement or decline of cognitive function and prevented the Physician from determining the needed care which could result in decline in the Patient's functional ability Review of Clinical Record #3 revealed the following: A. Document titled "PT (Physical Therapy) OASIS Start of Care (SOC) dated 1/20/23 showing documentation that "ST orders were obtained to assess pt (Patient) at home." Further review of this document showed report by Caregiver that Patient "is more confused since [Patient] most recent stroke." B. There was no evidence ST completed an evaluation of Patient #3. C. During an interview on 3/20/23 at 3:10 P.M. Agency staff #1 and #2 verified an ST evaluation was not completed as ordered 2. G0578 is a repeat deficient practice found on the previous survey completed 11/22/19.

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 Clinical Record review and staff interview it was determined the Agency failed to alert the Physician of relevant assessment findings which may have necessitated an alteration in the Plan of Care (POC) in 2 (#1, and #18) of 18 (#1 - #18) Clinical Records reviewed. This failed practice had the potential to affect all current patients on census in that Physicians may be unaware of new assessment findings resulting in missed opportunities for revision of patient goals, interventions and prevention of hospitalizations. 1. Review of Clinical Record #1 for certification period 12/9/2022 to 2/6/2023 revealed the following: A. Document titled "PT (Physical Therapy) Initial Evaluation" dated 12/13/2022 showed Patient #1 reported pain at a level of 8 out of 10 on a range of 0 out of 10 with 0 being the least amount of pain and 10 being the greatest level of pain. There was no evidence the PT reported the patient's reported level of pain at 8 to the physician. B. During an interview with Agency Staff on 3/20/2023 at 3:00p.m., Agency staff member #2 was asked by the Surveyor when a patient's pain would be considered at a level that it should be reported to the Physician since there were no parameters on Patient #1's POC and Pain was not included on the Agency's standard vital signs processes for reporting? Agency staff #2 responded, "the staff are instructed that any reports of pain greater than a level of 7 is to be reported to the Physician unless there are specific parameters for reporting". 2. Further review of Clinical Record #1 revealed: A. A Document titled "Baptist Health Home Health Network Parameters for Reporting Vital Signs and Other Metrics to Physicians" showed, "Report blood pressure of 160 or less than 90 systolic (top end of BP) and greater than 100 or less than 50, diastolic (bottom end) that persists beyond 30 minutes." B. Document titled "OT (Occupational Therapy) Home Visit" showed documentation of Patient #1's blood pressure (BP) at systolic of 90 and diastolic of 40. There was no evidence the OT reported this significantly low BP reading to the Physician. 3. Review of Clinical Record #18 revealed the following: A. Document titled "Home Health Certification and Plan of Care" with certification dates of 1/13/2022 through 3/13/2022 showed “PICC (Peripherally Inserted Central Catheter- a long tube that is inserted into a vein and guided into a larger vein close to the heart) line dressing changed 1/11/2022.” B. Document titled SN OASIS Start of Care dated 1/13/2022 showed no evidence the SN assessed or visually inspected the PICC site at the admission visit. C. Document titled “Home Care Visit” dated 1/18/2022, revealed SN documentation of “IV dressing changed. No leur-loc (a connector used to allow for syringes and tubing with threaded ends to be screwed onto the PICC for medication and flushing. This is changed weekly by the nurse) noted on end of line, cleaned with alcohol and placed new leur-loc and cap. Flushed per protocol. IV site noted to have dark purple bruising around puncture, skin around site sensitive and raw. Placed new tegaderm to avoid damaged skin.” There is no evidence in the documentation that the physician was contacted about the bruising, sensitivity, or damaged skin around the PICC insertion site. (insertion site is usually the inside of arm close to or in the bend of the arm). D. According to "Sloan Kettering Cancer Research Hospital in New York, teach the physician" the physician should be contacted when there is redness, tenderness, leakage, swelling or bleeding. E. The information given and taught to patients and families at "National Jewish Medical Center in Los Angeles, CA." instructs to call the physician if swelling, redness, red streaking, hot or hard area in arm PICC is in, PICC site pain or pain in the arm, fever or chills, swelling of the hand, arm and/or neck on the same side as PICC, leaking fluid when the catheter is flushed. 4. During an interview on 3/23/2023 at 3:00 p.m. Agency Staff #1 and #2 verified Patients #1 and #18 Physicians were not notified of significant changes in condition.

Coordinate care delivery CFR(s): 484.60(d)(4) Coordinate care delivery to meet the patient's needs, and involve the patient, representative (if any), and caregiver(s), as appropriate, in the coordination of care activities. This ELEMENT is not met as evidenced by: Based on Clinical Record Review, Agency Complaint documentation and Staff interviews, it was determined the Agency failed to ensure the Skilled Nurse (SN) coordinated care and treatment with patient/caregiver or physician in 1 (#18) of 18 (#1-#18) Clinical Records reviewed. This deficient practice, if continued, had the potential to result in adverse outcomes or hospitalization secondary to delay of interventions. Review of Patient #18 Clinical Record revealed the following: A. There was no evidence of further visits for Patient #18 to ascertain Patient's Caregiver was proficient in administering the medication and care of the PICC line until 5 days later on 1/18/2022 after the SOC visit on 1/13/2022. A review of a document titled, “SN Extended Home Visit” dated 01/18/2022, revealed documentation of “IV dressing changed." There was no evidence of Caregiver teaching on safe PICC use and care as evidenced by further documentation, "No leur-lock (lacking a necessary piece of the PICC line for safe home infusions of medications.) IV site noted to have dark purple bruising around puncture, skin around site sensitive and raw.” There was no evidence SN notified physician of change in condition of PICC site. B. A Document titled, “Telephone Encounter” dated 01/21/2022 showed, “The patient called in the middle of the night complaining of sob (shortness of breath)". The SN documented the Patient was advised to go to ER (Emergency Room) and the Caregiver stated "the patient was not wanting to do that.” There was no evidence the Agency followed up regarding the symptoms the patient described. C. A Document titled, "SN Visit Note" dated 01/22/2022, showed, “Midline (PICC) discontinued via sterile technique.” There was no reference of the call the patient made the night before, no instruction to patient/Caregiver about what to do should another episode of shortness of breath occur, and no other symptoms for the Patient/Caregiver for which to watch. D. Review of a document titled, "Complaint 272" and dated 02/17/2022, showed, “Patient went into the hospital with acute pulmonary edema (a buildup of fluid in the lungs), heart failure (a condition in where the heart doesn’t pump enough blood for needs of the body.), hypertensive emergency, history of lymphoma (Cancer of Lymph system) this was on 01/23/2022.” This same document showed, "Patient was discharged [from hospital] 2/3/2022." E. A Document titled "SN OASIS Resumption of Care (ROC)" revealed ROC did not occur until 5 days after discharge from the hospital on 02/07/2022, which was 3 days late past the 48 hour time frame. There was no evidence in the Clinical Record to indicate the Physician was contacted regarding the delay in the Resumption of Care. F. An Agency Complaint 272 Dated 02/17/2022, stated, "[Patient] was readmitted to Baptist Health Home Health on 2/07/22 but had no other visits due to the SN entering the Visit string incorrectly causing visits not to be scheduled out timely to patient.” On 2/15/2022 the Caregiver called the Agency and was told that the reason there had been no further visits was because the SN had entered the Visit string incorrectly "causing visits not to be scheduled out timely to patient.” There was no evidence to confirm the physician was contacted about the visits not being scheduled.

Visit schedule CFR(s): 484.60(e)(1) Visit schedule, including frequency of visits by HHA personnel and personnel acting on behalf of the HHA. This ELEMENT is not met as evidenced by: Based on clinical record review, staff interview, and patient schedule review, it was determined the Agency failed to provide the patient a written schedule in 1 (#18) of 18 (#1-#18) Clinical records reviewed. A practitioner ordered and Agency adherence of when the patient can plan on a home visit is a cornerstone of care delivery and provides a timeline of how patient monitoring, patient teaching and patient disease process self-management will occur during the episode of home health. This deficient practice, if not corrected, has the potential to affect all patients on census in that a lack of or nonadherence to a visit schedule may directly impact patient’s health status and possible rehospitalization. Review of clinical record for Patient #18 revealed the following: A. A Document titled "Certification and Plan of Care" dated 01/13/2022 through 03/13/2022, lists the frequency as “7 visits every 60 days for 60 days.” B. Agency Complaint documentation dated 02/17/2022 showed, “[patient] was readmitted to Baptist Health Home Health on 2/07/2022. Documentation showed Patient #18 had no further visits due to the SN “entering the Visit string incorrectly causing visits not to be scheduled out timely to patient.” C. Patient had no other visits after 02/15/2022 and was subsequently discharged without a visit on 02/22/2022. Patient was admitted to a different Home Health Agency per caregiver's request.

Infection Prevention CFR(s): 484.70(a) Standard: Infection Prevention. The HHA must follow accepted standards of practice, including the use of standard precautions, to prevent the transmission of infections and communicable diseases. This STANDARD is not met as evidenced by: Based on observations during home visits, staff interviews, review of the Agency’s Infection Control Plan, Center for Disease Control (CDC) guidelines, and manufactures guidelines, the Skilled Nurse (SN) failed to follow accepted professional standards for infection control in 4 (#7, #8, #10, and #12) of 7 home visits observed (#6-#12). This failed practice had the potential to place the patient at risk for a wound infection and hospitalization. The deficient practice identified, if continued, potentially placed all patients with wounds and wound care at risk of adverse outcomes and hospitalization. 1 1. Observations during a home visit for Patient #7 revealed the following: A. On 3/14/2023 at 9:05 a.m. the Skilled Nurse (SN) was observed providing wound care for Patient #7. The SN poured on gauze, Baxter (brand) saline (a liquid used to cleanse wounds) from a previously opened 1000 milliliter (ml) plastic bottle which contained approximately 100 ml of saline remaining in the bottle. There was no evidence the saline bottle had a written date on the bottle showing when the bottle had been opened for the first use. The Surveyor asked Patient #7 when the bottle was opened for use and the Patient stated, "It's been open a week." B. Review of Baxter manufacturers saline bottle label shows "Discard unused portion." C. Information from Advacare, a medical supply vendor, showed, "once opened, saline ought to last 24 hours." Information reviewed at Medscape.com, a website of medical information, reads, “It is important to note the date of opening a saline container, as bacterial growth in saline may be present within 24 hours of opening the container." 2. Observations during a home visit for Patient #8 revealed the following: On 3/15/23 at 9:35 a.m. the SN was observed providing wound care for Patient #8. The SN placed Dakin’s Solution (a prescribed wound cleanser/anti-infective agent) moistened sponges on the patients wound. It was noted a new bottle of Dakin’s Solution was opened for this. The SN did not follow standard and customary protocol by labeling the bottle with the date it was opened. 3. Observations during a home visit for Patient #10 revealed the following: A. On 3/15/2023 at 11:48 AM, wound care observed by the Surveyor for Patient #10 was an infected surgical site located on the upper back/neck area. The patient had a wound vac dressing (a wound treatment for larger/deeper wounds that are connected to suction for drainage control and healing). SN was observed sanitizing hands and donning clean gloves prior to preparing all the supplies needed for the dressing change. The SN was then observed removing the old/soiled dressing and without removal of soiled gloves and sanitizing hands and donning clean gloves, the SN was observed changing the reservoir cartridge on the wound vac machine, thus potentially contaminating the outside of the machine, (a handheld device that is transported throughout the Patient's home by the patient when moving about during daily activities). Due to the location of the wound, the patient’s shirt continued to cover and fall over the wound when SN failed to hold the shirt out of the way with one hand. Due to the nurse requiring both hands to perform wound care and dressing placement, this happened repeatedly throughout the visit. The patient’s long hair was also falling into the wound and the nurse moved the hair out of the wound repeatedly. B. Review of CMS.gov [Centers for Medicaid and Medicare] Hand hygiene guidelines showed, “Hygiene should be completed after contact with the patient or objects in the immediate vicinity of the patient; After contact with blood, body fluids or contaminated surfaces." 4. Observations during a home visit for Patient #12 revealed the following: A. On 3/16/2023 at 12:12 PM, the SN was observed providing wound care for Patient #12. The SN sanitized hands, donned gloves and removed the dressing and leg wrappings from the wound. Prior to removing gloves and re-sanitizing hands and donning clean gloves, the SN was observed reaching into the pocket of the lab coat the SN was wearing to retrieve a camera device (used to take a picture of the Patient's wound). B. Review of CMS guidelines showed hand hygiene should be performed “After contact with the patient or objects in the immediate vicinity of the patient; After contact with blood, body fluids or contaminated surfaces.” A review of information found at NIH (National Institute of Health) showed, “Contaminated textiles or fabrics may be a source of (bacterial and virus) transmission for weeks. The presence of pathogens on the coats of healthcare workers is associated with the presence of pathogens on their hands, demonstrating the relevance of textile contamination in patient care.”

Make patient and personnel assignments, CFR(s): 484.105(c)(1) Making patient and personnel assignments, This ELEMENT is not met as evidenced by: Based on Clinical Record review, Agency complaint records review and staff interview, the Agency's Clinical Manager failed to assure Skilled Nurse (SN) visit schedule was appropriate to meet the needs of the patient in 1 (#18) of 18 (#1-#18) clinical records reviewed. This failed practice resulted in Patient #18 not being scheduled for any visits after care was resumed post hospitalization. 1. Review of Patient #18 Clinical Record revealed the following: A Document titled, "Complaint 242" and dated 02/17/2022, showed, “[Named Patient] was readmitted to Baptist Health Home Health on 2/07/2022 but had no further visits due to the SN entering the Visit string incorrectly causing visits not to be scheduled out timely to patient.” 2. During an interview on 3/16/2023 at 3:00 PM, Agency Staff was asked when and how SN communicates with Clinical Manager about patients care needs and discussion of visit frequency at Start of Care or Resumption of Care. Per Agency Staff #1and Staff #2, “The nurses don’t call in report or communicate about the patient after start of care or resumption of care.”

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 Clinical Record review and staff interview, the Agency failed to ensure a complete Discharge/Transfer Summary was sent to the Physician after discharge or to the Facility upon patient transfer in 1 (#18) of 18 (#1-#18) Clinical Records reviewed with transfer/discharge status. This failed practice has the potential to place all patients currently on census at risk by preventing effective and efficient coordination of care among health care team members and providers. Review of clinical record #18 revealed the following: A. Document titled "OASIS transfer" showed Patient #18 was admitted to the hospital on 1/23/2022 for a diagnosis of Pneumonia. The transfer summary was completed on 1/31/2022 which was six (6) business days after Patient's admission to the hospital and therefore failed to be completed within 2 business days of hospitalization. 2. Agency Staff were provided an opportunity to provide additional documentation with no additional information provided, Agency staff #1 verified the Transfer Summary was not completed within two (2) business days of Patient #18 admission to the hospital.