Every finding on record at Bellator Health Care Management, LLC

Complaint Survey #LA100051. Abbreviations: mg-milligam LPN-Licensed Practical Nurse CPOC-Comprehensive Plan of Care

A review of all current medications CFR(s): 484.55(c)(5) A review of all medications the patient is currently using in order to identify any potential adverse effects and drug reactions, including ineffective drug therapy, significant side effects, significant drug interactions, duplicate drug therapy, and noncompliance with drug therapy. This ELEMENT is not met as evidenced by: Based on observation, interview and record review the agency failed to ensure a review of all medications was conducted each visit in order to identify any potential adverse effects and drug reactions, and noncompliance with drug therapy. The agency failed to ensure Drug Regimens were reviewed for medication changes for 2 (Patient #3 and Patient #4) of 2 (Patient #3 and Patient #4) patients medication profiles reviewed during home visits. Findings: Review of the provider’s policy titled: Medication Reconciliation revealed in part… 2. Medications ordered while the patient is receiving care will be compared to the medication list/profile. The medication list/profile will be updated with each new or changed medication. The patient’s medication list in the home will also be updated. #3 Review of Patient #3’s CPOC with a start of care date of 03/24/2023 and a certification date of 07/22/2023-09/19/2023 revealed Patient #3 had diagnoses that included Intraspinal Abscess, Chronic Pain Syndrome, Heart Failure and Chronic Atrial Fibrillation. Patient #3’s Plan of Care revealed the following Orders of Discipline and Treatments including: Skilled Nurse to review medication profile and reconcile medications as needed. Skilled Nurse may instruct and reinforce medication teaching related to use of medications to treat disease processes. Review of Resident #3’s Medication Profile revealed the orders for medications included: Buspirone 10mg tablet; 1 tablet two times daily. Lyrica 50mg capsule; 1 capsule three times daily. Oxycodone-Acetaminophen 5mg-325mg tablet; 1 tablet every 6 hours/PRN pain. Sertraline 100mg tablet; 1 tablet at bedtime. Observation on 08/16/2023 at 8:30 a.m. during a home visit revealed S2 LPN performed a medication reconciliation. Observation during the medication reconciliation revealed Patient #3 had the following medications on hand: Buspirone 30mg tablet; 1 tablet by mouth twice a day PRN. Filled on 07/05/2023. Lyrica 150mg capsule; 1 capsule by mouth twice a day. Filled on 07/11/2023. Oxycodone 30mg tablet; 1 tablet by mouth every 4-6 hours PRN pain. Filled on 08/03/2023. Paroxetine 20mg tablet; 1 tablet by mouth daily. Filled on 07/05/2023. Observation revealed Patient #3 had no Sertraline 100mg tablets in the home. Interview on 08/16/2023 at 8:45 a.m. with S2 LPN confirmed the above medication discrepancies. S2 LPN also confirmed Patient #3 did not have Sertraline on hand because the medication had been discontinued. Interview on 08/16/2023 at 8:50 a.m. with S2 LPN revealed Patient #3’s medication list was not accurate. S2 LPN confirmed Patient #2’s medication list should have been updated at the time of medication changes and had not been. #4 Review of Patient #4’s CPOC with a start of care date of 06/13/2023 and a certification date of 06/13/2023-08/11/2023 revealed Patient #4 had diagnoses that included Parkinson’s disease, Chronic Atrial Fibrillation, Localized Edema and Essential Hypertension. Patient #4’s Plan of Care revealed the following Orders of Discipline and Treatments including: Skilled Nurse to review medication profile and reconcile medications as needed. Skilled Nurse may instruct and reinforce medication teaching related to use of medications to treat disease processes. Patient #4’s SN visit schedule was noted as once a week for three weeks and then once every two weeks for six weeks. Review of the current certification period 08/10/2023-10/10/2023 revealed Patient #4 was being seen twice a week for eight weeks. Review of Resident #4’s Medication Profile revealed the orders for medications included: Atorvastatin 20mg tablet; 1 tablet at bedtime. Eliquis 5mg tablet; 1 tablet daily. Observation on 08/16/2023 at 9:30 a.m. during a home visit revealed S2 LPN performed a medication reconciliation. Observation during the medication reconciliation revealed Patient #4 had the following medications on hand: Atorvastatin 10mg 1 tablet daily. Filled on 06/21/2023. Eliquis 5mg 1 tablet twice a day. Filled on 05/17/2023. Interview on 08/16/2023 at 9:40 a.m. with S2 LPN confirmed the above medication discrepancies. S2 LPN also confirmed Patient #4’s medication list and medication bottle instructions did not match. Interview on 08/16/2023 at 8:50 a.m. with S2 LPN revealed Patient #4’s medication list was not accurate. S2 LPN confirmed Patient #4’s medication list should have been updated at the time of medication changes and had not been. Interview on 08/16/2023 at 1:00 p.m. with S1 Regional Director of Nursing revealed patients' medications should be reconciled at every skilled nurse visit. S1 Regional Director of Nursing confirmed medication profiles for Patient #3 and Patient #4 had not been reconciled and updated on skilled nurse visits and should have been.

The entity is in compliance with the federal emergency preparedness requirements.

Recertification Survey Abbreviations: HTN-Hypertension mg-milligram LPN-Licensed Practical Nurse TID-Three time a day

A review of all current medications CFR(s): 484.55(c)(5) A review of all medications the patient is currently using in order to identify any potential adverse effects and drug reactions, including ineffective drug therapy, significant side effects, significant drug interactions, duplicate drug therapy, and noncompliance with drug therapy. This ELEMENT is not met as evidenced by: Based on observation, record review and interview the agency failed to review all medications a patient is currently using to identify any potential adverse effects and drug reactions for 1 (Patient #5) of 5 (Patient #1, Patient #2, Patient #3, Patient #4 and Patient #5) sampled patients. Findings: Review of the Agency's Medication Reconciliation Policy revealed the following in part "Policy: The Agency will reconcile patient's medications at time of admission and on an ongoing basis. Procedure: 2. Medications ordered while the patient is receiving care will be compared to the medication list/profile. The medication list/profile will be updated with each new or changed medication. The patient's medication list in the home will also be updated." Review of Patient #5's Home Health Certification and Plan of Care for 05/02/2023 to 06/30/2023 revealed Patient #5 had the following diagnoses including: Hemiplegia following Cerebral Infarct affecting right dominant side and left non-dominant side; and Hypertensive Heart Disease without Heart Failure. Patient #5's Plan of Care included orders for skilled nurse to review medication profile and reconcile medications as needed; patient/caregiver verbalize understanding of medication compliance; and patient will receive medications as prescribed. Review of Patient #5's 05/02/2023 to 06/30/2023 Home Health Certification and Plan of Care included an order for Hydralazine 50 mg tablet 1 tablet every 6 hours for HTN. Visit conducted on 06/13/2023 at 9:39 a.m. at Patient #5's home with S3 LPN revealed the patient walking in his home using a walker. Patient #5 was alert and oriented and answered appropriately when questioned. S3 LPN performed a medication reconciliation of Patient #5's medication and noted no changes. S3 LPN was questioned concerning Patient #5's medications. Patient #5 had the following medication dated 04/21/2023: Hydralazine HCL 50 mg one tab po TID for Blood Pressure. Hold if systolic Blood Pressure <100. Review of Patient #5's plan of care revealed an order for Hydralazine 50 mg 1 tablet every 6 hours for HTN. Interview at this time with S3 LPN confirmed the dosage on the patient's medication bottle was not the dosage noted in her computer or on Patient #5's plan of care and it should be.

Recertification Survey A Focused Infection Control Survey was conducted on 06/28/2021. There were no deficiencies cited as a result of the FICS. Abbreviations: 1W1 - one time a week for one week a.m. - morning BP - blood pressure dl - deciliter LPN - Licensed Practical Nurse MD - Medical Doctor mg - milligram MSW - Medical Social Worker p.m. - evening q - every SN - Skilled Nurse SNV - Skilled Nursing Visit

A review of all current medications CFR(s): 484.55(c)(5) A review of all medications the patient is currently using in order to identify any potential adverse effects and drug reactions, including ineffective drug therapy, significant side effects, significant drug interactions, duplicate drug therapy, and noncompliance with drug therapy. This ELEMENT is not met as evidenced by: Based on observation, interview and record review, the agency failed to ensure a Patient's medication regimen was reviewed and updated for accuracy for 1 (#5) of 4 (#1, #2, #5, #6) patient home visits requiring medication monitoring. The agency census was 218. Findings: Observation on 06/22/2021 at 11:00 a.m. during a home visit with Patient #5 revealed S3 RN asked Patient #5 to look at her medications. Patient #5 asked the nurse why she needed to do this and S3 RN responded that all medications were to be reviewed at every visit. Patient #5 replied that the nurses had never checked her medications. S3 RN retrieved Patient #5's medications from her bedside table. Upon review of these medications, there were 7 medications that were not on the client's Plan of Care for the 05/15/2021 - 07/13/2021 Certification Period. These medications were Co-Q10 - OTC, Meclizine 25 mg q 8 hours prn - filled 04/06/2021, Allopurinol 100 mg daily - filled 05/19/2021, Vitamin D 50,000U q Tuesday - OTC, Metoprolol 12.5 mg bid - filled 05/14/2021, Ipratropium/Albuterol q 4 hours prn - Filled 03/10/2021 and Anora 62.5 mcg/25mcg 1 puff daily prn - filled 05/07/2021. Further review revealed that Patient #5 no longer took Lunesta. S3 RN failed to asked about other medications on the patient's medications list including Lopressor HCT 50 mg/25 mg, oxygen, Pravastatin 40 mg and Systane eye drops. Interview at on 06/22/2021 at 11:30 a.m. with S3 RN confirmed that Patient #5's medication had not been reviewed in a while and that her Plan of Care had not been updated. Telephone interview at 06/24/2021 at 9:45 a.m. with S1 Administrator revealed he had talked with S3 RN about Patient # 5's medication reconciliation of 06/22/2021. He stated that he was upset about the discrepancies found. Interview on 06/25/2021 at 1:00 p.m. with S2 Executive Director confirmed that all nursing staff should check all client's medications on each visit. Review of the agency's Medication Use policy revealed the following in part: "A medication profile will be completed at time of admission and updated as changes occur". "Medication changes are reviewed during each nursing visit".

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 interview and record review the agency failed to conform with physician orders for 1 (#1) of 7 (#1, #2, #3, #4, #5, #6, #7) home visits with record reviews. The agency census was 218. Findings: Observation during a home visit conducted at Patient #1's with S4 RN on 06/23/2021 at 8:30 a.m. revealed the following: S4 RN took Patient #1's blood pressure and found it to be elevated at 160/100. The patient stated he had not taken his medications this morning. S4 RN took the patient's blood pressure later in the visit and it was 142/92. Review of Patient #1's 05/02/2021 - 06/30/2021 Plan of Care revealed in part: Orders of Discipline and Treatments: Skilled Nurse to provide skilled teaching/reinforcement of management of hypertension. Skilled nurse to assess/evaluate co-morbid conditions including in part HTN. Licensed Professional to report vital signs falling outside the following established parameters: Systolic BP 160, Diastolic BP 90. Goals in part: Patient/Caregiver will verbalize/demonstrate ability to care for hypertension by EOE. Review of Patient #1's 05/19/2021 S4 RN nurse's note revealed a blood pressure reading of 180/100 at 8:02 a.m. A reading of 146/88 was obtained at 8:38 a.m. S4 RN further documented "BP today 180/100. Patient reports he took his medications before opening the door for SN. BP rechecked after wound care (Approx 40 minutes) to find down to 144/88. Educated to call office/nurse on call for any changes or issues." Review of Patient #1's vital sign report for 05/19/2021 revealed no information that Patient #1's MD had been notified of his elevated blood pressure. Further review revealed the patient's BP reading for 05/31/2021 was reported by S5 LPN on 06/02/2021. Review of Patient #1's 05/31/2021 S3 RN nurse's note revealed a blood pressure reading of 180/110 at 11:44 a.m., and 180/90 at 11:45 a.m. S3 RN further documented "Pt had not taken morning BP meds when SN arrived at 11:15 a.m. Pt did not take meds during visit. Stated that he needed to eat something first. Pt asymptomatic. Meds assessed and pt has one dose of Olmesartan remaining. Clinician placed call to pharmacy but pharmacy closed d/t Memorial Day holiday. Pt states he will pick up refill tomorrow. Follow-up comment entered by S5 LPN on 06/02/2021." Interview on 06/25/2021 at 1:00 p.m. with S2 Executive Director confirmed that Patient #1's MD was not notified on 05/19/2021 of the patient's elevated blood pressure. She confirmed that the patient's elevated BP readings of 180/110 and 180/90 obtained during the nurse visit on 05/31/2021 were not reported to the MD until 06/02/2021. She confirmed that staff should have notified the MD of the consistent elevation of Patient #5's BP results obtained in the morning hours.

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 observation, interview and record review the agency failed to coordinate care delivery to meet the patient's needs for 1 (#5) of 7 (#1, #2, #3, #4, #5, #6, #7) patients who received a home visit. The agency's census was 218. Findings: Review of Patient #5's Plan of Care dated 05/15/2021 - 07/13/2021 revealed the following in part: Diagnoses: Type 2 Diabetes Mellitus without complications; Orders of Discipline and Treatments: Skilled nurse to perform blood sugar analysis q SNV if patient/caregiver unable/unwilling; Skilled nurse to report a pattern of blood glucose levels greater than 200 mg/dl random and or greater than 130 mg/dl fasting; Skilled nurse for instructions/reinforcement of diabetic care to include diet, skin care, administration of insulin, blood glucose testing and diabetic foot care. SN to perform venipuncture for HBA1C if indicated. Goal/Rehabilitation Potential/Discharge Plans: Patient's blood glucose levels will be documented and managed by EOE; Abnormal blood sugar values will be reported to the physician for prompt intervention to minimize associated risks throughout cert. DME and Supplies: Diabetic Supplies. A home visit was conducted with Patient #5 on 06/22/2021 at 11:00 a.m. with S3 RN. S3 RN reported this was the first time visiting Patient #5. While reviewing Patient #5's current Plan of Care, S3 RN asked Patient #5 about the diagnosis of diabetes. The patient denied ever being diagnosed with DM and wanted it removed from her medical record. Patient #5 stated she had informed the nurses about this multiple times. S3 RN stated she would notify the MD of this information. Interview on 06/25/2021 at 1:00 p.m. with S2 Executive Director confirmed the nursing staff did not monitor Patient #5's DM or her capillary blood sugars as ordered on the patient's Plan of Care. She stated she had talked to the nurses about this and they told her that the client refused any care and services related to DM. She further stated they had been instructed that their should have been documentation about the refusal and the MD should have been notified.

Coordinate referrals; CFR(s): 484.105(c)(3) Coordinating referrals, This ELEMENT is not met as evidenced by: Based on interview and record review the agency failed to coordinate a MSW referral in a timely manner for 1 (# 4) of 17 (#1, #2, #3, #4, #5, #6, #7, #8, #9, #10, #11, #12, #13, #14, #15, #16, #17) patient record reviews. The agency's census was 218. Findings: Review of Patient #4's 05/28/2021 - 07/26/2021 Plan of Care revealed the following in part: Orders of Discipline and Treatments: Skilled nurse to observe and assess patient with generalized depression. Assess need for medication, medication changes and potential need for referral to provide counseling and assistance with managing depression; Goals/Rehabilitation Potential/Discharge Plans: Patient/Caregiver will verbalize understanding of medication compliance and measures to manage depression throughout cert; Medications: Trazodone 100 mg by mouth at bedtime. Review of 06/16/2021 MD order revealed MSW evaluation frequency 1W1. Review of 06/25/2021 Client Coordination Note Report revealed a missed visit notification written by S6 MSW. The reason for the missed visit was noted to be a scheduling conflict. The certifying physician was notified of the missed visit reason as being visit assigned late. Review of the agency's Care Plan Development policy revealed in part: 6. MSW patient will have a plan of care initiated by the primary MSW within twenty-four (24) hours of completion of the initial assessment and/or when service was ordered. Review of the agency's Clinical Note policy revealed in part: 10. Therapy/Social Services will commence within 24 hours of initial evaluation visit and/or when service was ordered. Interview on 06/25/2021 at 11:26 a.m. with S6 MSW revealed she did not receive the referral dated 06/16/2021 for the MSW evaluation visit until 06/21/2021. She stated it was too late to schedule a visit for the patient for this week due to scheduling conflicts. Interview on 06/24/2021 at 1:00 p.m. with S2 Executive Director revealed that when the agency gets a referral for a service such as a MSW, the agency has 24 hours to get the evaluation assigned. She confirmed the MSW referral dated 06/16/2021, was not received by the MSW until 06/21/2021. S2 Executive Director stated as a result, there was a delay in treatment for Patient #4.