Every finding on record at Baxter County Regional Hospital, Inc.

On 5/10/2022 at 10:40 AM an entrance conference was conducted with Agency Representatives. The Agency was informed the purpose of the visit was to conduct a Medicare Recertification survey for compliance with the Conditions of Participation for Home Health On 5/13/2022 at 10:00 AM an exit conference was conducted with Agency Representatives. Preliminary findings of the survey were discussed. On 5/16/2022 Additional information was requested and received. On 5/23/2022 Additional information was requested.

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, it was determined the Skilled Nurse (SN) failed to include Oxygen (O2) during the review of the patients’ medications in 1 (#8) of 5 (#1, #8, #9 #12 and #14) Clinical Records reviewed with orders for O2. This failed practice by the SN posed a risk of potential harm for patients on census receiving O2 therapy by inhibiting the Nurse and Physician's ability to make informed decisions regarding the patients’ medication regimen related to potential adverse effects, drug reactions, significant side effects or significant drug interactions. A review of Clinical Record Review #8 revealed the following: 1. A document titled, "Home Health Care Certification and Plan of Care" (POC) dated 2/16/22 to 4/16/22, listed a diagnosis of Heart Disease and showed the Patient with Oxygen Dependence. 2. Review of a document titled “Medication Profile” (the form the Agency uses to record all current medications) did not have Oxygen listed. There was no evidence O2 was reviewed related to potential adverse effects, drug reactions, significant side effects or significant drug interactions. 3. During an interview on 5/13/22 at 9:30 AM, Agency Personnel were provided an opportunity to present additional documentation. With no additional documentation presented, Agency Personnel #1 confirmed the Agency staff did not include Oxygen during a review of medications for Patient #8. Agency Personnel #1 stated "Oxygen was not on the medications list."

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 staff interview it was determined Agency staff Clinicians failed to include parameters of what constitute a significant change in patient condition of when to notify the physician in 4 (#2, #5, #12, and #14) of 17 (#1 - #17) Clinical Records reviewed. This deficient practice had the potential to prevent the patient from receiving appropriate care and delay attainment of personal goals for all patients on census. Review of Patient #12 Clinical Record revealed the following: A. A patient with a pertinent diagnosis of “Primary Generalized Osteoarthritis, and other Hypertrophic Osteoarthropathy, Multiple Sited. B. A Document titled, “Home Health Certificate and Plan of Care” (POC) dated 2/27/21 – 4/02/2021showed orders for SN (skilled nurse) for SN (skilled nurse) to teach cg/Pt (caregiver/Patient) on new and changed medications to include dosage, administration schedule, action, and side effects that require reporting to MD/RN. ( Doctor/Registered nurse). C. A Document titled “Medication Profile” showed medication of Norco 7.5-325 mg 1tab po every 4 hrs (hours) as needed for pain and Fentanyl transdermal 25mcg/hr 1 patch changes every 72hrs D. There are no measurable outcomes on the POC of what constitutes a significant change in patient pain of when to notify the physician. 2. Review of Patient #14 Clinical Record revealed the following: A. A patient with a pertinent diagnosis of “Primary Generalized Osteoarthritis, Low Back Pain and Multiple Myeloma in Relapse. B. A Document titled, “Home Health Certificate and Plan of Care” (POC) dated 2/02/22 – 4/02/2022 showed orders for SN (skilled nurse) to teach cg/Pt (caregiver/Patient) on new and changed medications to include dosage, administration schedule, action, and side effects that require reporting to MD/RN. ( Doctor/Registered nurse) C. A Document titled “ Medication Profile” showed medication of Oxycodone HCL oral 5 mg ( milligram) one tablet every 4 hrs (hours) as needed for pain. D. A Document titled, “Home Health Certificate and Plan of Care” (POC) dated 2/02/22 – 4/02/2022 under Homebound status showed patient is considered homebound as evidence by doe, fatigue, pain impacting mobility, high risk if exposed to covid. E. There are no measurable outcomes on the POC of what constitutes a significant change in patient pain of when to notify the physician. F. During an interview on 5/13/22 at 9:15 AM, Agency Representatives were provided an opportunity to present additional documentation. With no additional documentation presented, Agency Personnel #1 confirmed the Agency staff’s failure to provide measurable outcomes on the POC of what constitutes a significant change in patient pain of when to notify the physician in patient #12, and #14. In clinical record #2, a document titled Home Health Certification and Plan of Care (POC), period 4/18/22-6/16/22, patient had enteral nutrition. (Giving a liquid nutrition through a tube placed in stomach- also known as PEG tube).a) There is no listing on the POC indicating the type, amount, times given of the enteral nutrition. b) There is no listing of when or how much of water is to be used to flush the tube. Water flushes are used to maintain the patency of the PEG tube prior to and after giving the enteral nutrition. c) Under section on POC with heading “ST Interventions” is listed “PT (patient) will decrease tube feedings by 1/3 container every week.” d) During interview with staff #1, it was confirmed there was incomplete enteral feeding information, “because the patient is beginning to try and increase his food intake orally now.” 2. In Clinical Record #5, Clinical Record review of a document titled Home Health Certification and Plan of Care (POC) dated 4/15/2022-6/13/2022 revealed a diagnosis of Pressure Ulcer of sacral region, other chronic hematuria, chronic kidney disease, Type Two Diabetes with chronic kidney disease, Type Two Diabetes with diabetic neuropathy, Type Two Diabetes with diabetic peripheral angiopathy, Type Two Diabetes with unspecified macular degeneration. Diabetes is a serious condition and blood glucose fluctuations and/or poorly controlled blood glucose levels can affect every body system in an adverse way- including skin, wound healing, kidneys, cardiovascular system, nervous system, eyes, as well as the possibility of causing an emergent, life-threatening episode. a) In section DME & Supplies on POC, it is documented patient requires diabetic supplies. b) On a document titled Medication Profile, medication “Novolog subcutaneous 100 unit/ml as directed per sliding scale (This medication is administered by injection, under the skin and the amount given depends on what the patients blood glucose reading is.) c) There are no parameters for blood glucose readings listed on the POC to indicate when the physician is to be notified in case of a high or low blood glucose reading. d) During an interview with Agency Representative #1, it was stated, "Diabetes isn't our main focus of care this Certification Period. Her husband takes her blood sugar and gives her medications to her and has for years."

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 staff did not follow the Attending Physician orders contained in the Plan of Care (POC) for 4 (#6, #11, #12 and #15) of 17 (#1 - #17) Clinical Records reviewed. This failed practice had the potential of increased risk of rehospitalizations due to disease exacerbation and prevent the Physician, the Social Worker and the Agency staff from determining the Patient's Psychosocial needs for Patients/Families with needs for a Social Worker . This is a repeat deficiency from previous Medicare Conditions of Participation Survey dated 12/19/2019. Review Clinical Record #6 revealed the following: 1. A Document titled Home Health Certification and Plan of Care (POC) dated 11/14/20221- 01/12/2022 revealed an order for “MSW” (Social Worker) to “Eval (Evaluate) week of 11/14/21." 2. Document titled “MSW Phone Call” dated 11/15/2021showed documentation by the MSW of a phone call made to Patient #6 son to discuss possible Long Term Care Placement. 3. During an interview on 5/13/22 at 9:30 A.M. with Agency Personnel #1 verified the MSW did not evaluate the Patient/Family for Psychosocial needs. Review of Clinical Record #11 revealed the following: 1. A Patient with a pertinent diagnosis of Type 2 Diabetes Mellitus with Diabetic Neuropathy, Unspecified” 2. A Document titled, “Home Health Certificate and Plan of Care” (POC) dated 4/03/22 – 6/21/2022 showed orders for SN (skilled nurse) to notify physician of Fasting blood sugar greater than (>) 300 or less than ( A Document titled, “Skilled Observation” dated 4/15/2022, 4/27/2022, 5/02/2022, 5/4,2022, and 5/09/2022 showed no evidence of blood sugar readings documented by SN (Skilled Nurse) Review Clinical Record #12 revealed the following: 1. A Patient with a pertinent diagnosis of “Type 2 Diabetes Mellitus with Diabetic Polyneuropathy.” 2. A Document titled, “Home Health Certificate and Plan of Care” (POC) dated 2/27/22 – 4/27/2022 showed orders for SN (skilled nurse) to notify physician of random blood sugar greater than (>) 250 or less than ( A Document titled, “Skilled Observation” dated 3/04/2022, 3/30/2022, and 4/11/2022 showed no evidence of blood sugar readings documented by SN Review of Clinical Record #15 revealed the following: 1. A Patient with a primary diagnosis of “Disruption of external Operation (surgical) wound, NEC, Initial (O)” 2. A Document titled, “Home Health Certificate and Plan of Care” (POC) dated 3/06/22 – 5/04/2022 showed orders for SN (skilled nurse) to notify physician of Temperature greater than (>) 100 or less than (>) 96. 3. A Document titled, “Skilled Observation” dated 4/05/2022 showed no evidence of Temperature reading documented by SN 4. During an interview on 5/13/22 at 9:15 AM, Agency Personnel were provided an opportunity to present additional documentation. With no additional documentation presented, Agency Personnel #1 confirmed the Agency Personnel failure to provide interventions as ordered in the individualized POC for Patients #6, #11, #12 and #15.

Only as ordered by a physician CFR(s): 484.60(b)(1) Drugs, services, and treatments are administered only as ordered by a physician or allowed practitioner. This ELEMENT is not met as evidenced by: Based on Clinical Record Review and Staff interview it was determined this Element was not met As evidenced by: A review of Clinical Record #2 revealed the following: 1. A document titled home Health Certification and Plan of Care dated 2/17/2022 through 4/17/2022 showed no evidence of physician’s orders, interventions or goals for ST (speech therapist). 2. Review of a document titled' "Visit Calendar" revealed Speech Therapy made visits on 3/01/2022, 3/24/2022, 3/28/2022. 3.An interview with Agency Personnel #1 confirmed there wasn’t a physician order obtained for Speech Therapy nor was the patient’s physician consulted about appropriate treatments and goals for the patient’s condition.

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, the Skilled Nurse (SN) failed to alert the Physician to changes in patient’s condition which may have necessitated an alteration in the Plan of Care (POC) in 1 (#7) of 17 (#1-#17) Clinical Records reviewed. This failed practice had the potential for a negative outcome up to and including hospitalization.. Review of Clinical Record #7 revealed the following: Document titled “Home Health Certification and Plan of Care” dated 2/11/22 to 4/11/22 which included a pertinent diagnosis of “Heart Failure, unspecified” and orders for the Skilled Nurse (SN) to “obtain Patient’s weight EVERY visit and will notify physician of weight outside of set parameters, or if Patient gains > (greater than) 3 lbs. (pounds) over night or 5 lbs. in a week.” Document titled “RN-Skilled Nursing Visit” dated 2/14/22 showed documentation by the SN that Patient #7's weight was 205 lbs. Skilled Nursing Visit note dated 2/17/22 showed the Patient’s weight at 211.4 lbs. (a gain of 6.4 lbs. in 3 days). There was no evidence the SN notified the Physician change in the Patient’s weight. 3. During an interview on 5/13/22 at 9:30 A.M., Agency Personnel #1 confirmed the SN failed to notified the Physician of the Patient's weight gain as ordered in the POC until 2/25/22 after the Patient’s spouse had expressed wanting a consult for Hospice referral due to Patient #7 “rapid decline.”