Every finding on record at Bayada Home Health Care Inc

An onsite recertification survey was conducted 3/4/24-3/6/24. No deficiencies to the Emergency Preparedness Program were identified.

An onsite recertification survey was conducted 3/4/24-3/6/24. Deficiencies to the Medicare Conditions of Participation were identified.

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: G574 Based on agency policy review, clinical record review and patient/staff interviews the Plan of Care [POC] failed to include all current medications the patient was using for 5 of 7 home visits observed (#11,7, 12, 16, & 17); and failed to include a normal saline flush for 1 of 1 patient with a VAD [vascular access device-type of catheter that provides access to blood vessels without the need for repeated needle sticks](#5). The findings included: 2. Patient # 5 had a Start of Care date of 11/26/22 and admitting diagnoses of pressure ulcer of right buttock, unstageable [ulcers covered with slough or eschar so wound bed is not visible], pressure ulcer of sacral [base of spine] region, stage II [top and bottom layer of skin is worn away] and encounter for adjustment and management of VAD [vascular access device-type of catheter that provides access to blood vessels without the need for repeated needle sticks]. Review of the Plan of Care [POC] for the certification period 11/26/22-1/24/23 included orders for SN [skilled nursing] 1 time a week for 7 weeks and “skilled nurse may teach caregiver to infuse 200 ml of vancomycin [antibiotic]…Flush IV access with 5 mls of normal saline…” Review of the POC revealed the normal saline was not listed as a medication. During an interview with employee # 3 on 3/6/24 at approximately 11 am, employee # 3 confirmed the normal saline should have been included on the POC as a medication. 3. Patient # 7 had a Start of Care date of 1/17/24 with an admitting diagnosis of chronic obstructive pulmonary disease [COPD-condition making it difficult to breath]. Review of the Plan of care [POC] for the certification period 1/17/24-3/16/24 included orders for PT [physical therapy] 1 time a week for 1 week, 2 times a week for 1 week, 1 time a week for 7 weeks. On 3/4/24 at 3:30 pm a joint visit was made with PT # 8. During the visit, a medication review was conducted using a medication profile provided by the agency. The following discrepancy was noted: The medication profile listed Furosemide [fluid medication] 40 mg daily. During an interview with the patient, the patient reported the physician had recently changed this medication to 60 mg each day. During an interview with PT # 8 after the visit, PT # 8 confirmed the POC did not include the correct medications. 4. Patient # 12 had a Start of Care date of 2/10/24 and an admitting diagnosis of bilateral primary osteoarthritis of knee. Review of the Plan of Care [POC] for the certification period 2/10/24-4/9/24 included orders for PT [physical therapy] 1 time a week for 1 week, 2 time a week for 4 weeks. On 3/5/24 at approximately 3 pm, a joint visit was made with PTA [physical therapy assistant] # 5. During the visit, a medication review was conducted using a medication profile provided by the agency. During an interview with the patient, the patient reported using Advil [over the counter pain relief] 200 mg every 6 hours for pain control. Review of the POC did not include Advil. During an interview with employee # 3 on 3/6/24 at approximately 11 am, employee # 3 confirmed the POC did not include all medications the patient was using. 5. Patient # 16 had a Start of Care date of 2/17/24 with admitting diagnoses of acute embolism [blockage in an artery caused by blood clots or other substances] and thrombosis [blood clot in vein] of left femoral vein [vein in the thigh], acute embolism and thrombosis of left popliteal vein [vein behind the knee] and acute embolism and thrombosis of left tibial vein [vein that runs inside of thigh]. Review of the Plan of Care [POC] for the certification period 2/17/24-4/16/24 included orders for OT [occupational therapy] 1 time a week for 5 weeks. On 3/5/24 at approximately 9:30 am a joint visit was made with OTA [occupational therapy assistant] # 4. During the visit, a medication review was conducted using a medication profile provided by the agency. During the visit, an interview was conducted with the patient’s caregiver regarding the current medications the patient was taking. The caregiver presented a bottle of acetaminophen [over the counter pain medication] 325 mg. The caregiver reported the patient takes 2 tablets every 6 hours as needed for pain. Review of the POC did not include acetaminophen. On 3/6/24 at approximately 10 am, an interview was conducted with employee # 3. Employee # 3 confirmed the POC did not include all the medications the patient was taking. 6. Patient # 17 had a Start of Care date of 2/24/24 with an admitting diagnosis of fracture of left lower leg. Review of the Plan of Care [POC] for the certification period 2/24/24-4/23/24 included orders for SN [skilled nursing] 1 time a week for 4 weeks. On 3/5/24 at approximately 11 am, a joint visit was conducted with LPN # 6. During the visit, a medication review was conducted using a medication profile provided by the agency. The following discrepancies were noted: The medication profile listed Lantus Solostar U-100 [insulin-used to treat diabetes] take 18 units 2 times per week. During the visit, an interview was conducted with the patient. The patient reported taking 18 units of Lantus insulin every morning. The medication profile listed brimonidine [eye drops] 0.1 % 2 times daily. The medication profile failed to include which eye the eye drops would be placed in. During the interview with the patient, the patient reported the eye drops were used in both eyes. The medication profile listed MiraLAX [stool softener] 17 grams. Take 17 grams [1 capful] as needed for constipation. During the interview with the patient, the patient reported, “I don’t take that anymore. I don’t need it.” During an interview with LPN # 6, the LPN confirmed the medications on the POC were incorrect. The policy, “Client Plan of Care”, revised 07/05/21 was provided by the agency director on 03/6/24 at 11:04 a.m. The policy stated, "...the client plan of care includes all medications and treatments…”. 1.Patient #11 was admitted on 02/11/24 with diagnoses of fracture of femur (broken leg bone), heart disease, heart failure, and type 2 diabetes. The Plan of Care (POC) for 02/11/24-04/10/24 included orders for skilled nursing 1 time a week for 4 weeks, physical therapy 2 times a week for 2 weeks, 1 time a week for 6 weeks, and occupational therapy 1 time a week for 8 weeks. A home visit was conducted with the occupational therapist on 03/4/24 at 1:30 p.m. A medication review was conducted and revealed the following discrepancies: -aspirin 81mg (milligrams) 1 by mouth daily as a blood thinner was not included on the plan of care. -fish oil (supplement for cholesterol) daily was not included on the plan of care. Interview with the patient on 03/4/24 at 1:53 p.m. revealed the patient has been using these medicines for a long time.

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 interviews the agency failed to follow the physician's order for wound care for 1 of 5 patients with a wound [#1]; and failed to report vital signs outside the given parameters for 1 of 1 patient with a VAD [vascular access device-type of catheter that provides access to blood vessels without the need for repeated needle sticks] [#5]. The findings included: 1. Patient # 1 had a Start of Care [SOC] date of 6/26/23 with admitting diagnoses of type 1 diabetes mellitus with ketoacidosis without coma [body can’t produce enough insulin], pressure ulcer of left heel stage II [top layer of skin has worn away] and pressure ulcer of right heel stage II. Review of the Plan of Care [POC] for the certification period 6/26/23-8/24/23 included orders for SN [Skilled nursing] 2 times a week for 1 week, 1 time a week for 1 week, 2 times a week for 1 week, 1 time a week for 5 weeks and “SN to perform wound care…Perform wound care to bilateral heel pressure wounds. Cleanse with wound cleanser, apply barrier cream to wound bed, cover with dry gauze…change dressings daily…” Review of the clinical record revealed RN # 10 completed the SOC OASIS [Outcome and Assessment Information Set-comprehensive assessment done that measures quality and outcomes] on 6/26/23. Review of the OASIS documentation revealed the wound measurements of the right heel of 2 cm x 2.5 cm x 0 cm and the left heel measurements of 2 cm x 3 cm x 0.1 cm. Further review of the clinical record revealed no wound care was completed. RN # 10 documented “Wound care not provided; not ordered this visit”. RN # 10 was not available for interview. During an interview with employee # 3 on 3/6/24 at approximately 11:15 am, employee # 3 confirmed the POC did include orders for wound care at the SOC, however, the wound care was not completed by the RN. 2. Patient # 5 had a Start of Care date of 11/26/22 and admitting diagnoses of pressure ulcer of right buttock unstageable [ulcers covered with slough or eschar so wound bed is not visible], pressure ulcer of sacral [base of spine] region stage 2 [top and bottom layer of skin is worn away] and encounter for adjustment and management of VAD [vascular access device-type of catheter that provides access to blood vessels without the need for repeated needle sticks]. Review of the Plan of Care [POC] for the certification period 11/26/22-1/24/23 included orders for SN [skilled nursing] 1 time a week for 7 weeks and “Licensed professional to report vital signs falling outside the following established parameters, temperature greater than 100.4…” Review of the clinical record revealed RN # 7 documented a temperature of 100.5 on 11/26/22. There was no evidence the RN notified the physician. RN # 7 was not available for interview. During an interview with employee # 3 on 3/6/24 at a11 am, employee # 3 confirmed the physician was not notified in accordance with the POC.

Responsibilities of skilled professionals CFR(s): 484.75(b) Standard: Responsibilities of skilled professionals. Skilled professionals must assume responsibility for, but not be restricted to, the following: This STANDARD is not met as evidenced by: Based on agency policy, clinical record view and staff interviews, the skilled nurse failed to assess a wound for 1 of 5 patients with a wound [#3]; failed to write a verbal order related to administration of insulin for 1 of 8 patients with a diagnosis of diabetes [#4]; and failed to obtain wound measurements for 2 of 5 patients with a wound [#5, #13]. The findings included: 4.Patient # 13 had a Start of Care (SOC) date of 2/8/24 and an admitting diagnoses of encounter for surgical aftercare following surgery of circulatory system, heart disease, hypertension, and type 2 diabetes. A review of the Plan of Care (POC) for the certification period 2/8/24 to 4/7/24 revealed orders for skilled nursing 1 time a week for 1 week, 2 times a week for 1 week; and 1 time a week for 3 weeks “…skilled nurse will assess and monitor surgical incision…” A review of the clinical record revealed no wound measurements were obtained for the weeks of 2/19/24 and 2/26/24. Interview with the director of clinical operations on 3/6/24 at 9:18 a.m. confirmed no wound measurements are in the record for those weeks. The policy, “Wound Care-Assessment and Treatment” revised date of 9/9/21 was provided by the agency director on 3/6/24 at 11:04 a.m. The policy stated, “…Wounds should be measured in centimeters once per week and/or per physician’s order…” 1. Patient # 3 had a Start of Care date of 11/12/22 and admitting diagnoses of pressure-induced deep tissue damage [purple or maroon area of discolored intact skin or blood-filled blister due to damage of underlying soft tissue from pressure and/or shear] of right hip, pressure ulcer of sacral [base of spine] region, unstageable [wound bed is covered by slough and or eschar and the wound bed is not visible], pressure ulcer of left hip, stage I [skin is red and non-blanchable] and paraplegia, unspecified [inability to move lower part of body]. Review of the Plan of Care [POC] for the certification period 5/11/23-7/9/23 included orders for SN [skilled nursing] effective 5/14/23 1 time a week for 8 weeks. Review of the clinical record revealed the patient was seen at _____ [name] Wound Care Center on 5/23/23. The wound center identified the following wounds: Stage IV [full-thickness skin loss, extends through the fascia with considerable tissue loss. There may be muscle, bone, tendon, or joint involvement. The depth is unknown because slough and or eschar obscures the extent of tissue damage] to right hip. Stage III [full-thickness tissue loss. Fat may be visible, but bone, tendon or muscle are not exposed. Undermining and tunneling may be present] pressure ulcer of right buttock. Stage II [ulcer presents as a crater] of left buttock. Stage IV ulcer of sacral region [base of spine] RN # 12 made routine visits on 5/25/23 and 5/29/23 and assessed [identified] the wounds located on the right trochanter [pointed upper, outside edge of the femur], sacral area [base of spine] and right buttock. There was no assessment/documentation related to the wound to the left buttock identified by the wound care enter on 5/23/23 or 5/29/23. RN # 12 was not available for interview. An interview was conducted with employee # 3 on 3/6/24 at approximately 12 noon. During the interview, employee # 3 confirmed no assessment was documented of a wound to the left buttock. 2. Patient # 4 had a Start of Care date of 5/28/23 with admitting diagnoses of hypertensive chronic kidney disease, type 2 diabetes mellitus with diabetic chronic kidney disease, unspecified dementia and type 2 diabetes w diabetic peripheral angiopathy without gangrene [narrowing of the arteries caused by diabetes]. Review of the Plan of Care [POC] for the certification period 5/28/23-7/26/23 included orders for SN [skilled nursing] 2 times a week for 1 week, 1 time a week for 2 weeks. With supplemental orders written on 6/13/23 for SN visits 2 times a week for 2 weeks; 6/25/23 SN visits 2 times a week for 3 weeks and 7/9/23 for SN visits 2 times a week for 2 weeks then 1 time a week for 1 week. Review of the clinical record revealed LPN # 9 conducted a routine visit on 7/18/23 and documented the following information, “…Dr_______ [name] office called and notified of blood sugar [514]. RN gave very order for client to administer another 10 units of Humalog [insulin] and recheck blood sugar in 30 minutes…” LPN # 9 conducted another routine visit on 7/20/23 and documented the following, “…MD notified of blood sugar of 467…Per nurse at Dr.______ [name] office client to administer 10 additional units of Humalog…” Further review of the clinical record revealed no evidence the LPN had written the orders for the additional insulin. LPN # 9 was not available for interview. During an interview with employee # 3 on 3/6/24 at 1 pm, employee # 3 confirmed the LPN failed to write the verbal order related to additional administration of insulin. 3. Patient # 5 had a Start of Care date of 11/26/22 and admitting diagnoses of pressure ulcer of right buttock unstageable [ulcers covered with slough or eschar so wound bed is not visible], pressure ulcer of sacral [base of spine] region stage 2 [top and bottom layer of skin is worn away] and encounter for adjustment and management of VAD [vascular access device-type of catheter that provides access to blood vessels without the need for repeated needle sticks]. Review of the Plan of Care [POC] for the certification period 11/26/22-1/24/23 included orders for SN [skilled nursing] 1 time a week for 7 weeks and “Skilled nurse to perform wound care and instruct caregiver to perform wound care. Perform wound care to… stage II pressure ulcer…change dressing weekly and as needed…” Review of the clinical record revealed wound measurements of 4 cm x 2 cm x 0 cm documented on 12/6/22. The clinical record revealed no additional wound measurements after 12/6/22. The patient was discharged on 1/18/23. During an interview with employee # 3 on 3/6/24 at 11:30 am, employee # 3 confirmed the SN should have obtained wound measurements each week.

Preparing clinical notes CFR(s): 484.75(b)(6) Preparing clinical notes; This ELEMENT is not met as evidenced by: Based on clinical record review and staff interviews the skilled nurse failed to document follow-up related to a COVID 19 test for 1 of 1 patient [#1]; and failed to provide accurate documentation related to wounds/measurements of wounds for 1 of 5 patients with a wound [#3]. The findings included: 1. Patient # 1 had a Start of Care [SOC] date of 6/26/23 with admitting diagnoses of type 1 diabetes mellitus with ketoacidosis without coma [body can’t produce enough insulin], pressure ulcer of left heel stage II [top layer of skin has worn away] and pressure ulcer of right heel stage II. Review of the Plan of Care [POC] for the certification period 6/26/23-8/24/23 included orders for SN [Skilled nursing] 2 times a week for 1 week, 1 time a week for 1 week, 2 times a week for 1 week, 1 time a week for 5 weeks. Review of the clinical record revealed RN # 11 conducted a routine visit on 8/15/23 and documented the following information, “Blood sugar 87, has cough and diarrhea. Had recent visit to the ED [emergency department]. Patient found unresponsive, blood sugar 40. Advised to get COVID test…” Further review of the clinical record revealed no follow-up related to the results of the COVID test. RN # 11 was not available for interview. During an interview with employee # 3 on 3/6/24 at 11:15 am, employee # 3 confirmed the RN should have documented the follow up for the COVID test. 2A. Patient # 3 had a Start of Care date of 11/12/22 and admitting diagnoses of pressure-induced deep tissue damage [purple or maroon area of discolored intact skin or blood-filled blister due to damage of underlying soft tissue from pressure and/or shear] of right hip, pressure ulcer of sacral [base of spine] region, unstageable [wound bed is covered by slough and or eschar and the wound bed is not visible], pressure ulcer of left hip, stage I [skin is red and non-blanchable] and paraplegia, unspecified [inability to move lower part of body]. Review of the Plan of Care [POC] for the certification period 5/11/23-7/9/23 included orders for SN [skilled nursing] effective 5/14/23 1 time a week for 8 weeks and “…Perform wound care to sacral stage 3 pressure [sacral ulcer is listed as unstageable on the diagnosis list] ulcer as follows: cleanse with anasept, wound cleanser, normal saline or soap and water, apply medihoney to wound bed and cover and secure with a foam dressing…change dressing every other day…wound care to right hip unstageable pressure injury [right hip is listed as deep tissue injury on the diagnosis list] cleanse with anasept, wound cleanser, normal saline or soap and water, apply medihoney to wound bed and cover and secure with a foam dressing…change dressing every other day…” RN # 12 completed the POC on 5/7/23 and was not available for interview. During an interview with employee # 3 on 3/6/23 at approximately 12 pm, employee # 3 confirmed the stages of the ulcers documented did not match the orders on the POC. 2B. Patient # 3 had a Start of Care date of 11/12/22 and admitting diagnoses of pressure-induced deep tissue damage [purple or maroon area of discolored intact skin or blood-filled blister due to damage of underlying soft tissue from pressure and/or shear] of right hip, pressure ulcer of sacral [base of spine] region, unstageable [wound bed is covered by slough and or eschar and the wound bed is not visible], pressure ulcer of left hip, stage I [skin is red and non-blanchable] and paraplegia, unspecified [inability to move lower part of body]. Review of the Plan of Care [POC] for the certification period 5/11/23-7/9/23 included orders for SN [skilled nursing] effective 5/14/23 1 time a week for 8 weeks and “…Perform wound care to sacral stage 3 pressure [sacral ulcer is listed as unstageable on the diagnosis list] ulcer as follows: cleanse with anasept, wound cleanser, normal saline or soap and water, apply medihoney to wound bed and cover and secure with a foam dressing…change dressing every other day…wound care to right hip unstageable pressure injury [right hip is listed as deep tissue injury on the diagnosis list] cleanse with anasept, wound cleanser, normal saline or soap and water, apply medihoney to wound bed and cover and secure with a foam dressing…change dressing every other day…” Review of the wound assessments completed by RN # 12 revealed the patient had the following wound measurements: 5/16/23- stage 1 on left greater trochanter [pointed upper, outside edge of the femur] -healed right greater trochanter-unstageable deep tissue injury – 2 cm x 2 cm x 0.3 cm sacral unstageable ulcer – 3.5 cm x 3 cm x 0.5 cm 5/25/23- right greater trochanter-unstageable deep tissue injury – 3.5 cm x 3.5 cm x1 cm sacral unstageable ulcer – 5 cm x 4 cm x 1 cm with extensive depth Further review of the clinical record revealed a wound depth for the deep tissue injury and the unstageable pressure ulcer was documented from 5/16/23-6/26/23. RN # 12 was not available for interview. An interview was conducted with employee # 3 on 3/6/24 at approximately 12 noon. During the interview, employee # 3 confirmed the depth cannot be determined in a deep tissue injury or an unstageable ulcer.

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 and staff interviews the skilled nurse failed to communicate with physician when patient refused wound care for 1 of 5 patients with a wound [#5]; and failed to report patient's inability to monitor blood sugar for 1 of 8 patients with a diagnosis of diabetes [#17]. The findings included: 1. Patient # 5 had a Start of Care date of 11/26/22 and admitting diagnoses of pressure ulcer of right buttock unstageable [ulcers covered with slough or eschar so wound bed is not visible], pressure ulcer of sacral [base of spine] region stage 2 [top and bottom layer of skin is worn away] and encounter for adjustment and management of VAD [vascular access device-type of catheter that provides access to blood vessels without the need for repeated needle sticks]. Review of the Plan of Care [POC] for the certification period 11/26/22-1/24/23 included orders for SN [skilled nursing] 1 time a week for 7 weeks and “Skilled nurse to perform wound care and instruct caregiver to perform wound care. Perform wound care to coccyx [base of spine] stage II pressure ulcer…change dressing weekly and as needed…” Review of the clinical record revealed the wound care was completed on 11/26/22, 11/29/23, 12/6/23 and 12/13/23. The wound care was not completed on 12/20/22, 12/27/22 or 1/3/23. The clinical record revealed the SN documented, “Wound care not provided; refused care.” Further review of the clinical record revealed no evidence the physician was notified that the wound care was not completed by the SN. During an interview with employee # 3 on 3/6/24 at approximately 11:30 am, employee # 3 confirmed the physician was not notified of the patient’s refusal to allow the SN to complete the wound care. 2. Patient # 17 had a Start of Care date of 2/24/24 with an admitting diagnosis of fracture of left lower leg. Review of the Plan of Care [POC] for the certification period 2/24/24-4/23/24 included orders for SN [skilled nursing] 1 time a week for 4 weeks and “Skilled nurse to perform/instruct the client/caregiver to monitor blood glucose as ordered twice daily and PRN [as needed] …Notify physician of blood glucose greater than 350 or less than 70…” During an interview with the patient on 3/5/24, the patient stated, “I can’t check my blood sugars, I don’t have a glucometer…” Further review of the clinical record revealed the physician was not notified that the patient was unable to check his blood sugar. During an interview with employee # 3 on 3/6/24 at approximately 11:30 am, employee # 3 confirmed the physician should have been notified the patient was unable to monitor his blood glucose.

A recertification survey was conducted 9/20/21-9/22/21. No deficiencies to the Emergency Preparedness Plan was identified.

An onsite unannounced recertification survey was conducted 9/20/21 to 9/22/21. Standard level deficiencies to the Medicare CoP were identified.

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 agency policy review, clinical record review, virtual visits, staff interview and patient/caregiver interview the Plan of Care failed to include correct/current medications for 5 of 20 charts [#7, 3, 11, 12 and 14]. The findings included: The policy, Client Care Plan [revised date of 7/5/21], was provided by RN # 13 on 9/22/21. The policy stated, “…The client plan of care includes: The individualized plan of care based on the client’s medical diagnosis, physician’s order, comprehensive assessment and client input must include the following elements…all medications and treatments…” 3.Patient #11 was admitted on 07/08/21 with the following diagnoses: unspecified open wound to left lower leg, other disc displacement, lumbar region, old myocardial infarction, and heart failure. The Plan of Care (POC) for 09/06/21 to 11/04/21 included the following orders: skilled nursing 2 times a week for 1 week, 1 time for 1 week; physical therapy 1 time a week for 6 weeks. A virtual home visit was conducted on 9/21/21 at 9:30 a.m. with the registered nurse. A review of current medications was conducted with the patient during the home visit. The medication profile provided by the agency did not include the following medication: aspirin 81 mg (milligrams) 1 tablet by mouth daily. Interview with the patient on 09/21/21 at 9:42 a.m. confirmed she has been taking aspirin for years. 4. Patient #12 was admitted on 07/31/21 with the following diagnoses: encounter for orthopedic aftercare, type 2 diabetes, chronic kidney disease, and morbid obesity. The POC for 07/31/21 to 09/28/21 included the following orders: skilled nursing 1 time a week for 10 weeks; physical therapy 1 time a week for 6 weeks, occupational therapy 1 time a week for 1 week; and social work 1 time a week for 1 week. A virtual home visit was conducted on 09/21/21 at 11:30 a.m. with the licensed practical nurse. A review of the current medications was conducted with the patient during the home visit. The medication profile provided by the agency had the following discrepancy: Cymbalta 30 mg 1 capsule by mouth daily. The patient confirmed by interview on 09/21/21 at 12:09 p.m. that she is taking Cymbalta 30 mg 2 capsules by mouth daily, and this medication change occurred on 08/17/21. 5.Patent #14 was admitted on 06/25/21 with the following diagnoses: other sequelae of cerebral infarction (stroke), weakness, chronic systolic heart failure, and chronic kidney disease. The POC for 08/24/21 to 10/22/21 included the following orders: physical therapy 1 time a week for 9 weeks, and occupational therapy 1 time a week for 7 weeks. A virtual home visit was conducted on 09/21/21 at 2:00 p.m. with the occupational therapist. A review of the current medications was conducted with the patient during the home visit. The medication profile provided by the agency did not include the following medication: Eliquis 5mg 1 capsule by mouth twice daily. The patient’s caregiver confirmed by interview on 09/21/21 at 2:15 p.m. the patient started this medication on 08/17/21. 1. Patient # 7 had a Start of Care [SOC] date of 8/11/21 and an admitting diagnosis of Type 2 Diabetes Mellitus with foot ulcer. A review of the Plan of Care for the certification period 8/11/21 to 10/9/21 revealed orders for SN [skilled nursing] 1 time a week for 1 week; 2 times a week for 2 weeks; 1 time a week for 5 weeks and “…continuous review of medication regimen…” A virtual visit was conducted on 9/21/21 with RN # 9. During the visit a medication review as conducted using the Client Medication Report provided by the agency. The following discrepancies were noted: The medication report listed Vitamin D2 [supplement] 1,250 mcg capsule – take 1 capsule every 15 days. An interview was conducted with the patient during the visit and the patient stated, “I don’t take that anymore. The doctor told me my levels were good and I didn’t need it anymore.” The patient also reported taking Zinc [supplement] 50 mg every day. The patient reported, “I have been taking the Zinc for several months.” The Zinc was not listed on the Client Medication Report. An interview was conducted with RN # 9 on 9/22/21. The RN confirmed the POC did not contain the current/correct medication the patient was using. 2. Patient # 3 had a Start of Care [SOC] date of 3/12/21 and an admitting diagnosis of Hemiplegia, unspecified affecting right dominant side. A review of the Plan of Care for the certification period 3/12/21 to 5/10/21 revealed orders for SN [skilled nursing] 1 time a week for 4 weeks; 1 time every 2 weeks for 4 weeks. A review of the clinical record revealed a routine visit was made on 3/26/21 by LPN # 1. Further review of the clinical record revealed the following documentation, “Husband states client had BM [bowel movement] this am. However, had not had BM in about 3 days prior to. Client has been taking Milk of Magnesium. Also suggested client to start taking Miralax [stool softener] daily and use Milk of Magnesium only PRN [as needed]. Husband verbalizes understanding.” A review of the POC revealed no order for Milk of Magnesium or Miralax. An interview was conducted with RN # 13 on 9/22/21. During the interview RN # 13 confirmed the LPN educated the husband on a medication not listed on the POC.

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 interviews the agency failed to notify the physician of changes in condition for 2 of 20 patients {#3 and 8]. The findings included: 1. Patient # 3 had a Start of Care [SOC] date of 3/12/21 and an admitting diagnosis of Hemiplegia, unspecified affecting right dominant side. A review of the Plan of Care for the certification period 3/12/21 to 5/10/21 revealed orders for SN [skilled nursing] 1 time a week for 4 weeks; 1 time every 2 weeks for 4 weeks and “…perform coordination of care with internal and external team members…” A review of the clinical record revealed the following documentation by LPN # 1 on 3/19/21, “Client was experiencing shortness of breath 3/17. Was sent to _____ [name of hospital]. Diagnosed with PE [pulmonary embolism]. Husband states per MD at hospital informed that client had multiple DVT [deep vein thrombosis] in BLE [bilateral lower extremities], prescribed Eliquis [blood thinner].” Further review of the clinical record revealed the following documentation under the Care Coordination section of the visit note, “Indicate if you communicated with other disciplines involved in this case-No”. An interview with conducted with RN # 13 on 9/22/21. During the interview RN # 13 confirmed there is no evidence the LPN communicated the information related to the PEs to the primary MD. 2. Patient # 8 had a Start of Care [SOC] date of 7/31/21 and an admitting diagnosis of Infection and inflammatory reaction due to indwelling urethral catheter. A review of the Plan of Care [POC] for the certification period 7/31/21 to 9/28/21 revealed orders for SN [skilled nursing] 1 time a week for 4 weeks; 1 every 2 weeks for 6 weeks and “…perform coordination of care with internal and external team members…” A review of the clinical note by LPN # 1 dated 8/11/21 revealed the following information, “…No anchor stat lock in place, pt [patient] states it fell off. Yellow drainage noted around ureathra [sic] opening, strong foul odor…” There is no evidence the LPN advised the RN or the MD of her findings during this visit. An interview was conducted with RN # 13 on 9/22/21. During the interview RN # 13 confirmed the LPN did not report her findings to the MD.

Provide services in the plan of care CFR(s): 484.75(b)(3) Providing services that are ordered by the physician or allowed practitioner as indicated in the plan of care; This ELEMENT is not met as evidenced by: Based on policy review, clinical record review, observation, and staff interview the agency failed to follow the plan of care as ordered by the physician for weights for 1 of 4 virtual home visits (#14). Findings include: A policy, “0-945 Client Care Plan ” was provided by the clinical manager on 09/22/21 at 2:00 p.m. The policy stated, “ …the plan of care also includes documentation of the following…client specific interventions and education”. Patent #14 was admitted on 06/25/21 with the following diagnoses: other sequelae of cerebral infarction (stroke), weakness, chronic systolic heart failure, and chronic kidney disease. The POC for 08/24/21 to 10/22/21 included the following orders: physical therapy 1 time a week for 9 weeks, and occupational therapy 1 time a week for 7 weeks, and occupation therapy 1 time a week for 7 weeks. Orders were as follows: physical therapy to provide skilled observation and teaching of heart failure, early recognition of signs of exacerbation and client/caregiver self-management including activity tolerance, assess clients weigh, notify physician of weight gain of 3 pounds in one day or 5 pounds in one week; occupation therapy to provide skilled observation and teaching of heart failure, early recognition of signs of exacerbation and client/caregiver self-management including activity tolerance, assess clients weigh, notify physician of weight gain of 3 pounds in one day or 5 pounds in one week. A virtual home visit was conducted on 09/21/21 at 2:00 p.m. with the occupational therapist. During the visit the patient stated she hasn’t weighed today, she stated “It was last week when I weighed”. It was observed that the patient did not have a set of scales in her home. An interview with the clinical manager on 09/22/21 at 12:30 p.m. revealed, “ we have scales for our clients in the office for the clinicians to take out to the clients that cannot afford the scales, the patient should have had a set of scales in the home”.

Required items in clinical record CFR(s): 484.110(a)(1) The patient's current comprehensive assessment, including all of the assessments from the most recent home health admission, clinical notes, plans of care, and physician or allowed practitioner orders; This ELEMENT is not met as evidenced by: Based on agency policy, clinical record review and staff interviews the agency failed to document wound measurements for 3 of 9 patients with skin breakdown [#17, 4, 16] and failed to include a signed supplemental order for physical therapy for 1 of 15 charts with physical therapy orders [#2]. The findings included: The policy, Wound Care-Assessment and Treatment [revised date of 9/9/21] was provided by RN # 13 on 9/22/21. The policy stated, “…Wounds should be measured in centimeters once per week and/or per physician’s order…” 3. Patient #4 was admitted on 11/11/20 with diagnoses of pressure ulcer of sacral region, stage 3; pressure ulcer of right upper back, stage 2; pressure ulcer of left upper back, stage 2; pressure ulcer of right hip, unstageable; pressure ulcer of right elbow, unstageable, and pressure ulcer of right heel, stage 1. The plan of care for 11/20/20 to 01/09/21 had orders for skilled nursing 2 times a week for 1 week, and 1 time a week for 7 weeks. Orders for skilled nursing to perform wound care and instruct caregiver in wound care. Review of skilled nursing notes for dates of 11/11/20, 11/14/20, 11/16/20, 11/20/20, 11/25/20, 12/02/20, 12/09/20, 12/15/20, 12/17/20, 12/20/20, 12/24/20, and 01/05/21 revealed measurements were not obtained for the weeks of 11/20/20, 11/25/20, 12/9/20, and 12/15/20 skilled nurse visits. Interview with the clinical manager on 9/22/21 at 2:01 p.m. confirmed no wound measurements are in the record for those 4 weeks. 4. Patient #16 was admitted was admitted on 11/11/20 with diagnoses of heart failure, type 2 diabetes with foot ulcer, non-pressure chronic ulcer of left heel, and lymphedema. The plan of care for 09/07/21 to 11/05/21 had orders for skilled nursing 1 time a week for 1 week, 3 times a week for 7 weeks, and 1 time a week for 1 week. Orders for skilled nurse to provide wound care to left heel using clean technique as follows: removed old dressing and was lower leg/foot with soap and water, pat dry, cleanse ulcer and peri-ulcer with anasept spray, apply mepilex ag, cut to fit wound bed, cover with sorbex absorbent dressing secure with kerlix and medipore tape. . Review of skilled nursing notes for dates of 09/08/21, 09/13/21, 09/15/21, 09/17/21 and 09/20/21 revealed measurements were not obtained for the weeks of 09/13/21. Interview with clinical manager on 09/22/21 at 2:10 p.m. confirmed no wound measurements are in the record for the nursing visits of 9/13, 9/15 or 9/17. 1. Patient # 17 had a Start of Care [SOC] date of 8/10/21 and an admitting diagnosis of Type 2 Diabetes Mellitus with other skin ulcer. A review of the Plan of Car [POC] for the certification period 8/10/21 to 10/8/21 revealed orders for SN [skilled nursing] 2 times a week for 1 week; 3 times a week for 2 weeks; 2 times a week for 6 weeks and “…perform wound care to left lower leg venous ulcer and right lower leg diabetic ulcer…” A review of the clinical record revealed no wound measurements for the week of 8/15/21. An interview was conducted with RN # 13 on 9/22/21. During the interview RN # 13 confirmed no wound measurements were documented the week of 8/15/21. 2. Patient # 2 had a Start of Care [SOC] date of 2/20/21 and diagnoses of Dementia in other diseases classified elsewhere with behavioral disturbances, Delirium due to known physiological condition and Encephalopathy, unspecified. A review of the Plan of Care [POC] for the certification period 2/20/21 to 4/20/21 revealed orders for PT [physical therapy] effective 2/21/21 1 time a week for 7 weeks; 1 time every 2 weeks for 2 weeks. The physical therapy evaluation was completed on 2/22/21. Further review of the clinical record revealed a supplemental order was written on 2/22/21 with the frequency of 1 time a week for 9 weeks effective 2/21/21. The order was not sent out for signature by the physician. A phone interview was conducted with PT # 3 on 9/22/21. During the interview the PT stated, “I don’t know how that happened. I don’t think I am the one who did the evaluation and put those orders in.” An interview was conducted with RN # 13 on 9/22/21. During the interview RN # 13 confirmed the supplemental order [most recent order] was not sent to the physician for signature.