Every finding on record at Caresouth HHA Holdings of Greensboro, LLC

A recertification survey was conducted 10/28/24-10/30/24. No deficiencies to the Emergency Preparedness Plan was identified.

A recertification survey was conducted 10/28/24-1030/24. Standard level deficiencies were identified.

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 and procedure, clinical record review, and staff interview, the registered nurse removed the huber needle without a physician’s order for 1 of 1 records reviewed with an implanted port (medical device that allows for the administration of treatments and blood draws) [3]; and failed to monitor weights and blood sugar levels for 4 of 19 patients [ #5, 7, 13, 19]. Findings included: 2. Patient # 5 had a Start of Care date of 8/7/24 with admitting diagnosis of hemiplegia [paralysis of half of body] following cerebral infarct [stroke] and diabetes with hyperglycemia [high blood sugar]. Review of the Plan of Care [POC] for the certification period 8/7/24-10/5/24 included orders for PT [physical therapy] 1 time a week for 1 week, 2 times a week for 3 weeks, 1 time a week for 1 week, 2 times a week for 2 weeks, 1 time a week for 2 weeks; OT [occupational therapy] 1 time a week for 1 week, 2 times a week for 2 weeks, 1 time a week for 1 week and “Licensed professional to report vital signs falling outside of following established parameters...Weight less than 145 pounds or greater than 155 pounds, FBS [fasting blood sugar] less than 70 and greater than 180, Random blood sugar less than 70 and greater than 180...” Review of the clinical record revealed a weight of 150 pounds at the time of admission. The patient received 3 OT visits from 8/7/24-8/15/24. There were no blood sugar results or weights documented. The patient received 3 PT visits from 8/7/24-8/15/24. The only weight documented was obtained on admission. There were no blood sugar results documented. During an interview with RN # 2 on 10/30/24 at 2:230 pm, the RN confirmed the staff failed to monitor blood sugar levels and weights in accordance with the POC. 3. Patient # 7 had a Start of Care date of 9/14/24 and admitting diagnoses of radiculopathy lumbar region [painful condition that occurs when the nerve roots in the lower back are compressed or irritated] and type 2 diabetes mellitus with diabetic neuropathy [high blood sugars have damaged nerves]. Review of the Plan of Care [POC] for the certification period 9/14/24-11/12/24 included orders for PT [physical therapy] 1 time a week for 1 week, 2 times a week every 2 weeks for 2 weeks, 2 times a week for 4 weeks, 1 time a week for 2 weeks and “ Licensed professional to report vital signs falling outside the following established parameters...weight less than 215 or greater than 225, fasting blood sugar less than 70 or greater than 180, random blood sugar less than 70 or greater than 180...” Review of the clinical record revealed a weight of 220 obtained on 9/14/24. Further review of the clinical record revealed the patient received 8 visits from PT from 9/14/24-10/22/24. There was only 1 weight documented and no blood sugar readings. During an interview with RN # 2 on 10/30/24 at approximately 3 pm, the RN confirmed the clinicians failed to monitor the patient’s weight and blood sugar levels in accordance with the POC. 4. Patient # 13 had a Start of Care date of 12/5/23 and admitting diagnoses of encounter for fitting and adjustment of urinary device, retention of urine, and type 2 diabetes mellitus without complication. Review of the Plan of Care [POC] for the certification period 9/30/24-11/28/24 included orders for SN 1 time a week for 1 week, 1 time every 4 weeks for 8 weeks; PT [physical therapy] 1 time a week for 8 weeks and “ Licensed professional to report vital signs falling outside the following established parameters...Weight less than 235 and greater than 245...FBS [fasting blood sugar] less than 70 or greater than 180, RBS [random blood sugar] less than 70 or greater than 180...” ”Review of the clinical record revealed the patient received 8 visits [between SN and PT] from 10/2/24 and 10/29/24. The clinical record revealed no documented weights or blood sugars. During an interview with RN # 2 on 10/30/24 at approximately 3 pm, the RN confirmed the staff failed to obtain weights/blood sugars in accordance with the POC. 5. Patient # 19 had a Start of Care date of 9/13/23 with admitting diagnoses of hypertensive heart disease with heart failure [group of conditions that can occur when hypertension damages the heart] and chronic systolic heart failure [heart doesn’t pump effectively]. Review of the Plan of Care [POC] for the certification period 9/13/23-11/11/23 included orders for SN [skilled nursing] 1 time a week for 1 week, 2 times a week for 2 weeks, 1 time a week for 6 weeks; PT [physical therapy] effective 9/17/23 1 time a week for 1 week, then 2 times a week for 4 weeks, 1 time a week for 3 weeks; OT [occupational therapy] 1 time a week for 4 weeks, 2 times a week for 1 week and "Licensed professional to report vital signs falling outside the following established parameters...weight less than 156 or greater than 166...” Review of the clinical record revealed an admission weight of 161.2. Further review of the clinical record revealed the patient received 12 visits [between all disciplines] from 9/13/23 -10/12/23. The only weight was documented at the time of admission. During an interview with RN # 2 on 10/30/24 at approximately 3 pm, the RN confirmed the clinicians failed to monitor the patient’s weight in accordance with the POC. A policy “Physician’s role” revised 10/18/23 was provided by the administrator alternate on 10/30/24 at 8:15 AM. The policy stated…” verbal order is an order communicated from the physician prior to rending services…” 1.Patient #3 was admitted on 1/18/24 with diagnosis of malignant neoplasm (cancer) of the brain, fracture (break) of the fibula, and peripheral vascular disease. The plan of care for 1/18/24 to 3/17/24 had orders for skilled nursing 1 time a week for 4 weeks, and physical therapy 1 time a week for 1 week, 2 times a week for 3 weeks, and 1 time a week for 3 weeks. Review of the skilled nursing admission visit 1/18/24 on 10/28/24 revealed the registered nurse documented removing the huber needle from the implanted port per patient request. No physician’s order was in the record to remove the needle. Interview with the agency director on 10/31/24 at 3:01PM revealed, “she did pull the needle and didn’t think to get a doctor's order”.

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 clinical record review and staff interviews the agency failed to notify the physician prior to educating a patient to increase fluid intake [diagnosis of congestive heart failure] for 1 of 1 patients [#2]; and failed to notify physician when a patient reported the home was infested with bugs for 1 of 1 patients [#9]. The findings included: 1. Patient # 2 had a Start of Care [SOC] date of 5/30/24 and admitting diagnoses of type 2 diabetes with hypoglycemia [low blood sugar] without coma and acute systolic (congestive) heart failure [heart does not pump effectively. Review of the Plan of Care [POC] for the certification period 5/30/24-7/28/24 included orders for PT [physical therapy] 1 time a week for 1 week, 2 times a week for 4 weeks. Review of the clinical record revealed PT # completed the SOC visit on 5/30/24. Review of the clinical record revealed the following documentation,”...urine dark in urinal. Encouraged increased fluid intake...” There was no evidence the PT notified the physician before educating the patient to increase fluid intake [dx of CHF]. During an interview with RN # on 10/30/24 at approximately 2:30 pm, the RN confirmed the PT should have notified the MD prior to educating the patient to increase fluid intake. 2. Patient # 9 had a Start of Care date of 10/1/24 with an admitting diagnosis of sepsis [infection in the blood], type 2 diabetes mellitus with heart failure and stage 1-4 unspecified chronic kidney disease, and chronic combined systolic and diastolic heart failure [heart does not pump effectively]. Review of the Plan of Care [POC] for the certification period 10/1/24-11/29/24 included orders for OT [occupational therapy] 1 time a week for 1 week [initial visit], 1 time a week for 1 week, 2 times a week for 1 week, 1 time a week for 1 week. Review of the clinical record revealed OT # 4 completed the initial OT evaluation on 10/9/24 and documented, “...The client reports that it [apartment] is bug infested, but that her family cannot get approved for anything [likely due to the fact that she admitted they had failed to pay the rent for several months in a row]. The client is currently sleeping in a non-reclining chair...” On 10/23/24, COTA # 5 documented “evidence of infestation by insects or rodents.” There is no evidence that the physician was notified by the OT or COTA related to bug infestation. During an interview with RN # 2 on 10/30/24 at approximately 2:15 pm, RN # stated, “OT did not tell the physician because the presence of bugs was reported by the patient. They did not assess for any bug infestation.”

Infection Prevention CFR(s): 484.70(a) Standard: Infection Prevention. The HHA must follow accepted standards of practice, including the use of standard precautions, to prevent the transmission of infections and communicable diseases. This STANDARD is not met as evidenced by: Based on agency policy, home visit observation, and staff interviews, the RN failed to perform hand hygiene prior to entering the nursing bag and failed to place the documentation device on a clean barrier when not in use for 1 of 2 nursing home visits. The findings included: The policy, Bag/equipment technique [no date], was provided by RN # 1 on 10/30/24 at 8:15 am. The policy stated, “ …The clinical bag and related equipment will be used in accordance with the following directions...The inside pouches of the bag must be kept clean at all times and will not be entered into until hands are thoroughly cleaned...Remove a minimum of 2 barriers from the bag to be used for clean and dirty fields...Open bag and remove all items needed for the visit. Items are to be placed on the clean barrier...” Patient # 13 had a Start of Care date of 12/5/23 and admitting diagnoses of encounter for fitting and adjustment of urinary device, retention of urine, and type 2 diabetes mellitus without complications. Review of the Plan of Care for the certification period 9/30/24-11/28/24 included orders for SN [skilled nursing] 1 time a week for 1 week, 1 time every 4 weeks for 8 weeks and “Skilled nurse for insertion of foley catheter using catheter # 18...Skilled nurse to change Q [every] month ...” On 10/29/24 at approximately 11:30 am a joint visit was conducted with RN # 3. During the visit, the RN was observed putting clean barriers on a spare bed in the patient’s bedroom. The RN then placed her device [used for documentation] directly on the bed, not on the barrier. The RN was then observed entering the nursing bag without performing hand hygiene to retrieve the hand sanitizer which was in the center portion of the bag, not in a side pocket. During an interview with the RN on 10/29/24 at approximately 2 pm, the RN stated, “I should have put the device on the barrier. I was so nervous. I normally keep my sanitizer in the side pocket.”

An unannounced, onsite complaint investigation was conducted 5/22/23. The allegations were substantiated and standard level deficiencies were cited to the Medicare CoP.

Written notice for non-covered care CFR(s): 484.50(c)(8) Receive proper written notice, in advance of a specific service being furnished, if the HHA believes that the service may be non-covered care; or in advance of the HHA reducing or terminating on-going care. The HHA must also comply with the requirements of 42 CFR 405.1200 through 405.1204. This ELEMENT is not met as evidenced by: Based on agency policy, clinical record review and staff and caregiver interviews, the agency failed to give proper notification prior to discharging 1 of 3 discharged patients [#1]. The findings included: The policy, Transfer or Discharge From services [revised 7/2019], was provided by Clinical Manager # 3 on 5/22/23 at approximately 12:12 pm. The policy stated, “…Discharge is the discontinuation of agency services to a client when that client’s needs have been met or can no longer be met in the homecare setting…The agency plans and prepares for the client’s discharge…When considering discharge of the client from services, the appropriate licensed professional notifies the client or responsible party and the attending physician…The agency will deliver the generic notice (a prescribed CMS notice) to the patient or authorized representative no less than two days prior to the end of the covered period…The appropriate licensed professional obtains an order for discharge or documents physician notification and provides discharge instructions…" Patient # 1 had a Start of Care [SOC] date of 3/10/23 with admitting diagnoses of Alzheimer’s Disease and Vascular Dementia [problems with reasoning, planning, judgment, memory and other thought processes caused by brain damage from impaired blood flow to the brain]. Review of the Plan of Care [POC] for the certification period 3/10/23 to 5/8/23 included orders for Physical Therapy [PT] 1 time a week for 1 week, 2 times a week for 1 week, 1 time a week for 1 week and Occupational Therapy [OT] 1 time a week for 1 week. A supplemental order was written on 3/12/23 for OT 1 time a week for 4 weeks. Review of the OT evaluation dated 3/17/23 revealed OT # 1 documented the patient would benefit from ADL [activities of daily living] retraining, home exercise program, caregiver education and adaptive equipment retraining. The clinical record revealed a missed OT visit on 3/23/23. COTA [occupational therapist assistant] # 2 made a routine visit on 3/28/23. Review of the visit note dated 3/28/23 revealed the following documentation, “Pt [patient] continues to demo [demonstrate] ADL [activities of daily living] deficits with bathing and dressing task …” On 4/7/23, OT # 1 discharged the patient with "goals met". Review of the clinical record revealed no evidence the patient/caregiver received the required written notice prior to the discharge. An interview was conducted with the caregiver on 5/22/23 at approximately 1:15 pm. During the interview, the caregiver stated, “I didn’t have a clue my husband was discharged from home health until the doctor called me. They just didn’t come back.” During an interview with the agency administrator on 5/22/23 at approximately 3:15 pm, the administrator confirmed the patient was discharged without any discharge notice.

Document complaint and resolution CFR(s): 484.50(e)(1)(ii) (ii) Document both the existence of the complaint and the resolution of the complaint; and This ELEMENT is not met as evidenced by: Based on clinical record review and staff and caregiver interviews, the agency failed to document the existence and resolution of a complaint for 1 of 1 patients [#1]. The findings included: Patient # 1 had a Start of Care [SOC] date of 3/10/23 with admitting diagnoses of Alzheimer’s Disease and Vascular Dementia [problems with reasoning, planning, judgment, memory and other thought processes caused by brain damage from impaired blood flow to the brain]. Review of the Plan of Care [POC] for the certification period 3/10/23 to 5/8/23 included orders for Physical Therapy [PT] 1 time a week for 1 week, 2 times a week for 1 week, 1 time a week for 1 week and Occupational Therapy [OT] 1 time a week for 1 week. A supplemental order was written on 3/12/23 for OT 1 time a week for 4 weeks. Review of the clinical record revealed a missed OT visit on 3/23/23. COTA [occupational therapist assistant] # 2 made a routine visit on 3/28/23. Review of the visit note dated 3/28/23 revealed the following documentation: “Pt [patient] continues to demo [demonstrate] ADL [activities of daily living] deficits with bathing and dressing task…” The patient was discharged by OT # 1 on 4/7/23 with goals met. An interview was conducted with the caregiver on 5/22/23 at approximately 1:15 pm. During the interview, the caregiver stated, “I didn’t have a clue my husband was discharged from home health until the doctor called me. They just didn’t come back. About a week later, someone from the office called me to ask if I was pleased with the services we had received from home health. I told him under no circumstances was I pleased, and I was very vocal about the service. I went into great detail about the way my husband was treated, and how the therapist never came back, and we didn’t know he had been discharged until the doctor called me. They [agency] told the doctor we were noncompliant and wouldn’t answer the phone. That is completely untrue.” Review of the agency complaint log revealed no entry related to patient # 1. During an interview with the agency administrator on 5/22/23 at approximately 3:15 pm, the administrator confirmed the staff member [marketing] should have notified someone in the office so the concerns voiced by the caregiver could have been logged in the complaint log and been followed up on.

Discharge and transfer summaries CFR(s): 484.110(a)(6)(i-iii) (i) A completed discharge summary that is sent to the primary care practitioner or other health care professional who will be responsible for providing care and services to the patient after discharge from the HHA (if any) within 5 business days of the patient's discharge; or (ii) A completed transfer summary that is sent within 2 business days of a planned transfer, if the patient's care will be immediately continued in a health care facility; or (iii) A completed transfer summary that is sent within 2 business days of becoming aware of an unplanned transfer, if the patient is still receiving care in a health care facility at the time when the HHA becomes aware of the transfer. This ELEMENT is not met as evidenced by: Based on agency policy, clinical record review and staff interviews, the discharge summary failed to include accurate information related to the patient's goals for 1 of 3 patients [#1]. The findings included: The policy, Clinical Record [revised 5/23/22], was provided by Clinical Manager # 3 on 5/22/23 at approximately 12:12 pm. The policy stated, “…Clinical record is the compilation of the patient’s total home health care, related documentation of the care delivery process, and contains pertinent past and current findings…Discharge summary is a summary of pertinent facts of the patient’s care and progress documented in the clinical record … reason for discharge…” Patient # 1 had a Start of Care [SOC] date of 3/10/23 with admitting diagnoses of Alzheimer’s Disease and Vascular Dementia [problems with reasoning, planning, judgment, memory and other thought processes caused by brain damage from impaired blood flow to the brain]. Review of the Plan of Care [POC] for the certification period 3/10/23 to 5/8/23 included orders for Physical Therapy [PT] 1 time a week for 1 week, 2 times a week for 1 week, 1 time a week for 1 week and Occupational Therapy [OT] 1 time a week for 1 week. A supplemental order was written on 3/12/23 for OT 1 time a week for 4 weeks. Review of the clinical record revealed on 3/23/23, PT discharged the patient from PT services with goals met. Review of the OT evaluation dated 3/17/23 revealed OT # 1 documented the patient would benefit from ADL [activities of daily living] retraining, home exercise program, caregiver education and adaptive equipment retraining. Patient # 1 received a routine visit on 3/28/23 by COTA [occupational therapy assistant] # 2. COTA # 2 documented, ”Therapy Assessment-Pt [patient] continues to demo [demonstrate] basic ADL deficits with bathing and dressing task...Pt would benefit from continued OT services to max [maximize] functional potential.” On 4/7/23, OT # 1 completed a non-visit discharge [OT # 1 stated there was no answer when she attempted to schedule a visit on 4/7/23]. Further review of the clinical record revealed a discharge summary was not completed until 4/17/23. During an interview with the agency administrator on 5/22/23 at approximately 3 pm, the administrator confirmed the discharge summary was not completed within the required time frame.

An onsite recertification survey was conducted 4/4/22-4/6/22. No deficiencies to the Emergency Preparedness Plan was identified .

A recertification survey was conducted April 4, 2022-April 6, 2022. An Immediate Jeopardy was identified beginning on March 4, 2022 and cited at G718—Communication with all physicians involved in the plan of care. The agency was notified of the Immediate Jeopardy on April 5, 2022 at 9:38 a.m. and the Immediate Jeopardy Template was provided. The Immediate Jeopardy was abated on April 6, 2022 with an acceptable Allegation of Compliance. Deficient practice remained at a lower level with condition and standard level non-compliance. Patient #5 was admitted on 3/4/22 post-acute stroke. Patient also had a history of urinary retention. The patient had orders for speech therapy services (ST). During the ST evaluation coughing with eating and drinking was noted. Patient/caregiver complained of “food getting stuck in throat.” ST recommended Modified Barium Swallow Study (MBSS) for further evaluation. The physician was not notified of the need for the Modified Barium Swallow Study. Additionally, on 3/7/22, the patient began to present ongoing signs/symptom of a possible urinary tract infection (UTI). An order for skilled nursing to evaluation urinary symptoms was obtained, but there was no notification to the physician of the ongoing urinary symptoms. On 3/20/22, the patient was admitted to the hospital with diagnoses of “Severe sepsis secondary to UTI and pneumonia.”

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 agency policy, clinical record review and interviews with patients and staff the Plan of Care [POC] failed to include all the current/correct medication/doses the patient was taking for 4 of 6 virtual visits conducted [# 6, 7, 8 and 10]; failed to include a frequency for wound care for 2 of 9 records with a wound [# 4 and 17]. The findings included: 5. Patient #8 was admitted on 3/3/21 with diagnoses of pressure ulcer of left buttock, stage 4, and paraplegia. The Plan of Care (POC) for 2/26/22-4/26/22 included orders for skilled nursing (SN) visits weekly for nine weeks. A virtual home visit was conducted on 4/5/22 at 1:30 p.m. In an interview with the patient during the visit, the following medication discrepancies were identified: POC order-Baclofen 20 mg 1 tablet 4 times per day for muscle spasms. The patient stated she was taking every 5 hours (5 times per day) and had taken this dose for “a long time”POC order-Docusate Sodium 100 mg daily. The patient stated she was taking twice day and had taken this dose for “a long time”POC order-Lasix 40 mg daily for fluid. The patient stated she was taking ½ tab twice daily and had taken this dose for “a long time.” The prescription bottle in the home was dated 2/12/22.POC order-Senna lax 8.6 mg daily for constipation. The patient stated she was taking twice day and had taken this dose for “a long time”The patient stated she was also taking Lyrical 75 mg two times daily for 1-2 years. This was omitted from the POC. An interview was conducted with RN #5 on 4/6/22 at 9:20 a.m. The RN stated, “I ask about med [medication] changes each visit. I did go over meds at recert [recertification], but I did not get the bottles out. I should have gotten the bottles out.” Patient #10 had a Start of Care [SOC] 03/15/2022. Diagnoses on the Plan of Care [POC] 03/15/2022 to 05/13/2022 included Essential (Primary) Hypertension, Difficulty in walking, not elsewhere classified. Physical Therapy [PT] was ordered 2 times per week for 3 weeks, 1 time per week for 5 weeks. A virtual home visit was conducted on 04/05/2022 at 10:00 a.m. with PT #19 present. A review of medications in the home revealed the patient was on Amlodipine (Norvasc) 2.5 mg tablets, 1 tablet every day [used to treat high blood pressure and chest pain], and Refresh eye drops OTC [over the counter] as needed for [dry eye relief]. The patient reported taking Amlodipine for “a long time” and Refresh eye drops “a few times a week.” Amlodipine and Refresh eye drops were omitted from the Plan of Care. Other medication discrepancies identified in the POC include the following: The Aspirin Low Dose [per patient was being taken as blood thinner] 81 mg [milligram] tablet. In an interview with the patient during the home visit, the patient stated, “I stopped taking Aspirin Low Dose [03/15/2022] when Eliquis was ordered [03/15/2022].” Azelastine [used to treat allergic itching of the eyes.] 137 mcg [microgram] 0.1 percent Nasal spray aerosol, Nasal 1 puff 2 times daily, patient reported she “only takes as needed.” During the virtual home visit with PT #19 present in the patient’s home on 04/05/2022 at 10:00 a.m., it was confirmed all current medications were not included in the Plan of Care. The policy, Physician’s Role [reviewed date 10/8/21], was provided by the agency administrator on 4/6/22 at 10 am. The policy stated, “…Plan of care is a written plan developed with the participation of professional staff and the patient, in consultation with and authorized by the physician…The plan includes all pertinent diagnoses, mental status, types of services and equipment required, frequency and duration of visits…medications, treatments…” 1. Patient # 6 had a Start of Care [SOC] date of 2/14/22 with admitting diagnoses of Encounter for Orthopedic aftercare Following Surgical Amputation, Acquired Absence of Right Leg Below Knee and Type 2 Diabetes Mellitus with Diabetic Neuropathy. A review of the Plan of Care [POC] for the certification period 2/14/22 to 4/14/22 revealed orders for SN [skilled nursing] 1 time a week for 5 weeks. On 4/5/22 at approximately 10 am a virtual visit was conducted with LPN #2. During the visit a medication review was conducted using a Client Medication Report provided by the agency. The following discrepancies were noted: The medication report listed Methocarbamol [muscle relaxer] 750 mg. Take 1 tablet 2 times per day with a start date of 12/6/21 and Cyclobenzaprine [muscle relaxer] 10 mg. Take 1 tablet 3 times per day with a start date of 2/8/22. During an interview with patient # 6 on 4/5/22, the patient reported, “I am not taking those medicines anymore. One of them was when I was on home health before. I haven’t taken either in some time.” During the virtual visit the patient produced presented a bottle of Protonix [gastric reflux] 40 mg with a start date of 2/21/22 on the bottle with the following directions: Take 1 pill 30 minutes before breakfast. The medication report did not include the Protonix. During an interview with LPN # 2 on 4/6/22 at 8:45 am the LPN confirmed the POC did not include the medications the patient was using. 2. Patient # 7 had a Start of Care [SOC] date of 12/3/21 with admitting diagnoses of Encounter for Change or Removal of Nonsurgical Wound Dressing, Other Complications of Procedures, Type 1 Diabetes with Diabetic Peripheral Angiopathy without Gangrene and Type 1 Diabetes Mellitus with Hyperglycemia. A review of the Plan of Care [POC] for the certification period 4/2/22 to 5/31/22 revealed orders for SN [skilled nursing] 1 time a week for 9 weeks. On 4/5/22 at approximately 8:30 am a virtual visit was conducted with LPN # 4. During the virtual visit a medication review was conducted using a Client Medication Report provided by the agency. The following discrepancies were noted: The medication report listed Oxycodone-Acetaminophen [pain medication] 5 mg-325 mg. Take 1 tablet every 4 hours with a start date of 12/3/21. During a review with the patient, he reported, “I may have taken 1 or 2 of those when I first got out of the hospital back in December. I don’t even have the bottle.” During the interview with the patient, he presented a bottle of Amlodipine [blood pressure] with a start date of 2/23/22. The directions on the bottle were: Take 1 tablet every day. The Client Medication Report did not list the Amlodipine. The patient also presented a bottle of Novolog [insulin] with the following directions: 3 times per day using sliding scale. During the interview the patient recited a sliding scale for the following blood sugar readings: 151-200 take 10 units, 201-250 take 11 units, 251-300 take 12 units, 301-350 take 13 units, 351-400 take 14 units. For a blood sugar over 400 take 14 units. The patient reported he had been using the sliding scale for Novolog for “several months”. The Novolog was not included on the Client Medication Report. During an interview with LPN # 4 on 4/6/22 at approximately 9:10 am, the LPN stated, “I know I am supposed to look at the medications each visit but I always ask if the patient is on any new medications or if the medications have changed since the last visit even if I don’t look at the bottles.” On 4/6/22 at approximately 12 noon an interview was conducted with the agency administrator. During the interview the administrator stated, “Medications are supposed to be reviewed each visit by looking at each bottle.” The administrator confirmed the POC did not include the correct/current medications the patient was taking. 3. Patient # 4 had a Start of Care [SOC] date of 2/20/22 and an admitting diagnosis of Cutaneous Abscess of Left Lower Limb and Infection/Inflammation Reaction due to Other Cardiac/Vascular Device/Implanted/Graft. A review of the Plan of Care [POC] for the certification period 2/20/22 to 4/20/22 revealed orders for SN [skilled nursing] 4 times a week for 1 week, 3 times a week for 7 weeks, 1 time a week for 1 week and “…Skilled nurse to perform/teach wound care to left lower back. Cleanse with normal saline. Pat dry with gauze. Cover with gauze and secure with tape, using clean/aseptic technique. Cg [caregiver] may perform in SN absence…” There was no frequency for wound care included on the POC. [RN # 13-the nurse who obtained the order was not available for interview]. An interview was conducted with the agency administrator on 4/6/22 at approximately 12 noon. During the interview the director confirmed the POC did not include a frequency for wound care. 4. Patient # 17 had a Start of Care [SOC] date of 2/14/21 and admitting diagnoses of Pressure Ulcer of Sacral Region, Stage 4, Urinary Tract Infection, site not specified and Type 2 Diabetes Mellitus without Complications. A review of the Plan of Care [POC] for the certification period 2/14/21 to 4/14/21 revealed orders for SN [skilled nursing] 4 times a week for 1 week, 3 times a week for 7 weeks, 1 time a week for 1 week and “Cleanse Stage 4 pressure ulcer to sacrum with normal saline or wound cleanser, apply calcium alginate into wound bed, cover with foam bandage…” There was no frequency for which the dressing changes should be done on the POC. [RN # 12- the nurse who obtained the order was not available for interview]. An interview was conducted with the agency administrator on 4/6/22 at approximately 12 noon. During the interview the administrator confirmed there was no frequency for which the dressing to the sacrum should be done.

Conformance with physician orders CFR(s): 484.60(b) Standard: Conformance with physician or allowed practitioner orders. This STANDARD is not met as evidenced by: Based on clinical record review and staff interviews the agency failed to follow physician’s orders related to wound care for 1 of 9 records with a wound [# 1 ]; failed to follow the physician’s order related to pressure setting for a wound vac for 1 of 1 record with a wound vac [#4],failed to notify the physician when vital signs/blood sugars fell outside the given parameters for 1 of 9 records with a diagnosis of Diabetes [# 14]. The findings included: 1. Patient # 1 had a Start of Care [SOC] date of 3/6/22 and admitting diagnoses of Encounter for Orthopedic Aftercare Following a Surgical Amputation, Acquired Absence of Right Foot and Type 2 Diabetes Mellitus with Diabetic Chronic Kidney Disease. A review of the Plan of Care [POC] for the certification period 3/6/22 to 5/4/22 revealed orders for SN [skilled nursing] 2 times a week for 2 weeks, 1 time a week for 7 weeks. A supplemental order was written on 3/23/22 to “Discontinue all wound care orders. Patient to wash amputated site daily and apply a sock…” A review of the clinical record revealed RN # 12 made a routine visit on 4/1/22. Further review of the clinical record revealed the following documentation by RN # 10, “Dressing changed to his right foot where he has an [sic]surgical open area that is healing…” RN # 10 was not available for an interview. An interview was conducted with the agency administrator on 4/6/22 at approximately 12 noon. During the interview the administrator confirmed the dressing to the right foot was discontinued on 3/23/22 and the RN did not follow the physician’s order related to application of a sock to the site. 2A. Patient # 4 had a Start of Care [SOC] date of 2/20/22 and an admitting diagnosis of Cutaneous Abscess of Left Lower Limb and Infection/Inflammation Reaction due to Other Cardiac/Vascular Device/Implanted/Graft. A review of the Plan of Care [POC] for the certification period 2/20/22 to 4/20/22 revealed orders for SN [skilled nursing] 4 times a week for 1 week, 3 times a week for 7 weeks, 1 time a week for 1 week and “…Skilled nurse to perform/teach wound care to left lower back. Cleanse with normal saline. Pat dry with gauze. Cover with gauze and secure with tape, using clean/aseptic technique. Cg [caregiver] may perform in SN absence…” A review of the clinical record revealed LPN # 2 made routine visits on 2/21/22, 2/23/22, 3/4/22, 3/7/22, 3/9/22, 3/18/22, 3/21/22 and 3/25/22. Further review of the clinical record revealed the LPN documented she did not complete the wound care to the back as ordered. The LPN documented the patient refused care or the patient completed the care. There is no evidence the LPN notified the physician the dressing to the back was not completed in accordance with the POC. An interview was conducted with LPN # 2 on 4/6/22 at approximately 8:45 am. During the interview the LPN confirmed she did not notify the physician the dressing to the back was not changed in accordance with the POC. Further review of the clinical record revealed LPN # 4 completed routine visits on 3/8/22 and 3/14/22. A review of the visit notes for those dates revealed LPN # 4 did not complete the wound care but documented, “Patient completed wound care…” There is no evidence the LPN notified the physician that she did not complete the wound care in accordance with the physician’s orders. During an interview with LPN # 4 on 4/6/22 at 9:05 am, LPN # 4 confirmed she did not notify the physician the wound care was not completed. 2B. Patient # 4 had a Start of Care [SOC] date of 2/20/22 and an admitting diagnosis of Cutaneous Abscess of Left Lower Limb and Infection/Inflammation Reaction due to Other Cardiac/Vascular Device/Implanted/Graft. A review of the Plan of Care [POC] for the certification period 2/20/22 to 4/20/22 revealed orders for SN [skilled nursing] 4 times a week for 1 week, 3 times a week for 7 weeks, 1 time a week for 1 week and “Skilled nurse to cleanse wound to left groin normal saline [sic]. Prepare peri-wound area with skin prep. Fill entire cavity with foam. Apply tubing and cover with transparent drape. Apply negative pressure device at 125 mmHg continuously. Change dressing tree times weekly…” A review of the referral information dated 2/16/22 revealed the following orders, “…wound vac 3 times per week at 100 mm/Hg continuous pressure…” Further review of the clinical record revealed there was no evidence the nurse contacted the physician to clarify the amount of pressure. RN # 13 [completed the Start of Care visit and initiated the wound vac] was not available for interview. An interview was conducted with the agency director on 4/6/22 at approximately 12 noon. During the interview the director confirmed the referral indicated the pressure should be at 100mm/Hg. 3A. Patient # 14 had a Start of Care [SOC] date of 12/2/21 and admitting diagnoses of Cutaneous Abscess to Left Lower Limb, Other Acute Osteomyelitis, Left Ankle and Foot, and Type 2 Diabetes Mellitus with Hyperglycemia. A review of the Plan of Care [POC] for the certification period 12/2/21 TO 1/30/22 revealed orders for SN [skilled nursing] 1 time a week for 1 week, 2 times a week for 1 week, 1 time a week for 7 weeks and “SN to perform/teach wound care to rash to buttocks daily. Cleanse with soap and water, apply barrier cream…cg [caregiver] to perform in SN absence…” A review of the clinical record revealed RN # 5 made a routine visit on 12/22/21. A review of the visit note revealed the following findings “Wound 4- coccyx-rash- wound care not provided: not ordered this visit…” During an interview with RN # 5 on 4/6/22 at approximately 9:20 am she confirmed she did not complete the wound care in accordance with the physician’s order. 3B. Patient # 14 had a Start of Care [SOC] date of 12/2/21 and admitting diagnoses of Cutaneous Abscess to Left Lower Limb, Other Acute Osteomyelitis, Left Ankle and Foot, and Type 2 Diabetes Mellitus with Hyperglycemia. A review of the Plan of Care [POC] for the certification period 12/2/21 TO 1/30/22 revealed orders for SN [skilled nursing] 1 time a week for 1 week, 2 times a week for 1 week, 1 time a week for 7 weeks and “Licensed professionals to report vital signs falling outside the following parameters…FBS [fasting blood sugar] less than 60 or greater than 300 and RBS [random blood sugar] less than 60 or greater than 350…” A review of the clinical record revealed RN # 5 made a routine visit on 12/22/21. A review of the visit note revealed RN # 5 documented the patient’s blood sugar readings for the past 2 weeks had ranged from 47-high. There was no evidence the RN notified the physician of the blood sugar readings in accordance with the POC. An interview was conducted with RN # 5 on 4/6/22 at approximately 9:20 am. During the interview the RN confirmed she did not notify the physician of the blood sugar readings. The RN stated, “I just figured he already knew.”

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 and procedure, clinical record review, and staff interview, the agency failed to obtain orders for disimpaction for 1 of 1 patients that required disimpaction (#8); failed to obtain orders for wound care for 1 of 9 records with wounds [#6]. Findings include: Patient #6 was admitted on 02/14/2022 with diagnoses of Encounter for orthopedic aftercare following surgical amputation, Acquired absence of right leg below knee, Type 2 diabetes mellitus with diabetic neuropathy, Atherosclerotic heart disease of native coronary artery without angina pectoris ( a disease caused by consistent high levels of bad cholesterol in the blood that lead to the buildup of plaque on the walls of the arteries), and peripheral vascular disease (a slow and progressive circulation disorder.) A review of the Plan of Care (POC) for the certification period 02/14/2022 to 04/14/2022 revealed Skilled nursing (SN) 1 time per week for 5 weeks; Physical Therapy (PT) 2 times per week for 4 weeks, 1 time per week for 3 weeks. In a clinical review of the Home health referral orders from the hospital dated 02/08/2022 the wound care read “see order attached.” The plan of care did not include any wound care orders. The “Orders of Discipline and Treatments” at Start of Care (SOC) for PT states, “PT will provide ongoing monitoring for … treatment regimen… PT will develop plan of care in coordination with interdisciplinary care team.” Orders at SOC for SN states “skilled nurse to evaluate patient and develop plan of care to be counter signed by the physician… skilled nurse to perform a comprehensive assessment and evaluate need for home health services. Plan of care developed in coordination between agency staff, physician, and patient… Skilled nurse to asses/ evaluate co-morbid conditions including …recent amputation…” In review of the PT documentation on the SOC “Oasis (Outcome and Assessment in formation set it the patient-specific, standardized assessment used in Medicare home health care to plan care, determine reimbursement, and measure quality.) data collection visit note, Integumentary assessment” it was noted the patient had “ulcers/wounds present.” Also, under Integumentary assessment, “Does this patient have a surgical wound?” the PT documented “surgical wound known but not observable due to non-removable dressing/device.” Documentation of nursing evaluation visit on 02/15/2022 reported “objective findings, stump incision is open to air with staples in place...” SN assessment 02/22/2022, 02/24/2022, 03/04/2022, “examination of skin reveals no abnormal findings.” A clinical record review of SN visit assessments 02/24/2022, 03/04/2022 and 03/24/2022 revealed the SN provided wound care without evidence of wound care instructions. SN documentation on 02/24/2022 states, “SN assessed surgical incision to right BKA (below the knee amputation). Moderate amount of bloody drainage noted… SN applied dry dressing to site.” On 03/04/2022 documentation states, “Bloody drainage noted…wife applied new dressing to right residual limb.” On 03/24/2022 documentation states, “Right stump incision…bloody drainage on gauze. SN cleansed area, applied gauze and ABD, applied shrinker.” An interview with agency administrator on 04/06/2022 at 12:30 confirmed the agency did not have the order for wound care. A policy and procedure, “Fecal impaction removal, digital” revised 11/18/21, was provided by the agency director on 4/6/22 at 12:40 p.m. The procedure stated, “Verify the practitioner’s order.” 1. Patient #8 was admitted on 3/3/21 with diagnoses of pressure ulcer of left buttock, stage 4, and paraplegia. The Plan of Care for 2/26/22-4/26/22 included orders for skilled nursing (SN) visits weekly for nine weeks. On 3/22/22, RN #5 conducted a home visit. The visit note stated, “SN disimpacted client and was able to get a large hard stool out of rectum. In an interview with RN #5 on 4/6/22 at 9:20 a.m., the RN asked, “Is an order required [for disimpaction]?" The RN confirmed she did not have an order for disimpaction.

Infection Prevention CFR(s): 484.70(a) Standard: Infection Prevention. The HHA must follow accepted standards of practice, including the use of standard precautions, to prevent the transmission of infections and communicable diseases. This STANDARD is not met as evidenced by: Based on clinical record review, observation during a virtual visit and staff interviews the agency failed to change gloves [practice proper hand hygiene] when doing a dressing change for 1 of 3 visits [#7] with a dressing change. The findings included: Patient # 7 had a Start of Care [SOC] date of 12/3/21 with admitting diagnoses of Encounter for Change or Removal of Nonsurgical Wound Dressing, Other Complications of Procedures, Type 1 Diabetes with Diabetic Peripheral Angiopathy without Gangrene and Type 1 Diabetes Mellitus with Hyperglycemia. A review of the Plan of Care [POC] for the certification period 4/2/22 to 5/31/22 revealed orders for SN [skilled nursing] 1 time a week for 9 weeks and “SN to perform/teach wound care to right foot. Cleanse with wound cleanser. Pack with saline moist to dry gauze. Cover with dry gauze. Wrap with rolled gauze and ace wrap daily. CG [caregiver] to perform in nurses [sic] absence.” On 4/5/22 at approximately 8:30 am a virtual visit was conducted with LPN # 4. During the virtual visit, LPN # 4 completed a dressing change to the patient’s right foot. During the dressing change, LPN # 4 was observed applying gloves to obtain vital signs. After obtaining the patient’s vital signs, LPN # 4 gathered her clean dressing supplies using the same gloved hands as obtaining vital signs. The LPN then removed the old dressing, completed hand hygiene and applied clean gloves. The LPN then proceeded to measure the wound and then obtained a pack of 4x4’s from the box containing the clean packs of 4x4’s. The LPN opened the 4x4’s and cleaned the wound, then using the same gloved hands obtained more 4x4s from the clean box of supplies. The LPN was noted getting clean 4x4’s out of the box while wearing the same gloves on 3 separate occasions while doing the dressing change. An interview was conducted with LPN # 4 on 4/6/22 at approximately 9:10 am. During the interview the LPN reported, “I thought about that after I had already done the dressing change. I should have gotten all the packs of 4x4’s I needed out of the box instead of reaching back into the box each time I needed one.”

Skilled professional services CFR(s): 484.75 Condition of participation: Skilled professional services. Skilled professional services include skilled nursing services, physical therapy, speech-language pathology services, and occupational therapy, as specified in §409.44 of this chapter, and physician or allowed practitioner and medical social work services as specified in §409.45 of this chapter. Skilled professionals who provide services to HHA patients directly or under arrangement must participate in the coordination of care. This CONDITION is not met as evidenced by: Findings include: Based on policy review, clinical record review, infection report, hospital records, staff interview, licensed staff failed to coordinate care with the physician and other interdisciplinary staff for 5 of 18 records reviewed (#5, 15, 17, 18, and 1). Cross refer to 484.47(b)(7) tag G718 and 484.75(b)(1) G706

Interdisciplinary assessment of the patient CFR(s): 484.75(b)(1) Ongoing interdisciplinary assessment of the patient; This ELEMENT is not met as evidenced by: Based on clinical record review and staff interview, the agency failed to coordinate care between disciplines for 2 of 18 patients (#5, 17). Findings include: 1. Patient #5 was admitted on 3/3/22 with diagnoses including dysphagia (difficulty swallowing) following cerebrovascular disease, hemiplegia following cerebral infarction affecting left side (paralysis after a stroke), essential hypertension (high blood pressure), and type 2 diabetes. The Plan of Care (POC) for 3/4/22-5/2/22 included orders for speech therapy (ST) one time for one week, twice weekly for four weeks, then weekly for four weeks. On 3/10/22, orders obtained for skilled nursing weekly for four weeks. Patient #5 received a speech therapy (ST) visit on 3/7/22. The ST noted “Spouse and son reports patient has slept minimally across past 3 days. He had diarrhea last night with no further occurences [sic]. Family reports he was up all night urinating with darker (“orangy” [sic]) colored urine…Patient exhibits possible signs of UTI [urinary tract infection] including frequent trips to the bathroom and discolored urine. Patient’s son have [sic] already left voicemail with PCP’s office [primary care provider] and hope to schedule an appointment tomorrow for follow up or take patient to urgent care. Family was encouraged to contact HH [home health] agency with any changes to patient’s status...Education with spouse and son regarding recommendations for contacting MD regarding concerns for UTI or urgent care. Son called PCP office during visit. Staff was unavailable to take call therefore son left message and plans to call again tomorrow.” On 3/9/22, the ST conducts another visit. The patient’s temperature was 99.7. The note stated, spouse “…reported frequent trips to the bathroom”…continues to present with symptoms concerning for UTI as evidenced by family report of increased urination frequency. Order has been placed for skilled nursing to assess this week.” A Coordination Note by the ST stated, “____ (triage nurse) was also made aware of patient’s signs and symptoms of UTI. On 3/10/22, RN #5 conducted the initial assessment. The note stated, “Spouse reported “He’s been peeing on himself now”. Also states “He doesn’t want to do anything.”…Spouse reports new onset of urinary incontinence beginning Sunday 3/13/22. Patient displays overal [sic] demeanor concerning for depression. Question if incontinence episodes could be related toward lack of motivation for personal care.” There was no evidence that the speech therapist notified skilled nursing of the urinary symptoms. An interview with ST #11 on 4/4/22 at 3:10 p.m. confirmed the ST did not communicate with nursing related to the urinary symptoms. 2. Patient #17 was admitted on 5/2/21 with a diagnosis of cerebral infarction. The Plan of Care for 5/2/21-6/30/21 included orders for Physical Therapy (PT) three times for one week, then two times per week for five weeks; and Occupational Therapy one-time visit. PT #18 conducted the initial visit on 5/2/21. The assessment identified the patient was “unable to afford prescribed medications…unable to afford basic necessities.” The intervention stated, “Will follow-up with MSW [medical social work] consult/evaluation for further assessment as needed. On 5/27/22, the physical therapy assistant (PTA) visited the patient. The visit note stated, “PTA assigned cg [caregiver] to purchase SPC [single point cane]. An interview with the agency director on 4/6/22 at 11:20 a.m. confirmed there was no evidence that the PT consulted the medical social worker or that the PT reported to the PTA the patient was unable to afford “basic necessities.”

Communication with physicians CFR(s): 484.75(b)(7) Communication with all physicians involved in the plan of care and other health care practitioners (as appropriate) related to the current plan of care; This ELEMENT is not met as evidenced by: Based on policy review, clinical record review, infection report, hospital records, staff interviews, the agency failed to notify the physician of the need for further testing for 1 of 1 patient’s with swallowing problems; failed to notify the physician of signs or symptoms related to possible urinary tract infection for 4 of 4 patients with urinary symptoms (#5, 15, 17, and 18); failed to notify the physician the patient needed a refill on blood thinner for 1 of 1 patient’s admitted to the agency post stroke (#5); and failed to contact the physician for a medical social consult for 1 of 1 patients with documentation that were unable to afford basic necessities (#17). Immediate Jeopardy was identified beginning on 4/4/22 and abated on 4/6/22 with an acceptable credible allegation of compliance. Findings include: 4A. Patient # 18 had a Start of Care [SOC] date of 2/14/21 and admitting diagnoses of Pressure Ulcer of Sacral Region, Stage 4, Urinary Tract Infection and Type 2 Diabetes Mellitus without Complications. A review of the Plan of Care [POC] for the certification period 2/14/21 to 4/14/21 revealed the following orders SN [skilled nursing] 2 times a week for 1 week, 3 times a week for 4 weeks, 2 times a week for 1 week. A review of the ROC [resumption of care] visit note completed by RN # 14 revealed the patient was readmitted with a foley catheter [no size was documented]. Further review of the ROC orders revealed the following order, “Skilled nurse to instruct patient/caregiver on indwelling urinary catheter management including care of foley catheter, signs and symptoms of perineal care, tube and bag placement.” There was no evidence the physician was contacted to obtain orders related to changing the foley catheter. A review of the clinical record revealed RN # 15 made a PRN [as needed] visit to assess the patient on 3/20/21 after the patient contacted the on-call nurse with complaints of nausea and vomiting. RN # 15 documented the following information, “Subjective: [Patient/caregiver statements]-My stomach was hurting this morning and there wasn’t any urine in the catheter. Then I threw up and my stomach felt better, and some urine came out. The doctor put my catheter in at the hospital. The nurse was not able to get it in…No order found for catheter change. Slightly cloudy urine noted in the catheter bag, approximately 150 cc. Noted that peri-area needed cleaning. Lots of residue noted in peri area. Macular rash to groin area. Peri care performed and tubing milked. Urine flow continued. Approximately 300 cc noted in bag prior to RN departure…” Further review of the clinical record there was no evidence the RN made any attempts to contact the physician related to the patient’s condition. A review of the on-call coordination note dated 3/20/21 [no time] revealed the following documentation by RN #16, “Call from patient’s cg [caregiver]. He reports earlier his mother’s catheter came out and the nurse put it back in. However, it looks like there is red like puss [sic] coming out of it instead of urine. She also has a fever of 102 with chills…I spoke with ______ [name of RN # 15] who stated she did not change the catheter and that it was draining when she was there…” A review of the clinical record revealed the patient was admitted to ______ [name of the hospital] on 3/20/21 with a diagnosis of Sepsis due to urinary tract infection. RN # 15 was not available for interview. An interview was conducted with the agency’s administrator on 4/6/22 at approximately 12 noon. During the interview the administrator confirmed there was no evidence the physician was notified of the nurse’s findings and the RN should have contacted the MD. 4B. Patient # 18 had a Start of Care [SOC] date of 2/14/21 and admitting diagnoses of Pressure Ulcer of Sacral Region, Stage 4, Urinary Tract Infection, site not specified and Type 2 Diabetes Mellitus without Complications. A review of the Plan of Care [POC] for the certification period 2/14/21 to 4/14/21 revealed orders for SN [skilled nursing] 4 times a week for 1 week, 3 times a week for 7 weeks, 1 time a week for 1 week and “Cleanse Stage 4 pressure ulcer to sacrum with normal saline or wound cleanser, apply calcium alginate into wound bed, cover with foam bandage…”A review of the clinical record revealed RN # 12 completed the admission on 2/14/21. A review of the visit note report for 2/14/21 revealed the following documentation: “Wound measurements 5.3 cm x 8.4 cm x 2.6 cm with 1 cm undermining at 3-6 o’clock and 1.6 cm undermining at 6-9 o’clock…Will contact MD on Monday request [sic] wound vac…” There was no evidence the RN contacted the MD regarding placement of a wound vac. RN # 12 was not available for interview. An interview was conducted with the agency administrator on 4/6/22 at approximately 12 noon. During the interview the administrator confirmed the RN failed to contact the physician related to a possible wound vac. Further review of the clinical record revealed LPN # 2 made a routine visit on 3/3/21. A review of the SN visit note revealed the following documentation, “Subjective [Patient/Caregiver Statements]- The visit with Dr. _____ [name] went good. He said he ordered me some more colostomy supplies. He also said he put in for a wound vac and a Hoyer lift…” A review of the clinical record revealed no evidence the LPN contacted the MD regarding follow up for a wound vac or the Hoyer lift. No wound vac had been ordered for patient # 18 at the time of discharge from the agency on 3/10/21. An interview was contacted with LPN # 2 on 4/6/22 at approximately 8:45 am. During the interview the LPN confirmed she did not contact the MD related to the conversation with the patient regarding the wound vac or Hoyer lift. 5. Patient # 1 had a Start of Care [SOC] date of 3/6/22 and admitting diagnoses of Encounter for Orthopedic Aftercare Following a Surgical Amputation, Acquired Absence of Right Foot and Type 2 Diabetes Mellitus with Diabetic Chronic Kidney Disease. A review of the Plan of Care [POC] for the certification period 3/6/22 to 5/4/22 revealed orders for SN [skilled nursing] 2 times a week for 2 weeks, 1 time a week for 7 weeks. A review of the clinical record revealed LPN # 7 made a routine visit on 3/14/22. Further review of the clinical record revealed the following documentation by LPN # 7. “…Blister noted to shin of LLE [left lower extremity]. Bandaid [sic] placed on area…” There was no evidence the LPN contacted the physician to inform him of the blister. An interview was conducted with LPN # 7 on 4/6/22 at approximately 10:05 am. During the interview the LPN confirmed she did not notify the physician. She reported, “No, I didn’t inform the physician, I may have forgotten.” A policy, “Coordination of services” revised 10/8/21, was provided by the agency director on 4/6/22 at 10:15 a.m. The policy stated, “Professional staff coordinate services with the physician. Staff…Develop the plan of care in consultation with the physician, the patient, and/or family and others involved in care of the patient as appropriate…Promptly alert the physician to any changes which suggest a need to modify the plan of care…Review the plan of care with the physician…as often as the severity of the patient’s condition requires… 1A. Patient #5 was admitted on 3/3/22 with diagnoses including dysphagia (difficulty swallowing) following cerebrovascular disease, hemiplegia following cerebral infarction affecting left side (paralysis after a stroke), essential hypertension (high blood pressure), and type 2 diabetes. The Plan of Care (POC) for 3/4/22-5/2/22 included orders for speech therapy (ST) one time for one week, twice weekly for four weeks, then weekly for four weeks. The ST POC stated, “ST will provide ongoing monitoring for changes in health status, treatment regimen, and medication regimen; and will report clinically significant problems to the physician. ST will develop plan of care in coordination with interdisciplinary care team, physician, and patient…ST will provide treatment for dysphagia...” The POC also included orders for skilled nursing effective the week of 3/6/22 weekly for four weeks—“RN to evaluate client for needs requiring physician orders and skilled nursing interventions.” Safety precautions listed on the POC included aspiration precautions and dysphagia. A Coordination Note on 3/3/22 stated, “Welcome call completed…Son reports, “I’m glad yall [sic] called because I had a hard time getting his medicines in him this morning. He’s acting a like he’s having trouble swallowing and he’s choking a little. He’s sleeping a lot too.” ___ informed son that ST would eval tomorrow.” ST #11 conducted the initial assessment on 3/4/22. The “Dysphagia Assessment” revealed the patient was “coughing while eating/drinking” and the patient/caregiver had “complaint of food or drink “getting stuck in throat”.” The “Therapy/Assessment/Plan stated, “Bedside swallow evaluation revealed signs and symptoms of oropharyngeal dysphagia. Oral deficits can be characterized by increased oral residue, decreased oral coordination. Son reports patient occasionally spits out food thus suggesting possible sensory deficits. Pharyngeal deficits unremarkable, however son reports occasional coughing with intake and complaints [sic] “I can’t get it down”. Recommend ST intervention for ongoing assessment and treatment of dysphagia symptoms and caregiver education. Modified barium swallow study is recommended to further assess. Without ST intervention, ________[patient name] is at risk for aspiration, pneumonia related to aspiration, and nutrition and hydration concerns.” On 3/7/22, ST #11 conducted a home visit. The visit note stated, “Coughing while eating/drinking” and “Throat clearing while eating/drinking.” The note also stated, “He displayed no overt s/sx [signs or symptoms] of aspiration with consumption of easy to chew consistencies and thin liquids. Delayed throat clear was noted x1 after about 2 minutes post swallows. Son reports symptoms of coughing while drinking water and also expressed patient consumes liquids all at once without stopping which may attribute to coughing episodes. Recommend modified barium swallow study to further evaluate. Family and patient in agreement. Will send order request to physician.” On 3/9/22, the ST conducted another visit. The ST stated the “verbal orders received from ___ with Dr. ___ office for ST POC…Plan to request order for modified barium swallow study to further evaluation oropharyngeal swallow function.” There was no evidence that the modified swallow study was requested. On 3/17/22, ST #11 conducted a visit and stated, “Spouse also reports no overt s/sx of aspiration or swallowing difficulty. This was consistent with report during previous session as well [3/15/22]. At this timem [sic], modified barium swallow study does not appear clinically indicated…” A Coordination Note on 3/18/22 stated, “CG [caregiver] called office reporting he tried feeding patient this afternoon and as soon as he put food in his mouth, patient started coughing. CG denies fever, denies SOB [shortness of breath]. Reports is [sic] a dry hacking cough that started today.” A request was made for ST to call the caregiver. The ST called on 3/18/22. The note stated, “Spoke with patient’s son regarding concerns with increased coughing both with and without PO [oral] intake. Patient’s son stated, “He’s just coughing all the time” and frequently states he is cold even though they increased heat within the home. He denied other cold/flu symptoms including no fever, SOB, nausea, vomiting. Son described cough as non-productive and occurring most frequently without presence of food/liquid…suggested taking at-home COVID test…” On 3/20/22, the son called the ST to notify that the patient was at the hospital with a blood sugar greaten than 310, hallucinations, incontinence, and worsening chills. On 3/21/22, RN #5 documented the patient had gone to the hospital via EMS and was admitted. The agency provided the hospital discharge summary dated 3/25/22. The discharge summary stated the patient was admitted to the hospital on 3/20/22 with diagnoses of “Severe sepsis secondary to UTI and pneumonia.” This discharge summary also stated, “On 3/21/2022 afternoon progressed to respiratory failure, hypoxic on room air, was placed on 2 [liters of oxygen] increased to 6 L of oxygen via nasal cannula…” The chest x-ray on 3/21/22 stated “Increasing density as the left lung base behind the heart may reflect developing pneumonia perhaps due to aspiration.” The Modified Barium Swallow Study on 3/23/22 stated, “towards the endo of the study one episode of TRACE aspiration (small amount of the penetrates were not cleared during the swallow)…question Pt’s [patient’s] swallowing being negatively impacted by fatigue and if frequency of aspiration may increase over the course of/toward then [sic] end of an entire meal…” Nectar thickened liquids were recommended. Blood cultures on 3/20/22 showed “GRAM POSITIVE RODS AEROBIC BOTTLE.” An interview with ST #11 on 4/4/22 at 3:10 p.m. confirmed the Modified Barium Swallow Study was never requested. 1B. Patient #5 received a speech therapy (ST) visit on 3/7/22. The ST noted “Spouse and son reports patient has slept minimally across past 3 days. He had diarrhea last night with no further occurences [sic]. Family reports he was up all night urinating with darker (“orangy” [sic]) colored urine…Patient exhibits possible signs of UTI [urinary tract infection] including frequent trips to the bathroom and discolored urine. Patient’s son have [sic] already left voicemail with PCP’s office [primary care provider] and hope to schedule an appointment tomorrow for follow up or take patient to urgent care. Family was encouraged to contact HH [home health] agency with any changes to patient’s status...Education with spouse and son regarding recommendations for contacting MD regarding concerns for UTI or urgent care. Son called PCP office during visit. Staff was unavailable to take call therefore son left message and plans to call again tomorrow.” On 3/9/22, the ST conducts another visit. The patient’s temperature was 99.7. The note stated, spouse “…reported frequent trips to the bathroom”…continues to present with symptoms concerning for UTI as evidenced by family report of increased urination frequency. Order has been placed for skilled nursing to assess this week.” A Coordination Note by the ST stated, “____ (triage nurse) was also made aware of patient’s signs and symptoms of UTI. On 3/10/22, RN #5 conducted the initial assessment. The visit note identified urinary incontinence and also stated the patient was to follow up with a “urologist for urination issues.” On 3/15/22, LPN #4 conducted a visit. Urinary incontinence was noted and the narrative stated, “Subjective…I have a follow up appointment with primary care on 28th [sic]. They are getting me a referral to urologist.” On 3/15/22, the ST visited and documented a temperature of 99.7. The note stated, “Spouse reported “He’s been peeing on himself now”. Also states “He doesn’t want to do anything.”…Spouse reports new onset of urinary incontinence beginning Sunday 3/13/22. Patient displays overal [sic] demeanor concerning for depression. Question if incontinence episodes could be related toward lack of motivation for personal care.” The agency director provided an Infection Report on 4/4/22 at 4:00 p.m. The Infection Report was completed by the ST on 3/7/22 and included the following: “Suspected Site of Infection: Urinary…Signs/Symptoms: Dark concentrated urine…Seen By Physician… N/A…Other Status: Son left voicemail for PCP…” The agency provided the hospital discharge summary dated 3/25/22. The discharge summary stated the patient was admitted to the hospital on 3/20/22 with diagnoses of “Severe sepsis secondary to UTI and pneumonia.” This discharge summary also stated, “On 3/21/2022 afternoon progressed to respiratory failure, hypoxic on room air, was placed on 2 [liters of oxygen] increased to 6 L of oxygen via nasal cannula…” A urine culture collected on 3/20/22 showed greater than 100,000 colonies of Klebsiella Pneumoniae.” Blood cultures on 3/20/22 showed “GRAM POSITIVE RODS AEROBIC BOTTLE.” An interview with ST #11 on 4/4/22 at 3:10 p.m. revealed the ST left a message with the physician’s office to obtain a nursing evaluation due to symptoms of UTI. There was no further communication regarding the persistence of urinary symptoms. An interview with RN #5on 4/4/22 revealed, “The main issue that day was his doctor’s office had not refilled his Plavix.” The nurse also stated, she “could not recall” if the patient of caregiver had complained of urinary symptoms during the 3/10/22 visit. But the nurse stated, “When I spoke to his son the night before the next visit, the son said he was having some incontinence.” 1C. On 3/10/22 RN #5 conducted a visit. The RN obtained orders to visit weekly for four weeks. On the visit the RN identified the patient did not have his Plavix (blood thinner). “Son states he has been off his Plavix for 1 week because he [sic] PCP [primary care physician] will not fill it or call him back.” The RN called the physician’s office during the visit and the physician sent a prescription for Plavix to the pharmacy. Son was instructed to pick up the medication. There was no evidence that agency staff contacted the physician regarding the lack of Plavix prior to 3/10/22. An interview with Speech Therapist (ST) #11 (the admitting clinician) was conducted on 4/4/22 at 3:10 p.m. The ST stated, “There was one medicine they couldn’t get…I think the nurse documented it…I don’t recall calling the doctor about it (Plavix). 2. Patient #15 was admitted on 2/11/21 with a diagnosis of dementia. The Plan of Care for 2/11/21-___ included orders for skilled nursing visits weekly for seven weeks. The patient resides in an assisted living facility. On 2/17/21, LPN #17 conducted a visit. The visit noted stated, “She just finished up an ABT [antibiotic] for UTI [urinary tract infection]. Her urine still smells a little.” LPN #17 conducted the next visit on 2/24/21. The genitourinary assessment identified “hematuria” [blood in the urine]. The visit note stated that a caregiver reported, “She just finished up a [sic] ABT for UTI, but her urine still smells. She bleeds when she urinate [sic]. She sticks tissue up their [sic].” The visit note revealed the nurse called the physician’s office to report urine, but had not received a call back during the visit. On 2/25/21, a clinical note stated, “CAN YOU PLEASE FAX OVER ORDERS TO COLLECT A UA/CS [urinalysis with culture and sensitivity] DT [due to] URINE ABNORMALITIES ON NEXT VISIT. CALLED MD [physician] OFFICE YESTERDAY AND LEFT A MESSAGE NO ONE RETURNED A CALL BACK.” On 3/3/21, the LPN conducted a visit. The caregiver reported, “The only thing is her urine still smells, she [sic] been bleeding. She put tissue in her private part [sic]. The LPN notified ___NP and obtained orders for urinalysis with culture and sensitivity and collected the specimen during the visit. During the 3/9/21 LPN visit, the patient was noted to have begun antibiotic for urinary tract infection on 3/2/21. There was no evidence the nurse had notified the physician of the foul-smelling urine on 2/17/21. There was no evidence the nurse had attempted to notify the physician between 2/25/21 and 3/3/21. An interview with the agency director on 4/6/22 at 10:00 a.m. revealed the nurse should not have waited until the next visit (between 2/24/21 and 3/3/21) to call the physician and obtain a urine specimen. 3A. Patient #17 was admitted on 5/2/21 with a diagnosis of cerebral infarction. The Plan of Care for 5/2/21-6/30/21 included orders for Physical Therapy (PT) three times for one week, then two times per week for five weeks; and Occupational Therapy one-time visit. PT #18 conducted the initial visit on 5/2/21. The genitourinary assessment revealed “no abnormal findings…” On 5/6/21, PT #18 conducted a home visit. The visit note stated, “Patient is having some burning with urination. Took a UA to MD and awaiting results.” There was no evidence that PT followed up with the physician regarding urine specimen. There was no further mention of UTI symptoms until 6/8/21. On 6/8/21, the physical therapy assistant documented, “Per patient’s wife____ “____[patient’s name] eurologist [sic], put him on an antibiotic for a UTI on Saturday 6/5, he had some burning when he urinated, but no temperature, but his BP [blood pressure] went up…” The patient was discharged on 6/11/21. An interview with the agency director on 4/6/22 at 11:00 a.m. confirmed there was no evidence of follow-up with the physician related to urinary symptoms identified on 5/6/21. 3B. Patient #17 was admitted on 5/2/21 with a diagnosis of cerebral infarction. The Plan of Care for 5/2/21-6/30/21 included orders for Physical Therapy (PT) three times for one week, then two times per week for five weeks; and Occupational Therapy one-time visit. PT #18 conducted the initial visit on 5/2/21. The assessment identified the patient was “unable to afford prescribed medications…unable to afford basic necessities.” The intervention stated, “Will follow-up with MSW [medical social work] consult/evaluation for further assessment as needed. There was no evidence that the physician was notified of the inability to afford medications and basic necessities; or that a medical social work consult was requested from the physician. In an interview with the agency director on 4/6/22 at 11:20 a.m., the director stated, the PT should “Notify the doctor and see about a social work consults to see if there are available option.” The director confirmed there was no evidence of follow-up with the physician. Credible Allegation of Compliance The plan of correcting the specific deficiency. The plan should address the processes that lead to the deficiency cited. Surveyors arrived on site for survey. Upon review of the charts the surveyor identified an issue with the clinical record on patient #5 admitted to services on 3/4/22 post-acute MCA stroke with a history of urinary retention. In reviewing the record a credible allegation which lead to notification of an Immediate Jeopardy situation related to the home health agency failure to adhere to agency’s policy and procedures and non-compliance with Condition G700 Skilled Professional Services; Standard G718 Communication with all physicians involved in the plan of care. Agency received referral for S.T. services and admitted patient on 3/4/22. Upon admission the speech therapist noted that she recommended a Modified Barium Swallow Study for further evaluation. There is no documentation that the speech therapist communicated her findings and recommendations for the MBSS with the physician. No orders were obtained. The speech therapist performed a visit on 3/7/22 and again recommended a MBSS and stated she would send the request. There is no documentation that request for MBSS was ever submitted to the physician. There is also documentation that the patient had been up most of the night and experienced dark orange urine and that the son was concerned about a potential UTI. The speech therapist noted that the patient’s son had called and left a message with the primary care physician to see about a visit with the PCP or need to take patient to urgent care. There is no documentation that the speech therapist notified the physician or the agency R.N. about signs and symptoms of UTI. The speech therapist performed a visit on 3/9/22 and noted that the patient needed a MBSS and she would submit the request to the physician. The speech therapist also noted that patient was continuing to exhibit signs of a U.T.I. The speech therapist noted in a coordination note that she had communicated with the physician’s triage nurse about the symptoms of a potential UTI. An orders was received for skilled nursing to evaluate due to symptoms of UTI. There is no documentation that the speech therapist coordinated with the agency R.N regarding symptoms of a UTI. The speech therapist did not follow policy and procedure for coordination of care with the physician or the care team regarding the need for a MBSS nor the symptoms of a UTI. The skilled nurse performed an evaluation visit on 3/10/22 and did not identify any signs/symptoms of a UTI but noted that the patient was to follow up with physician on urinary issues. On 3/15/22 the speech therapist performed a visit and documented that the family stated he was no “peeing on himself”. There is no documentation that the speech therapist notified either the physician or the R.N. The speech therapist did state that the MBSS was no longer clinically indicated. 3/15/22 the skilled nurse performed a visit and did not identify any signs and symptoms of a UTI. There is documentation that the patient had an appointment scheduled with the PCP for the 28th and that the PCP was obtaining a referral with an urologist. On 3/18/22 the family communicated that the patient was having a continual cough with or without intake and was complaining of being cold. Denied any fever. Speech therapist reviewed safe swallowing strategies with son and recommended he do a Covid test. There is no documentation of coordination with the physician or the care team. Patient was subsequently admitted to the hospital on 3/21/22 with a diagnosis of severe sepsis related to pneumonia and UTI. The procedure for implementing the acceptable plan of correction for the specific deficiency cited; The Administrator has completed an individual disciplinary action with the Speech Therapist regarding care of the patient and has reviewed requirements for coordination of care with the physician, coordination with care team and medication reconciliation. The Speech Therapist received counseling regarding this matter on 4/5/22 Administrator has scheduled Speech Therapist to complete education module on Dysphagia and Safe Swallowing strategies within by 4/5/22.Administrator will provide additional education to the S.T. on policy S02 Admission and Assessment to the Speech Therapist by 4/5/22. Speech Therapist will not be allowed to perform Admission Assessments until successful completion of an on-site supervisory visits by agency approved clinicians. The Administrator has implemented additional education with all FT and PRN licensed staff on policy SO2 Admission/Assessment, S05 Coordination of services, SO6 Role of the Physician and SO7 Medications. Education to be completed for all fulltime and prn staff on 4/5 and 4/6/22. Staff returning from PDO or PRN employees who are not scheduled to work this week will not be scheduled for any patient visits until education is completed. All staff to complete education and training by 4/12/22. The Administrator will complete an individual counseling with the R.N. who performed the skilled nursing evaluation. Counseling will be focused on S05 Coordination of care with focus on requirement to coordinate care with other disciplines within the home by 4/6/12.Administrator will implement a chart review on 100% of all patients currently receiving multiple skilled services with focus of audit to be SO5 Coordination of Services, SO6 Role of the Physician and S07 Medication Reviews for the next 30 days. Agency Administrator or designee will follow up individually with any employee who has incomplete documentation regarding care coordination, medication reconciliation and/or physician notification and provide additional education and/or disciplinary action up to and including termination. Administrator will implement additional training modules for 100% of all licensed clinicians on Medication Profile and Care Coordination to be completed by all licensed clinicians with a score of 100% by 4/7/22. Any PRN or employees on PDO will not be assigned patient visits until education is complete. Agency Administrator will perform onsite skill check off visits with 100% of all licensed field clinicians who perform admission visits to be completed by 5/4/22.Agency Administrator will assign additional modules for 100% of Speech Therapy field clinicians on Oropharyngeal Swallowing Precautions and employees will not be scheduled patient visits until education is completed. Education to be completed by 4/12/22. Monitoring procedure to ensure that the plan of correction is effective and that specific deficiency cited remains corrected and/or in compliance with the regulatory requirements;Agency Administrator will implement utilize of a Post Admission Recertification Call (PARC) coordination note on 100% of all new admissions. All clinicians performing admission visits will be required to contact the Agency Branch or Clinical Team Leader to review the findings of the initial assessment and required coordination of care with physician and/if required coordination of care has been completed for a period of 30 days. Once 100% compliance is achieved agency will continue to monitor 50% of admissions visits quarterly for a period of 1 year. Results to be reported to the QAPI team quarterly for review and recommendation.Agency Administrator implemented chart audits for 100% of clients receiving multiple skilled services to be completed within 30 days with focus on SO5 Coordination of Services, SO6 Role of the Physician and SO6 Medication reviews. Once the audits have identified 100% compliance. Agency Administrator will implement additional audits for the remainder of the year with 30% of patients receiving multiple skilled disciplines in quarter 1 then if compliance is maintained audits will be decreased to 20% quarter 2 and if ongoing compliance is maintained audits will be deceased to 10% of all patients receiving skilled care from multiple disciplines to 10% for the remainder of the year. If compliance is not maintained ongoing education and or disciplinary action will be implemented up to and including termination if indicated. Results of audits to be reported quarterly to the QAPI team for review and recommendations. Agency Administrator will ensure that licensed PT/ST/OT/RN new hires receive onsite supervisory visits to perform skills checklist on assessment skills quarterly for a period of 1 year with results reported to the QAPI team quarterly. The title of the person responsible for implementing the acceptable plan of correction. Agency Administrator.