Every finding on record at Carolinals Medical Center at Home LLC

An unannounced, onsite recertification survey was conducted 4/7/25-4/9/25. No deficiencies were noted to the Emergency Preparedness Plan.

An onsite, unannounced recertification survey was conducted 4/7/25-4/9/25. Standard level deficiencies were cited to the Medicare CoP.

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, direct observations, staff/patient/caregiver interviews, the Plan of Care failed to include all the current/correct medications for 3 of 7 home visits [#6, 12, 10]. The findings included: The policy, Medication Reconciliation [8/7/24], was provided by the accreditation coordinator on 4/9/25 at approximately 2:08 pm. The policy stated, “At the time of the comprehensive assessment, the clinician will create and document a complete list of medications that patient is taking...The medication list/profile will be revised with each new, changed, or discontinued medication...” 3. Patient #10 had a Start of Care date of 1/10/2025 with an admitting diagnosis of Hypertensive heart and chronic kidney disease (CKD) with heart failure (High blood pressure causes damage to the small blood vessels in the kidneys causing damage to the kidneys leading to kidney disease, resulting in heart failure, which is a chronic condition in which the heart doesn’t pump blood as well as it should). Review of the Plan of Care (POC) for the certification period 3/11/25-5/9/25 included orders for OT (Occupational Therapy) 1 time a week for 1 week, 2 times a week for 3 weeks. On 4/8/25 at approximately 1:15 pm, a joint visit was conducted with OT#1. During the visit, a medication review was conducted using the medication profile provided by the agency. The following discrepancies were noted: Furosemide (used to help the kidneys remove excess fluid) 20mg daily. During the visit the patient presented a bottle of the medication with instructions to take 40mg 2 times a day. During the visit, the patient also presented a bottle of Clonazepam (used to treat anxiety) 0.5 mg with instructions to take ½ tab daily as needed. Clonazepam 0.5 mg 1 tab daily was listed on the medication profile as discontinued. During an interview with the patient, it was confirmed that the patient takes these medications as they are directed on the medication bottles. During an interview with the accreditation coordinator on 4/9/25 at approximately 2:30 pm, the accreditation coordinator confirmed that the medication profile did not include the correct medications. 1.Patient # 6 had a Start of Care date of 2/25/25 with an admitting diagnosis of hypertensive chronic kidney disease [hypertension over a long period of time damages the kidneys]. Review of the Plan of Care [POC] for the certification period 2/25/25-4/25/25 included orders for SN [skilled nursing] 2 times a week for 1 week, 1 time a week for 2 weeks, 1 time every 2 weeks for 6 weeks and “Skilled nurse to review medication profile and reconcile medications as needed...” On 4/7/25 at approximately 4:15 pm a joint visit was made with RN # 2. During the visit a medication review was conducted using the medication profile provided by the agency. The following discrepancies were noted: The medication profile listed amlodipine [blood pressure] 5 mg daily. The patient had a bottle on hand of the medication. The directions were 10 mg daily. During an interview with the patient, he reported he took 10 mg of the medication daily. The patient also presented a bottle of carvedilol [blood pressure] 1 tablet 2 times a day. He stated, “I have been taking this for about 10 years.” On the medication profile the carvedilol had been discontinued. During an interview with RN # 2, he confirmed the medication on the profile/POC was not correct. 2. Patient # 12 had a Start of Care date of 11/13/24 with admitting diagnoses of hypertensive heart and chronic kidney disease with heart failure [hypertension over a long period of time damages the kidneys] and congestive heart failure [heart does not pump adequately]. Review of the Plan of Care [POC] for the certification period 3/13/25-5/11/25 included orders for SN [skilled nursing] 1 time a week for 8 weeks and “Skilled nurse to review medication profile and reconcile medications as needed...” On 4/8/25 at approximately 2 pm a joint visit was conducted with RN # 4. During the visit a medication review was conducted using the medication profile provided by the agency. The following discrepancy was noted: The medication profile listed Amiodarone [used to treat abnormal heart rhythms] 200 mg daily. During the visit the patient presented a bottle of the medication dated 12/24/24 with instructions to take the medication 2 times per day. During an interview with the patient, he confirmed he was taking the medication 2 times per day.

An onsite recertification survey was conducted 05/09/22-05/10/22. No deficiencies to the Emergency Preparedness Program were identified. ABH

An onsite recertification survey was conducted 05/09/22-05/10/22. Deficiencies to the Medicare Conditions of Participation were identified. ABH

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 staff and patient interview the agency failed to review all current medications for 5 of 6 patients that received a virtual home visit (#12,#15, #11,#13, and #16). Findings included 3. Patient # 11 had a Start of Care [SOC] date of 4/11/22 and an admitting diagnosis of Encounter for Orthopedic Aftercare following Surgical Amputation, Type 2 Diabetes Mellitus with other Specified Complication and Osteomyelitis [inflammation of bone usually caused by infection]. A review of the Plan of Care [POC] for the certification period 4/11/22 to 6/9/22 revealed orders for PT [physical therapy] 1 time a week for 9 weeks and Therapist to monitor and follow up regarding management of medications -PT”. A virtual visit was conducted on 5/9/22 with PT # 1. During the visit a medication review was conducted using a Client Medication Report provided by the agency. The following discrepancy was noted: Tresiba U100/ml- take 10 units per day for Diabetes Mellitus was not included on the Client Medication Report. An interview was conducted with the patient during the virtual visit. During the interview the patient stated, “The doctor ordered the Tresiba on 4/20/22.” A visit had been conducted the week after the patient was started on the medication. An interview was conducted with the executive director on 5/10/22 at approximately 2:30 pm. During the interview the director confirmed the Tresiba should have been included on the Client Medication Report. 4. Patient # 13 had a Start of Care [SOC] date of 4/6/22 and admitting diagnoses of Urinary Tract Infection, Constipation and Essential Hypertension. A review of the Plan of Care for the certification period 4/6/22 to 6/4/22 revealed orders for PT [physical therapy] 2 times a week for 8 weeks and “Therapist to monitor and follow up regarding management of medications -PT”. A virtual visit was conducted on 5/9/22 with PTA [physical therapist assistant] # 3. During the visit a medication review was conducted using a Client Medication Report provided by the agency. The following discrepancies were noted: During the visit, Patient # 13 presented a bottle of Senokot [stool softener] and MiraLAX [stool softener]. Patient # 13 stated, “I use both of these when I need them for constipation. I might not have to take them every day. It just depends. I have been using both of those since before I left the hospital.” A review of the POC revealed neither the Senokot nor MiraLAX where included. An interview was conducted with executive director on 5/10/22 at approximately 2:30 pm. During the interview the director confirmed the medications should have been included on Client Medication Report. 5. Patient # 16 had a Start of Care [SOC] date of 2/11/22 and admitting diagnoses of Osteoporosis with Pathological Fracture Left Humerus, Secondary Hypertension and Unspecified Diastolic [Congestive] Heart Failure. A review of the Plan of Care [POC] for the certification period 4/12/22 to 6/10/22 revealed a supplemental order dated 4/24/22 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. A virtual visit was conducted on 5/10/22 with PT # 6. During the visit a medication review was conducted using a Client Medication Report provided by the agency. The following discrepancy was noted: The Client Medication Report listed Docusate Sodium [stool softener] 100 mg. Take 1 capsule as needed for constipation. An interview was conducted with the patient during the visit. During the interview the patient reported, “I don’t take that anymore. I haven’t taken any of those for several weeks.” An interview was conducted with the executive director on 5/10/22 at approximately 2:30 pm. During the interview the director confirmed the medications on the Client Medication Report were not correct. 1.Patient #12 was admitted on 02/26/22 with diagnoses of aftercare following joint replacement surgery, type 2 diabetes, hypertension, and obstructive sleep apnea . The plan of care for 04/07/22 to 06/05/22 included the following orders: occupational therapy 2 times a week for 3 weeks. A virtual home visit was conducted on 05/09/22 at 12:54 p.m. with the occupational therapist assistant. A review of current medications was conducted with the patient during the home visit. The review revealed the following discrepancy: furosemide 20 mg (milligram) 2 tablets daily by mouth. Per interview with the patient, “I’m not taking this medicine anymore, it was changed when I went to the doctor in April”. 2.Patient #15 was admitted on 04/17/22 with diagnoses of aftercare following circulatory surgery, infection following a procedure, cellulitis (infection) of groin, heart failure, and type 2 diabetes. The plan of care for 04/17/22 to 06/15/22 included the following orders: skilled nursing 3 times a week for 8 weeks, and physical therapy 1 time a week for 1 week. A virtual home visit was conducted on 05/10/22 at 12:31 p.m. with the registered nurse. A review of current medications was conducted with the patient/caregiver during the home visit. The review revealed the following discrepancies: Benadryl 25mg tablet 2 tablets twice a day by mouth. Per interview with the patient, “I have been taking this since I’ve been home in April for my allergies”.

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 policy review, clinical record review, and staff interview the agency failed to follow the plan of care as ordered by the physician for weights for 1 of 4 records reviewed with heart failure (#4) and wound care for 1 of 6 records with a wound (#5 ). Findings included: 2. Patient # 5 had a Start of Care [SOC] date of 8/1/21 and admitting diagnoses of Pressure Ulcer of Sacral Region, Stage 4, Pressure Ulcer of Left Heel, Stage 3 and Pressure Ulcer of Right Ankle, Stage 2. A review of the Plan of Care [POC] for the certification period 8/1/21 to 9/29/01 included orders for SN [Skilled nursing] 3 times a week for 2 weeks, 2 times a week for 4 weeks, 1 time a week for 3 weeks, 3 PRN [as needed] for signs of infection and “…SN to provide assessment, skilled teaching, and reinforcement on the management of wounds…Using clean technique, cleanse wound with Anasept, pat dry, apply Anasept soaked gauze to wound bed, cover with Mepilex foam…Location of wound: Sacrum-frequency of wound care- daily to begin on 8/1/21…Cleans wound with Anasept, pat dry, apply Aquacel AG, cover with dry dressing…Location of wound: Right ankle-frequency of wound care-3 times per week to begin on 8/1/21…Cleanse wound with Anasept, pat dry, cover with foam dressing…Location of wound: Left heel-frequency of dressing change 3 times a week to begin on 8/1/21…May instruct patient/cg [caregiver] in wound care. Patient/cg to change dressing on non-nurse days and PRN [as needed] when loose or soiled…”A review of the clinical record revealed 8 routine SN visits were conducted from 8/3/21 to 8/23/21. Further review of the clinical record revealed the SN did not perform wound care during 5 of the 8 visits. The SN documented “Wound care not provided- cg completed wound care.” An interview was conducted with the executive director on 5/10/22 at approximately 1:15 pm. During the interview the executive director confirmed wound care was not completed in accordance with the POC for 5 of the 8 routine visits. A policy, “Plan of Care and Provider Orders ” was provided by Employee #2 on 05/10/22 at 3:53 p.m. The policy stated, “ …care and services, including drugs and treatments, will be provided according to provider orders”. 1. Patent #4 was admitted on 02/23/21 with the following diagnoses: chronic atrial fibrillation, type 2 diabetes, pulmonary hypertension, old myocardial infarction (heart attack), and heart failure. The plan of care for 02/23/21 to 04/23/21 had orders for skilled nursing 1 time a week for 8 weeks, and 2 times a week for 1 week, and 1 time a week for 6 weeks. Orders were as follows: skilled nurse to instruct patient to weigh daily if safety permits, skilled nurse to instruct patient/caregiver to notify agency with weight gain of 3 pounds in 1 day or 5 pounds in 1 week, skilled nurse to monitor patients weight log and document in medical record if patient is safe to weigh and scale is available. Review of skilled nursing notes for dates of 02/23/21, 02/25/21, 03/01/21, 03/05/21, and 03/9/21 revealed weight were not in the medical record for 02/25/21, 03/01/21, 03/05/21 and 03/09/21. An interview with Employee #2 on 05/10/22 at 3:15 p.m. revealed, “no weights are in the record for those dates”.

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 policy review, client record review, and staff interview the clinical record failed to include PICC (peripherally inserted central catheter) line measurements for 1 of 1 records with picc lines (#4). Findings included: Review of policy “Peripherally inserted central catheter dressing change, home care”, revised 08/20/2021 was received from Employee #2 on 05/10/22 at 3:53 p.m. The policy stated,” …measure upper arm circumference when clinically indicated to assess for edema and deep vein thrombosis take the measurement 10 cm (centimeters) above the antecubital fossa and compare the measurement to the baseline…”. Patient #4 was admitted on 02/23/21 with diagnoses of chronic atrial fibrillation, type 2 diabetes, pulmonary hypertension, old myocardial infarction (heart attack), and heart failure. The plan of care for 02/23/21 to 04/23/21 had orders for skilled nursing 1 time a week for 8 weeks, and 2 times a week for 1 week, and 1 time a week for 6 weeks. Orders for skilled nurse to perform site care to infusion access device 1 time a week and as needed for loose and soiled dressing as follows: clean with chlorhexidine swabs using friction scrub for 30 seconds, allow to dry, apply skin prep, apply biopatch if appropriate, apply external securement device cover with transparent dressing. Change extension tubing and injection cap weekly and after blood draws. Review of the skilled nurse visit note of 03/09/21 revealed PICC line measurements were not obtained. Interview with Employee #2 on 05/10/22 at 10:37 a.m. revealed, “no measurements are in the record for 3/9/21.”