Every finding on record at Bjc Home Care Services

A complaint investigation 3034317 was completed on 07/15/2026 at the home health provider. The provider had 1162 current patients. The complaint is substantiated. One or more of the allegations reported occurred and is verified, but the allegations were corrected prior to the complaint investigation. The provider had identified the concern and initiated corrective actions however, those corrective actions were not fully implemented at the time of the survey.

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 policy review, clinical record review, hospital record review, and interviews, the home health provider failed to promptly alert the physician of changes in the patient’s condition that suggested the plan of care may need to be altered in, one of three patients sampled (Record/Patient #1). This deficient practice had the potential to affect all patients receiving services from the provider who experienced significant changes in condition. Findings included: Review of the provider's policy titled, "Care Planning Process-Provision of Care Treatment and Service/Home Health," revised November 2020, showed in part, clinicians were required to inform the physician of changes suggesting a need to alter the plan of care. Review of the provider's policy titled, "Reassessments/Recertification-Provision of Care Treatment and Service/Home Health," revised April 2019, showed in part, the physician was to be notified when the patient’s condition deteriorated, or a significant change occurred. RECORD/PATIENT #1: Review of the clinical record showed the patient required management of an indwelling urethral Foley catheter (a sterile tube placed in the bladder to drain urine). Physician orders directed staff to change the catheter monthly and as needed for leakage, obstruction, or dislodgement using a 16 French (thickness of the catheter) catheter with a 5-10 milliliter balloon. The catheter could be irrigated with 60-120 milliliters of sterile saline as needed for obstruction or sediment. Review of the skilled nursing visit dated 10/29/2025 at 9:50 AM showed a registered nurse changed the urinary catheter using sterile technique. The nurse documented that the patient tolerated the procedure without observed pain and that yellow urine returned to the drainage bag. Review of a telephone encounter dated 10/29/2025 at 5:36 PM, showed the patient’s caregiver reported that the catheter had been changed that day and that there was “a lot of blood” in the patient’s urine. The caregiver asked whether the patient’s blood-thinning medications should be withheld. The telephone record showed a nurse returned the call on 10/29/2025 at 5:41 PM and instructed the caregiver to contact the patient’s physician to obtain an order regarding the blood-thinning medications. The caregiver stated that he/she would contact the patient’s cardiologist. The charge nurse was notified by e-mail. The clinical record contained no evidence that the provider staff: - Promptly notify the physician of the significant hematuria (presence of blood in the urine) following the catheter change; or - Obtained physician-directed instructions regarding evaluation or management of the hematuria. The clinical record contained no physician order directing that the blood thinning medications be withheld and no documentation showing whether the medications were withheld. Review of telephone documentation dated 11/07/2025 at 5:07 PM showed the caregiver reported that the Foley catheter was leaking urine, stated something was wrong with it, and reported the caregiver had previously requested a nursing visit but had not received information regarding the plan. Review of an unscheduled licensed practical nurse (LPN) visit dated 11/07/2025 at 5:35 PM showed the Foley catheter was replaced. The record documented yellow urine with sediment and “stones” and described the catheter as draining, intact, and patent following the intervention. The clinical record contained no evidence that the physician was notified of the recurrent catheter complication or catheter replacement on 11/07/2025. Review of the telephone documentation dated 11/15/2025 at 3:28 PM showed the caregiver reported decreased urinary output, concern that the Foley catheter was blocked, and several blood clots following irrigation. Review of the on-call nursing visit dated 11/15/2025 at 4:04 PM, showed the Foley catheter was not draining. The nurse removed the catheter and observed bleeding from the penis. Following placement of a new catheter, the nurse observed bright red urine and blood clots. The nurse notified the physician and called 911 when the bleeding did not completely stop. The patient was transported to the emergency department. Review of the emergency department documentation dated 11/15/2025 and 11/16/2025, showed the patient presented with gross hematuria, blood clots, and decreased urinary output and required hospital admission. During an interview on 07/15/2026 at 11:53 AM, the RN case manager stated that the physician was not notified of the catheter complication on 11/07/2025. The RN case manager further stated that, based on the reported catheter leakage and concern that something was wrong with the catheter, the patient should have been referred to emergency evaluation. During an interview on 07/15/2026 at 12:08 PM, the clinical manager stated that the clinical record contained no documentation showing that the physician was notified of the significant hematuria reported on 10/29/2025 or that an order was obtained to hold or discontinue the patient’s blood-thinning medications. The clinical manager stated that the caregiver had called the provider to report that the patient was bleeding and to ask whether the blood-thinning medications should be withheld. The clinical manager confirmed the provider’s staff did not notify the physician.

Revised plan of care CFR(s): 484.60(c)(2) A revised plan of care must reflect current information from the patient's updated comprehensive assessment, and contain information concerning the patient's progress toward the measurable outcomes and goals identified by the HHA and patient in the plan of care. 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 individualized plan of care was reviewed and revised to reflect significant and recurring catheter-related changes in condition in, one of three sampled patients (Record/Patient #1). This deficient practice had the potential to affect patients receiving services from the provider whose changes in condition or care needs were not reflected in the individualized plan of care. Findings included: Review of the provider's policy titled, "Care Planning Process-Provision of Care Treatment and Service/Home Health," revised November 2020, showed in part: - The plan of care was to be revised as frequently as necessary based on ongoing assessments; - Care planning decisions were to be reflected in the specific services and actions implemented to meet the patient’s individualized problems and goals; and - Problems and needs related to the patient’s condition were to be included in the plan of care. Review of the provider's policy titled, "Reassessments/Recertification-Provision of Care Treatment and Service/Home Health," revised April 2019, showed in part, patients were to be reassessed when they were not responding to care, when their condition deteriorated, or when a significant change occurred. The policy required the clinical record and plan of care to be updated to reflect assessment findings and actions taken. RECORD/PATIENT #1: Review of the clinical record showed the patient required management of an indwelling urinary urethral Foley catheter (a sterile tube placed in the bladder to drain urine) due to urinary retention and neurogenic bladder (lower urinary tract dysfunction). The physician orders directed provider staff to change the catheter monthly and as needed for leakage, obstruction, or dislodgement using a 16 French (thickness of the catheter) catheter with a 5-10 milliliter balloon. The catheter could be irrigated with 60-120 milliliters of sterile saline as needed for obstruction or sediment. Review of the skilled nursing visit dated 10/29/2025 at 9:50 AM, showed a registered nurse (RN) changed the Foley catheter. The nurse documented that the patient tolerated the procedure without observed pain and that yellow urine returned to the drainage bag. Review of a telephone encounter dated 10/29/2025 at 5:36 PM, showed the caregiver reported that the catheter had been changed that day and that there was “a lot of blood” in the patient’s urine. Review of telephone records dated 11/07/2025 at 5:07 PM, showed the caregiver reported that the catheter was leaking urine, stated that something was wrong with it, and reported that he/she had previously requested a nursing visit. Review of an unscheduled licensed practical nurse (LPN) visit dated 11/07/2025 at 5:35 PM, showed the Foley catheter was replaced. The record documented yellow urine with sediment and “stones” and described the catheter as draining, intact, and patent following the intervention. Review of a skilled nursing visit dated 11/13/2025 at 10:34 AM, showed the catheter placed on 11/07/2025 was documented as draining, intact, and patent, with yellow urine. Review of the telephone documentation dated 11/15/2025 at 3:28 PM, showed the caregiver reported decreased urine output, concern that the patient did not appear to be producing urine, and that the Foley catheter might be blocked. The caregiver reported he/she had irrigated the catheter, the irrigation amount returned, and several blood clots were expelled. Review of the on-call nursing visit dated 11/15/2025 at 4:04 PM, showed the Foley catheter was not draining. The nurse removed the catheter and observed bleeding from the penis. Following placement of a new catheter, the nurse observed bright-red urine and blood clots. The patient was transported to the emergency department and subsequently admitted to the hospital. Despite the catheter-related changes in condition documented on 10/29/2025 and 11/07/2025, the clinical record contained no evidence that provider staff reviewed and revised the individualized plan of care to reflect: - Significant hematuria (blood in the urine) following a catheter change; - Recurrent catheter leakage; - The need for an unscheduled catheter replacement; - Increased risk for catheter obstruction, bleeding, or catheter-related trauma; - Whether additional monitoring or follow-up was needed; - Whether instructions concerning emergency evaluation needed to be revised; or - Whether physician direction was needed to revise the catheter-management approach. The plan of care continued to contain the existing routine and as-needed catheter-change and irrigation instructions without revisions addressing the recurring catheter complications. During an interview on 07/15/2026 at 12:08 PM, the clinical manager stated that the plan of care was not updated following the catheter-related changes in condition.

The Emergency Preparedness regulations were reviewed as part of the Medicare recertification survey completed on 04/17/2025. 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 04/17/2025. The provider had 1235 current patients.

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, record review, and interview, the home health provider failed to conduct the initial assessment of the patient within 48 hours of the referral to home care, in but not limited to, one of five full records reviewed (Record/Patient #2). This deficient practice has the potential to affect all the patients served by the provider. Findings included: RECORD/PATIENT #2: Review of the referral information, showed, in part: - Referral for home health services was sent to the home health provider on 03/13/2025; - Date to start labs: 03/14/2025; - Requested 24-48 hours; - Disciplines: Skilled nurse (SN), Physical therapy (PT), and Occupational therapy (OT); and - Skilled interventions: disease and medication management, and labs. Review of the clinical record showed, in part: - SOC (start of care) was dated 03/16/2025; - OASIS (Outcome and Assessment Information Set- is a standardized data set that measures quality and outcomes) question M0102 (Physician ordered start of care date), was answered with N/A- No specific SOC/ROC (resumption of care) date ordered by the physician; - OASIS question M0104 (Date of Referral), was answered with 03/13/2025; and - The clinical record failed to show documentation of the reason the SOC was late and no documentation of verbal order being received for late SOC within 48 (forty-eight) hours of the referral and/or the patient returning home. During an interview on 04/17/2025, at 12:43 PM, the administrator stated that she would expect the SOC to be done within 48 hours of the referral. Findings included: Review of the provider’s policy titled, “Admission And Comprehensive Assessment – Provision of Care Treatment And Service,” last revised April 2021, showed in part an initial patient assessment will be performed and documented in the patient's clinical record by a registered nurse, physical therapist, or speech therapist on all patients referred. The initial assessment visit must be performed either within 48 hours of the referral, within 48 hours of the patients return home, on the start of care (SOC) date ordered by the physician, or at the patient/family request with the approval of the physician.

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 the patients served by the provider. Findings included: Review of the provider’s policy titled, “Admission and Comprehensive Assessment- Provision of Care Treatment and Service/Home Health,” revised April 2021, showed in part: - During the initial and comprehensive patient assessments, all baseline data to be used in measuring the patient's progress towards goals and other relevant information will be documented in the patient’s clinical record, including at least the following information, if applicable: * The patient's medical and psychosocial history, including pertinent diagnosis and prognosis * Equipment presently in the home and potentially needed by a patient; and - Information gathered during the initial and comprehensive assessments will be used by the physician and developing and authorizing the plan of care. RECORD/PATIENT #1: Review of the inpatient hospital discharge summary, dated 02/01/2025, showed in part: - The pt (patient) had a fall in November of 2024 that resulted in a cervical fracture (broken neck) and (he/she) was placed in a cervical collar (c-collar - a neck brace); - The patient was admitted to the hospital on 01/22/2025 with “uncontrolled pain and an inability to wear (his/her) CPAP (continuous positive airway pressure- is a machine that delivers continuous air through the mouth and nose to keep the airway open while sleeping) while wearing the collar resulting in increased sleepiness”; - The past medical history (PMH) included a diagnosis of obstructive sleep apnea (a condition where breathing repeatedly stops and starts during sleep due to a blockage in the upper airway) that required the use of a CPAP and a history of deep vein thrombosis (DVT, a blood clot in a deep vein) of the lower extremity; - “Previously on Eliquis (a medication used to prevent blood clots) as OP which was d/c during recent admission”; - “Pt is not taking aspirin”; - “Cervical collar no longer required, but because of disuse and MSK injury/tightness, pain was ongoing while it was off. OK to wear the brace as needed especially when OOB and upright, but take off at night so (he/she) can use (his/her) CPAP”; and - Aspirin and Eliquis were not listed on the discharge medication list. Review of the clinical record, showed in part: - The patient was admitted to home health services on 02/02/2025 with primary diagnosis of stable burst fracture of first cervical vertebra (occurs when a vertebra breaks in multiple directions); and - The patient resided at home alone. Review of the OASIS (Outcome and Assessment Information Set; a standardized data collection tool) SOC (start of care) visit note dated 02/02/2025, showed in part: - The high-risk medication assessment section showed, in part: Anticoagulant use was answered with “Yes;” (The referral record showed that the Eliquis was discontinued during a recent admission and was not listed on the hospital discharge medication list); - The comprehensive assessment failed to show documentation of the patient’s health status related to the discontinuation of Eliquis; - Special treatments, procedures, and programs section showed, in part: CPAP use was answered with “No” (The referral record showed that the patient was to take the cervical collar off at night to wear his/her CPAP machine while sleeping); and - The comprehensive assessment failed to show documentation of the patient’s health/functional status with sleepiness and taking off the cervical collar at night to wear CPAP machine. During an interview on 04/16/2025 that began at 2:30 PM, the administrator stated that: - The patient had a BiPAP (Bilevel Positive Airway Pressure- is a machine that pushes air into the lungs through a mask) but couldn’t use it with the c-collar; - During the patient’s hospitalization the patient was cleared to take the c-collar off at night to wear the BiPAP while sleeping; - The patient continued to wear the c-collar at all times and not take it off at night to wear the BiPap; and - The patient wanted to wear the c-collar at all times and reported that (he/she) did not need the BiPAP.

Patient's needs CFR(s): 484.55(c)(4) The patient's medical, nursing, rehabilitative, social, and discharge planning needs; 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 included the names of other agencies and persons involved in the past and present care of the patient in one of five full records reviewed (Record/Patient #4). This deficient practice has the potential to affect all the patients served by the provider. Findings included: Review of the provider’s undated policy titled, “Admission and Comprehensive Assessment,” showed that the comprehensive assessment would include the name of the hospital, other agencies, and persons involved in the past and present care of the patient. RECORD/PATIENT #4: Review of the clinical record showed the patient was admitted to home health services on 05/03/2023. The patient was recertified on 02/21/2025 with a primary diagnosis of pressure ulcer (skin injury caused by unrelieved pressure) of the left ankle. The patient had secondary diagnoses of paraplegia (paralysis in the lower limbs and trunk), emphysema (a lung disease that blocks airflow and makes it difficult to breathe), peripheral vascular disease (a condition where blood flow to the limbs is reduced due to narrowed or blocked veins), and neuromuscular dysfunction of the bladder (a disorder of the bladder caused by nerve damage which limits urine flow). The patient resided in his/her own home with the assistance of family. Review of the nursing recertification, comprehensive visit documentation, dated 02/19/2025, showed in part that the patient had a suprapubic catheter (a catheter surgically inserted through the wall of the abdomen into the bladder) that was inserted on 01/31/2025. The catheter was due to be changed on 02/25/2025. Review of the document titled, “Home Health Recertification,” dated 02/21/2025, showed in part that the suprapubic catheter was changed every month at the urologist’s office and PRN (as needed) if leaking, clogged or dislodged. During an interview on 04/16/2025 at 4:15 PM, the administrator stated that: - The comprehensive assessment did not identify that a urologist routinely changed the patient's catheter; - The plan of care contained information that the catheter was changed at the urologist's office; and - Neither document identified the name nor contact information of the urologist involved in the patient's care.

A review of all current medications CFR(s): 484.55(c)(5) A review of all medications the patient is currently using in order to identify any potential adverse effects and drug reactions, including ineffective drug therapy, significant side effects, significant drug interactions, duplicate drug therapy, and noncompliance with drug therapy. This ELEMENT is not met as evidenced by: Based on policy review, record review, home visit observation, and interview, the home health provider failed to ensure staff performed a complete medication review in three of five full records reviewed (Records/Patients #1, #2, and #3). This deficient practice has the potential to affect all the patients served by the provider. RECORD/PATIENT #3: Review of the clinical record showed the patient was admitted to home health services on 03/20/2025 with a primary diagnosis of cellulitis (a bacterial infection of the skin) of the right lower limb. The patient had a secondary diagnosis of chronic venous insufficiency (a condition where blood flow to the limbs was reduced due to narrowed or blocked veins). The patient resided in a private residence with the assistance of his/her spouse and adult child. Review of the nursing visit notes showed the patient had received nursing visits on, but not limited to, 04/08/2025 and 04/11/2025. Observation and interview on 04/15/2025 at 11:00 AM showed the patient was taking trimethoprim/sulfamethoxazole ((Tri/Sulfa) an antibiotic used to treat bacterial infections). During the medication review, the patient stated that he/she: - Was prescribed Tri/Sulfa following his/her physician appointment on 04/07/2025; - Began taking the medication the morning of 04/08/2025; - Had taken a dose of the new medication prior to his/her nursing visit on 04/08/2025; and - Had been taking the medication two times per day since 04/08/2025. Review of the provider’s current medication profile provided to the state agent (SA) prior to the home visit observation showed the document failed to include Tri/Sulfa. Review of the document titled, “Home Health Initial Plan of Care,” with effective dates of 03/20/2025 to 05/18/2025, showed the document failed to contain orders for Tri/Sulfa. During an interview on 04/16/2025 at 1:10 PM, the administrator stated that: - There were nursing visits on 04/08/2025 and 04/11/2025; - The nurse did enter Tri/Sulfa to the patient’s medication profile after the observation visit with the surveyor on 04/15/2025; and - They would have expected the medication Tri/Sulfa to be placed on the patient’s medication profile at the nursing visits dated 04/08/2025 or 04/11/2025. RECORD/PATIENT #2: Review of the clinical record showed the patient was admitted to the home health provider on 3/16/2025 after an inpatient hospital stay for primary diagnosis of subarachnoid hemorrhage (a life-threatening type of stroke where bleeding occurs in the space between the brain and the thin tissues covering it) and the patient resided at home alone with a caregiver checking on him/her. The patient received skilled nursing, physical therapy, and occupational therapy services. Observation on 4/15/2025 at 11:03 AM, during the patient's home visit, showed the following: - The skilled nurse asked the patient if there had been any medication changes. The patient verbalized there had been no changes; - The state surveyor reviewed the provider's Medication Profile form with the skilled nurse, along with the patient present, with the following discrepancies; * Cetirizine (antihistamine) 10 milligrams (mg) take 5 mg by mouth daily as needed. The medication bottle showed to take daily. The patient stated he/she takes one daily; * Cholecalciferol (Vitamin D-3) 2000 unit capsule take one capsule by mouth daily. The patient stated he/she is not taking because he/she never got it; * Glucagon (hyperglycemic agent to treat severe low blood sugar) 1 mg kit inject 1 mg into the muscle once as directed for low blood sugar. The medication failed to be available in the patient’s home. He/she does not know where it is and drinks milk or eats candy if blood sugar is low; * Insulin aspart niacinamide (FIASP) (rapid-acting insulin) 100 unit/3 milliliters (ml) pen for injection inject 2 units under the skin three times a day before meals. The patient stated he/she is not taking and uses Novolog insulin; * Insulin glargine (Lantus semglee) (long-acting insulin) 100 unit/ml vial for injection inject 5 units under the skin nightly. The patient stated he/she injects 6 units nightly; * NovoLog (rapid-acting insulin) 5 units three times a day. The medication failed to be on the provider’s list. The patient stated he/she has been taking for about one month and on his/her second pen; * Levothyroxine (used to treat hypothyroidism) 88 micrograms (mcg) one daily. The medication failed to be on the provider’s list. The bottle was filled on 3/28/2025); * Hair, Skin & Nails vitamins (gummies) two daily. The medication failed to be on the provider’s list. The patient stated he/she had been taking them for a couple weeks; and * CBD gummies (used for sleep and pain) nightly. The medication failed to be on the provider’s list. The patient stated he/she had been taking for a couple weeks since his/her last hospital stay. (The SN made a call to the physician for medication clarifications during the home visit) During an interview on 04/15/2025 at 1:05 PM, RN A stated medications are to be reviewed at each visit. During an interview on 04/17/2025 at 12:45 PM, the administrator stated she expects the case manager or designee to reconcile medications at each visit. RECORD/PATIENT #1: Review of the clinical record, showed in part: - The patient was admitted to home health services on 02/02/2025 with primary diagnosis of stable burst fracture of first cervical vertebra (occurs when a vertebra breaks in multiple directions); and - The patient resided at home alone. Review of the referral record, dated 02/01/2025, showed the discharge medication list that included Naloxone (Commonly known as Narcan- a medication that rapidly reverses an opioid overdose) 4mg/actuation spray, non-aersol, administer 1 spray into affected nostril(s) as needed for opioid reversal or respiratory depression. Call 911. Administer a single spray in one nostril. Repeat every 3 minutes as needed if no or minimal response. Review of the plan of care medication profile dated 02/02/2025 to 04/02/2025, failed to show Naloxone listed. Review of the clinical record failed to show documentation of the medication discrepancy being reported to the physician. Review of an office visit summary with the patient’s physician on 04/08/2025, showed, in part: - A list of the patient’s current outpatient medications; and - Naloxone, 1 spray, nasal, PRN (as needed) was listed. Review of the clinical record failed to show the plan of care/medication profile were updated to include the Naloxone. During an interview on 04/16/2025 that began at 2:30 PM, the administrator stated that: - The Naloxone was not on the patient’s medication profile because the patient did not have the medication in the home; - The Naloxone was ordered during the previous hospital admission; - When the patient was discharged from the hospital the medication was not discontinued when the discharge orders were being entered; - It was possible that the hospital physician did not complete the discharge medication reconciliation correctly and that resulted in the Naloxone being listed on the patient’s discharge medication list; - There was no documentation that the patient’s physician was notified of the medication being listed and the patient not having it in the home; and - He/she would notify the physician about the medication and report that the patient does not have it.

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, record review, home visit observation, and interview, the home health provider failed to ensure the individualized plan of care (POC) included all pertinent interventions and treatment orders, in two of five full records reviewed (Record/Patient #1 and #2). This deficient practice has the potential to affect the coordination of care and services for all the patients on service with the provider. Findings included: Review of the provider’s policy titled, “Care Planning Process – Provision of Care Treatment And Service,” last revised November 2020, showed in part: - The plan of care will be developed or revised within five (5) working days of initiation of each service or of the reassessment of the patient; - The care planning process will be documented on the plan of care; - At the initial assessment, the clinician along with the physician and other involved disciplines, will develop the patient plan of care based upon the patient’s identified needs and will review it with the patient and family or caregiver; - All clinicians will consider the conclusions of initial and ongoing assessments in their care planning process, including, but not limited to: * Individualized patient needs, and resultant problems related to care functional status and family caregiver support systems; * Changes in patient’s condition; * Clinical drug monitoring; - Based on the assessment and conclusions, the plan of care will include, but not be limited to: * Patient specific interventions and education; * All patient care orders from all physicians involved in the plan of care including verbal orders; * Identified patient problems and needs, including functional limitations, activities permitted, nutritional requirements; * Specific services and treatments to be provided; * Actions to be taken to meet the patient’s goals; * Equipment and supplies; * Patient and caregiver education and training to facilitate timely discharge; and - The plan of care will be revised as frequently as deemed necessary by the clinician, based on the ongoing assessments of the patient. RECORD/PATIENT #1: RECORD/PATIENT #2: Review of the clinical record, showed in part: - The patient was admitted to home health services on 03/16/2025 with primary diagnosis of subarachnoid hemorrhage (a life-threatening type of stroke where bleeding occurs in the space between the brain and the thin tissues covering it); and - The patient resided at home alone and a caregiver checking on him/her. Review of the skilled nurse (SN) OASIS (Outcome and Assessment Information Set; a standardized data collection tool) resumption of care dated 04/07/205, showed in part: - Immobilized digits 2 and 3 of right hand since recent diagnosis of phalanx fracture 2nd digit; - Surgery scheduled April 17,2025; - OT educated patient on new precautions for right hand after new diagnosis of 2nd digit fracture; and - Index finger fracture right February (mid-February) 2025. Review of the occupational therapy (OT) reassessment dated 04/08/205, showed in part: - Immobilized digits 2 and 3 of right hand since recent diagnosis of phalanx fracture 2nd digit; - Surgery scheduled April 17, 2025; - OT educated patient on new precautions for right hand after new diagnosis of 2nd digit fracture; and - Index finger fracture right February (mid-February) 2025. Review of the physical therapy (PT) reassessment dated 04/09/205, showed in part: - The patient reported increased difficulty transferring from lower surfaces due to unable to use right hand; - PT instructed patient to have assist with mobility due to decreased use of right upper extremity (UE); and - The patient has an appointment with orthopedic for right finger fracture 04/17/2025. Review of the home health resumption plan of care dated 04/07/2025 to 04/14/2025, last updated 04/14/2025, failed to show the right-hand fracture. Observation and interview on 04/15/2025 at 11:03 AM, with Registered Nurse (RN) A, showed: - The patient had an ace wrap bandage wrapped around the hand, fingers and wrist area of his/her right hand; - The patient reported he/she had a fractured right finger and an appointment with the orthopedic doctor on 04/17/2025; and - The POC failed to show documentation of the fractured right-hand finger. During an interview on 04/17/2025 at 12:47 PM, the Administrator stated that: - The provider was not providing treatment directly for the fractured right hand digit so it was just in the notes and not on the POC; and - She would expect to see it on the POC. Findings included: Review of the provider’s policy titled, “Care Planning Process- Provision of Care Treatment and Service/Home Health,” revised November 2020, showed in part: - Based on the assessment and conclusions, the plan of care will include, but not be limited to: * Patient specific interventions and education * Equipment and supplies; and - The plan of care will be based upon the physician’s (or authorized licensed independent practitioner’s) orders and will encompass the equipment, supplies, and services required to meet the patient’s needs. RECORD/PATIENT #1: Review of the clinical record, showed in part: - The patient was admitted to home health services on 02/02/2025 with primary diagnosis of stable burst fracture of first cervical vertebra (occurs when a vertebra breaks in multiple directions); and - The patient resided at home alone. Review of the inpatient discharge summary, dated 02/01/2025, showed in part: - The pt (patient) had a fall in November of 2024 that resulted in a cervical fracture (broken neck) and (he/she) was placed in a cervical collar (neck brace); - The patient was admitted to the hospital on 01/22/2025 with “uncontrolled pain and an inability to wear (his/her) CPAP (continuous positive airway pressure- is a machine that delivers continuous air through the mouth and nose to keep the airway open while sleeping) while wearing the collar resulting in increased sleepiness;” - The PMH (past medical history) included a diagnosis of obstructive sleep apnea (a condition where breathing repeatedly stops and starts during sleep due to a blockage in the upper airway) that required the use of a CPAP and a history of DVT (deep vein thrombosis- is a blood clot in a deep vein) of the lower extremity; - “Previously on Eliquis as OP which was d/c during recent admission;” - “Pt is not taking aspirin;” - “Cervical collar no longer required, but because of disuse and MSK injury/tightness, pain was ongoing while it was off. OK to wear the brace as needed especially when OOB and upright, but take off at night so (he/she) can use (his/her) CPAP;” - Ambulatory referral to home health showed a primary reason of: Pt (patient) with neck fracture, freq (frequent) fall history, BLE (bilateral lower extremity) edema and disciplines to evaluate and treat showed PT (physical therapy) and OT (occupational therapy); and - The discharge Medication list failed show Eliquis (an anticoagulant medication that helps prevent blood clots) and Aspirin (a nonsteroid anti-inflammatory medication used to treat pain, fever, or inflammation. It can also be used to treat or prevent heart attacks, strokes, and chest pain). Review of the POC dated 02/02/2025 to 04/02/2025, showed in part: - The DME (durable medical equipment) failed to show a CPAP machine listed - The POC failed to show CPAP orders/interventions; - BLE edema was listed as a problem on the referral record and the POC failed to show interventions for edema; - Impaired UE (upper extremity) function and/or fine motor skills: Intervention of splint/brace; OT to instruct patient/caregiver in wearing schedule of splint/brace on neck, ensure proper fit to decrease skin breakdown in 6 (six) weeks. (The interventions failed to show what the brace schedule was); - Impaired functional mobility/balance transfer training: PT to instruct patient/caregiver and perform transfer training (The intervention failed to show how the patient/caregiver was to perform transfers); - The POC medication section showed Eliquis and Aspirin listed but failed to show interventions/instructions for anticoagulant use; - Fall precautions/safety concerns: Fall precautions and general safety; Skilled disciplines to instruct patient to use proper lighting in all areas, stand/sit up slowly, use appropriate footwear when walking, use proper assistive devices, and to keep pathways clear of cords and clutter to prevent falls. Remove secure throw regs. Educate patient on medications and disease processes that increase fall risk, using corrective lenses as prescribed, placing hard to reach items within reach, what to do in the event of a fall and to report any falls to the home health agency; and - The POC failed to show what medications increased the risk for falls and/or what patient-specific education was to be provided. During an interview on 04/16/2025 that began at 2:30 PM, the administrator stated that: - The patient had a BiPap (Bilevel Positive Airway Pressure- is a machine that pushes air into the lungs through a mask) but couldn’t use it with the c-collar (cervical collar); - During the patient’s hospitalization the patient was cleared to take the c-collar off at night to wear the Bipap while sleeping but the patient chose to continue to wear the c-collar at all times; - Therapy used a gait belt for fall precautions when the patient ambulated; and - The patient’s mother walked behind the patient with the wheelchair for fall precautions when the patient ambulated.

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 policy review, record review, and interview, the home health provider failed to ensure the physician was promptly notified of changes in the patient’s condition or needs that suggest that the plan of care should be altered in one of five full records reviewed (Record/Patient #3). This deficient practice has the potential to affect all patients served by the provider. Findings included: Review of the provider’s undated policy titled, “Care Planning Process,” showed in part that clinicians would inform the patient’s physician of any changes that suggest a need to alter the plan of care. RECORD/PATIENT #3: Review of the clinical record showed the patient was admitted to home health services on 03/20/2025 with a primary diagnosis of cellulitis (a bacterial skin infection) of the right lower limb. The patient had a secondary diagnosis of chronic venous insufficiency (a condition where blood flow to the limbs is reduced due to narrowed or blocked veins). The patient resided in a private residence with the assistance of his/her spouse and adult child. Review of the document titled, “Home Health Initial Plan of Care,” dated 03/20/2025, showed in part that the patient was to use alcohol wipes between his/her toes daily. Review of nursing visit documentation showed that: - On 03/20/2025, the patient and spouse were instructed to use alcohol wipes between his/her toes daily; and - On 03/24/2025, 03/27/2025, 04/04/2025, 04/08/2025, and 04/11/2025, the intervention note showed the clinician observed or performed wound care per physician’s order, dated 03/20/2025. Per interview conducted during a home visit observation on 04/15/2025 beginning at 11:00 AM, the patient stated that he/she had not been using alcohol wipes between his/her toes since he/she was discharged from the hospital. He/she stated that the alcohol wipes caused stinging and pain when applied between his/her toes. During an interview on 04/16/2025 at 1:10 PM, the administrator stated that: - There was no documentation prior to 04/15/2025 showing that the patient was experiencing pain with his/her wound care; - On 04/15/2025, the nurse notified the physician that the patient was not using alcohol pads between his/her toes during the wound care procedure; and - They would have expected the clinicians to notify the physician of the patient’s report of discomfort during the wound care procedure prior to the nursing visit performed 04/15/2025.

Coordinate care delivery CFR(s): 484.60(d)(4) Coordinate care delivery to meet the patient's needs, and involve the patient, representative (if any), and caregiver(s), as appropriate, in the coordination of care activities. This ELEMENT is not met as evidenced by: Based on policy review, record review, and interview, the home health provider failed to assure coordination of care to meet the needs of the patient when the provider failed to verify discrepancies and/or orders in the referral record in, one of five full records reviewed (Record/Patient #1). This deficient practice has the potential to affect all the patients served by the provider. Findings included: Review of the provider’s policy titled, “Admission and Comprehensive Assessment- Provision of Care Treatment and Service/Home Health,” revised April 2021, showed in part: - Coordinate communication with all physicians involved in the plan of care; - Integrate orders from all physicians involved in the plan of care so that all services and interventions are coordinated; and - Coordination of care delivery to meet the patient’s needs, and involve the patient, representative, and caregivers, as appropriate, in the coordination of care activities. Review of the provider’s policy titled, “Verification of Physician Orders - Provision of Care Treatment and Service/Home Health,” revised November 2020, showed all orders and prescriptions will be reviewed for appropriateness and accuracy before providing care, treatment, or services. RECORD/PATIENT #1: Review of the clinical record, showed in part: - The patient was admitted to home health services on 02/02/2025 with primary diagnosis of stable burst fracture of first cervical vertebra (occurs when a vertebra breaks in multiple directions); and - The patient resided at home alone. Review of the referral record dated 02/01/2025, showed in part: - The past medical history (PMH) included a diagnosis of obstructive sleep apnea (a condition where breathing repeatedly stops and starts during sleep due to a blockage in the upper airway) that required the use of a continuous positive airway pressure (CPAP, a machine that delivers continuous air through the mouth and nose to keep the airway open while sleeping) and a history of deep vein thrombosis DVT, a blood clot in a deep vein) of the lower extremity; - “Previously on Eliquis (an anticoagulant medication used to prevent blood clots) as OP which was d/c during recent admission”; - “Pt is not taking aspirin”; and - Eliquis and aspirin (a non-steroid anti-inflammatory medication used to treat pain, fever, or inflammation. It can also be used to treat or prevent heart attacks, strokes, and chest pain) were not listed on the discharge medication list. Review of the plan of care (POC) dated 02/02/2025 to 04/02/2025, showed in part: - Aspirin 81 milligrams (mg) enteric coated tablet, take one by mouth daily and the start and end dates were left blank (The clinical record failed to show documentation and/or orders that the physician was notified that this was not on the discharge medication list and orders received to restart the aspirin after the hospitalization); - Apixaban (Eliquis) 5mg tablet, take one tablet by mouth two times a day and the start and end dates were left blank; and - The clinical record failed to show documentation of coordination of care with the physician regarding the Eliquis and aspirin not being on the discharge medication list. The inpatient discharge summary showed the patient was not taking aspirin, the Eliquis was discontinued during the recent hospitalization, and clarification/confirmation was not received for the patient to take the medications. Review of an office visit summary with the patient’s physician on 04/08/2025, showed, in part: - A diagnosis of nocturnal hypoxia (a condition where blood oxygen levels drop during sleep) and the treatment plan was “on overnight O2 (oxygen)”; - “Needs home O2. Unable to wear BIPAP (BiPAP - bi-level positive airway pressure, a device that pushes air into the lungs through a mask)”; and - Naloxone (a medication that rapidly reverses an opioid overdose), one spray nasal, as needed (PRN) was listed for current outpatient medications (The clinical record failed to show the naloxone listed on the patient’s medication profile and/or coordination of care with the physician to clarify/confirm if the patient was to have the naloxone PRN). Review of the clinical record failed to show documentation that the patient received the oxygen and/or a follow-up to ensure that the patient was wearing oxygen at night as ordered by the physician. During an interview on 04/16/2025 that began at 2:30 PM, the administrator stated that: - The naloxone was not on the patient’s medication profile because the patient did not have the medication in the home; - There was no documentation that the patient’s physician was notified of the medication being listed and the patient not having it in the home; - He/she would notify the physician about the medication and report that the patient did not have it; - He/she was unaware that the physician ordered oxygen for the patient; - The patient had a BiPAP but couldn’t use it with the cervical collar (c-collar, a neck brace); - During the patient’s hospitalization the patient was cleared to take the c-collar off at night to wear the BiPAP while sleeping; - The patient wanted to wear the c-collar at all times and reported that (he/she) did not need the BiPAP; and - There was no documentation of the physician being notified that the patient was not wearing the BiPAP or the oxygen at night.

The Emergency Preparedness regulations were reviewed as part of the Medicare certification survey completed on 03/28/2022. During the survey it was determined BJC Home Care Services 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 BJC Home Care Services was completed on 03/28/2022. The agency had 1493 current patients.

Written notice within 4 business days CFR(s): 484.50(a)(4) Provide written notice of the patient's rights and responsibilities under this rule and the HHA's transfer and discharge policies as set forth in paragraph (d) of this section to a patient-selected representative within 4 business days of the initial evaluation visit. This ELEMENT is not met as evidenced by: Based on policy review and review of the agency's current patient rights information, the agency failed to provide written notice of patient rights regarding their right to have a copy of the patient's rights and responsibilities provided to a patient-selected representative within four business days of the initial evaluation visit. This deficient practice has the potential to affect all patients served by the agency. Findings included: Review of the agency's policy titled, "BJCHC- Rights and Responsibilities- Rights and Ethics/Home Health," dated, 02/05/2021, showed, in part: - Purpose: To encourage awareness of patient’s rights and responsibilities, to provide guidelines to assist patients making decisions regarding care, and to support active participation in care planning; and - Within four (4) business days of the initial evaluation visit, the organization shall provide written notice of the transfer and discharge policies, provide contact information of the administrator, provide verbal notice of the rights and responsibilities, and obtain signature from the patient and legal representative to confirm that they have received a copy of the notice of rights and responsibilities. Review of the agency's preprinted admission patient handbook, with current patient rights information, section titled, "Patient Bill of Rights," failed to show patient rights information regarding their right to have a copy of the patient's rights and responsibilities provided to a patient-selected representative within four business days of the initial evaluation visit. The findings were reviewed with the director of home health on 03/29/2022 at 1:00 PM. No additional information was provided.

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 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: Review of the agency's policy titled, "BJCHC- Rights and Responsibilities- Rights and Ethics/Home Health," dated, 02/05/2021, showed, in part: - Purpose: To encourage awareness of patient’s rights and responsibilities, to provide guidelines to assist patients making decisions regarding care, and to support active participation in care planning; - The right to voice a complaint or concern regarding care, treatment or services that are (or fail to be) provided or are provided inconsistently or inappropriately without fear of reprisal for exercising this right; - The right to voice grievances regarding lack of respect for property; - The availability of other sources to receive questions and complaint and assist in resolution; and - The availability of the applicable toll-free home health agency hotline and other sources to receive questions or complaints and assist in resolution including implementation of the advance directives requirements. Review of the agency's preprinted admission patient handbook, with current patient rights information, section titled, "Patient Bill of Rights," showed: - The patient also has the right to use this hotline to lodge complaints concerning the implementation of the advance directives requirement; and - In Missouri, the number is: 800-392-0210, answered 7AM to 12AM, seven days a week. During an interview with the director of home health on 03/29/2022 at 1:00 PM, the director stated that: - He/she was aware of the hotline hours being changed; - The admission booklets are preprinted; - Stickers with the updated hours have been ordered; and - Agency staff were instructed to make corrections in the admission booklets until the stickers arrive.

Provide contact info other services CFR(s): 484.50(d)(5)(iii) (iii) Provide the patient and representative (if any), with contact information for other agencies or providers who may be able to provide care; and 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 update the written notice of patient rights to include that if the patient is being considered for discharge for cause, the agency must provide the patient or representative with contact information for other agencies or providers who may be able to provide care after discharge. This deficient practice has the potential to affect the knowledge and comprehension of the rights and responsibilities of all agency patients. Findings included: Review of the agency's policy titled, "BJCHC- Rights and Responsibilities- Rights and Ethics/Home Health," dated, 02/05/2021, showed, in part: - Purpose: To encourage awareness of patient’s rights and responsibilities, to provide guidelines to assist patients making decisions regarding care, and to support active participation in care planning; - The establishment and revision of the plan of care, including disciplines that will furnish the care and the frequency of visits as well as any changes in the care to be furnished; - The right to be informed of his/her condition, participate in all aspects of care, and the right to refuse all or part of his/her care to the extent permitted by law; - The organizations transfer and discharge policies; - The patient and family/caregiver are responsible for: ** Following instructions: ** Understanding and accepting the consequences for outcomes if the care, services, and/or treatment plan are not followed; ** Following the organizations policies and procedures concerning patient care and conduct; ** Showing respect and consideration for the organizations personnel and property; and - The agency policy failed to include written notice of patient rights to include that if the patient is being considered for discharge for cause, the agency must provide the patient or representative with contact information for other agencies or providers who may be able to provide care after discharge. Review of the agency's preprinted admission patient handbook, with current patient rights information, section titled, "Patient Bill of Rights," showed: - The agency must advise the patient in advance of any changes in the plan of care before the change is made; - The patient and their representative (if the patient has one) have the right to be informed of the agency’s policies governing admission, transfer, and discharge in advance of the agency providing care; - The patient has the right to be informed in writing and in advance, within a reasonable time of anticipated termination of service, reduction of service, or plans to transfer to another agency; and - Patient Bill of Rights failed to include written notice of patient rights to include that if the patient is being considered for discharge for cause, the agency must provide the patient or representative with contact information for other agencies or providers who may be able to provide care after discharge. During an interview with the director of home health on 03/29/2022 at 1:00 PM, the director stated that: - The informational insert with the names, addresses, and telephone numbers of the federally-funded and state-funded entities is provided to the patient; - The MSW (medical social worker) has a list of agencies and providers who may be able to provide care; - The MSW provides patients with the list of agencies or providers if the need arises; and - The admission booklet with the patient rights, does not state that the agency will provide the patient and representative (if any) with contact information for other agencies or providers who may be able to provide care.

A review of all current medications CFR(s): 484.55(c)(5) A review of all medications the patient is currently using in order to identify any potential adverse effects and drug reactions, including ineffective drug therapy, significant side effects, significant drug interactions, duplicate drug therapy, and noncompliance with drug therapy. This ELEMENT is not met as evidenced by: Based on policy review, record review, and interview, the agency failed to ensure an accurate medication review and/or update of patient medications was completed in, one (Record/Patient #5) of five full records reviewed. This deficient practice has the potential to adversely affect the agency’s ability to ensure safe and effective use of medications for all patients served by the agency. Findings included: Review of the agency’s policy titled, “BJCHC- MEDICATION PROFILE-MEDICATION MANAGEMENT-HOME HEALTH”, dated reviewed 04/01/2021, showed the following: - Patients receiving medications will have a current, accurate medication profile in the clinical record; - Medication profiles will be updated for each change to reflect current medications and new and/or discontinued medications; - In rehabilitation therapy-only cases, the patient’s therapist must submit a list of patient medications to a registered nurse for review; - During subsequent home visits, the medication profile will be used as a care planning and teaching guide to ensure that the patient and family/caregiver, as well as other clinicians, understand the medication regimen. This includes, but will not be limited to using the medication profile in conjunction with other pertinent data, to evaluate the use of drugs in the home setting; - Each patient and/or family/caregiver will receive appropriate material for specific medications he/she is receiving; - Any conclusions and findings of patient medication use, including herbal and over the counter medication or monitoring should be communicated to the pharmacist, physicians, and other clinicians, when appropriate; and - Deviations in taking medications as ordered will be documented in clinical notes, and the physician (or other authorized licensed independent practitioner) will be notified. RECORD/PATIENT #5: Review of the clinical record showed: - The patient was admitted to home health services on 01/19/2022 with diagnoses of, but not limited to, encounter for surgical aftercare following surgery on the digestive system (hollow organs that make up the GI (gastrointestinal) tract including the mouth, esophagus, stomach, small intestine, large intestine, and anus as well as solid organs including the liver, pancreas and gall bladder), gastrointestinal (gastrointestinal) hemorrhage- unspecified, acute post hemorrhagic anemia (acute, large loss of blood), pain in the right foot, unspecified abnormalities of gait and mobility (walking disorder) and unsteadiness on feet; and - The disciplines providing care included PT (physical therapy) and OT (occupational therapy). Review of the OT note dated 02/08/2022 at 10:31 AM showed: - Current pain treatments: patient takes Tylenol PRN (as needed) for pain; and - Patient medication list reconciled. Review of the POC (plan of care) dated 01/19/2022 through 03/19/2022 failed to include Tylenol. Further review of the clinical record failed to show any physician communication or physician order for Tylenol. During chart reviews with the home health director on 03/30/2022 at 9:49 AM, the director stated that he/she would look for additional documentation to clarify the use of Tylenol by the patient. On 03/30/2022 at 12:40 PM the director stated that he/she was unable to find an order or communication with the physician regarding the administration of Tylenol. No further information was provided.

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 agency failed to ensure that the patients received the home health services that were written on the individualized POC (plan of care) when the patients did not receive visits according to the visit frequency ordered on the POC in one (Record/Patient #5) of five full record reviews completed. This deficient practice has the potential to adversely affect the ordered care provided to all the agency’s patients. Findings included: Review of the agency’s policy titled “BJCHC – CARE PLANNING PROCESS – PROVISION OF CARE TREATMENT AND SERVICE/HOME HEALTH” dated reviewed 04/29/2021, showed in part: - Purpose: to provide clinical direction to clinicians providing direct patient care; - Based on the assessment and conclusions, the plan of care will include, but not be limited to: type, including identifying the responsible discipline(s), frequency, and duration; -The plan of care will be based upon the physician’s (or other licensed independent practitioner’s) orders and will encompass the equipment, supplies, and services required to meet the patient’s needs; - Changes in the plan of care will be noted with the following documentation: verbal orders; and - Clinicians will inform the patient’s physician of any changes that suggest a need to alter the plan of care and changes must be written, dated and signed by the professional making the change. RECORD/PATIENT #5: Review of the clinical record showed the patient was admitted to the agency on 01/19/2022 with diagnoses of, but not limited to, encounter for surgical aftercare following surgery on the digestive system (hollow organs that make up the GI (gastrointestinal) tract including the mouth, esophagus, stomach, small intestine, large intestine, and anus as well as solid organs including the liver, pancreas and gall bladder), gastrointestinal (gastrointestinal) hemorrhage- unspecified, acute post hemorrhagic anemia (acute, large loss of blood), pain in the right foot, unspecified abnormalities of gait and mobility (walking disorder) and unsteadiness on feet. Review of the physician order dated 01/27/2022 at 9:57 AM, and electronically signed by the physician on 1/27/2022 at 10:03 AM, showed: - Updated visits for physical therapy 1 visit every week for 1 week (1/27/2022-1/29/2022); and - 1 to 2 visits every week for 4 weeks (1/30/2022-2/26/2022). Further review of the clinical record: - Failed to show any physical therapy visits the week of 01/30/2022; and - Failed to show any physician communication or physician order regarding the missed visits. During chart reviews with the home health director on 03/30/2022 at 9:49 AM, the director stated that he/she would look for additional documentation to clarify the missed physical therapy visits the week of 01/30/20200. On 03/30/2022 at 12:40 PM the director stated that he/she was unable to find an order or communication with the physician regarding the missed visits. No further information 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, one (Record/Patient #5) of five full records reviewed. This deficient practice has the potential to adversely affect the care provided to all patients served by the agency. Findings included: Review of the agency’s policy titled “BJCHC – CARE PLANNING PROCESS – PROVISION OF CARE TREATMENT AND SERVICE/HOME HEALTH” dated reviewed 04/29/2021, showed in part: - Purpose: to provide clinical direction to clinicians providing direct patient care; - Based on the assessment and conclusions, the plan of care will include, but not be limited to: equipment and supplies; -The plan of care will be based upon the physician’s (or other licensed independent practitioner’s) orders and will encompass the equipment, supplies, and services required to meet the patient’s needs; - Changes in the plan of care will be noted with the following documentation: verbal orders; and - Clinicians will inform the patient’s physician of any changes that suggest a need to alter the plan of care and changes must be written, dated and signed by the professional making the change. RECORD/PATIENT #5: Review of the clinical record showed: - The patient was admitted to home health services on 01/19/2022; - The disciplines providing care included PT (physical therapy) and OT (occupational therapy); Review of the PT note dated 02/21/2022 showed: - With increased pain patient is wearing a boot on her right foot again and is moving more slowly; - Transition to rigid shoe last week may have caused on set of pain in hips; and - Pt (patient) would benefit from continued skilled PT for balance, gait, stairs, and right foot pain and ROM (range of motion- joint movement capabilities). Review of the PT note dated 02/23/2022 showed: - Pain rated a 3 out of 10; and - Relieving factors included removing the walking boot and switching to orthopedic shoe. Review of the POC (plan of care) dated 01/19/2022 through 03/19/2022 failed to show any type of orthopedic shoe or walking boot listed. Further review of the clinical record failed to show any physician communication or physician order for any type of orthopedic shoe or walking boot. During chart reviews with the home health director on 03/30/2022 at 9:49 AM, the director stated that he/she would look for additional documentation to clarify the use of orthopedic shoes and/or any type of boot to be used by the patient. On 03/30/2022 at 12:40 PM the director stated that he/she was unable to find an order or communication with the physician regarding orthopedic shoes or any type of boot. No further information 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 policy review, record review, 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. PATIENT/RECORD #5: Review of the POC (plan of care) dated 01/19/2022 through 03/19/2022 showed the following: - Disciplines providing care included PT (physical therapy) and OT (occupational therapy); - Diagnoses included, but not limited to, hypertensive heart disease with heart failure (a group of medical problems- like heart failure (a chronic condition in which the heart does not pump as well as it should) and conduction arrhythmias (a problem with the electrical system of the heart that controls your heart’s rate and rhythm); -Medications including losartan (Cozaar) 50mg (milligrams) (medication used to treat high blood pressure) 1 tablet by mouth two times daily and clonidine (Catapres-TTS) 0.2mg/24 hr. (medication used alone or with other medications to treat high blood pressure), place 0.2mg on the skin once a week on Tuesdays; - Supervising discipline notification of abnormal vital signs using standardized vital signs to report prn (as needed) SBP (systolic blood pressure- pressure caused by your heart contracting and pushing blood out- the first or top number) 90-160 and DBP (diastolic blood pressure- the pressure in your arteries when your heart rests between beats- the second or bottom number) 40-90; Further review of the clinical record showed: - A PT visit note dated 02/09/2022 with a blood pressure recorded of 200/70. Visit noted: called MD (doctor of medicine) about elevated BP (blood pressure); return call from MD office stated to monitor patient’s vital signs and see if they decrease in follow up visits. No change noted in the plan of care and no physician order changes noted from phone call; - A PT visit note dated 02/11/2022 with a BP documented of 188/70 and no documentation of MD notification; - A PT visit note dated 02/14/2022 with a BP documented of 184/70 and no documentation of MD notification; - A PT visit note dated 02/16/2022 with a BP documented of 180/70 and no documentation of MD notification; During chart reviews with the home health director on 03/30/2022 at 9:49 AM, the director stated that he/she would look for additional documentation regarding the lack of physician notification of the BP’s out of standardized guidelines outlined on the POC. On 03/30/2022 at 12:40 PM the director furnished me with a paper titled “Intervention Documentation – Physical therapy” that had highlighted: 02/09/2022 Visit Notes: Called MD about elevated BP; return call from the office stated to monitor pt. vitals and see if they decrease in follow up visits. No further information provided. Findings included: Review of the agency policy titled, "BJCHC- Care Planning Process- Provision of Care Treatment and Service/Home Health”," dated 04/29/2021, showed, in part: - Clinicians will inform the patient’s physician of any changes that suggest a need to alter the plan of care; and - Changes must be written, dated, and signed by the professional making the changes. RECORD/PATIENT #1: Review of the plan of care, dated, 03/23/2022 through 05/21/2022, showed, in part: - Diagnosis included encounter for fitting and adjustment of non-vascular catheter (pleurx drain to drain fluid from pleural space), chronic combined systolic and diastolic congestive heart failure (the heart cannot pump or fill adequately), chronic kidney disease (longstanding disease of the kidneys resulting in kidneys failing to filter waste adequately), ischemic cardiomyopathy (hearts ability to pump blood is decreased because the hearts main pumping chamber is enlarged), malignant neoplasm of right kidney (kidney cancer), atherosclerotic heart disease of native coronary artery without angina pectoris (buildup of plaque inside the artery walls), pulmonary hypertension (a type of high blood pressure that affects arteries in the lungs and in the heart), atrial fibrillation (irregular heart rate that commonly causes poor blood flow), type 2 diabetes (chronic condition that affects the way the body processes blood sugar), and hyperlipidemia (blood has too many lipids, also known as fats, in it); - Skilled disciplines to monitor patient’s vital signs every home health visit; and - Supervising discipline notification of abnormal vital signs to report for SBP (systolic blood pressure) less than 90 and greater than 160, DBP (diastolic blood pressure) less than 40 and greater than 90, O2 Sat (oxygen saturation) less than 88%, and temp (temperature) greater than 101.5. Review of the clinical record, showed, in part: - SN (skilled nurse) visit note on 03/25/2022 showed the patient’s blood pressure 85/60 (no documentation of physician notification); and -SN visit note on 03/29/2022 showed the patient’s blood pressure of 88/50 (no documentation of physician notification). During chart review with the administrator and director of home health on 03/30/2022 at 9:45 AM, surveyor addressed the blood pressures and no documentation for physician being notified. No further documentation provided.

Name/contact information of clinical manager CFR(s): 484.60(e)(5) Name and contact information of the HHA clinical manager. This ELEMENT is not met as evidenced by: Based on policy review, admission patient handbook review, home visit observation, and interview, the agency failed to provide the name and contact information for the clinical manager, in one (Record/Patient #2) of three home visits conducted. This deficient practice has the potential to adversely affect all agency patient’s knowledge of the name of clinical manager and how to contact them. Findings included: Review of the agency’s policy titled “BJCHC – CARE PLANNING PROCESS – PROVISION OF CARE TREATMENT AND SERVICE/HOME HEALTH” dated reviewed 04/29/2021, showed in part: - The organization shall provide the patient and caregiver with a copy of written instructions outlining the name and contact information of the organization’s clinical manager. Review of the agency’s pre-printed admission patient handbook showed: - The front cover with titles and lines to fill in after the following disciplines: nursing, physical therapy, occupational therapy, speech therapy, social worker, aide, team supervisor and clinical manager/administrator; and - An insert in the front of the handbook with a number to reach out to the appropriate clinical manager for the parent office as well as the three branches which included the clinical manager’s name and title. RECORD/PATIENT #2: Observation on 03/29/2022 at 10:00 AM, during the patient’s home visit, showed the agency’s patient handbook failed to include the insert with the clinical manager’s name and contact information. The front of the handbook was left blank following the title clinical manager/ administrator. Per interviews conducted during the home visit observation on 03/29/2022 starting at 10:00 AM, registered nurse (RN) A, stated that he/she usually writes it (clinical manager's name and phone number) on the front of the booklet and the patient stated that he/she had not removed any inserts from the admission patient handbook.