Every finding on record at Benders Home Care Inc

The Emergency Preparedness regulations were reviewed as part of the Medicare certification survey completed on 07/15/2021. During the survey it was determined Benders Home Care Incorporated is in compliance with the requirements of 42 CFR 484.102 Condition of Participation: Emergency Preparedness for Home Health Agencies.

A partial extended survey for Medicare certification for Benders Home Care, Inc. was completed on 07/15/21. The agency had 16 current patients. A COVID-19 Focused Infection Control Survey was completed in conjunction with the survey and no deficiencies were identified related to the Focused Infection Control Survey.

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 agency policy review, clinical record review, home visit observation, and interview, the agency failed to complete medication reconciliations and ensure staff reviewed all of the medications the patients were currently using in order to identify any potential adverse effects, drug interactions and noncompliance with drug therapy in three (Record/Patient #1, #2, and #3) of three home visit observations and two (Record/Patient #4 and #5) of two additional full record reviews. This deficient practice has the potential to affect all patients served by the agency. Findings included: Review of the agency's policy titled, "Medication Profile," reviewed 01/25/20 showed: - Purpose: To define the use of the medication profile in evaluating a patient/client's current medication regimen; - All patients/clients receiving home health services will have a current, accurate medication profile in the clinical record; - Upon admission to home care services, the admitting clinician will initiate a medication profile; - During subsequent home visits, the medication profile will be used as a care planning and teaching guide to assure the patients/clients and patient/client/ representatives as well as other clinicians understand the medication regimen; - This includes but not limited to : Using the medication profile to evaluate the use of the drugs in the home setting; using the medication profile to teach purposes, dosages, routes, times, side effects and contraindications; and using the medication profile as a communication tool for other clinicians involved in the care; - Based on review of the medication profile as well as medication handouts, changes in the plan of care (POC) may be required; - Each patient's/client's physician will be notified either verbally or in writing of medication duplications and/or medication interactions; - If changes are made by the physician, the medication profile will be updated and patient/client/representative will be given instructions on the changes; and - All changes in medications will be communicated to the pharmacist and/or other clinicians on the case if needed. Review of the agency's policy titled, "Drug Regimen Review," reviewed 04/16/97 showed: - Drug regimen review or medication review shall mean all prescription and over the counter (OTC) drugs which are currently ordered for the patient/client and include all drugs which are available in the patient/client's home even though they may not have been recently used; - The software program shall review on request a patient's/client's drug regimen, clinical record contents, nurse's clinical notes, physician's clinical notes and other documentation to determine any irregularities; and - Irregularities detected that require immediate correction will be related by the consultant pharmacist to the care coordinator/case manager for communicating the concern to the attending physician. RECORD/PATIENT #1: Review of the plan of care (POC) dated 06/03/21 through 08/01/21 showed: - Diagnoses included but not limited to: Pressure ulcers to right and left buttocks, hypertension (high blood pressure) muscle weakness, history of urinary tract infection (UTI), and disorder of the prostate (located just below the bladder in males and surrounds the top portion of the tube (urethra) that drains urine from the bladder); - Medications included but not limited to: * Fish oil (a supplement) 1200 milligrams (mg), 2 tablets twice daily (BID); * Furosemide (rids body of excess fluid) 20 mg, 1½ tablets (30 mg) every AM; * Terazosin hydrochloride (relaxes the muscles in the prostate and bladder neck, making it easier to urinate) 10 mg, 2 tablets at bedtime (HS); * Doc-Q-Lace (stool softener/laxative) 60 mg, 1 tablet daily; * Aspirin (blood thinner and pain/fever reliever) 81 milligrams (mg) 1 tablet daily * 8 hour Equate arthritis pain relief 200 mg, 1 tablet every 4-8 hours PRN (as needed); * Normal saline flush 30-60 cubic centimeters (cc) for catheter flush PRN; * Nystatin (used to treat yeast infection) 100,000 units, cream daily; * Gabapentin (used to treat neuropathy (nerve) pain, restless leg syndrome and/or seizures) 100 mg, 1 tablet three times a day (TID); * Niferex 150/50 mg 1 capsule BID; * Flomax (used by men to treat the symptoms of an enlarged prostate), 0.4 mg, 1 tablet at HS; * Diclofenac (a non-steroidal medication to treat arthritis pain) topical gel, 1%, apply to affected areas four times per day (QID); * Acetaminophen (pain reliever) 500 mg, 2 tablets (1000 mg) for pain, QID; * Bio Freeze 0.2%-3.5% apply for muscle aches and pain PRN; * Zinc Oxide ointment (healing agent) 20% to affected area in groin PRN; * A&D Ointment (skin barrier), apply to affected areas in groin PRN; * Vitamin B Complex (supplement), 1 tablet daily; and * Vitamin D3, (supplement) 1 tablet daily. Review of the agency's medication profile/active medication list left in the patient's home, dated 06/03/21 showed: - Fish oil (a supplement) 1200 mg, 2 tablets twice daily (BID); - Furosemide (rids body of excess fluid) 20 mg, 1½ tablets (30 mg) every AM; - Terazosin hydrochloride (relaxes the muscles in the prostate and bladder neck, making it easier to urinate) 10 mg, 2 tablets at bedtime (HS); - Doc-Q-Lace (stool softener/laxative) 60 mg, 1 tablet daily; - Aspirin (blood thinner and pain/fever reliever) 81 milligrams (mg) 1 tablet daily; - 8 hour Equate arthritis pain relief 200 mg, 1 tablet every 4-8 hours PRN (as needed); - Normal saline flush 30-60 cubic centimeters (cc) for catheter flush PRN; - Nystatin (used to treat yeast infection) 100,000 units, cream daily; - Gabapentin (used to treat neuropathy (nerve) pain, restless leg syndrome and/or seizures) 100 mg, 1 tablet three times a day (TID); - Niferex 150/50 mg 1 capsule BID; - Flomax (used by men to treat the symptoms of an enlarged prostate), 0.4 mg, 1 tablet at HS; - Diclofenac (a non-steroidal medication to treat arthritis pain) topical gel, 1%, apply to affected areas four times per day (QID); - Acetaminophen (pain reliever) 500 mg, 2 tablets (1000 mg) for pain, QID; - Bio Freeze 0.2%-3.5% apply for muscle aches and pain PRN; - Zinc Oxide ointment (healing agent) 20% to affected area in groin PRN; - A&D Ointment (skin barrier), apply to affected areas in groin PRN; - Vitamin B Complex (supplement), 1 tablet daily; and - Vitamin D3, (supplement) 1 tablet daily. Review of the bottles of medications for the patient during a home visit observation on 07/14/2021 at 7:00 AM showed: - The patient was very hard of hearing and could not answer questions about medications; - No Fish oil found in the home; - No Furosemide tablets found in the home; - No Terazosin hydrochloride tablets found in the home; - No Niferex tablets found in the home; - No 8 hour Equate arthritis tablets found in the home; - No Diclofenac topical gel found in the home; and - Hydrochlorothiazide (a blood pressure medication) 25 mg, one daily in the home but not on the POC or medication profile. During an interview on 07/14/2021 at 8:00 AM, registered nurse (RN) A stated: - The patient is very hard of hearing; - He/she did not know why the medications were not in the patient's home; - He/she went over the medications with the patient each visit and made sure he/she took the medications set up for him/her; - Another agency/staff set up the patient's medications for him/her; and - RN A would contact the attending nurse practitioner about the missing medications and the Hydrochlorothiazide medication. During an interview on 07/14/2021 at 9:10 AM, the director of nursing stated: - Staff should reconcile medications each visit; - The VA sends medications of Patient #1 and sometimes we do not know medications have been changed until we get to the home; - Medications should be entered correctly on the medication profile list. RECORD/PATIENT #2: Review of the POC dated 07/03/2021 through 08/31/2021 showed: - Diagnoses included but not limited to: COPD (chronic obstructive pulmonary disease, a chronic inflammatory lung disease that causes obstructed airflow from the lungs), arteriosclerotic heart disease (a thickening and hardening of the walls of the coronary arteries,) atrial fibrillation (an irregular and often rapid heart rate that occurs when the two upper chambers of your heart experience chaotic electrical signals), acute and chronic respiratory failure, osteoporosis (a bone disease that causes a loss of bone density, which increases your risk of fractures), gastro-esophageal reflux (a chronic digestive disease with symptoms of esophageal burning and heartburn), and long term use of anticoagulants (blood thinners) - Medications included but not limited to: * Apixaban (an anticoagulant), 2.5 mg, 1 tablet BID; * Aspirin 81 mg, 1 tablet daily; * Centrum Silver, 1 tablet daily; * Cetirizine hydrochloride (used to temporarily relieve the symptoms of hay fever (allergy to pollen, dust, or other substances in the air), 10 mg, take 1 tablet daily; * Duoneb (used to treat the symptoms of COPD), 3 milliliters (ml), 2.5 mg-0.5 mg, QID (per nebulizer treatments); * Flonase (relieves sneezing, runny nose, itchy nose, itchy eyes, watery eyes, plus nasal drainage) 0.05 mg, 1 spray daily; * Lidoderm (non-narcotic pain medication) patch 5%, 1 patch on 12 hours and off 12 hours; * Lorazepam (used to treat anxiety) 0.5 mg, 1 tablet TID PRN; * Melatonin (used for insomnia and improving sleep) 10 mg, 1 tablet at HS; * Singular (used to treat symptoms of COPD) 10 mg, 1 table every AM; * Oxygen 4.5 liters/minute (l/min) continuous per nasal cannula; * Spiriva (used to treat symptoms of COPD) 18 micrograms (mcg), 1 inhalation daily; * Tramadol (a pain relief medication similar to an opioid, addictive) 50 mg, 1 tablet every 6 hours PRN; * Xopenex (used to treat symptoms of COPD) 3 ml, 0.63 mg/3 ml for wheezing TID PRN; * Colace (a stool softener), 100 mg, 1 tablet TID; * Diltiazem hydrochloride OD (used to treat high blood pressure and to control angina/chest pain) 240 mg/24 hours, 1 capsule daily; * Systane (used to treat dry eye syndrome) PRN; * Symbicort (used to treat symptoms of COPD), 160 mcg, 1 puff QID; * Omeprazole (used to treat reflux disease), 40 mg, 1 tablet daily; * Nystatin suspension (used to treat thrush, yeast in the mouth, throat and stomach), 5 ml, QID (swish and swallow); * Tessalon perles (used to treat coughs caused by the common cold and other breathing problems) 100 mg, 1 tablet TID; and * Prednisone (a steroid to treat symptoms of COPD) 20 mg, 1 tablet daily. Review of the agency's medication profile/active medication list left in the patient's home, dated 07/03/2021 showed: - Apixaban (an anticoagulant), 2.5 mg, 1 tablet BID; - Aspirin 81 mg, 1 tablet daily; - Centrum Silver, 1 tablet daily; - Cetirizine hydrochloride (used to temporarily relieve the symptoms of hay fever (allergy to pollen, dust, or other substances in the air), 10 mg, take 1 tablet daily; - Duoneb (used to treat the symptoms of COPD), 3 milliliters (ml), 2.5 mg-0.5 mg, QID (per nebulizer treatments); - Flonase (relieves sneezing, runny nose, itchy nose, itchy eyes, watery eyes, plus nasal drainage) 0.05 mg, 1 spray daily; - Lidoderm (non-narcotic pain medication) patch 5%, 1 patch on 12 hours and off 12 hours; - Lorazepam (used to treat anxiety) 0.5 mg, 1 tablet TID PRN; - Melatonin (used for insomnia and improving sleep) 10 mg, 1 tablet at HS; - Singular (used to treat symptoms of COPD) 10 mg, 1 table every AM; - Oxygen 4.5 liters/minute (l/min) continuous per nasal cannula; - Spiriva (used to treat symptoms of COPD) 18 micrograms (mcg), 1 inhalation daily; - Tramadol (a pain relief medication similar to an opioid, addictive) 50 mg, 1 tablet every 6 hours PRN; - Xopenex (used to treat symptoms of COPD) 3 ml, 0.63 mg/3 ml for wheezing TID PRN; - Colace (a stool softener), 100 mg, 1 tablet TID; - Diltiazem hydrochloride OD (used to treat high blood pressure and to control angina/chest pain) 240 mg/24 hours, 1 capsule daily; - Systane (used to treat dry eye syndrome) PRN; - Symbicort (used to treat symptoms of COPD), 160 mcg, 1 puff QID; - Omeprazole (used to treat reflux disease), 40 mg, 1 tablet daily; - Nystatin suspension (used to treat thrush, yeast in the mouth, throat and stomach), 5 ml, QID (swish and swallow); - Tessalon perles (used to treat coughs caused by the common cold and other breathing problems) 100 mg, 1 tablet TID; and - Prednisone (a steroid to treat symptoms of COPD) 20 mg, 1 tablet daily. Review of the bottles of medications for the patient during a home visit observation and patient interview on 07/14/2021 at 11:00 AM showed: - Aspirin 81 mg 1 tablet, now taking PRN, not daily; - Lidoderm patch, not using now, but liked it, it helped; - Melatonin 3 mg, now taking PRN, not every HS; - Colace 100 mg, now taking PRN, not daily; - Nystatin suspension, now taking BID PRN, not TID; - Taking Elderberry Immune tablets, 50 mg, 1 daily; - Miralax (a laxative) 1 capful PRN with water; - Tylenol (pain reliever) 500 mg, 1 tablet PRN; - Glycerin suppositories (a bowel stimulant for constipation) 1 rectally PRN; - Vitamin D3, 2000 International Units (IU) 1 daily, has taken for a long time; - Deep sea nasal spray PRN; and - Neosporin pain relieving ointment (antibiotic with pain reliever) PRN to skin tear on arm. During an interview on 07/14/2021 at 11:00 AM, RN B stated: - He/she did not know the patient took the OTC medications he/she reported; - He/she did not know the Aspirin, Melatonin, Colace, and Nystatin were used PRN; that the patient did not use the Lidocaine patch; and did not know that the patient took/used Elderberry, Miralax, Tylenol, Glycerin suppositories, Vitamin D 3, nasal spray and applied Neosporin to the arm. RECORD/PATIENT #3: Review of the clinical record showed the patient was admitted to the agency on 06/29/2021 with a diagnosis of idiopathic pulmonary fibrosis (chronic, progressive lung disease that causes scar tissue (fibrosis) to build up in the lungs, which makes the lungs unable to transport oxygen into the bloodstream effectively), pulmonary hypertension (high blood pressure in the arteries to your lungs), chronic respiratory failure with hypoxia (lung problems that may require oxygen to breathe), interstitial pulmonary disease (group of lung disorders in which the lung tissues become inflamed and then damaged) and congestive heart failure (condition in which the heart can't pump enough blood to meet the body's needs). Review of the admission plan of care (POC) dated 06/29/2021 through 08/27/2021 showed the following: - Torsemide (diuretics ('water pills') - works by causing the kidneys to get rid of unneeded water and salt from the body into the urine) 20 mg (milligrams) one by mouth daily; - Advair HFA (bronchodilator - combination of fluticasone and salmeterol used to treat difficulty breathing, wheezing, shortness of breath, coughing, and chest tightness. Fluticasone is in a class of medications called steroids. It works by reducing swelling in the airways. Salmeterol is in a class of medications called long-acting beta-agonists (LABAs). It works by relaxing and opening air passages in the lungs, making it easier to breathe) 230 mcg (micrograms) -21 / two puffs orally twice a day; and - Spiriva (bronchodilators. - works by relaxing and opening the air passages to the lungs to make breathing easier) 18 mcg one inhalation daily. Review of the skilled nursing progress report dated 07/09/2021 showed the registered nurse charted the patient saw the physician on Wednesday and ordered to increase Torsemide to twice a day. During a home visit observation on 07/14/2021 beginning at 09:27 AM, the physical therapist assistant (PTA) provided a folder located in the patient's home which included the current agency medication profile sheet. The following discrepancies were found: - Agency medication profile showed Advair HFA 230 mcg -21 / two puffs orally twice a day. No Advair HFA in the home, and patient stated that he/she does not take; - Agency medication profile showed Spiriva 18 mcg one inhalation daily. No Spiriva in the home, and patient stated that he/she does not take; - Agency medication profile showed Torsemide 20 mg one tablet by mouth twice a day and patient stated he/she takes it twice a day; and - The patient walked with the PTA providing stand by assist approximately 40 to 50 feet with oxygen at 5 liters via nasal cannula and the patient's oxygen saturation (percentage of oxygen in your blood) dropped to 78% (normal is between 95% and 100% for most healthy adults) after the walk and took approximately five minutes of pursed lip breathing (helps control shortness of breath by inhaling through nose and exhaling out the mouth) to get oxygen saturation up to 90%. During an interview with the patient on 07/14/2021 at 10:15 AM, he/she stated that the nurse was aware he/she doesn't take the inhalers because they were too expensive and he/she hasn't taken them since returning home from his/her hospital stay. During an interview on 07/14/2021 at 11:03 AM, the DON stated that the Advair and Spiriva inhalers should be in the home and the nurse should be checking the medications and doing a medication reconciliation every visit. He/she did not find an order in the chart for Torsemide 20 mg by mouth twice a day. RECORD/PATIENT #4: Review of the clinical record showed the patient was admitted to the agency on 07/25/2019 with a diagnosis of postprocedural hematoma (bad bruise) of skin and subcutaneous tissue following other procedure, stage 2 pressure ulcer of right elbow (partial thickness skin loss involving, epidermis, dermis, or both. The ulcer is superficial and presents clinically as an abrasion, blister, or shallow crater), hypertensive heart disease (heart conditions caused by high blood pressure) with heart failure (condition in which the heart can't pump enough blood to meet the body's needs), stage 2 pressure ulcer of left buttock, and type II diabetes mellitus (impairment in the way the body regulates and uses sugar (glucose) as a fuel) without complications. Review of the POC dated 05/15/2021 through 07/13/2021 showed no metoprolol (slows down your heart rate and makes it easier for your heart to pump blood around your body). Review of the Medication Profile sheet dated 05/15/2021 showed no metoprolol started or discontinued. Review of the Skilled Nursing Progress Report dated 05/17/2021 showed the registered nurse documented the following vital signs: - Apical pulse (heart rate with normal 60-100 beats per a minute) 58. Review of the Skilled Nursing Progress Report dated 05/19/2021 showed the registered nurse documented the patient's apical pulse 59. Review of the Skilled Nursing Progress Report dated 05/24/2021 showed the registered nurse documented the patient's apical pulse 54. Review of the Skilled Nursing Progress Report dated 05/26/2021 showed the registered nurse documented the patient's apical pulse 56. Review of the Skilled Nursing Progress Report dated 06/01/2021 showed the registered nurse documented the patient's apical pulse 58. Review of the Skilled Nursing Progress Report dated 06/02/2021 showed the registered nurse documented the patient's apical pulse 55. Review of the Skilled Nursing Progress Report dated 06/07/2021 showed the registered nurse documented the following: - Apical pulse (heart rate with normal 60-100 beats per a minute) 57 standing, 62 sitting and 64 after sitting 10 minutes; and - Metoprolol 50 milligrams (mg) one by mouth at bedtime. (There was no documentation of who ordered the medication). Review of the record showed no physician order to start or stop metoprolol. During an interview on 07/15/2021 at 08:48 AM the DON stated there was no order for the metoprolol and she would call the nurse and ask about the metoprolol. He/she then stated at 09:08 AM, the nurse practitioner decided not to start the patient on the medication. RECORD/PATIENT #5: Review of the POC dated 06/07/2021 through 08/05/2021 showed: - Diagnoses included but not limited to: UTI, Parkinson's disease (a progressive nervous system disorder that affects movement), spinal stenosis (a narrowing of the spaces within your spine, which can put pressure on the nerves that travel through the spine, may experience pain, tingling, numbness and muscle weakness), and chronic pain; - Medications included but not limited to: * Butrans (an opioid/narcotic pain medication patches that is used for around-the-clock treatment of moderate to severe chronic pain that is not controlled by other medicines) transdermal patch, 1 patch daily, no dose documented. Review of the agency's medication profile/active medication list dated 06/07/2021 showed: - Butrans transdermal patch, 1 patch daily. Review of the clinical record showed Butrans transdermal patch was not listed in the High Alert Medications information in the record or left in the patient's home. Review of a skilled nurse progress note dated 07/05/2021 showed: - RN B documented the Butrans patch changed weekly; and - Patient does not feel the patch helps much but continues to use. Review of https://butrans.com/ showed: 2.1 Important Dosage and Administration Information - BUTRANS should be prescribed only by healthcare professionals who are knowledgeable in the use of potent opioids for the management of chronic pain. - BUTRANS doses of 7.5, 10, 15, and 20 mcg/hour are only for use in patients who are opioid experienced and in whom tolerance to an opioid of comparable potency has been established. Patients who are opioid-experienced are those receiving, for one week or longer, daily opioid doses up to 80 mg/day of oral morphine or an equianalgesic dose of another opioid. - Use the lowest effective dosage for the shortest duration consistent with individual patient's treatment goals. - Initiate the dosing regimen for each patient individually, taking into account the patient's severity of pain, patient response, prior analgesic treatment experience, and risk factors for addiction, abuse, and misuse. - Monitor patients closely for respiratory depression, especially within the first 24-72 hours of initiating therapy and following dosage increases with BUTRANS. - Instruct patients not to use BUTRANS if the pouch seal is broken or the patch is cut, damaged, or changed in any way and not to cut BUTRANS. - Instruct patients to avoid exposing BUTRANS to external heat sources, hot water, or prolonged direct sunlight. - BUTRANS is for transdermal use (on intact skin) only. - Each BUTRANS patch is intended to be worn for 7 days. During an interview on 07/14/2021 at 2:00 PM, RN B stated: - The Butrans transdermal patch should be used weekly not daily as stated on the medication profile kept in the clinical record and in the patient's home. During an interview on 07/14/2021 at 9:10 AM, the director of nursing stated: - Staff should reconcile medications each visit; - The VA sends medications of Patient #1 and sometimes we do not know medications have been changed until we get to the home; - Medications should be entered correctly on the medication profile 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 review of agency policy, clinical record review, home visit observation, and interview, the agency failed to ensure staff developed an individualized care plan to include nutritional requirements for wound healing and sufficient hydration which affected one (Record/Patient #1) of three home visit records reviewed. This deficient practice has the potential to affect all patients served by the agency. Findings included: Review of the agency's policy titled, "Contents of the Clinical Record," reviewed 04/18/1997 showed: - The clinical record will contain sufficient information to identify the patient/client, describe the patient/client problems/needs, justify care service, accurately document care/service provided and results in detail and facilitate continuity of care among direct care clinicians and contract agency personnel; and - The plan of care (POC) should include diagnoses and documentation of the assessment data collected, actions and interventions performed and the patient/client's response to the care provided. RECORD/PATIENT #1: Review of the POC dated 06/03/2021 through 08/01/2021 showed: - Diagnoses included but not limited to: Stage 2 (partial thickness skin loss involving, epidermis, dermis, or both. The ulcer is superficial and presents clinically as an abrasion, blister, or shallow crater) pressure ulcer to the left buttock, Stage 3 (full thickness skin break into the subcutaneous tissue but does not go into the muscle or bone) pressure ulcer to the right buttock, history of urinary tract infections (UTI), cystostomy (the surgical creation of an opening into the bladder for placement of a urinary drainage tube (catheter) to drain urine), and disorder of the prostate ((located just below the bladder in males and surrounds the top portion of the tube (urethra) that drains urine from the bladder); - Nutritional requirements: General diet; and - Ensure (a nutritional, high protein shake/drink that can assist with wound healing, weight gain, and provide meal replacement or supplement) and Gatorade were not listed on the POC. Review of a nurse's progress note dated 06/25/2021 at 9:40 AM showed registered nurse (RN) A documented he/she instructed patient to drink Ensure two to three times daily. Review of a nurse's progress note dated 07/02/2021 at 8:30 AM showed RN A documented he/she instructed the patient to drink more clear liquids to keep the catheter draining. A home visit observation and interview on 07/14/2021 at 7:00 AM showed: - RN A instructed the patient to drink Ensure to assist with the healing of his/her pressure ulcers and to continue to drink Gatorade to keep him/her hydrated. - RN A stated the patient drank one Ensure a day to help heal his/her wounds and drank water or Gatorade to help with hydration; and - The patient's private care giver stated the patient drank one Gatorade per day to help with hydration. During an interview on 07/15/2021 at 9:00 AM, the director of nursing (DON) stated: - The Ensure should be listed on the POC if used/instructed for wound healing; - He/she was not sure Gatorade should be listed because the patient could drink it because he/she liked it, not necessarily for a specified reason.

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 review of the agency's policy, clinical record review, and interview, the agency failed to ensure staff notified the physician of emergency room (ER) visits for a change in condition or needs for one (Record/Patient #1) of five full record reviews. This deficient practice has the potential to affect all patients served by the agency. Findings included: Review of the agency's policy titled, "Clinical Documentation in Home Health Care, Satisfy Regulatory Compliance," dated 2011, clinical record review showed: - The supervising nurse or registered nurse (RN) shall be managed in accordance with the following: Informing the patient's physician of changes in a patient's condition. Review of the agency's policy titled, "Registered Nurse, Responsibilities and Duties," reviewed February, 2017 showed: - Observes the patient/client for changes in condition and reports these changes and the patient/clients need to the attending physician and appropriate supervisory personnel. RECORD/PATIENT #1: Review of the plan of care (POC) dated 06/03/2021 through 08/01/2021 showed: - Start of care (SOC): 10/27/2018; and - Diagnoses included but not limited to: Pressure ulcers to right and left buttocks, cystostomy (the surgical creation of an opening into the bladder for placement of a urinary drainage tube (catheter) to drain urine), hypertension (high blood pressure), muscle weakness, and history of a urinary tract infection. Review of a skilled nursing progress note dated 07/02/2021 showed: - Patient went to the ER with kinked (catheter not able to drain properly) catheter tubing and sent back home; - Instructed patient to contact home health prior to going to the hospital with catheter issues; and - Severely hard of hearing. Review of a skilled nursing progress note dated 07/05/2021 showed: - Patient stated he/she went to the ER at 11:00 AM on Saturday (07/03/2021); - He/she passed out while watching a movie; - Before he/she got into the ambulance, he/she came to and was able to answer questions; - At the ER, a CAT (a computerized tomography (CT) scan combines a series of X-ray images taken from different angles around your body and uses computer processing to create cross-sectional images (slices) of the bones, blood vessels and soft tissues inside your body) scan was done; and - The licensed practical nurse (LPN) contacted the registered nurse/case manager (RN/CM) regarding the ER visit the patient made. Review of the clinical record did not show documentation that the RN/CM contacted the patient's physician of the ER visits on 07/02/2021 or 07/03/2021. During an interview on 07/14/2021 at 9:20 AM, the director of nursing (DON) stated she did not know why the RN did not notify the physician of the ER visit on 07/03/2021. The RN should have documented the notification of the physician in a skilled note. During an interview on 07/15/2021 at 9:00 AM the DON stated the RN should notify physicians of ER visits.