Every finding on record at Bentley Enterprises, LLC

The Emergency Preparedness regulations were reviewed as part of the Medicare recertification survey completed on 01/15/2025. During the survey it was determined the home health provider is in compliance with the requirements of 42 CFR 484.102 Condition of Participation: Emergency Preparedness for Home Health Providers.

A partial extended survey for Medicare recertification for the home health provider was completed on 01/15/2025. The provider had 60 current patients.

HHA administrator contact information CFR(s): 484.50(a)(1)(ii) (ii) Contact information for the HHA administrator, including the administrator's name, business address, and business phone number in order to receive complaints. This ELEMENT is not met as evidenced by: Based on policy review, review of the provider’s patient rights information in the home binder, home visit observation, and interview, the home health provider failed to provide, in writing the correct business address, in, but not limited to, one of three home visit observations (Record/Patient #2). This deficient practice has the potential to affect all patients served by the provider. Findings included: Review of the home health provider’s policy titled, “Admission Documentation/Patient Education” (policy number C:4), dated initiated “05/2020”, showed in part: - “Named provider” will be in compliance with state and federal regulations regarding patient admission paperwork; - The patients of “named provider” will receive paperwork upon admission per state, local, and federal regulation; and - The following forms/documents shall be reviewed by our agency’s (provider’s) clinician upon the initial visit to the new patients or prior to initiating services: patient rights and responsibilities in writing. Review of the admission binder provided upon entrance to the provider on 01/13/2025, showed on the binder cover, on page 1 (one) and page 19, the address failed to be listed correctly. Each had the address listed as 100 East Main, Fairfax Missouri 64446. The current address is 208 East 5th Street Mound City, Missouri 64470. Review of a letter from “Named” Medicare billing service showed an approval for change of information (primary practice location address) dated 11/27/2024. RECORD/PATIENT #2: Review of the clinical record showed the patient was admitted to home health services on 01/03/2025 with a primary diagnosis of a stage two pressure ulcer/injury (a partial thickness loss of the skin caused by unrelieved pressure) of the right medial foot with skilled nursing visits to provide wound care. Observation on 01/12/2025 at 4:37 PM, during the patient’s home visit, when reviewing of the patient rights information in the admission binder showed if failed to have the correct/current Mound City address listed. (The previous Fairfax address was still listed). During an interview on 01/15/2025 at 10:03 AM, the administrator stated that he/she: - Had emailed “named person” (the program assistant of the Bureau of Home Care and Rehabilitative Standards) of the address change on 11/01/2024; - Realized it (the address) was incorrect in the admission binder and on the patient rights information, but it was fixed at that time; - The date on the 855 (Medicare enrollment form) of the address change was 11/01/2024; - They would send out a letter to all the current patients with the correct information; and - They had it fixed at that time.

State toll free HH telephone hotline CFR(s): 484.50(c)(9) Be advised of the state toll free home health telephone hot line, its contact information, its hours of operation, and that its purpose is to receive complaints or questions about local HHAs. This ELEMENT is not met as evidenced by: Based on policy review, review of the Missouri Adult Abuse and Neglect Hotline Online reporting system, review of the home health provider’s current patient rights information, home visit observation, and interview, the provider failed to provide written notice of the correct state toll free home health hotline number hours of operation in, but not limited to, one of three home visits observed (Patient/Record #2). This deficient practice has the potential to adversely affect the knowledge and comprehension of the rights and responsibilities of all the providers patients. Findings included: Review of the home health provider’s policy titled, “Admission Documentation/Patient Education” (policy number C:4), dated initiated “05/2020”, showed in part: - “Named provider” will be in compliance with state and federal regulations regarding patient admission paperwork; - The patients of “named provider” will receive paperwork upon admission per state, local, and federal regulation; - The following forms/documents shall be reviewed by our agency’s (provider’s) clinician upon the initial visit to the new patients or prior to initiating services: patient rights and responsibilities in writing; and - “State hotline numbers, office phone (accreditation body hotline after accreditation)”. Review of the Missouri Adult Abuse and Neglect Hotline Online Reporting System showed the hotline hours of operation as 7 (seven) AM to 8 (eight) PM, 365 days a year. Review of the patient rights listed in the admission binder provided upon entrance to the provider on 01/13/2025, showed on page 7 and page 10, the hotline hours failed to be listed correctly. They were incorrectly listed as “7 AM to Midnight 7 days a week”. RECORD/PATIENT #2: Review of the clinical record showed the patient was admitted to home health services on 01/03/2025 with a primary diagnosis of a stage two pressure ulcer/injury (a partial thickness loss of the skin caused by unrelieved pressure) of the right medial foot with skilled nursing visits to provide wound care. Observation on 01/12/2025 at 4:37 PM, during the patient’s home visit, when reviewing of the patient rights information in the admission binder showed if failed to have the correct hotline hours. The hours were incorrectly listed as “7 AM to Midnight 7 days a week”. During an interview on 01/15/2025 at 10:03 AM, the administrator stated that: - He/she knew they had that fixed; - The COO (Chief Operating Officer that is responsible for printing the binders) needed to delete the old files out; - They would send out a letter to all current patients with the correct information; and - They had it fixed at that time.

Contact info Federal/State-funded entities CFR(s): 484.50(c)(10)(i,ii,iii,iv,v) Be advised of the names, addresses, and telephone numbers of the following Federally-funded and state-funded entities that serve the area where the patient resides: (i) Agency on Aging (ii) Center for Independent Living (iii) Protection and Advocacy Agency, (iv) Aging and Disability Resource Center; and (v) Quality Improvement Organization. This ELEMENT is not met as evidenced by: Based on policy review, review of the Quality Improvement Organization (QIO) website, review of the home health provider’s current patient rights information, home visit observation, and interview, the provider failed to update the written notice of patient rights to meet the requirements of the federal home health regulations to include the name address and phone number of the current QIO that serves the area where the patient resides in, but not limited to, one of three home visit observations (Record/Patient #2). This deficient practice has the potential to affect all patients served by the provider. Findings included: Review of the home health provider’s policy titled, “Admission Documentation/Patient Education” (policy number C:4), dated initiated “05/2020”, showed in part: - “Named provider” will be in compliance with state and federal regulations regarding patient admission paperwork; - The patients of “named provider” will receive paperwork upon admission per state, local, and federal regulation; and - The following forms/documents shall be reviewed by our agency’s (provider’s) clinician upon the initial visit to the new patients or prior to initiating services: patient rights and responsibilities in writing. Review of the QIO website for Missouri, showed the following: Livanta LLC P.O. Box 2687 Virginia Beach, VA 23450 (888)755-5580 TTY (teletypewriter) 711. Review of the admission binder, including the patient right’s information, provided upon entrance to the provider on 01/13/2025, showed on page 11, Livanta failed to be listed as the QIO. (No organization was listed, just an address of 5918 West Courtyard Drive, Austin, Texas 78730-5036 and a phone number of 800-725-9216). RECORD/PATIENT #2: Review of the clinical record showed the patient was admitted to home health services on 01/03/2025 with a primary diagnosis of a stage two pressure ulcer/injury (a partial thickness loss of the skin caused by unrelieved pressure) of the right medial foot with skilled nursing visits to provide wound care. Observation on 01/12/2025 at 4:37 PM, during the patient’s home visit, when reviewing of the patient rights information in the admission binder showed it failed to have the correct QIO listed. (No organization was listed, just an address of 5918 West Courtyard Drive, Austin, Texas 78730-5036 and a phone number of 800-725-9216). During an interview on 01/15/2025 at 10:03 AM, the administrator stated that he/she: - Was unaware the correct QIO was not listed; and - Would send out a letter to all the current patients with the correct information.

RN performs assessment CFR(s): 484.55(a)(1) A registered nurse must conduct an initial assessment visit to determine the immediate care and support needs of the patient; and, for Medicare patients, to determine eligibility for the Medicare home health benefit, including homebound status. The initial assessment visit must be held either within 48 hours of referral, or within 48 hours of the patient's return home, or on the physician or allowed practitioner - ordered start of care date. This ELEMENT is not met as evidenced by: Based on policy review, clinical record review, and interview the home health provider failed to ensure the initial assessment was completed within 48 hours of the referral in one of five full records reviewed (Record/Patient #4). This deficient practice has the potential to affect the immediate care needs of all the provider’s patients. Findings included: Review of the providers policy titled “Assessments” (policy number C: 7), dated initiated 05/2020, showed in part: - All patients referred to our agency (provider) will receive an assessment according to the physician services ordered; and - An initial SOC (start of care) assessment will be performed by the primary care RN (registered nurse) unless therapy only case, then PT (physical therapy) or SLP (speech/language pathologist) within 48 hours of the patient’s referral, discharged from the facility to home or specific date specified by the MD (medical doctor). RECORD/PATIENT #4: Review of the clinical record showed the patient was admitted to home health services on 12/16/2024 with a primary diagnosis of malfunction of tracheostomy stoma (the failure to function in a normal manner of a surgically created opening in the neck that allows air to reach the lungs). Review of a faxed referral from the patient’s PCP (primary care provider), showed in part: - A handwritten date of 11/27/2024 on the faxed referral cover sheet; and - A time stamped date in the upper left-hand corner of the faxed referral cover sheet of 12/07/2024. Review of the SOC OASIS (Start of Care Outcome and Assessment Information Set; a standardized data collection tool) dated 12/16/2024, (Nineteen days from the handwritten referral date and nine days from the time stamped date on the referral) showed: - Item M0104- Date of referral 12/16/2024; Item M0102- Date of physician-ordered SOC (start of care) marked NA (non-applicable), no specific date ordered by physician. Further review of the clinical record showed the following undated documentation; - Referral 12/16/2024; - MD-ordered SOC: 12/16/2024; - Point of Origin: Clinic referral; - Notes: “Patient requested SOC date for 12/15/2024. PCP notified and updated referral date to 12/16/2024.”; and - There failed to be any documentation within 48 (forty-eight) hours of referral of any communication regarding the late start of care (the documentation was undated). During an interview on 01/15/2025 at 10:36 AM, the clinical manager stated that he/she had nothing to show the actual date the PCP was contacted about changing the SOC date per patient request.

Health, psychosocial, functional, cognition CFR(s): 484.55(c)(1) Standard: Content of the comprehensive assessment. The comprehensive assessment must accurately reflect the patient's status, and must include, at a minimum, the following information: (1) The patient's current health, psychosocial, functional, and cognitive status; This ELEMENT is not met as evidenced by: Based on policy review, record review, and interview, the home health provider failed to ensure the comprehensive assessment accurately reflected the patient’s current health status including relevant past medical history in, one of five full records reviewed (Record/Patient #1). This deficient practice has the potential to affect all patients served by the provider. Findings included: Review of the provider’s policy titled, “Assessments,” dated 05/2020, showed in part: - The comprehensive assessment must accurately reflect the patient’s status and must include, current health, psychosocial, functional and cognitive status; and - Systems assessment including, integumentary (skin) status. RECORD/PATIENT #1: Review of the clinical record, showed in part: - The patient was admitted to home health services on 12/04/2024 with a primary diagnosis of encounter for fitting and adjustment of urinary device (foley catheter- a flexible tube that drains urine from the bladder into a bag outside of the body) with a secondary diagnosis of malignant neoplasm (cancer) of prostate (a gland below the bladder and in front of the rectum in men that produces fluid for semen); and - The patient resided in the home with his/her spouse as the primary caregiver. Review of the referral record, dated 12/03/2024, showed in part: - The patient had a past medical history that included the diagnosis of “type 2 diabetes mellitus without complications, with long-term current use of insulin” (a long-term condition in which the body has trouble controlling the levels of sugar in the blood); - The patients “blood sugar levels have been stable, with no instances of hypoglycemia;” - The patient to “check blood sugars 3 (three) times weekly” (a type of blood test that checks the amount of sugar levels within the blood); and - The patient had an “approx. (approximately) 3mm (millimeter) superficial abrasion (a minor skin injury that occurs when the skin’s surface layers are broken) to left elbow.” Review of the SOC visit note dated 12/04/2024, showed in part: - The endocrine (a group of glands and organs that produce and release hormones into the bloodstream) status section showed that the patient was a diabetic, “controlled by insulin injection,” and “blood sugar: random,” (No documentation of blood sugar ranges); and - “The patient has areas of concern to buttock and left bottom foot;” - The SN (skilled nurse) educated the patient and the spouse on “skin care techniques” and provided the patient and the spouse with “supplies to prevent skin breakdown;” and - The documentation failed to include the status of the abrasion to the left elbow. During an interview on 01/15/2025 that began at 10:45 AM, the clinical manager stated that: - He/she would have expected the SN to assess the patient’s blood sugar ranges; - He/she was only able to find skin assessment documentation related to the areas of concern to the buttocks and the left bottom foot; and - He/she was unsure why the SN did not document the abrasion to the left elbow.

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 policy review, record review, home visit observation and interview, the home health provider failed to ensure an accurate medication review and/or update of the patient medications was completed, in one of three home visit observations (Record/Patient #3). This deficient practice has the potential to affect all patients served by the provider. Findings included: Review of the provider’s policy titled, “Assessments,” dated 05/2020 ,showed in part: - The comprehensive assessment must accurately reflect the patient’s status and must include, a review of all medications (current, including over the counter and supplements)/medication instruction; and - Every skilled visit will have a physical assessment and routine assessment of the patient’s home. RECORD/PATIENT #3: Review of the clinical record, showed in part: - The patient was admitted to home health services on 12/24/2024 with primary diagnosis of neurocognitive disorder with Lewy bodies (a type of progressive dementia caused by degeneration of the tissues in the brain, that leads to a decline in thinking, reasoning and independent function); and - The patient resided at home with his/her spouse. On 01/14/2025 at 2:10 PM, during the home visit observation with OT (occupational therapist), showed the following medication discrepancies: - Mannose cranberry 900mg/500mg (a supplement containing 900 milligrams of mannose and 500 milligrams of cranberry in each capsule) 1 (one) capsule daily was being administered (The provider's medication profile failed to include this supplement). - Calcium citrate-vitamin D3 (supplement)/ 315MG (milligrams) calcium- 6.25mcg (micrograms) 1 tablet daily was being administered (The provider's medication profile showed the frequency of every 48 hours); and - The patient’s spouse managed and administered the patient’s medications using his/her own handwritten medication list. During an interview on 01/15/2025 that began at 10:45 AM, the clinical manager stated that: - He/she was surprised that the spouse had his/her own handwritten medication list because the nurse (RN A) usually filled out a paper medication list on admission; - The medication profile was last updated with medication changes on 01/10/2025 during the last skilled nursing visit; and - He/she was not sure if the patient’s spouse didn’t inform the nurse about the medication changes or if the changes were made since the nurse had been there last.

Plan of care CFR(s): 484.60(a)(1) Each patient must receive the home health services that are written in an individualized plan of care that identifies patient-specific measurable outcomes and goals, and which is established, periodically reviewed, and signed by a doctor of medicine, osteopathy, or podiatry acting within the scope of his or her state license, certification, or registration. If a physician or allowed practitioner refers a patient under a plan of care that cannot be completed until after an evaluation visit, the physician or allowed practitioner is consulted to approve additions or modifications to the original plan. This STANDARD is not met as evidenced by: Based on policy review, record review, and interview, the home health provider failed to ensure an individualized plan of care (POC) that included all patient-specific interventions, in three of five full records reviewed (Records/Patients #1, #2, and #4). This deficient practice has the potential to affect the coordination of care and services for all patients on service with the provider. Findings included: Review of the provider’s policy titled, “Plan of Care (POC),” dated 05/2020 showed, in part: - The plan of care is a written plan that specifies the care and services necessary to meet the patient-specific needs; and -The POC is developed in consultation with staff, patient, physician and other providers involved in the patient’s care; and - The POC includes all medications and treatments and patient-specific interventions and education. RECORD/PATIENT #1: Review of the clinical record, showed, in part: - The patient was admitted to home health services on 12/04/2024 with a primary diagnosis of encounter for fitting and adjustment of urinary device (foley catheter- a flexible tube that drains urine from the bladder into a bag outside of the body) with a secondary diagnosis of malignant neoplasm (cancer) of prostate (a gland below the bladder and in front of the rectum in men that produces fluid for semen); and - The patient resided in the home with his/her spouse as the primary caregiver. Review of the referral record, dated 12/03/2024 showed, in part: - The patient had a past medical history that included the diagnosis of “type 2 diabetes mellitus without complications, with long-term current use of insulin” (a long-term condition in which the body has trouble controlling the levels of sugar in the blood); and - The patient to “check blood sugars 3 times weekly” (a type of blood test that checks the amount of sugar levels within the blood). Review of the POC dated 12/04/2024, failed to show orders/interventions for blood sugar checks three times a week. During an interview on 01/15/2025 that began at 10:45 AM, the Clinical Manager stated that: - The blood sugar check frequency of three times a week was on the referral; and - He/she has no idea how it was missed and left off of the POC. RECORD/PATIENT #2: Review of the clinical record showed the patient was admitted to home health services on 01/03/2025 with a primary diagnosis of a stage two pressure ulcer/injury (a partial thickness loss of the skin caused by unrelieved pressure) of the right medial foot with skilled nursing visits to provide wound care; and - The patient resided in an apartment with a friend. Review of the referral record, dated 01/02/2025 showed, in part: - The patient had a past medical history that included the diagnosis of type 2 diabetes mellitus (a long-term condition in which the body has trouble controlling the levels of sugar in the blood) with foot ulcer and was on insulin (an injectable medication used to help regulate blood sugar). Review of the SOC (start of care) visit note, dated 01/03/2025, showed a glucose meter (a portable machine that measures the amount of sugar in a small blood sample) had been called into the pharmacy. Review of the POC dated 01/03/2025 to 03/032025 showed: - Insulin lispro 100 unit/ml (milliliter) sliding scale insulin (the dose is adjusted based on the blood sugar level before a meal) pen before meals subcutaneously (the fatty tissue just under the skin). For blood sugar 100-150 give 6 units, for blood sugar greater than 151 give 10 units; and - It failed to list a frequency for the blood sugar to be checked. RECORD/PATIENT #4: Review of the clinical record showed the patient was admitted to home health services on 12/16/2024 with a primary diagnosis of malfunction of tracheostomy stoma (the failure to function in a normal manner of a surgically created opening in the neck that allows air to reach the lungs). Review of the referral record, with a service date of November 24, 2024, showed, in part: the tracheostomy is capped on room air. Review of the SOC (start of care) visit note, dated 12/16/2024, showed the trach is not used and is capped off. Review of the POC, dated 12/16/2024 to 02/13/2024, failed to show evidence the trach was capped off. During an interview on 01/15/2025 at 10:36 AM the administrator stated that it was kind of a grey area. It was in the SOC assessment that the trach was capped off so it probably should have been on the POC. During an interview on 01/12/2025 at 10:40 AM the clinical manager stated that ideally, he/she would expect that the trach being capped off was listed on the POC.

Only as ordered by a physician CFR(s): 484.60(b)(1) Drugs, services, and treatments are administered only as ordered by a physician or allowed practitioner. This ELEMENT is not met as evidenced by: Based on policy review, record review, home visit observation, and interview, the home health provider failed to ensure that education and treatments were provided as ordered by the physician, in two of five full records reviewed (Records/Patients #1 and #3). This deficient practice has the potential to affect all patients served by the provider. Findings included: Review of the provider’s policy titled, “Plan of Care (POC),” dated 05/2020, showed in part: - The plan of care is a written plan that specifies the care and services necessary to meet the patient-specific needs; - Individualized written plan of care which would specify the care and services necessary to meet the patient’s needs, including the patient and caregiver education and training specific to the patient’s care needs; - The POC includes all medications and treatments and patient-specific interventions and education; and - The POC will include any additional interventions/orders the provider/physician chose to include. Review of the provider’s policy titled, “Wound Care,” dated 05/2020, showed in part: - Wounds are not to be treated without doctor orders; - Continue dressing changes and supplies as prescribed by the physician; - Obtain new orders as needed from the physician for lack of healing and new wounds; and - Education with the patient and/or caregiver regarding wound prevention and wound healing will be ongoing and documented in the patient’s record. RECORD/PATIENT #1: Review of the clinical record, showed in part: - The patient was admitted to home health services on 12/04/2024 with a primary diagnosis of encounter for fitting and adjustment of urinary device (foley catheter- a flexible tube that drains urine from the bladder into a bag outside of the body) with a secondary diagnosis of malignant neoplasm (cancer) of prostate (a gland below the bladder and in front of the rectum in men that produces fluid for semen); and - The patient resided in the home with his/her spouse as the primary caregiver. Review of a physicians order, dated 12/26/2024, showed in part: - SN (skilled nurse) to perform/instruct on wound care; and - Wound care for skin tear to left elbow, cleanse with Vashe wash (a solution for cleansing, irrigating, moistening, and debriding acute and chronic wounds) or wound cleanser, apply Tegaderm absorbent (a sterile, transparent and waterproof wound dressing that helps protect wounds from bacteria and viruses), change weekly and PRN (as needed), and okay for caregiver to perform dressing changes. Observation on 01/14/2025 at 8:00 AM, with RN (registered nurse) A, showed: - RN A performed wound care to the patient’s left elbow; - After RN A cleansed the wound with wound cleanser, he/she sprayed the patient’s left elbow with skin-prep (a fast-drying, liquid film-forming skin protectant that prepares damaged or intact skin for the application of adhesive dressings) prior to applying the tegaderm absorbent dressing; and - The wound care orders failed to include the use of skin prep to the patient’s left elbow. During an interview on 01/15/2025 that began at 10:45 AM, the administrator stated that the use of skin prep needed to be included in the wound care orders. RECORD/PATIENT #3: Review of the clinical record, showed in part: - The patient was admitted to home health services on 12/24/2024 with primary diagnosis of neurocognitive disorder with Lewy bodies (a type of progressive dementia caused by degeneration of the tissues in the brain, that leads to a decline in thinking, reasoning and independent function); and - The patient resided at home with his/her spouse. Review of a SN visit note, dated 01/10/2025, showed that the SN provided education on the importance of TED hose (elastic stockings/socks that gently squeeze the legs to improve blood flow and circulation) and the patient agreed to put the TED hose back on after his/her shower. Review of the POC failed to include orders/interventions for TED hose. During an interview on 01/15/2025 that began at 10:45 AM, the clinical manager stated that: - The referral did show orders/interventions for TED hose; - The POC failed to include orders/interventions for TED hose; and - They (the staff) needed to be making sure that they had orders for them.

Authentication CFR(s): 484.110(b) Standard: Authentication. All entries must be legible, clear, complete, and appropriately authenticated, dated, and timed. Authentication must include a signature and a title (occupation), or a secured computer entry by a unique identifier, of a primary author who has reviewed and approved the entry. This STANDARD is not met as evidenced by: Based on policy review, record review, home visit observation, and interview, the home health provider failed to ensure all documented entries were complete, clear, and accurately reflected the skilled visit, in one of three home visit observations (Record/Patient #1). This deficient practice has the potential to affect all patients served by the provider. Findings included: Review of the provider’s policy titled, “Assessments,” dated 05/2020, showed in part: - The POC (plan of care) includes all medications and treatments and patient-specific interventions and education; and - All patients will receive an assessment according to the Physician services ordered. Review of the provider’s policy titled, “Wound Care,” dated 05/2020, showed in part: - Assess patient for wound(s); - The wound shall be measured weekly and documented in the patient’s record to show a progression or decline; - All wound care education is to be documented in nursing notes; and - Education with the patient and/or caregiver regarding wound prevention and wound healing will be ongoing and documented in the patient’s record. RECORD/PATIENT #1: Review of the clinical record, showed in part: - The patient was admitted to home health services on 12/04/2024 with a primary diagnosis of encounter for fitting and adjustment of urinary device (foley catheter- a flexible tube that drains urine from the bladder into a bag outside of the body) with a secondary diagnosis of malignant neoplasm (cancer) of prostate (a gland below the bladder and in front of the rectum in men that produces fluid for semen); and - The patient resided in the home with his/her spouse as the primary caregiver. Review of a POC, dated 12/04/2024, showed in part: - SN (skilled nurse) visit frequency of 2 week 1 (two times a week for one week) and 1 week 8 (one time a week for eight weeks); - SN to assess and instruct on diabetic care to include: diet, activity, stress, foot care, and skin care; - SN to perform diabetic foot care including monitoring for the presence of skin lesions on lower extremities and patient/caregiver education on proper foot care; and - Observation and assessment of integumentary system. Review of the SN visit note, dated 01/14/2025 at 8:00 AM, during the survey home visit observation with RN A, showed: - Diabetic foot screen section showed, “not assessed during this visit” (RN A assessed both feet during the observation visit); - Skin assessment section showed, poor skin turgor (This section failed to include further documentation of the additional assessment findings, SN interventions and education that was provided during the observation visit); - The wound assessment section showed the wound care that was performed to the left elbow and the wound measurements that were obtained (The documentation failed to show the dressing changes that were performed on the bottom of the left foot and buttocks that were being used to maintain skin integrity and prevent skin breakdown); - The clinical notes visit summary section, showed in part: * SN contacted PCP (primary care provider) office and left a message in regards to a rash and bruised area to the patient’s left shoulder; * “SN educates about seeing the PCP in regards to bruised area and rash”; * “SN educates on dressing changes to prevent skin breakdown. Patient and (spouse) verbalize understanding"; * The “PCP office calls SN back reports to have the patient monitor area if it does not go away to make an appointment with PCP. PCP also reports that patient can have visitors so long as rashes are covered. Patient made aware of this”; and - The skilled nurse visit failed to include documentation that showed: * RN A referred to the patient’s rash as “shingles” (a viral infection that causes a painful rash) during the observation visit; * RN A assessed the patient’s skin and educated the patient and spouse that the shingles “looked better” since the previous visit but “a new area” was located on the patient’s lower back; * RN A educated the patient and spouse to avoid having visitors while the patient had shingles; * RN A informed the patient and the spouse that when he/she received a return call from the PCP office, he/she would ask the doctor if it was okay if family came to visit; * RN A removed the silicone foam dressings (used to maintain skin integrity) from the bottom of the left foot and buttocks so he/she could assess the areas and obtain photos; * RN A cleansed the areas of concern prior to applying skin prep and new foam dressings; and * The visit documentation failed to include coordination of care details with the urologist office, new foley catheter orders/interventions obtained at the beginning of the observation visit clarifying that the new orders could start after the supplies were received, and detailed interventions performed by RN A during the changing of the patient’s foley catheter. During an interview on 01/15/2025 that began at 10:45 AM, the administrator stated that he/she would expect the documentation to be complete and accurately reflect the visit.

The Emergency Preparedness regulations were reviewed as part of the Medicare certification survey completed on 01/19/2022. During the survey it was determined that Community Home Health and Restorative Care is in compliance with the requirements of 42 CFR 484.102 Condition of Participation: Emergency Preparedness for Home Health Agencies.

An extended survey for Medicare certification for Community Home Health and Restorative Care was completed on 01/19/2022. The agency had 66 current patients. On condition-level deficiency was identified during this survey at 484.60 Condition of Participation: Care Planning, Coordination of Services, and Quality of Care. A home health agency that is found out of compliance with any Condition of Participation evaluated as part of a standard survey may not train or competency evaluate their home health aides for a period of two (2) years following the date of this survey. A deficiency has been cited at 484.80(f)(3) - see Tag G788. 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.

Payment from federally funded programs CFR(s): 484.50(c)(7)(i, ii, iii, iv) Be advised, orally and in writing, of- (i) The extent to which payment for HHA services may be expected from Medicare, Medicaid, or any other federally-funded or federal aid program known to the HHA, (ii) The charges for services that may not be covered by Medicare, Medicaid, or any other federally-funded or federal aid program known to the HHA, (iii) The charges the individual may have to pay before care is initiated; and (iv) Any changes in the information provided in accordance with paragraph (c)(7) of this section when they occur. The HHA must advise the patient and representative (if any), of these changes as soon as possible, in advance of the next home health visit. The HHA must comply with the patient notice requirements at 42 CFR 411.408(d)(2) and 42 CFR 411.408(f). This ELEMENT is not met as evidenced by: Based on policy review, record review, home visit observation, and interview, the agency failed to ensure the patient was advised orally and in writing of the extent to which payment for services may be expected from Medicare, Medicaid, or any other federally-funded aid program, the charges of services that may not be covered in one, (Record/Patient #2) of three home visit observations and one, (Record/Patient #4) of five full records reviewed. This deficient practice has the potential to adversely affect the patient’s ability to pay for services for all the agency’s patients. Findings included: Review of the agency’s policy titled, “Admission Documentation/Patient Education Policy Number: C: 4” dated initiated 05/2020 showed, in part: - At the start of service, the agency will establish a written service agreement with the patient, which will be signed & dated by the patient & agency; - The agreement will contain “rates/changes” for services paid with private funds; - Sources of payment (i.e. Medicare, Medicaid, private insurance, personal funds, or a combination; and - The patient/family will be provided a copy of the service agreement. RECORD/PATIENT #2: Review of the clinical record showed the patient was admitted to home health services 06/15/2021 with in part, diagnoses of chronic obstructive pulmonary disease with acute lower respiratory infection (chronic inflammatory lung disease that causes obstructed airflow from the lungs with acute infection of the lower lung), hypokalemia (a blood level that is below normal in potassium), and anxiety disorder (a mental health disorder characterized by feelings of worry, anxiety, or fear that are strong enough to interfere with one’s daily activities). Observation on 01/18/2022 starting at 2:30 PM, during the patient's home visit, showed the home folder/booklet failed to show written evidence of patient financial liability amounts. The booklet contained a form with areas to fill in for the amounts the patient was expected to pay, that were left blank. Per interview conducted during observation, the patient stated that he/she was unaware of if they owed anything for home health services. During an interview with the administrator on 01/19/2022 at 2:30 PM, he/she stated that normally the financial liability was not left blank on the consent form and that they had been working on that, and thought all the patient’s forms were completed, but must have missed that one. RECORD/PATIENT #4 Review of the clinical record showed the patient was admitted to home health services on 11/01/2021 with diagnoses to include of urinary tract infection (an infection in any part of the urinary system), malignant neoplasm of the right breast (breast cancer), type 2 diabetes mellitus (a chronic condition that affects the way the body processes blood sugar) and long term use of anticoagulants (blood thinning medication). Further review of the clinical record showed in part, an agency patient consent form signed by the patient and the nurse on 11/01/2021, with the section to fill in the amounts the patient was expected to pay left blank. During an interview with the administrator on 01/19/2022 at 2:30 PM, he/she provided no further information.

State toll free HH telephone hotline CFR(s): 484.50(c)(9) Be advised of the state toll free home health telephone hot line, its contact information, its hours of operation, and that its purpose is to receive complaints or questions about local HHAs. This ELEMENT is not met as evidenced by: Based on review of the agency's current patient rights information, and interview, the agency failed to ensure staff provided the written notice of the updated state toll free home health telephone hotline hours of operation (7:00 AM to 8:00 PM, seven days a week) in the admission booklet. This deficient practice has the potential to adversely affect the patient's knowledge and comprehension of the rights and responsibilities of all the agency's patients. Findings included: The office manager provided the current admit folder/booklet for review on 01/18/2022. The agency notice of patient rights and other information given to a patient during the initial visit showed inaccurate information regarding the toll free hotline number hours of operation. The admission booklet showed the hotline hours listed as “7:00 AM to Midnight, seven days a week.” The findings were reviewed with the administrator on 01/19/2022 at 2:30 PM. The administrator stated that he/she was unaware of the change in the hotline hour availability.

RN performs assessment CFR(s): 484.55(a)(1) A registered nurse must conduct an initial assessment visit to determine the immediate care and support needs of the patient; and, for Medicare patients, to determine eligibility for the Medicare home health benefit, including homebound status. The initial assessment visit must be held either within 48 hours of referral, or within 48 hours of the patient's return home, or on the physician or allowed practitioner - ordered start of care date. This ELEMENT is not met as evidenced by: Based on policy review, clinical record review, and interview, the agency failed to conduct the initial assessment of the patient within 48 hours of the referral to home care, or 48 hours after the patient's return home, or on the physician ordered start of care date in one (Record/Patient #1) of five full 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 "Acceptance of Patients/Medical Supervision" dated 05/2020, showed, in part: - An initial patient OASIS (Outcome and Assessment Information Set - a patient specific standardized assessment used to plan care, determine reimbursement, and measure quality) assessment is performed within 48 hours after discharge and documented in the patient’s record by a registered nurse or by a therapist, if the patient needs therapy services; and - If a patient is not assessed within 48 hours then a new order must be obtained for a late start of care. RECORD/PATIENT #1: Review of the referral information, dated 06/11/2021, showed, in part: - Order date of June 10th, 2021 for home health services; - Disciplines requested for skilled nursing and physical therapy; and - Referred for generalized weakness and medication management. Review of the clinical record showed, in part: - Start of care was on 06/14/2021: - Oasis question M0104 (Date of referral), was answered with 06/11/2021; and - Oasis question M0102 (Physician ordered start of care date), was answered with no specific SOC (start of care) date ordered by physician. During an interview on 01/19/2022 at 3:00 PM, the office manager stated that the referral was received on 06/11/2021, with an order date of 06/10/2021. No documentation was found for start of care to be on 06/14/2021.

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 policy review, record review, home visit observation and interview, the agency failed to ensure an accurate medication review and/or update of the patient medications was completed in three (Records/Patients #1, #2, and #3) of three home visit observations. This deficient practice has the potential to adversely affect the accurate administration of medications to all the agency’s patients. Findings included: Review of the agency’s policy titled “Medication Management Policy Number: C: 41” initiated date of 05/2020 showed, in part: - Home medications shall be administered only with appropriate, current, MD (doctor of medicine) ordered prescription medications; - Medication in the home (prescriptions presently being taken) shall be compared against the ordered medications for discrepancies; - Any drug or dosage discrepancy is to be reported to the MD immediately for resolution; - All over the counter pills the patient is taking will be recorded on the medication profile; - Appropriate documentation of medication administration shall be maintained in the patient record; - Documentation shall also include “Over the counter” medication the patient self-administers; - The agency will have complete and up to date medication profiles for each patient; - The medication profile will be a part of the patient’s clinical record, with a copy in the patient’s home file; - Prescriptions and all OTC (over the counter) drugs shall be included; and - Therapy only cases: should there be any concerns/issues that arise during the provision of care regarding the patient’s medication, it is the responsibility of the clinician (PT (physical therapy), OT (occupational therapy), SLP (speech and language pathology)) to contact the MD for a nursing evaluation of the medications. RECORD/PATIENT #1 Review of the plan of care (POC) dated 12/11/2021 through 02/08/2022 showed, in part, the following: - Diagnoses included, but not limited to, urinary tract infection (infection that affects part of the urinary tract), infectious gastroenteritis (inflammation of the gastrointestinal tract) and colitis (inflammation of the colon), acute (happens suddenly) on chronic (happens slowly over time) combined systolic and diastolic heart failure (the heart does not pump efficiently and does not contract the way it should between heartbeats), weakness, hypertension (force of blood against the artery walls are too high) , atrioventricular block (Electrical signal that controls your heartbeat is partially or completely blocked), dysuria (discomfort, pain, or burning with urination), chronic kidney disease (gradual loss of kidney function), epigastric (upper abdomen) pain, and low back pain. Review of the clinical record showed: - Occupational therapy visit note on 01/05/2022 documented patient's pain slightly relieved by hot pack and deep blue (topical cream for pain relief) cream that the patient’s husband rubs on patient’s back; - Occupational therapy visit note on 01/18/2022 documented some pain relieved by using hot pack and biofreeze (topical pain relief analgesic gel); - Deep blue cream and biofreeze are not listed on the MAR (medication administration record); and - No documentation regarding physician’s orders for deep blue cream or biofreeze. RECORD/PATIENT #2 Review of the clinical record showed the patient was admitted to home health services 06/15/2021 with in part, diagnoses of chronic obstructive pulmonary disease with acute lower respiratory infection (chronic inflammatory lung disease that causes obstructed airflow from the lungs with acute infection of the lower lung), hypokalemia (a blood level that is below normal in potassium), and anxiety disorder (a mental health disorder characterized by feelings of worry, anxiety, or fear that are strong enough to interfere with one’s daily activities.) Review of the most recent hospital discharge medication list dated 12/30/21, in comparison to the current medication profile showed the following discrepancies: - Vitamin D3 (vitamin supplement) 5,000 IU (international units) 1 capsule daily by mouth: Current medication profile- Vitamin D3 1,000 IU 1 capsule daily by mouth; - Pro Air HFA (inhaler used to prevent and treat wheezing and shortness of breath) 0.09mg/1 actuation inhalation suspension, inhale 2 puff inhalation as needed every 4 hours: Current medication profile failed to list Pro Air HFA; - Metoprolol Succinate 25mg (milligram) extended release, take one tablet by mouth daily for blood pressure: Current medication profile- Metoprolol 50mg extended release, take one tablet daily; - Melatonin (supplement used to treat inability to fall/stay sleep) 10mg oral tablet extended release, take one tablet by mouth daily at bedtime: Current medication profile- Melatonin 10mg 1 tablet daily at bedtime as needed by mouth; - Inderal (blood pressure and/or chest pain medication) 40mg oral tablet, 1 tablet daily by mouth is listed on the current medication profile, but failed to be on the 12/30/2021 hospital discharge medication list; - Aleve (nonsteroidal anti-inflammatory) 220mg oral capsule 1 capsule every 12 hours as needed for pain by mouth is listed on the current medication profile, but failed to be on the 12/30/2021 hospital discharge medication list; and - The clinical record failed to show any clarification orders for the medication discrepancies. During an interview with the patient during the home visit observation, the patient stated that he/she follows the agency medication list. During an interview with the administrator on 01/19/2021 at 2:30 PM he/she stated: - It was the agency policy to notify the doctor of discrepancies; and - "We will get ahold of the PCP [primary care physician] and get these clarified." RECORD/PATIENT #3 Review of the clinical record showed the patient was admitted to home health services 11/19/2021 with in part, diagnoses of type 2 diabetes mellitus (a chronic condition that affects the way the body processes blood sugar), weakness, difficulty walking, cervicalgia (neck pain), and long term use of anticoagulants (blood thinning medication). Review of the most recent hospital discharge medication list dated 12/23/21, in comparison to the current medication profile showed the following discrepancies: - Carvedilol (medication used to treat high blood pressure) 6.25mg oral tablet take 6.25mg tablet twice daily: Carvedilol failed to be listed on current medication profile; - Coumadin (medication used to prevent blood clots) 7.5mg oral tablet take 0.5 tablet oral daily: Current medication profile- Warfarin(Coumadin) 7.5 mg oral tablet take ½ tablet on Tuesday-Thursday-Saturday-Sunday; - Warfarin Sodium 7.5mg oral tablet take 7.5mg oral daily: Current medication profile- Warfarin 7.5mg 1 tablet on Monday-Wednesday-Friday; -Potassium Chloride (supplement) 10mEq oral tablet, extended release, take 1 tablet by mouth twice a day: Current medication profile Potassium Chloride (EQV-KLOR-CON 10) 1 tablet by mouth daily; - Meclizine (medication used to prevent and control dizziness, nausea and vomiting) 12.5 mg oral tablet 1 tablet daily by mouth is listed on the current medication profile, but failed to be on the 12/23/21 hospital discharge medication list; and - The clinical record failed to show any clarification orders for the medication discrepancies. Review of the medication bottle labels in comparison with the current medication profile showed the following discrepancies: - Bottle showed Potassium Chloride extended release 10mEQ 1 twice daily: Current medication profile Potassium Chloride (EQV-KLOR-CON 10) 1 tablet by mouth daily; - Carvedilol 6.25mg oral tablet take 6.25mg tablet twice daily: Carvedilol failed to be listed on current medication profile; and - Meclizine 12.5 mg oral tablet 1 tablet daily by mouth in the morning and a bedtime: Current medication profile- Meclizine 12.5mg oral tablet 1 tablet daily. During an interview with the patient during the home visit observation, the patient stated that: - He/she follows the directions on the bottles and does not use the agency list; - He/she takes the meclizine in the morning and at bedtime; and - He/she has taken the carvedilol for a long time. During chart reviews conducted with the administrator on 01/19/2022 at 11:35 PM, he/she stated that topical ointments should be listed on the MAR (medication administration record). No additional documentation was provided. During an interview with the administrator on 01/19/2021 at 2:30 PM he/she stated: - It is the agency policy to notify the doctor of discrepancies; and - "We will get ahold of the PCP and get these clarified."

Care planning, coordination, quality of care CFR(s): 484.60 Condition of participation: Care planning, coordination of services, and quality of care. Patients are accepted for treatment on the reasonable expectation that an HHA can meet the patient's medical, nursing, rehabilitative, and social needs in his or her place of residence. Each patient must receive an individualized written plan of care, including any revisions or additions. The individualized plan of care must specify the care and services necessary to meet the patient-specific needs as identified in the comprehensive assessment, including identification of the responsible discipline(s), and the measurable outcomes that the HHA anticipates will occur as a result of implementing and coordinating the plan of care. The individualized plan of care must also specify the patient and caregiver education and training. Services must be furnished in accordance with accepted standards of practice. This CONDITION is not met as evidenced by: Based on policy review, record review, and interview, the agency failed to: - Ensure that each patient's written individualized plan of care (POC) included all required elements (G574); - Ensure services and treatments were administered only as ordered by a physician (G580); and - Promptly alert the physician to changes in the patient's condition that may suggest a need to alter the POC (G590). The cumulative effect of these deficient practices has the potential to affect the provision of safe care for all patients served by the agency.

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 policy review, clinical record review, and interview, the agency failed to ensure that each patient's written individualized plan of care (POC) included all required elements in one (Record/Patient #1) of five full 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 “Plan of Care” (POC), dated 05/2020 showed, in part: - The plan of care is required to include all pertinent diagnosis; - The individualized plan of care is to be reviewed or revised by the physician who was responsible for the agencies plan of care, and as frequently as the patient’s condition or needs require, but no less than once every 60 days, beginning with the start of care date; and - Agency professional staff will revise the plan of care, as necessary, to reflect current information from the patient’s updated comprehensive assessment, and to record the patient’s progress towards meeting the patient-specific measurable outcomes and goals selected by the agency and patient, as specified in the plan of care. RECORD/PATIENT #1: Review of the POC dated 12/11/2021 through 02/08/2022 showed, in part, the following: - Diagnoses include, but not limited to, urinary tract infection (infection that affects part of the urinary tract), infectious gastroenteritis (inflammation of the gastrointestinal tract) and colitis (inflammation of the colon), acute (happens suddenly) on chronic (happens slowly over time) combined systolic and diastolic heart failure (the heart does not pump efficiently and does not contract the way it should between heartbeats), weakness, hypertension (force of blood against the artery walls are too high) , atrioventricular block (Electrical signal that controls your heartbeat is partially or completely blocked), dysuria (discomfort, pain, or burning with urination), chronic kidney disease (gradual loss of kidney function), epigastric (upper abdomen) pain, and low back pain; - The POC did not include diagnosis for clostridium difficile colitis (C. Diff); and - The POC did not include infection control precautions, interventions, or education for clostridium difficile colitis. Review of the clinical records showed, in part, the following: - Skilled nurse visit on 12/31/2021 noted that the patient was prescribed Vancomycin (antibiotic) 125mg (milligrams) four times daily for 10 days for diagnosis of C. Diff; and - The POC was not updated to include the new diagnosis. During chart review with the administrator on 01/19/2022 at 11:35 AM, the diagnosis not being on the plan of care was discussed. The administrator reported that he/she was unable to find record of the physician communication regarding the new diagnosis; and that all documentation regarding C. Diff had been noted from the patient’s report of the diagnosis only. No further documentation was provided.

Only as ordered by a physician CFR(s): 484.60(b)(1) Drugs, services, and treatments are administered only as ordered by a physician or allowed practitioner. This ELEMENT is not met as evidenced by: Based on policy review, clinical record review, and interview, the agency failed to ensure services and treatments were administered only as ordered by a physician in, but not limited to, one (Record/Patient #1) of five full 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, "Plan of Care (POC),” dated 05/2020 showed in part, the POC includes: - All pertinent diagnosis; - All medications and treatments; - Patient specific interventions and education; and - All patient care orders, including verbal orders, must be recorded in the plan of care. RECORD/PATIENT #1: Review of the clinical record showed, in part: - Recent plan of care date of 12/11/2021 to 02/08/2022; - Diagnoses include, but not limited to, urinary tract infection (infection that affects part of the urinary tract), infectious gastroenteritis (inflammation of the gastrointestinal tract) and colitis (inflammation of the colon), acute (happens suddenly) on chronic (happens slowly over time) combined systolic and diastolic heart failure (the heart does not pump efficiently and does not contract the way it should between heartbeats), weakness, hypertension (force of blood against the artery walls are too high) , atrioventricular block (Electrical signal that controls your heartbeat is partially or completely blocked), dysuria (discomfort, pain, or burning with urination), chronic kidney disease (gradual loss of kidney function), epigastric (upper abdomen) pain, and low back pain; - SN (skilled nurse) to instruct patient/caregiver regarding strategies to mitigate pain including medication administration, recording and reporting pain, non-pharmacological treatments including positioning, massage, visualization, distraction and cold or warm compresses; - Skilled nurse visit note on 01/04/2022, notes that SN encouraged patient to use heating pad with 15 minutes on and 15 minutes off; - Occupational therapy visit note on 01/05/2022, noted that pain slightly relieved by hot pack and deep blue (topical cream for pain relief) cream that the patient’s husband rubs on patient’s back; - Skilled nurse visit note on 01/06/2022, notes that SN instructed patient to use ice for 15 minutes a couple times daily and report to PCP (primary care provider) as needed; - Occupational therapy visit note on 01/18/2022, noted that some pain relieved by using hot pack and biofreeze (topical pain relief analgesic gel); and - No documentation was found regarding physician’s orders for deep blue cream, biofreeze, or duration and frequency for cold or heat therapy. During chart reviews with the administrator on 01/19/2022 at 11:35 PM, the administrator acknowledged the findings and reported that they are working on including specific instructions for use regarding cold or heat therapy. The administrator reported that topical ointments should be listed on the MAR (medication administration record). No additional documentation was provided.

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 record review, observation, and interview, the agency failed to promptly alert the physician to changes in the patient's condition that may suggest a need to alter the plan of care (POC) in two (Records/Patients #1 and #5) of five full records reviewed. This deficient practice has the potential to affect all patients served by the agency. Findings included: Review of the agency policy titled “Coordination of Care/Patient Education,” dated 05/2020, showed, in part: - The agency’s professional/supervisory staff responsible for any specific care/treatment shall notify the patient physicians of any changes in the patient’s condition immediately upon discovery; and - Examples include but are not limited to: fluctuation in vital signs and/or other clinical findings outside normal range, pain reported as not relieved with prescribed interventions, and failure of patient to respond therapeutically to prescribed medications or treatments. RECORD/PATIENT #1: Review of the clinical record, showed, in part: - Plan of care dated 12/11/2021, showed, in part, physician to be notified if heart rate is greater than 110 beats per minute or less than 60 beats per minute and pain greater than 8 (0 being no pain and 10 being the worst pain); - Skilled nurse visit note on 12/31/2021, patient with a heart rate of 58 beats per minute (parameters are 60 to 110 beats per minute) and pain a 9 (0 being no pain and 10 being the worst pain); - Occupation therapy visit note on 01/05/2022, patient with a heart rate of 56 beats per minute; - Skilled nurse visit note on 01/06/2022, patient heart rate of 52 beats per minute; - Physical therapy visit note on 01/07/2022, patient’s heart rate was 54 beats per minute; - Skilled nurse visit note on 01/11/2022, patient heart rate of 55 beats per minute; - Occupational therapy visit note on 01/14/2022, patient’s pain reported at a 9 with patient unable to complete exercise due to increased pain in back, patient was educated through verbal instruction on pain management and verbalized understanding; - Skilled nurse visit note on 01/17/2022, pain noted a 10 (worse possible pain) and that patient had just taken tramadol prior to visit and it was starting to help; - Occupational therapy visit note on 01/18/2022, patient’s heart rate was 51 beats per minute; and - No documentation of physician notification noted for any of the visits with heart rate or pain outside of normal parameters. RECORD/PATIENT #5: Review of the clinical record, showed, in part: - Plan of care dated 11/15/2021 showed, in part, physician to be notified if heart rate is greater than 110 beats per minute or less than 60 beats per minute; - Skilled nurse visit note on 12/01/2021, patient with a heart rate of 56 beats per minute (parameters are 60 to 110 beats per minute); and - No documentation of physician notification. During chart review on 01/19/2022 at 11:45 AM, the administrator reported that he/she was unable to find documentation regarding the physician being notified and stated, “I am certain it just wasn’t reported.”

Org. had partial/extended survey CFR(s): 484.80(f)(3) Was subjected to an extended (or partially extended) survey as a result of having been found to have furnished substandard care (or for other reasons as determined by CMS or the state); or This ELEMENT is not met as evidenced by: Based on the results of this extended level survey, resulting in noncompliance with one Condition of Participation: Care Planning, Coordination of Services and Quality of Care, the agency may not train or competency evaluate their home health aides for a period of two (2) years following, the date of this survey. The restriction ends 01/19/2024.

Discharge and transfer summaries CFR(s): 484.110(a)(6)(i-iii) (i) A completed discharge summary that is sent to the primary care practitioner or other health care professional who will be responsible for providing care and services to the patient after discharge from the HHA (if any) within 5 business days of the patient's discharge; or (ii) A completed transfer summary that is sent within 2 business days of a planned transfer, if the patient's care will be immediately continued in a health care facility; or (iii) A completed transfer summary that is sent within 2 business days of becoming aware of an unplanned transfer, if the patient is still receiving care in a health care facility at the time when the HHA becomes aware of the transfer. This ELEMENT is not met as evidenced by: Based on policy review, record review and interview, the agency failed to send a completed transfer summary to the healthcare facility that the patient was receiving care within two business days of becoming aware of an unplanned transfer in three (Records/Patients #1, #2 and #3) of five full records reviewed. This deficient practice has the potential to adversely affect the continued care needs for all patients discharged or transferred from the agency. Findings included: Review of the policy titled “Transfers Policy Number: C: 59” dated initiated 05/2020 showed in part: - It is the policy of the agency that if care/service is required that cannot be provided by the organization, or a patient determines that they would like another agency to provide them services, a transfer/referral to another service provider will be made in compliance with all regulations; - When an active open case meets the conditions for transfer to another agency or facility, a transfer summary shall be completed and forwarded to both the primary MD (doctor of medicine) and the receiving agency/facility; - Timeframe for a transfer summary for a planned transfer: completed and sent within two business days of a planned transfer if the care will be immediately continued in the healthcare facility; and - Timeframe for a transfer summary for an unplanned transfer: completed and sent within two business days of becoming aware of the unplanned transfer if the patient is still receiving care in the health care facility at the time when the agency becomes aware of the transfer. RECORD/PATIENT #1: Review of the clinical record showed, in part; - The patient was admitted to home health services on 06/14/2021; - Diagnoses included, but not limited to, heart failure (the heart does not pump efficiently and does not contract the way it should between heartbeats), weakness, hypertension (force of blood against the artery walls are too high), atrioventricular block (Electrical signal that controls your heartbeat is partially or completely blocked), dysuria (discomfort, pain, or burning with urination), chronic kidney disease (gradual loss of kidney function), epigastric (upper abdomen) pain, and low back pain; - Transfer summary dated 12/22/2021, showed, patient hospitalized for a UTI (urinary tract infection); and - No documentation of transfer summary being sent to inpatient receiving facility. RECORD/PATIENT #2: Review of the clinical record showed the patient was admitted to home health services 06/15/2021 with in part, diagnoses of Chronic obstructive pulmonary disease with acute lower respiratory infection (chronic inflammatory lung disease that causes obstructed airflow from the lungs with acute infection of the lower lung), hypokalemia (a blood level that is below normal in potassium), and anxiety disorder (a mental health disorder characterized by feelings of worry, anxiety, or fear that are strong enough to interfere with one’s daily activities.) Review of the transfer OASIS (Outcome and Assessment Information Set- a patient specific standardized assessment used to plan care, determine reimbursement, and measure quality) dated 12/27/2021showed, in part: - Item M0100 marked transferred to inpatient facility (patient not discharged from agency); and - Page 3 notifications area all left bank for copy of transfer summary sent to inpatient receiving facility or physician. Review of a communication note date 12/28/2021 showed: - The agency called to set up visit time and the patient’s daughter stated that the patient got the flu from them and is in the hospital; and - The plan was for discharge tomorrow. Review of the transfer summary dated 12/29/2021 showed, in part on page 3: - Copy of transfer summary sent to inpatient receiving facility and date left blank; and - Copy of transfer summary sent to physician and date left blank Review of the order history dashboard showed the transfer summary was sent to the PCP (primary care provider) on 12/30/2021 and failed to be sent to the receiving facility. During an interview with the administrator on 01/19/2022 at 11:00 AM, he/she stated that: - The agency doesn’t normally send the transfer summary to the receiving facility; - We call the hospital and ask what they want; - What we send depends on what the receiving facility wants; and - The agency sends the transfer summary to the PCP. RECORD/PATIENT #3: Review of the clinical record showed the patient was admitted to home health services on 11/19/2021 with in part, diagnoses of type 2 diabetes mellitus (a chronic condition that affects the way the body processes blood sugar), weakness, difficulty walking, cervicalgia (neck pain), and long term use of anticoagulants (blood thinning medication). Review of the transfer OASIS dated 12/20/2021showed, in part: - Item M0100 marked transferred to inpatient facility (patient not discharged from agency); and - Page 3 notifications area all left bank for copy of transfer summary sent to inpatient receiving facility or physician. Review of the transfer summary dated 12/22/2021 showed, in part on page 3: - Copy of transfer summary sent to inpatient receiving facility and date left blank; and - Copy of transfer summary sent to physician and date left blank. Review of the order history dashboard showed the transfer summary was sent to the PCP on 12/22/2021, and failed to be sent to the receiving facility. During an interview with the administrator on 01/19/2022 at 11:00 AM, he/she stated that: - The agency doesn’t normally send the transfer summary to the receiving facility; - We call the hospital and ask what they want; - What we send depends on what the receiving facility wants; and - The agency sends the transfer summary to the PCP.