Every finding on record at Cantex Home Health Lewisville LLC

Purpose of visit: Complaint Survey Entrance: 02/27/2023 at 9:44 AM with the Administrator/Director of Nursing, Assistant Director of Nursing, Senior Administrator, and Director of Quality Agency Census: Licensed and Certified Home Health Services L&CHHS-85 Licensed Home Health Services LHHS-10 Personal Assistance Services PAS-0 Complaint: #408344 Exit Conference was conducted on 02/27/2023 with the Administrator/Director of Nursing, Assistant Director of Nursing, Senior Administrator, and Director of Quality at 2:45 PM. The preliminary findings were discussed. The agency was afforded the opportunity to provide additional information. Written instructions were provided for submitting a plan of correction within 10 days of the receipt of the Statement of Deficiencies. Abbreviations: Licensed and Certified Home Health Services (L&CHHS) Licensed Home Health Services (LHHS) Personal Assistance Services (PAS) Plan of Care (POC) Quality Improvement (QI). Disease (DIS) Classified (CLSSD) Elsewhere (ELSWHR) Other (OTH) 2 times a week for two weeks (2w3) One time a week for seven weeks (1w7) Milligram (mg)

Purpose of visit: Complaint Survey Entrance: 02/27/2023 at 9:44 AM with the Administrator/Director of Nursing, Assistant Director of Nursing, Senior Administrator, and Director of Quality Agency Census: Licensed and Certified Home Health Services L&CHHS-85 Licensed Home Health Services LHHS-10 Personal Assistance Services PAS-0 Complaint: #408344 Exit Conference was conducted on 02/27/2023 with the Administrator/Director of Nursing, Assistant Director of Nursing, Senior Administrator, and Director of Quality at 2:45 PM. The preliminary findings were discussed. The agency was afforded the opportunity to provide additional information. Written instructions were provided for submitting a plan of correction within 10 days of the receipt of the Statement of Deficiencies. Abbreviations: Licensed and Certified Home Health Services (L&CHHS) Licensed Home Health Services (LHHS) Personal Assistance Services (PAS) Plan of Care (POC) Quality Improvement (QI). Disease (DIS) Classified (CLSSD) Elsewhere (ELSWHR) Other (OTH) 2 times a week for two weeks (2w3) One time a week for seven weeks (1w7) Milligram (mg)

Be free from abuse CFR(s): 484.50(c)(2) Be free from verbal, mental, sexual, and physical abuse, including injuries of unknown source, neglect and misappropriation of property; This ELEMENT is not met as evidenced by: Based on record review and interview, the agency failed to ensure a Patient's right to be free from neglect for one of one Patient (#1) in that: - The agency failed to report allegations of neglect for one of one self-reported incident (Intake #408344) Texas Health and Human Services Commission (HHSC) immediately, meaning within 24 hours after becoming aware of the allegations. This failure placed agency Patient #1 at an increased risk of neglect by agency staff and delayed investigation of the incident. The findings included: During pre-entrance preparation, a review of the Incident Investigation Worksheet for Intake #408344, dated 02/23/23, indicated possible neglect of patient #1 by an agency employee. Review of the agency's complaint documentation revealed a form titled; “QI Event Summary COMPLAINT Date of Event 02/22/2023…Client #1…” Another form …. Type of Event” revealed a document titled; "Complaint Form," The documentation also revealed a form titled; “Complaint Report Client: Client #1…Date: 02/22/2023 12:05 PM…Identifying Person: Administrator/Alternate Director of Nursing…Complainant Caregiver/Family Name/Relationship: Family Member #1 Description: 2/21 Received a call from Identifier A that patient was in hospital and the 3rd toe next to the amputated toe was infected and may have to have surgery. Family Member #1 was very upset, she asked if we had a picture of the wound, and she wanted a pic. I (Administrator/Alternate Director of Nursing) sent what the Nurse had taken on 2/20... 2/22 Identifier A called Family Members #2 and #3 were on the call. They were very upset They said the Podiatrist...said the wound dehisced…She was very upset and feels we failed Client #1. She said she would be making a formal complaint and talking to an attorney…” Further review of the complaint forms failed to reveal documentation the agency reported this incident to HHSC and DFPS within 24 hours of being made aware of the incident of neglect on 02/22/23. During an interview on 02/27/23 at 2:40 p.m. with the Administrator/Alternate Director of Nursing, the surveyor presented the above findings. After review of the agency complaint forms, the agency policy and procedure titled "Abuse, Neglect, and Exploitation - Addendum” and “Patient/Client Rights and Responsibilities" the Administrator/Alternate Director of Nursing stated the incident was not reported within 24 hours of being notified on 02/21/23 and 02/22/23. The Administrator/Alternate Director of Nursing stated, "We were doing the investigation first.” Agency policy titled: "Abuse, Neglect, and Exploitation - Addendum” PC. 20-TX Last Reviewed: 021423 read in part: "Report if there is cause to believe abuse, neglect, or exploitation of the patient/client… has occurred by staff member, representative, or contractor, immediately, meaning within 24 hours, to: Texas Department of Family and Protective Services…Texas Health and Human Services Commission (HHSC)…” Agency policy titled: "Patient/Client Rights and Responsibilities - Addendum" number RI.5- TX Last Reviewed 030122 read in part: "D. The patient/client has the right to: …9. Be free from abuse, neglect, and exploitation by an Agency employee, volunteer, or contractor… Reference Texas Administrative Code (TAC) Title 26, Part 1 558.282"

Infection control CFR(s): 484.70(b)(1)(2) Standard: Control. The HHA must maintain a coordinated agency-wide program for the surveillance, identification, prevention, control, and investigation of infectious and communicable diseases that is an integral part of the HHA's quality assessment and performance improvement (QAPI) program. The infection control program must include: (1) A method for identifying infectious and communicable disease problems; and (2) A plan for the appropriate actions that are expected to result in improvement and disease prevention. This STANDARD is not met as evidenced by: Based on interview and record review, the agency failed to enforce written policies to control infections and communicable diseases that included requirements to document infections that the patient acquires while receiving services from the agency for two of two active patients (Patient #1 and Patient #2), in that: 1. Patient #1 received Minocycline (antibiotic) and there was no documented evidence that it was included in the infection control log. 2. Patient #2 received Cefdinir (antibiotic) and there was no documented evidence that it was included in the infection control log. This deficient practice placed the patients #1 and #2 at risk of receiving inadequate care and services from the agency's inability to monitor and trend infections and antibiotic use while receiving care from the agency. The findings included: Medical record review: Review of Patient #1's medical record revealed a SOC of 02/12/2023 for a certification Plan of Care (POC) from 02/12/2023 through 04/12/2023 read in part, “…Diagnosis….Encounter For Change Or Removal Of Surgical Wound Dressing…Proteus (Mirabilis) (Morganii) (bacterium) Causing Dis Classd Elshwhr, OTH Staphyloccoccus (bacteria) As The Cause Of Diseases Classd Elswhr,and Celllitis Of Left Lower Limb (bacterial infection of the skin)…Skilled Nurse frequency of 2 times a week for two weeks (2w3) and one time a week for seven weeks (1w7)…Medications…Minocycline 100mg Capsule 1 capsule 2 Times Daily…” Review of Patient #2's medical record revealed a SOC of 08/10/2022 for a certification Plan of Care (POC) from 08/10/2022 through 10/08/2022 read in part, “…Diagnosis….Encounter For Change Or Removal Of Surgical Wound Dressing…Proteus (Mirabilis) (Morganii) (bacterium) Causing Dis Classd Elshwhr, OTH Staphyloccoccus (bacteria) As The Cause Of Diseases Classd Elswhr,and Celllitis Of Left Lower Limb (bacterial infection of the skin)…Skilled Nurse frequency of 2 times a week for two weeks (2w3) and one time a week for seven weeks (1w7)…Medications…Cefdinir 300mg Capsule 1 capsule 2 Times Daily Oral New Reason: UTI(urinary tract infection)….” Review of the Infection Control Documents: Review of the agency's Infection Control documentation revealed a form titled; “QI Event Summary INFECTION revealed no documented evidence for Patient #1 or Patient #2. During an interview on 02/27/23 at 2:35 p.m. with the Administrator/Alternate Director of Nursing, the surveyor presented the above findings including the agency policy and procedure titled "Infection Control Program.” The Administrator/Alternate Director of Nursing stated the infections for patients #1 and #2 was not documented in the infection control program. The Administrator/Alternate Director of Nursing stated, "As a practice we don’t document clients that were on antibiotics when they were admitted to the agency only the patients that acquire the infection while they were at the agency.” Agency policy titled "Infection Control Program IC.10" Last Reviewed: 070120 "read in part, “...The Infection Control Program will include…C. A system that coordinates: 1. Surveillance for the occurrence of an infection 2. Identification of the occurrence…5. review of the data collected to evaluate trends, pattern, etc., 6. Reporting the data and any identified trends as appropriate...Every patient/client infection will be reported and documented as soon as any Agency staff member is aware of it…An “Infection Control Report will be completed within 48 hours…The Agency will track all infections..."

A Recertification Survey entrance conference was conducted on 07/13/2021 with the Adm/Alt DON, Alt Adm/DON and an RN/Clinical Supervisor at 12:20 PM. Census L&CHHS: 204 LHHS: 0 PAS: 0 An exit conference was conducted on 07/21/2021 with the Adm/Alt DON, Alt Adm/DON, an RN/Clinical Supervisor, the RD (via phone) and the DQ (via phone) at 3:25 PM. The preliminary findings were discussed. The agency was found in compliance with 42 CFR Part 484.22 Medicare Conditions of Participation and no deficiencies were cited. ABBREVIATIONS Adm - Administrator Alt - Alternate CFR - Code of Federal Regulations DON -Director of Nurses DQ - Director of Quality L&CHHS - Licensed and Certified Home Health Services LHHS - Licensed Home Health Services PAS - Personal Assistance Services RD - Regional Director

A Recertification and Follow-up survey entrance conference was conducted on 07/13/2021 with the Adm/Alt DON, Alt Adm/DON and an RN/Clinical Supervisor at 12:20 PM. Written information regarding "What to Expect During Your Agency's Survey" was provided. Census L&CHHS: 204 LHHS: 0 PAS: 0 An exit conference was conducted on 07/21/2021 with the Adm/Alt DON, Alt Adm/DON, an RN/Clinical Supervisor, the RD (via phone) and the DQ (via phone) at 3:25 PM. The preliminary findings were discussed. The agency was afforded the opportunity to provide additional information. Written instructions were provided for submitting a plan of correction within 10 days of the receipt of the Statement of Deficiencies. ABBREVIATIONS + - positive Abd - abdominal Adm - Administrator Alt - Alternate appt - appointment AV - Arteriovenous CFR - Code of Federal Regulations Co-morb - co-morbidity COVID-19 -Novel Coronavirus Disease of 2019 DON - Director of Nurses DQ - Director of Quality EMR: electronic medical record ESRD - End Stage Renal Disease FA - forearm hha - Home Health Aide L - left L&CHHS - Licensed and Certified Home Health LHHS - Licensed Home Health Services LVN -Licensed Vocational Nurse NS - normal saline PAS- Personal Assistance Services PT - Physical Therapist POC - plan of care R - right RD - Regional Director RN - registered nurse SN - skilled nurse SOC - start of care wk - week

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 record review and interviews, the Alt Adm/DON and the Adm/Alt DON failed to ensure the patients received the services written in their POC's. In one of two (Patient 1) active patient records reviewed, the nurse failed to report significant changes in the wound to the physician and instruct the patient/caregiver to perform wound care. In two of two (Patient 2 and 3) active patient records reviewed, weights were not performed by the SN every visit. This failure resulted in Patient 1 having an Emergency Department visit and hospitalization due to wound deterioration. This failure placed Patient 2 and 3 at risk of not receiving interventions as needed and could cause complications and a decline in health status. Findings include: Definitions: Subcutaneous: situated or applied under the skin. Cellulitis: a deep, potentially complicated infection of the skin caused by bacteria. abd pads: used for large wounds or for wounds requiring high absorbency. Medihoney: a brand name wound and burn gel made from 100% Leptospermum (Manuka) honey used to it decrease bacterial growth within wounds. Medihoney is used to treat open wounds, preventing gangrene and infection and has shown to decrease odors that may accompany wounds. Abdominal girth: the measurement of the distance around the abdomen at a specific point to monitor a buildup of fluid in the abdomen, often caused by heart failure] Purulent: containing or consisting of pus, exudate. Patient 1: Record review of the EMR included a POC for the certification period 04/21/2021 to 06/19/2021 electronically signed by RN B and C on 04/20/2021 with a primary diagnosis of disorders of the skin and subcutaneous tissue related to radiation and secondary diagnoses' of malignant neoplasm of floor of mouth and cellulitis. The POC included orders that read in part, " ...skilled nurse to assess/evaluate all ...conditions including wound care, cellulitis, squamous cell carcinoma floor of mouth ...to identify changes and interventions to minimize complications ...Notify provider of signs and symptoms requiring medical attention ...skilled nurse to observe and assess integumentary status to identify changes and intervene to minimize complications. Skilled nurse to provide skilled teaching related to altered skin integrity ...and wound care ...skilled nurse to instruct patient/caregiver to perform wound care to R jaw wound. Using clean technique as follows: 1. Cleanse with NS/wound cleanser 2. Pat dry with gauze 3. Apply medihoney to fit shape of wound 4. Cover with ...abd pad 5. Secure with medipore tape 6. Wound care frequency SN 3 days/wk Skilled nurse will assess wound and perform wound care every skilled nursing visit Skilled nurse to instruct patient/caregiver on signs and symptoms of wound infection and to report complications to provider ... Goals/Rehabilitation Potential/Discharge plans ...changes in skin integrity status will be identified and reported to the physician for prompt intervention throughout episode. Patient/caregiver will verbalize/demonstrate adequate knowledge of integumentary status and appropriate measures to promote skin integrity ...changes in patient co-morbid status will be promptly identified and reported to the physician ...patient/caregiver will verbalize/demonstrate ability to perform wound care ...changes in wound status will be identified and reported to physician for prompt intervention to minimize associated risks ...Supporting Documentation for Risk of Hospital Readmission ...reported or observed history of difficulty complying with any medical instructions ...in the past 3 months ..." Eleven SN visits were made between Patient 1's SOC SN visit on 04/21/2021 through 05/17/2021. Patient 1 was admitted to the hospital on 05/18/2021. An SN SOC visit was conducted on 04/21/2021 by RN B that read in part, " ...Wound care provided skilled nurse to instruct patient/caregiver to perform wound care to r jaw wound. Using clean technique as follows: 1. Cleansed with ns/wound cleanser 2. Patted dry with gauze. 3. Applied medihoney to fit shape of wound 4. Covered with ...abd pad 5. Secured with medipore tape ... Skilled nurse to instruct patient/caregiver to perform wound care in the absence of the nurse. Skilled nurse will assess wound and perform wound care every skilled nursing visit skilled nurse to instruct patient/caregiver on signs and symptoms of wound infection and to report complications to provider ...wound with large amount of purulent foul smelling drainage noted on old dressing ...reviewed wound care ..." There was no documentation in the EMR to indicate the SN instructed the patient/caregiver to perform wound care or that the patient/caregiver demonstrated competency to perform wound care. An SN visit was conducted on 04/26/2021 by LVN A that read in part, " ...upon arrival, wound dressing was very saturated and large odor noted. Patient states that he hasn't been able to change the dressing on his own through the weekend ...Instructed spouse to try and change the bandage any time it gets saturated ..." There was no documentation in the EMR to indicate the SN instructed the patient/caregiver to perform wound care or that the patient/caregiver demonstrated competency to perform wound care. There was no indication the physician was notified of the patient's condition. The record included a Client Coordination Note Report dated 04/26/2021 that read in part, " ...upon arrival, wound dressing was very saturated and large odor noted. Patient states that he hasn't been able to change the dressing on his own through the weekend ...Wound care completed as ordered ..." There was no indication the coordination note was sent to the physician or that the physician was notified of the patient's condition. An SN visit was conducted on 04/28/2021 by LVN A that read in part, " ...Patient drainage to wound continues to be very large and due to location of wound, dressing is very hard for patient to change on his own. His spouse is also just as weak and not doing as well and therefore cannot change the dressing. Dressing is saturated very quickly due to the wound depth extending all the way into the oral cavity. Wound care completed as ordered ...Instructed patient on easier ways that he might be able to change outer dressing to wound. Patient stated that he would try but it is difficult due to the location ..." There was no documentation in the EMR to indicate the SN instructed the patient/caregiver to perform wound care or that the patient/caregiver demonstrated competency to perform wound care. There was no indication the physician was notified of the patient's condition. An SN visit was conducted on 04/30/2021 by LVN A that read in part, " ...Wound care provided as ordered ...Instructed patient to change bandage as it gets saturated to help protect surrounding skin and would from further deterioration ..." There was no documentation in the EMR to indicate the SN instructed the patient/caregiver to perform wound care or that the patient/caregiver demonstrated competency to perform wound care. There was no indication the physician was notified of the patient's condition. An SN visit was conducted on 05/03/2021 by LVN A that read in part, " ...Patient has been having some increase in drainage and has attempted to change his outer dressing to help soak up the drainage. Patient ended up just holding the adb pad to his jaw for several hours at a time ...Instructed patient to contact [Identifier Z] with any dressing that fall (sic) off or he is having a very difficult time with ..." There was no documentation in the EMR to indicate the SN instructed the patient/caregiver to perform wound care or that the patient/caregiver demonstrated competency to perform wound care. There was no indication the physician was notified of the patient's condition. An SN visit was conducted on 05/07/2021 by LVN A that read in part, " ...Patient has very large amounts of drainage from wound. He is unable to change outer dressing due to location of the wound ..." There was no documentation in the EMR to indicate the SN instructed the patient/caregiver to perform wound care or that the patient/caregiver demonstrated competency to perform wound care. There was no indication the physician was notified of the patient's condition. The record included a Client Coordination Note Report dated 05/07/2021 that read in part, " ...Patient has very large amounts of drainage from wound. He is unable to change outer dressing due to location of the wound ..." There was no indication the coordination note was sent to the physician or that the physician was notified of the patient's condition. An SN visit was conducted on 05/11/2021 by LVN A that read in part, " ...Wound to right lower jaw with purulent drainage and significant odor from the drainage ...Patient states that he feels a little off today and his balance and stability is lacking. SN watched patient walk with assistive device and he was struggling to keep the walker going in a straight line. Patient stated he is just feeling weak today ..." There was no documentation in the EMR to indicate the SN instructed the patient/caregiver to perform wound care or that the patient/caregiver demonstrated competency to perform wound care. There was no indication the physician was notified of the patient's condition. An SN visit was conducted on 05/12/2021 by LVN A. There was no documentation in the EMR to indicate the SN instructed the patient/caregiver to perform wound care or that the patient/caregiver demonstrated competency to perform wound care. There was no indication the physician was notified of the patient's condition. An SN visit was conducted on 05/14/2021 by LVN A that read in part, " ...Patient lower lip has recently had less swelling but today, it is noteable (sic) that swelling is beginning to get bigger. Patient is about to finish antibiotic round. Daughter instructed on signs and symptoms of infection and the risk of that (sic) the lip is swelling again. Daughter works in healthcare and is placing a call to the wound care clinic to see if antibiotics need to be continued or appt moved forward ..." There was no documentation in the EMR to indicate the SN instructed the patient/caregiver to perform wound care or that the patient/caregiver demonstrated competency to perform wound care. There was no indication the physician was notified of the patient's condition. The record included a Client Coordination Note Report dated 05/14/2021 that read in part, " ...Patient lower lip has recently had less swelling but today, it is notable that swelling is beginning to get bigger ...Daughter instructed on signs and symptoms of infection ...daughter works in healthcare and is placing a call to the wound care clinic to see if antibiotics need to be continued or appt moved forward ..." There was no indication the coordination note was sent to the physician or that the physician was notified of the patient's condition. An SN visit was conducted on 05/17/2021 by LVN A that read in part, " ...Patient has a large wound to his right lower jaw with very large amounts of drainage. Patient has a difficult time changing the bandage due to location of the wound. Wound dressing completely full of drainage and being held on with a face mask. Patient lip is beginning to swell and redness is returning ...Instructed patient that changing the outside bandage was important to help decrease the risk of infection ..." There was no documentation in the EMR to indicate the SN instructed the patient/caregiver to perform wound care or that the patient/caregiver demonstrated competency to perform wound care. There was no indication the physician was notified of the patient's condition. The record included a Client Coordination Note Report dated 05/17/2021 that read in part, " ...Patient has a large wound to his right lower jaw with very large amounts of drainage ...Patient has a difficult time changing bandage ...wound dressing completely full of drainage and being held on with face mask ...lip beginning to swell and redness returning ..." There was no indication the coordination note was sent to the physician or that the physician was notified of the patient's condition. Patient 1 was transferred to the emergency room and hospitalized on 05/18/2021 due to increased drainage to facial wound, wound evaluation and a referral for antibiotics. During an interview with the Adm/Alt DON, DON/Alt Adm, and RN A, on 07/21/2021 at approximately 2:20 PM, the surveyor reviewed the above surveyor findings and asked why the SN did not instruct the patient/caregiver how to perform wound care on the SOC visit on 04/21/2021 and document competency of wound care by the patient/caregiver. RN A stated the SOC SN documentation stated, " ...Skilled nurse to instruct patient/caregiver to perform wound care to r jaw wound. using clean technique as follows ..." The surveyor asked if that documentation meant the SN instructed the patient/caregiver on how to perform wound care. The Adm/Alt DON stated no, the documentation was the SN wound care order that transferred directly from the POC onto all SN notes. The surveyor asked why the agency waited five days following the SOC visit to conduct the next SN visit on 04/26/2021 since wound care instructions were not provided at the SOC visit to the patient/caregiver. The Adm/Alt DON stated the patient had been on service with the agency prior to this admission and that the physician should have been notified. The Adm/Alt DON stated she had no idea and thinks the physician should have been called and Patient 1 needed to be on hospice care. The surveyor asked why LVN A instructed the patient/caregiver on only changing the bandage instead of instructing on the ordered wound care (Cleanse with ns/wound cleanser, Pat dry with gauze, Apply medihoney to fit shape of wound, Cover with abd pad, Secure with medipore tape). The Adm/Alt DON stated it should have been. The surveyor asked why the agency did not notify the physician of Patient 1's condition and obtain orders for additional SN visits following the 11 SN visits made between 04/21/2021-05/17/2021. The Adm/Alt DON reviewed the EMR and stated she did not see where the physician was notified, or additional orders obtained. The surveyor asked if the Client Coordination Note Reports dated 04/26/2021, 05/07/2021, 05/14/2021 and 05/17/2021 were sent to the physician or if the physician was notified following the SN visits. The Adm/Alt DON stated the coordination reports contained a narrative of the SN's visit but were not sent to the physician. The Adm/Alt DON stated she did not see that the physician was notified. Patient 2: Record review of the EMR included a POC for the certification period 04/11/2021 to 06/09/2021 electronically signed by RN D and E on 04/11/2021 with a primary diagnosis of COVID-19 and secondary diagnoses of hypertensive heart disease with heart failure and chronic diastolic congestive heart failure. The POC read in part, " ...Skilled nurse to obtain weight during skilled nurse visit. If weights cannot be obtained, calf circumference/abdominal girth measurements may be obtained ..." An SN SOC visit was conducted on 04/11/2021 by RN D that read in part, " ...Was weight assessed? ...not assessed ..." There was no documentation in the EMR that Patient 2 was weighed, or calf circumference/abdominal girth measurement was obtained. LVN A conducted SN visits on 04/15/2021 and 04/19/2021. There was no documentation in the EMR that Patient 2 was weighed, or calf circumference/abdominal girth measurement was obtained. During an interview with the Adm/Alt DON, DON/Alt Adm, and RN A, on 07/21/2021 at approximately 2:04 PM, the surveyor asked why Patient 2 was not weighed or calf circumference/abdominal girth measurement obtained on 04/11/2021, 04/15/2021 and 04/19/2021. RN A stated, "I see the SOC assessment says not weighed ...It says requires two people to assist in standing ..." The Adm/Alt DON stated it was probably the third week of the episode before Patient 2 was strong enough to weigh. Patient 3: Record review of the EMR included a POC for the certification period 02/02/2021 to 04/02/2021 electronically signed by RN B and E on 02/02/2021 with a secondary diagnosis of hypertensive heart and chronic kidney disease with heart failure and chronic diastolic congestive heart failure. The POC read in part, " ...Skilled nurse to obtain weight during skilled nurse visit. If weights cannot be obtained, calf circumference/abdominal girth measurements may be obtained ..." LVN A conducted SN visits on 02/04/2021, 02/05/2021, 02/12/2021, 02/16/2021, 02/19/2021, 02/26/2021, 03/19/2021 and 03/26/2021. RN B conducted SN visits on 03/05/2021, 03/12/2021 and 04/02/2021. There was no documentation in the EMR that Patient 3 was weighed, or calf circumference/abdominal girth measurement was obtained. During an interview with the Adm/Alt DON, DON/Alt Adm, and RN A, on 07/21/2021 at approximately 2:49 PM, the surveyor asked why Patient 3 was not weighed or calf circumference/abdominal girth measurement obtained on 02/04/2021, 02/05/2021, 02/12/2021, 02/16/2021, 02/19/2021, 02/26/2021, 03/05/2021, 03/12/2021, 03/19/2021, 03/26/2021 and 04/02/2021. The Adm/Alt DON stated she wondered why the weight section did not populate on the SN notes to prompt the nurses to weigh the patient. Agency Policy titled, "ORDERS FOR CARE PC.7" with a revision date of 11/01/2020, read in part, "PURPOSE To ensure patient/client care is provided in accordance with a physician and/or non-physician practitioner order and federal and state laws and regulations. POLICY The Agency will obtain orders and provide care in accordance with physician's and/or non-physician practitioners orders which are established prior to initiating patient/client care ..." Agency Policy titled, "PLAN OF CARE PC.8" with a revision date of 11/01/2020, read in part, "PURPOSE To ensure that care provided is appropriately planned in a timely manner to meet the patient's/client's specific needs and problems ...PROCEDURE ...Each patient/client must receive the home health services that are written in an individualized plan of care ..."

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: THIS IS A CONTINUING DEFICIENCY from survey dated 07/23/2018. Based on record review and interview, the agency failed to develop a POC that covered all required elements for all patients. In one (Patient 4) of one active record reviewed where the patient had an AV shunt and received services from a dialysis facility, the POC failed to include: instructions for the SN/PT to assess the AV access shunt for bruit and thrill, to assess the AV shunt site for signs and symptoms of infection, the dialysis center where the patient received dialysis treatments, the patient's Nephrologist, and safety measures for the renal dialysis access site to include the location of the AV Shunt to ensure no blood pressures were taken from the arm where the shunt was located. This failure placed Patient 4 at risk for infection, bleeding or obstruction of the AV fistulas with complications that could cause a permanent decline in the patients' functional status or death. Findings Include: Definitions: "Dialysis arteriovenous fistula: A surgically created connection between an artery and vein in the arm of patients who need to undergo hemodialysis, a process in which blood is removed from the body, cleansed and then returned to the body." Resource: www.radiologyinfo.org Jan 2021 "A healthy AV fistula has: A bruit (a rumbling sound that you can hear) A thrill (a rumbling sensation that you can feel) Good blood flow rate." Resource: www.azuravascularcare.com 10/18/2018 Patient 4: Record review of the EMR included a POC for the certification period 03/19/2021 to 05/17/2021 electronically signed by RN F and PT A on 03/19/2021 that included a diagnosis of Hypertensive chronic kidney disease with stage 5 chronic kidney disease or ESRD and Dependence on Renal Dialysis. Physician orders included, "... Skilled Nurse to assess/evaluate all co-morbid conditions including ...ESRD ...to identify changes and interventions to minimize complications ..." The POC did not include orders for the SN/PT to assess the AV access shunt for bruit and thrill, to assess the shunt site for signs and symptoms of infection, the dialysis center where the patient received dialysis treatments, the patient's Nephrologist, and safety measures for the renal dialysis access site to include the location of the AV Shunt to ensure no blood pressures were taken from the arm where the shunt was located. An SN visit dated 03/26/2021 was conducted by RN B that read in part, " ...Dependent on Dialysis ...L FA AV shunt with (+) thrill ..." During an interview with the Adm/Alt DON, DON/Alt Adm, and RN A, on 07/21/2021 at approximately 1:40 PM, the surveyor asked why the POC did not include instructions for the SN/PT to assess the AV access shunt for bruit and thrill, to assess the shunt site for signs and symptoms of infection, the dialysis center where the patient received dialysis treatments, the patient's Nephrologist, and safety measures for the renal dialysis access site to include the location of the AV Shunt to ensure no blood pressures were taken from the arm where the shunt was located. The Adm/Alt DON stated, " ...We've had her on service before and I don't know why it isn't on there." Agency Policy titled, "PLAN OF CARE PC.8" with a revision date of 11/01/2020, read in part, "PURPOSE To ensure that care provided is appropriately planned in a timely manner to meet the patient's/client's specific needs and problems ...PROCEDURE ...Each patient/client must receive the home health services that are written in an individualized plan of care ...Procedure...III...A. The individualized plan of care must include the following...11. Safety measures to protect against injury ...14. Patient/client-specific interventions..."

Home health aide assignments and duties CFR(s): 484.80(g)(1) Standard: Home health aide assignments and duties. Home health aides are assigned to a specific patient by a registered nurse or other appropriate skilled professional, with written patient care instructions for a home health aide prepared by that registered nurse or other appropriate skilled professional (that is, physical therapist, speech-language pathologist, or occupational therapist). This STANDARD is not met as evidenced by: THIS IS A CONTINUING DEFICIENCY from survey dated 07/23/2018. Based on record review and interview, the RN failed to prepare written patient care instructions for the hha that included specific directions for the hha in one (Patient 4) of two active patients whose records were reviewed and received hha services. Patient 4 had an AV shunt used for renal dialysis. The hha care plan did not include Patient 4 specific directions regarding safety measures for the renal dialysis access site to include the location of the AV Shunt to ensure no blood pressures were taken from the arm where the shunt was located and signs and symptoms of complications to report to the RN. This failure placed Patient 4 at risk of receiving unsafe and inappropriate care from the hha and could lead to negative outcomes. FINDINGS INCLUDE: Definitions: "Dialysis arteriovenous fistula: A surgically created connection between an artery and vein in the arm of patients who need to undergo hemodialysis, a process in which blood is removed from the body, cleansed and then returned to the body." Resource: www.radiologyinfo.org Jan 2021 "How do I take care of my hemodialysis catheter ...Access arm should not be used to check blood pressure...Redness, swelling, numbness, weakness, bleeding or oozing in ...access arm should be brought to the attention of ...dialysis caregivers immediately ..." Resource: www.azuravascularcare.com 10/03/2017 Patient 4: Record review of the EMR included a POC for the certification period 03/19/2021 to 05/17/2021 electronically signed by RN F and PT A on 03/19/2021 that included a diagnosis of Hypertensive chronic kidney disease with stage 5 chronic kidney disease or ESRD and Dependence on Renal Dialysis. The record included a supplemental physician order dated 03/26/2021 for hha services with a visit frequency of two times a week for four weeks effective 03/28/2021 signed by RN A and PT A. The record included an aide care plan report that read in part, " ...Entered by: [PT A] ...Approved by [RN A] ..." The aide care plan report was not signed or dated. The aide care plan report indicated the hha was to take Patient 4's blood pressure on every visit and report to the supervisor if the systolic blood pressure was lower than 90 or above 150; the diastolic blood pressure was below 50 or above 90; assist with ambulation; turn and position in bed; assist to toilet; bathing (bed/bath); hair, skin, nail and ear care every visit and shampoo and shaving weekly. The aide care plan report did not include specific directions regarding safety measures for the renal dialysis access site to include the location of the AV Shunt to ensure no blood pressures were taken from the arm where the shunt was located and signs and symptoms of complications to report to the RN. The record included hha visits made by hha A on 04/06/21, 04/09/2021, 04/12/2021, 04/16/2021, 04/19/2021, 04/23/2021, 04/29/2021, 04/30/2021, 05/04/2021, 05/07/2021, 05/11/2021 and 05/14/2021 and indicated blood pressure checks and personal care was provided on each visit. During an interview with the Adm/Alt DON, DON/Alt Adm, and RN A, on 07/21/2021 at approximately 1:50 PM, the surveyor asked why the hha care plan did not include safety measures for the renal dialysis access site to include the location of the AV Shunt to ensure no blood pressures were taken from the arm where the shunt was located and signs and symptoms of complications to report to the RN. The Adm stated, "Oh, ok." Agency Policy titled, " IMPLEMENTING CARE AND TREATMENT PC.9" with a revision date of 08/01/2020, read in part, ""PURPOSE to ensure patient care and treatment are provided as identified in the care planning ... PROCEDURE III. The assigned discipline(s) will be provided with information needed to provide patient/client care and treatment ...V. Home Health Aides ...The aide will be provided with written patient/client care instructions ..."