Every finding on record at Caresouth HHA Holdings of Western Carolina, LLC

An onsite recertification survey was conducted 07/08/2025-07/09/2025. No deficiencies to the Emergency Preparedness Program were identified.

An onsite recertification survey was conducted 07/08/2025-07/09/2025. Deficiencies to the Medicare Conditions of Participation were identified.

A review of all current medications CFR(s): 484.55(c)(5) A review of all medications the patient is currently using in order to identify any potential adverse effects and drug reactions, including ineffective drug therapy, significant side effects, significant drug interactions, duplicate drug therapy, and noncompliance with drug therapy. This ELEMENT is not met as evidenced by: Based on observation, clinical record review, and patient interviews, the agency failed to review all current medications for 1 of 5 home visits conducted (#2) Findings include Patient #2 was admitted on 05/21/2025 with diagnoses of parkinson’s disease and essential hypertension. The Plan of Care (POC) for 05/25/25-07/19/25 included the following orders: physical therapy 1 time a week for 3 weeks. A home visit was conducted on 07/08/2025 at 1300 with the physical therapist assistant. A review of current medications was conducted with the patient during the home visit. The review revealed the following discrepancy: Carbidopa 25 mg(milligram) -Levodopa 100 mg ER (extended release) take 2 tablets 4 times daily (medicine for parkinson’s disease) was not included on the medication list. Interview with the patient on 07/08/2025 at 1319 revealed, “I’ve been taking the medicine for 2 years”.

Communication with all physicians CFR(s): 484.60(d)(1) Standard: Coordination of Care. The HHA must: (1) Assure communication with all physicians or allowed practitioners involved in the plan of care. This ELEMENT is not met as evidenced by: Based on agency policy and procedure, clinical record review, and staff interview the agency failed to coordinate care with the physician regarding a reported fall for 1 of 1 patients with a history of parkinson's disease (#2). Findings include: A procedure “QI event-occurrences”, was received from the director of operations on 07/09/2025 at 1325. The procedure stated, “…physician notification is necessary for all occurrences…”. Patient #2 had a SOC (start of care) of 05/21/2025 and included diagnoses of parkinson’s disease and essential hypertension. Review of the skilled nurse visit for 06/25/2025 revealed Patient #2 had reported a fall to the nurse. No documentation was in the record of a documented incident report or that the physician was notified of the fall. Interview with the branch director on 07/09/2025 at 1259 confirmed no documentation is in the record for an incident report, or reporting the fall to the physician.

An unannounced complaint investigation was conducted on 2/5/24. A deficiency to the Medicare Conditions of Participation was identified. The complaint was substantiated.

Communication with all physicians CFR(s): 484.60(d)(1) Assure communication with all physicians or allowed practitioners involved in the plan of care. This ELEMENT is not met as evidenced by: Based on agency policy review, clinical record review, and staff interview the agency failed to notify the physician of a non-admission for 1 of 3 records reviewed (#1). Findings included: On 02/05/2024 at 10:02 a.m. the policy, “Non-Admit Procedure” with a revised date of 02/03/2023 was provided by the branch director. The policy stated, “if a referred patient is not going to be admitted for service for reasons such as…this can be accomplished as long as the physician has been contacted…”. Clinical record review revealed a referral was received on Patient #1 01/02/2024 with orders for start of care for 01/08/2024. Review of coordination note on 01/08/2024 by the registered nurse noted that patient’s wife and son requesting skilled nursing placement and patient agreeable. Patient is non home health appropriate, notified branch director and sales team. No additional documentation is in the record that the physician was notified of the non-admission. Interview with the branch director on 02/05/2024 at 10:23a.m. revealed, " I don’t see any documentation that the physician was notified of the non-admit

An onsite recertification survey was conducted 7/18/22-7/20/22. No deficiencies to the Emergency Preparedness Plan were identified.

An onsite, unannounced recertification survey was conducted 7/18/22-7/20/22. Standard level deficiencies to the Medicare CoP were identified.

Content of the comprehensive assessment CFR(s): 484.55(c) Standard: Content of the comprehensive assessment. The comprehensive assessment must accurately reflect the patient's status, and must include, at a minimum, the following information: This STANDARD is not met as evidenced by: Based on clinical record review and staff interviews the agency failed to complete a skilled nursing assessment for wound care within a reasonable time frame for 1 of 13 patients with a wound [#23]. The findings included: Patient #23 was referred to the home health agency on 6/23/22 with a need for physical therapy and wound care and a discharge diagnosis of “wound care.” The patient was admitted on 6/24/22 with diagnoses of open wound to left buttock that required wound care and multiple sclerosis (a disease that affects the central nervous system). The Plan of Care (POC) for 6/24/22-8/22/22 included orders for physical therapy one time per week for one week, two times per week for two weeks, then one time per week for one week; and skilled nursing visits effective 6/26/22 one time weekly for two weeks, twice weekly for six weeks, the one time for one week. On 6/29/22, the nurse attempted to conduct the evaluation visit, but the caregiver declined the visit. The skilled nurse evaluation visit was conducted on 6/30/22. The visit note stated, “Has wounds on buttocks. Hospital wanted pt [patient] to stay in inpt [inpatient] rehab for an extended amount of time but both pt and wife did not want that. Hospital did not send home much wound care supplies. Wife has been using what she has on hand…Pt is bedridden. Skin breakdown and wound noted on whole bottucks [sic]…Pt has impaired integumentary [skin] system r/t [related to] wounds on buttocks requiring SN for wound care…” The visit note did not provide a description of the wound. An interview with the branch director on 7/20/22 at 4:20 p.m. revealed that there was no clarification why nursing did not evaluate the patient until 6/30/22 for wound care services as ordered in the referral.

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 staff interviews the agency failed to include oxygen on the Plan of Care [POC] for 2 of 2 patients with oxygen ordered [#9, 21]; dose/units of insulin to be given for 1 of 6 discharged records [#22];list a latex allergy for 1 of 1 patient with a latex allergy [#1]; list the correct route of administration for for an intravenous medication for 1 of 1 patient with intravenous medication [#8]; list the frequency of wound care for 1 of 13 patients with a wound. The findings included: 4) Patient # 1 was referred to home health on 6/22/22. The referral documentation included a list of patient allergies, which included a latex allergy. Patient #1 had a Start of Care date of 6/25/22 and a diagnosis of Hemiplegia (paralysis of one side of the body) following cerebral infarction (occurs as a result of disrupted blood flow to the brain) affecting [the] left nondominant side. A review of the Plan of Care (POC) for the certification period 6/25/22 to 8/23/22 revealed orders for a Skilled nurse 1 time per week for 9 weeks and Physical therapy for 1 time per week for 1 week; 3 times per week for 1 week; 2 times per week for 3 weeks and 1 time per week for 2 weeks. The POC did not include latex as an allergy. In an interview with the branch director on 7/19/22 at 3:56pm, verified that latex was not listed on the POC. 5A. Patient #8 had a start of care date of 5/29/22 and a diagnosis of infection following a procedure, deep incisional surgical site. A review of the plan of care for the certification period 5/29/22 through 7/27/22 included orders for skilled nursing 3 times per week for 8 weeks; 2 times per week for 1 week. A prescription was written for an antibiotic, Cefazolin 2 gram IV [intravenous] every 8 hours. The POC listed the route of administration as an injection instead of intravenous. In an interview on 7/19/22 at 2:02pm, staff member # 8 verified that the antibiotic was being administered IV push. 5B. Patient #8 had a start of care date of 5/29/22 and a diagnosis of infection following a procedure, deep incisional surgical site. The plan of care for the certification period 5/29/22 through 7/27/22 included orders for skilled nursing 3 times per week for 8 weeks; 2 times per week for 1 week. The POC also included wound care orders for skilled nurse to “perform/teach wound care to incision/sutures located right 3rd toe, cleanse with wound cleanser, apply xeroform. Cover with gauze, kerlix and coban using clean/aseptic technique.” Patient #8's Plan of Care for 5/29/22 through 7/27/22 included wound care as follows, “ skilled nurse (SN) to cleanse wound to right top middle foot with wound cleanser… change dressing every M, W, F ( Monday, Wednesday and Friday) and skilled nurse to perform/teach wound care to incision/suture site located right 3rd toe…” There was no frequency for wound care to right 3rd toe listed on the POC. An interview on 7/19/22 at 2:02pm with staff member #8 stated, the staff member stated “… I am assuming it is 3 times per week [ wound care].” The branch manager verified in an interview on 7/19/22 at 3:29pm that “no frequency was listed (on the POC). 3. Patient #21 was admitted on 6/30/22 with diagnoses of chronic obstructive pulmonary disease (a lung disease) and dependence on supplemental oxygen. The Plan of Care (POC) for 6/30/22-8/28/22 included orders for skilled nursing one time per week for two weeks, one time every other week for two weeks, then weekly for five weeks. The RN conducted the initial assessment on 6/30/22. The assessment revealed the patient was using oxygen 8 liters per minute via nasal cannula. The POC did not include oxygen. An interview with the branch director on 7/20/22 at 4:10 p.m. confirmed oxygen was not on included on the POC. The policy, Medications [10/4/21], was provided by the branch director on 7/19/22 at approximately 2:40 pm. The policy stated, “…Medication profile is a listing of the medications which includes oxygen and medicated dressing: Prescribed by a physician for the patient, identifying the name, dose, route, frequency and the date drug was started or changed or discontinued…The case manager consolidates all pertinent orders for medications into the plan of care at the time the medication is prescribed, or for over the counter medications at the time that they are found in the home…” The policy, Physician’s Role [10/8/21], was provided by the branch director on 7/19/22 at approximately 2:40 pm. 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 that supports the patient’s medical, nursing and psychosocial needs in the home setting and serves as the basis of care delivery. The plan includes…medications, treatments…The agency obtains complete orders for care. The orders will include…Specific procedures and treatments…Professional staff notifies the physician if required and documents according to…Changes in patient’s condition which suggest a need to modify the plan of care…A missed visit which results in modification of the plan…” 1. Patient # 9 had a Start of Care [SOC] date of 6/24/22 and admitting diagnoses of Malignant Neoplasm of Pancreas, Pressure Ulcer of Sacral [the portion of the spine between the lower back and the tailbone], Unstageable [full thickness tissue loss of which actual depth of the ulcer is completely obscured by slough [dead tissue] and/or eschar [dead tissue], Pressure Ulcer of Left Buttock, Stage 2 [ulcer has broken through the top layer of the skin and part of the layer below]. A review of the Plan of Care for the certification period 6/24/22 to 8/22/22 included orders for SN [skilled nurse] 1 time a week for 1 week, 3 times a week for 8 weeks, 1 time a week for 1 week and “SN to educate on best practices for oxygen safety.” RN # 2 completed the SOC visit on 6/24/22. The Visit Note Report revealed the patient was using Oxygen at 5 liters continuously. Further review of the POC [medication section] revealed Oxygen was not included. RN # 2 was not available for interview. RN # 3 was interviewed on 7/20/22 at approximately 4:15 pm. During the interview the RN confirmed Oxygen should have been included on the POC. 2. Patient # 22 had a Start of Care date of 1/4/22. A review of the Plan of Care [POC] for the certification period 5/4/22 to 7/2/22 revealed diagnoses of Encounter for Surgical aftercare Following Surgery on the Digestive System, Encounter for Attention to Colostomy [an operation that creates an opening for the large intestine through the abdomen] and Type 2 Diabetes Mellitus with Diabetic Chronic Kidney Disease. The POC included orders for SN [skilled nursing] 1 time a week for 9 weeks. A review of the medication section of the POC revealed the following medication, “Novolin R Regular U-100 Insulin [given for diabetes] 100 unit/ml Injection. Take 3 times daily.” The POC did not include the number of units or a sliding scale dosage. An interview was conducted with RN # 3 on 7/20/22 at approximately 4:00 pm. During the interview the RN confirmed the POC did not include dose of insulin.

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 agency policy, clinical record review and staff interviews the agency failed to perform wound care in accordance with the physician’s order for 1 of 13 patients with a wound [#4];obtain orders for wound care for 3 of 13 patients with a wound [#17, 22, 8]. The findings included: 4) Patient #8 had a start of care 5/29/22 with diagnosis of infection following a procedure, deep incisional surgical site {sic}. The plan of care for certification period 5/29/22 through 7/27/22 included orders for skilled nursing [SN] 3 times per week for 8 weeks; 2 times per week for 1 week. Wound care orders were “skilled nurse to cleanse wound to right top middle foot with wound cleanser…apply negative pressure device… change dressing every M, W, F [Monday, Wednesday and Friday].” Documentation showed SN visits were made on Tuesday 5/31/22 and Thursday 6/9/22 instead of Monday 5/30/22 and Wednesday 6/8/22 as ordered on the plan of care. During an interview with SN #7 on 7/20/22 at 1:35pm, SN #7 stated she did not call the physician herself and “the visit was on my schedule [on the schedule for 5/31/22].” The branch director #3 reported there was no order or other documentation regarding the reason for the visit on 6/8/22. Branch director verified the physician was not notified of any changes in the scheduling of wound care. The policy, Physician’s Role [10/8/21], was provided by the branch director on 7/19/22 at approximately 2:40 pm. 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 that supports the patient’s medical, nursing and psychosocial needs in the home setting and serves as the basis of care delivery. The plan includes…medications, treatments…The agency obtains complete orders for care. The orders will include…Specific procedures and treatments…Professional staff notifies the physician if required and documents according to…Changes in patient’s condition which suggest a need to modify the plan of care…A missed visit which results in modification of the plan…” 1. Patient # 4 had a Start of Care of 12/15/21. A review of the Plan of Care [POC] for the certification period 6/13/22 to 8/11/22 revealed diagnoses of Venous Insufficiency, Non-Pressure Chronic Ulcer of Right Calf with Muscle Involvement and Non-Pressure Ulcer of Left Calf with Muscle Involvement. The POC included orders for SN [skilled nursing] 3 times a week for 8 weeks, 2 times a week for 1 week and “SN to cleanse wounds to BLE [bilateral lower extremities] with wound cleanser, pat dry with clean gauze. Paint wounds with Genitan Violet [antiseptic violet dye used to treat/prevent infections]. Cover with ABD pad and absorbent pads…” A supplemental order was written on 7/18/22 at 9:53 am for wound care. The new order stated, “SN to provide wound care to left and right lower leg. Clean wound with wound Vashe Solution. Apply moistened gauze with Vashe Solution and allow to sit on wound for 10-15 minutes before changes. Apply Zinc Oxide to wound edges. Paint wounds with Gentian [sic] Violet. Cover wound with Optilock and then Abd pad…” RN # 23 conducted a routine visit for wound care on 7/18/22 10:52 am. A review of the Visit Note Report revealed RN # 23 did not follow the newest order related to the dressing change. RN # 23 as not available for interview. RN # 3 was interviewed on 7/20/22 at approximately 4:30 pm. During the interview the RN confirmed the wound care was not completed in accordance with the physician’s order 2. Patient # 17 had a Start of Care date of 3/25/22 and admitting diagnosis of Unspecified Open wound, Left Lower Leg. The Plan of Care for the certification period 3/25/22 to 5/24/22 included orders for SN [skilled nursing] 1 time a week for 1 week, 3 times a week for 8 weeks, 1 time a week for 1 week. RN # 14 completed a routine visit on 4/23/22. The Visit Note Report revealed the following information,” …Pressure area noted to outer right Malleolus [ankle] 0.2x0.1x0.2. Covered with Mepilex…SN called PCP define office regarding area to right ankle. Awaiting return call…” During an interview with Rn # 14 on 7/20/22 at approximately 1:30 pm, the RN stated, “I put the mepilex on the wound to protect it. I didn’t have an order, but I did call the doctor’s office.” 3. Patient # 22 had a Start of Care date of 1/4/22. A review of the Plan of Care [POC] for the certification period 5/4/22 to 7/2/22 revealed diagnoses of Encounter for Surgical aftercare Following Surgery on the Digestive System and Encounter for Attention to Colostomy [an operation that creates an opening for the large intestine through the abdomen]. The POC included orders for SN [skilled nursing] 1 time a week for 9 weeks. Patient # 22 was hospitalized from 5/26/22 to 6/2/22 for a revision of the colostomy [a procedure to attach the intestines together]. A review of the Resumption of Care orders [orders obtained after the patient has had or been admitted and discharged to an inpatient facility] dated 6/10/22 included orders for SN visits 1 time a week for 1 week, 3 times a week for 2 weeks, 1 time a week for 1 week. A review of the clinical record revealed LPN # 4 made a routine visit on 6/17/22. The Visit Note Record for 6/17/22 revealed the following documentation by LPN # 4, “…Patient again began [sic] verbal aggressive behavior with SN while doing incision care…” A review of the POC did not include orders for incision care. An interview was conducted with LPN # 4 on 7/20/22 at approximately 11:00 am. During the interview the LPN stated, “she [patient] wanted a “bandage” applied to the incision. I was applying the bandage.” An interview was conducted with RN # 3 on 7/20/22 at approximately 4 pm. RN # 3 confirmed the LPN should not have applied a bandage to the incision site without a physician’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 agency policy, clinical record review and staff interviews the agency failed to notify the physician of a blood sugar reading outside the given parameters for 1 of 1 patient with a diagnosis of Malignant Neoplasm of Pancreas [organ which aides in digestion and regulating blood sugar] [#9];weight outside the given parameters for 1 of 1 patient with a diagnosis of Congestive Heart Failure [condition in which the heart has trouble pumping blood through the body] [#10]; patient fall for 2 of 4 patients with patient falls [#16, 24]; new wound in 1 of 13 patients with wounds [#17]; request order for speech therapy evaluation in a timely manner for 1 of 1 records with speech therapy services [#24]; patient's complaints of inability to use the right hand for 1 of 2 patients with a diagnosis of Parkinson's Disease [#6]; patient stopped taking medication as ordered for 1 of 24 patients [#3]; the caregiver was not doing wound care as frequently as ordered for 1 of 13 patients with a wound [#23]. The findings included 8. Patient #23 was admitted on 6/24/22 with a diagnosis of open wound to left buttock requiring wound care and multiple sclerosis (a disease that affects the central nervous system). The Plan of Care (POC) for 6/24/22-8/22/22 included orders for skilled nursing visits effective 6/26/22 one time weekly for two weeks, twice weekly for six weeks, the one time for one week. The POC also included orders for wound care to the “deep wound on buttocks.” Cleanse entire buttocks with normal saline, pack with Promogran Prisma (brand of dressing composed of collagen, oxidized regenerated cellulose, and silver oxidized regenerated cellulose), cover with a bordered gauze daily. Apply a thin layer of protective ointment to the remainder of the buttock area not covered by the dressing. The caregiver was to perform wound care daily in the absence of a skilled nurse visit. On 7/7/22, RN #1 conducted a home visit. The visit note stated that the caregiver had decreased wound care to every other day. There was no evidence the physician was notified the caregiver was not performing wound care as ordered. An interview with RN #1 was conducted on 7/20/22 at 3:00 p.m. The RN stated that the physician was notified that the caregiver had decreased the wound care frequency but confirmed there was evidence of physician notification in the clinical record. 6) Patient #2 had a start of care of 6/20/22 with a diagnosis of Parkinson’s disease. The plan of care for the certification period of 6/20/22 through 8/18/22 included orders for skilled nursing [SN] 1 time per week for 1 week; physical therapy [PT] 1 time per week for 1 week; and occupational therapy [OT] 1 time per week for 1 week. A home visit on 7/6/22 by the physical therapist assistant #26, revealed patient #2 had reported “my R [right] shoulder is still sore from that shot [sic].” On 7/8/22 OT #30 documented patient #2 reported, “shoulder a little sore.” The patient reported to OT #30 “shoulder pain, had shingles vaccine last week.” Patient #2 reported to PT #28 on 7/13/22, “… R [right] shoulder pain and difficulty using R hand.” An interview with the branch director #3, on 7/20/22 at 4:08pm verified there was no evidence of communication with the physician related to the continued pain and difficulty using the right hand. 7) Patient #3 had a start of care of 6/9/22 with a diagnosis of type 2 diabetes mellitus with diabetic neuropathy (a type of nerve damage that can occur with diabetes.). The plan of care for the certification period 6/9/22 through 8/7/22 included an order for physical therapy [PT] 1 time per week for 1 week, 2 times per week for 4 weeks and 1 time per week for 4 weeks. A home visit was made by PTA #29 on 6/28/22. Documentation revealed patient #3 reported starting a new medication (Hydroxyzine- antihistamine) but stopped taking after 2 days because the medication “… made me feel weird.” PTA #29 documented that an email had been sent to PT #27 for medication updates regarding the patient discontinuing a new medication. Physical therapist #27 was not available for interview. An interview with branch director #3 on 7/20/22 at 3:20pm verified there was no evidence the physical therapist notified the physician that patient #3 stopped the Hydroxyzine. The policy, Coordination of Services [10/8/21], was provided by the branch director on 7/19/21 at approximately 2:40 pm. The policy stated, “…Professional staff coordinate services with the physician. Staff…Promptly alert the physician to any changes which suggest a need to modify the plan of care…” 1. Patient # 9 had a Start of Care date of 6/24/22 and admitting diagnoses of Malignant Neoplasm of Pancreas, Pressure Ulcer of Sacral [the portion of the spine between the lower back and the tailbone], Unstageable [full thickness tissue loss of which actual depth of the ulcer is completely obscured by slough [dead tissue] and/or eschar [dead tissue], Pressure Ulcer of Left Buttock, Stage 2 [ulcer has broken through the top layer of the skin and part of the layer below] and Type 2 Diabetes Mellitus without Complications. A review of the Plan of Care [POC] for the certification period 6/24/22 to 8/22/22 included orders for SN [skilled nursing] 1 time a week for 1 week, 3 times a week for 8 weeks, 1 time a week for 1 week and “Licensed Professional to report vital signs falling outside the following established parameters…FBS [fasting blood sugar] less than 70 or greater than 180 and RBS [random blood sugar] less than 70 or greater than 180. A review of the SN visit note dated 6/24/22 revealed a RBS reading of 246. Further review of the visit noted revealed no evidence RN # 2 contacted the physician. RN # 2 was not available for interview. An interview was conducted with RN # 3 on 7/20/22 at approximately 4:15 pm. During the interview the RN confirmed the physician was not notified of the blood sugar reading in accordance with the POC. 2.Patient # 10 had a Start of Care date of 5/27/22 and an admitting diagnosis of Heart Failure. A review of the Plan of Care [POC] for the certification period 5/27/22 to 7/25/22 included orders for PT [physical therapy] 1 time a week for 1 week [effective 6/29/22] then 2 times a week for 2 weeks, 1 time a week for 1 week and “Licensed professional to report vital signs falling outside established parameters…weight less than 195 pounds or greater than 204 pounds…” The Visit Note Report dated 7/19/22 and completed by PT # 30 revealed a weight of 193.2 pounds. There was no evidence the PT notified the physician of the weight being outside the given parameters. PT # 30 was not available for interview. An interview was conducted with RN # 3 on 7/20/22 at approximately 4:25 pm. During the interview the RN confirmed the physician was notified of the weight. 3. Patient # 16 had a Start of Care date of 2/16/22 and admitting diagnoses of Cellulitis [infection involving the inner layers of skin] of Right Lower Limb and Pressure Ulcer of other Site, Stage 3 [the ulcer extends into the tissue beneath the skin, forming a small crater]. A review of the Plan of Care for the certification period 2/16/22 to 4/16/22 included orders for SN [skilled nursing] 1 time a week for 9 weeks. A review of the clinical record revealed LPN # 15 made a routine visit on 3/23/22 and documented the following information, “Subjective statements-I fell Sunday. I was reaching to pick something off of the floor…My husband was trying to help me and he stepped on my left hand…” There was no evidence the LPN notified the physician of the fall. During an interview with RN # 3 on 7/20/22 at approximately 510 pm the RN stated, “Yes, we notify the physician of any falls, witnessed or unwitnessed. I do not see where she notified the physician of this fall.” 4A. Patient # 24 had a Start of Care date of 12/3/21. A review of the Plan of Care for the certification period 6/1/22 to 7/30/22 included diagnoses of Encephalitis [inflammation of the meninges] and Encephalomyelitis [inflammation of the meninges of both the brain and the spinal cord] and orders for SN [skilled nursing] 1 time a week for 9 weeks. A review of the clinical record revealed LPN # 6 made a routine visit on 7/14/22 and documented the following information, “Patient reports having another fall on Sunday [7/10/22]. No injuries noted. Patient reports physical therapy is already aware of the fall…” There was no evidence the LPN notified the physician of the fall. During an interview with LPN # 6 on 7/20/22 at approximately 1:45 pm the LPN stated, “No, I didn’t call the physician to let him know about the fall.” 4B. Patient # 24 had a Start of Care date of 12/3/21. A review of the Plan of Care for the certification period 6/1/22 to 7/30/22 included diagnoses of Encephalitis [inflammation of the meninges] and Encephalomyelitis [inflammation of the meninges of both the brain and the spinal cord] and orders for SN [skilled nursing] 1 time a week for 9 weeks. A review of the clinical record revealed LPN # 6 made a routine visit on 6/16/22 and documented the following information, “…Spouse would like for patient to have a speech therapy evaluation as soon as possible due to aspiration.” Further review of the clinical record revealed the order for speech therapy to evaluate was not obtained until 7/13/22 and the evaluation visit was not made until 7/18/22. During an interview with RN # 3 on 7/20/22 the RN stated, “That branch did not have a speech therapist. I sent the speech therapist from this office.” 5. Patient # 17 had a Start of Care date of 3/25/22 and admitting diagnosis of Unspecified Open wound, Left Lower Leg. The Plan of Care for the certification period 3/25/22 to 5/24/22 included orders for SN [skilled nursing] 1 time a week for 1 week, 3 times a week for 8 weeks, 1 time a week for 1 week. RN # 14 made a routine visit on 4/16/22. A review of the clinical record revealed Patient # 17’s daughter identified a new wound and advised the RN of her finding. Further review of the clinical record revealed no evidence the RN notified the physician of the wound on the heel. During an interview with the RN # 14 on 7/20/22 at approximately 1:30 pm. RN # 14 stated, “If I told the physician I would have documented it.”

Revised plan of care CFR(s): 484.60(c)(2) A revised plan of care must reflect current information from the patient's updated comprehensive assessment, and contain information concerning the patient's progress toward the measurable outcomes and goals identified by the HHA and patient in the plan of care. This ELEMENT is not met as evidenced by: Based on clinical record review and staff interview, the agency failed to revise the plan of care for 1 of 1 patient that reported a torn meniscus (#20). Findings included: Patient #20 was admitted on 6/3/22 with a diagnosis of multiple sclerosis (a disease that affects the central nervous system). The Plan of Care (POC) for 6/3/22-8/1/22 included orders for physical therapy and occupational therapy (OT). There was a nursing evaluation ordered for the week beginning 6/19/22. On 6/21/22, the OT visit note stated that the patient reported a torn meniscus (tendon in knee) and was using Tylenol for pain. The RN conducted the nursing evaluation on 6/24/22. The note indicated the patient was taking Tylenol, ibuprofen, and Tramadol for pain relief. The POC was not updated to include these medications. An interview with the branch director on 7/20/22 at 5:20 p.m. confirmed the Tylenol, ibuprofen, and Tramadol were not part of the current POC.

Patients receive education and training CFR(s): 484.60(d)(5) Ensure that each patient, and his or her caregiver(s) where applicable, receive ongoing education and training provided by the HHA, as appropriate, regarding the care and services identified in the plan of care. The HHA must provide training, as necessary, to ensure a timely discharge. This ELEMENT is not met as evidenced by: Based on review of policy, clinical record and staff interviews the agency failed to show evidence of education provided to patient/ caregiver regarding how to administer intravenous (IV) antibiotics for 1 of 1 (#8) patients receiving IV antibiotics. The findings included: The policy “service delivery, medications revised 10/4/21,” stated “If the patient is self-administering medications, staff will provide training and supervision and allow for the teach- back method to be implemented to ensure they are safely administering these medications. The training and teach back will be documented in the medical record.” Patient #8 had a start of care of 5/29/22 with diagnosis of an “infection following a procedure, deep incisional surgical site.” The plan of care for the certification period 5/29/22 through 7/27/22 had orders for Skilled nursing [SN] 3 times per week for 8 weeks and 2 times per week for 1 week. The plan of care order states, “SN (skilled nurse) to educate patient/caregiver on interventions used to help reduce patient from having an acute care hospitalization …” Referral information included an order “Cefazolin 2 g/ IV q8 hr {sic}”, with a start date of 5/24/22. An interview with SN #8 and #18 on 7/20/22 at approximately 3:00pm it was reported the SN will teach the patient/caregiver to administer the medications. SN #8 and #18 both stated patient #8 wife/ caregiver could administer IV antibiotics. There was no evidence of that the caregiver had been instructed on administering IV antibiotics.

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 agency policy, clinical record review and staff interviews the agency failed to measure wound for 2 of 13 patients with a wound [#5, 19]; assess wounds for 3 of 13 patients with a wound [#17, 8, 23]; failed to obtain order for speech therapy evaluation in a timely manner for 1 of 1 record with speech therapy orders [#24]. The findings included: 5. Patient #23 was admitted on 6/24/22 with a diagnosis of open wound to left buttock requiring wound care and multiple sclerosis (a disease that affects the central nervous system). The Plan of Care (POC) for 6/24/22-8/22/22 included orders for skilled nursing visits effective 6/26/22 one time weekly for two weeks, twice weekly for six weeks, the one time for one week. The POC also included orders for wound care to the “deep wound on buttocks.” Cleanse entire buttocks with normal saline, pack with Promogran Prisma (brand of dressing composed of collagen, oxidized regenerated cellulose, and silver oxidized regenerated cellulose), cover with a bordered gauze daily. Apply a thin layer of protective ointment to the remainder of the buttock area not covered by the dressing. The skilled nurse evaluation visit was conducted on 6/30/22 by RN #1. The visit note stated, “Has wounds on buttocks. Hospital wanted pt [patient] to stay in inpt [inpatient] rehab for an extended amount of time but both pt and wife did not want that. Hospital did not send home much wound care supplies. Wife has been using what she has on hand…Pt is bedridden. Skin breakdown and wound noted on whole bottucks [sic]…Pt has impaired integumentary [skin] system r/t [related to] wounds on buttocks requiring SN for wound care…” The visit note did not provide a description of the wound bed and surrounding skin. The next visit was conducted on 7/7/22 by RN #1. There was not a wound description in the visit note. In an interview with RN #1 on 7/20/22 at 3:00 p.m., it was stated that the RN had completed the wound documentation on 6/30/22 and 7/7/22. The interview revealed the entire buttocks area was reddened, and there were “a couple of open areas.” RN #6 conducted a home visit on 7/11/22. The visit documentation revealed a stage II pressure ulcer (a shallow wound caused by pressure) that measured 0.4 centimeters (cm) x 0.7 cm x 0.6 cm. An interview with RN #6 on 7/20/22 at 1:50 p.m. revealed the patient’s entire buttock area was severely macerated (skin breakdown caused by moisture) and there was “one area that looked like a hole.” The measurements documented were of the open area. In an interview with the branch director on 7/20/22 at 3:00 p.m., it was confirmed the wound did not have a comprehensive wound assessment until 7/11/22. RN #5 conducted home visits on 7/15/22 and 7/18/22. The RN documented the wounds on the left back fold, mid-back, buttocks, and groin were “progressing well.” There was no evidence of wound assessments to the left back fold, mid-back, or groin. In an interview with the branch director on 7/20/22 at 3:00 p.m., it was confirmed there was no assessment of wounds to the left back fold, mid-back, or groin. 4)Patient #8 had a start of care of 5/29/22 with diagnosis of an “infection following a procedure, deep incisional surgical site.” The plan of care for the certification period 5/29/22 through 7/27/22 had orders for Skilled nursing [SN] 3 times per week for 8 weeks and 2 times per week for 1 week. The plan of care included orders, “skilled nurse to assess/evaluate co-morbid conditions including surgical incision, wound, diabetes and other conditions that present themselves during the course of this episode to identify changes and intervene to minimize complications.” On 6/29/22 SN #7 documented wound care on patient #8 left ankle ulcer and right second amputation site. SN #11 and #16 also documented wound care during home visits. Seven of seven SN visits had no evidence of the assessment of the wounds; (6/29/22, 7/1/22, 7/6/22, 7/8/22, 7/11/22, 7/13/22). During an interview with SN #7 on 7/20/22 at 1:42pm, it was reported a photograph and measurements of the wounds had been taken on 6/29/22. An interview with the branch director #3 verified there was no evidence of a wound assessment. The policy, Wound Ulcer Management [10/11/21], was provided by the branch director on 7/19/22 at approximately 2:40 pm. The policy stated, “…At minimum, the wound/ulcer shall be measured using the following criteria for Home Health…patients once a week or when wound care is provided if wound care is ordered less than once weekly…Should the clinician find a new wound during an assessment, basic first aide procedures may be administered…Wound/ulcer care shall be in accordance with the plan of care…” 1. Patient # 5 had a Start of Care date of 5/27/22 and admitting diagnoses of Disruption of External Operation [surgical] Wound, Peripheral Vascular Disease [PVD-narrowing of peripheral blood vessels] and Type 2 diabetes Mellitus with Diabetic Neuropathy. A review of the Plan of Care for the certification period 5/27/22 to 7/25/22 included orders for SN [skilled nursing] 1 time a week for 2 weeks, 3 times a week for 7 weeks, 1 time a week for 1 week and “SN to cleanse wound to left groin with wound cleanser…Fill entire cavity with black foam…Apply negative pressure device t 125 mmhg …Change dressing 3 times per week…SN to perform wound care to right groin. Cleanse with wound cleanser…Cover with dry dressing…SN to perform dressing change 3 times per week…” A review of the clinical record revealed RN # 14 made a routine visit on 6/3/22. The Visit Note Report revealed no wound measurements for the week of 5/29/22. During an interview with RN # 14 on 7/20/22 at approximately 1:00 pm, the RN stated, “I see no wound measurements for that visit.” 2. Patient # 19 had a Start of Care date of 6/4/22 and admitting diagnoses of Type 2 Diabetes Mellitus with other Skin Ulcer and Non-Pressure Chronic Ulcer of Right Ankle. A review of the Plan of Care for the certification period 6/4/22 to 8/2/22 included orders for SN [skilled nursing] 1 time a week for 1 week, 2 times a week for 8 weeks, 1 time a week for 1 week and “SN to perform wound care to pressure ulcer/pressure injury to R [right] ankle. Cleanse with wound cleanser, pat dry. Apply Medihoney and calcium silver…” A review of the clinical record revealed a routine visit was made on 7/5/22 by LPN # 9. Further review of the clinical record revealed the LPN failed to measure the wound to the right ankle. LPN # 9 was not available for interview. An interview was conducted with RN # 3 on 7/20/22 at approximately 4:20 pm. During the interview RN # 3 stated, “Wounds are to be measured each week. I do not see any wound measurements for the week of 7/3/22.” 3. A. Patient # 17 had a Start of Care date of 3/25/22 and admitting diagnosis of Unspecified Open wound, Left Lower Leg. The Plan of Care for the certification period 3/25/22 to 5/24/22 included orders for SN [skilled nursing] 1 time a week for 1 week, 3 times a week for 8 weeks, 1 time a week for 1 week. RN # 11 made a routine visit on 4/5/22 and documented the following information, “…Skin tears to left arm healing. New order obtained for wound care to left arm…” A supplemental order was written for “SN to instruct CG [caregiver] to perform wound care to left arm. CG to cleanse skin tears to left arm with wound cleanser, pat dry and apply Proximel 3 times a week.” Further review of the clinical record no assessment of the skin tear was completed. An interview was conducted with RN # 11 on 7/20/22 at approximately 1 pm. During the interview the RN stated, “I thought I had done an ICC [wound assessment] note on the skin tear.” An interview was conducted with RN # 3 on 7/20/22 at approximately 5:00 pm. During the interview RN # 3 confirmed no wound assessment for the skin tear was completed. 3B. Patient # 17 had a Start of Care date of 3/25/22 and admitting diagnosis of Unspecified Open wound, Left Lower Leg. The Plan of Care for the certification period 3/25/22 to 5/24/22 included orders for SN [skilled nursing] 1 time a week for 1 week, 3 times a week for 8 weeks, 1 time a week for 1 week add the period. RN # 14 completed a routine visit on 4/23/22. The Visit Note Report revealed the following information, “Patient denies pain at present…Daughter states, she had a scab to this [sic] right heel and it came off and she has this little wound now…” Further review of the clinical record revealed RN # 14 did not complete a wound assessment related to the area on the heel. An interview was conducted with RN # 14 on 7/20/22 at approximately 1:30 pm. During the interview the RN stated, “I should have done an assessment.” An interview was conducted with RN # 3 on 7/20/22 at approximately 5 pm. RN # 3 confirmed no assessment was completed related to the wound on the heel [documentation did not specify which heel].

Provide services in the plan of care CFR(s): 484.75(b)(3) Providing services that are ordered by the physician or allowed practitioner as indicated in the plan of care; This ELEMENT is not met as evidenced by: Based on clinical record review and staff interviews the agency failed to obtain an order for a Unna boot for 1 of 13 patients with a wound [#23]. The findings included: Patient #23 was admitted on 6/24/22 with a diagnosis of open wound to left buttock requiring wound care and multiple sclerosis (a disease that affects the central nervous system). The Plan of Care (POC) for 6/24/22-8/22/22 included orders for skilled nursing visits effective 6/26/22 one time weekly for two weeks, twice weekly for six weeks, the one time for one week. The POC also included orders for wound care to the “deep wound on buttocks.” An updated wound care order was entered on 7/11/22 to pack with Tegaderm AG rope dressing and leave open to air. On 7/18/22, RN #5 conducted a home visit for wound care. The visit note stated, “Provided wound care as ordered and place Unna boot [a bandage impregnated with zinc oxide] on buttocks and groin part [sic].” An interview with the branch director on 7/20/22 at 4:20 p.m. confirmed there was no order for an Unna boot to the buttocks and groin.

Required items in clinical record CFR(s): 484.110(a)(1) The patient's current comprehensive assessment, including all of the assessments from the most recent home health admission, clinical notes, plans of care, and physician or allowed practitioner orders; This ELEMENT is not met as evidenced by: Based on agency policy, clinical record review and staff interviews the agency failed to update the Plan of Care [POC] with new medication orders for 2 of 24 records [#10, 18]. The findings included: The policy, Medications [10/4/21], was provided by the branch director on 7/19/22 at approximately 2:40 pm. The policy stated, “…The clinical record includes appropriate physician orders for all medications prescribed by the physician(s)…” 1. Patient # 10 had a Start of Care date of 5/27/22 and an admitting diagnosis of Heart Failure. A review of the Plan of Care [POC] for the certification period 5/27/22 to 7/25/22 included orders for SN [skilled nurse] 1 time a week for 9 weeks and “Skilled nurse to review medication profile and reconcile medications as needed…” The medication section of the POC revealed Metoprolol Succinate ER [beta blocker that affects heart and circulation] 50 mg 0.5 mg each day. A supplemental order was written on 7/12/22 for Metoprolol ER 25 mg two times per day. A review of the Client Medication Report dated 7/20/22 revealed the new order for Metoprolol ER 25 mg two times per day was not transferred to the patient’s POC. An interview was conducted with RN # 3 on 7/20/22 at approximately 4:30 pm. During the interview the RN confirmed the new dose of medication should have been included on the POC. 2. Patient # 18 had a Start of Care date of 6/18/22 and an admitting diagnosis of Acute on Chronic Diastolic [Congestive] Heart Failure [CHF]. A review of the Plan of Care [POC] for the certification period 6/18/22 to 8/16/22 included orders for SN [skilled nurse] 1 time a week for 6 weeks, 1 time every 2 weeks for 4 weeks. A review of the POC under the medication section revealed Lasix [fluid] 40 mg each day. A review of the clinical record revealed a supplemental order to discontinue the Lasix on 6/24/22 with a new order for Lasix 40 mg-Take 80 mg each day. A review of the Client Medication Report revealed the Lasix was entered as 40 mg tablet, take 1 tablet each morning. An interview was conducted with RN # 3 on 7/20/22 at approximately 4:45 pm. During the interview the RN confirmed the Client Medication Report was not correct.