Every finding on record at Carolinas Medical Center at Home, LLC

An unannounced on-site recertification survey was conducted on 05/19/2025-05/21/2025 . No deficiencies for Emergency Preparedness were identified.

An unannounced on-site recertification survey was conducted on 05/19/2025-05/21/2025. Standard level deficiencies to the Medicare Conditions of Participation were identified.

Accuracy of encoded OASIS data CFR(s): 484.45(b) Standard: The encoded OASIS data must accurately reflect the patient's status at the time of assessment. This STANDARD is not met as evidenced by: Based on clinical record review, and staff interviews, the agency failed to ensure OASIS [Outcome and Assessment Information Set] accuracy related to N0415 [high risk medications for 4 of 17 records reviewed [ # 1, 15, 16 and 8]. The findings included: 4. Patient #8 had an admission date of 5/12/2025 with a diagnosis of Acute and chronic respiratory failure with hypoxia (long-term “chronic” severe impairment of the respiratory system causing low blood oxygen levels and a sudden “acute” worsening of symptoms including shortness of breath). The Plan of Care (POC) for 5/12/2025-7/10/2025 included orders for skilled nurse (SN) visits 2 times a week for 2 weeks, 1 time a week for 4 weeks and physical therapy (PT) 2 times a week for 1 week, 1 time a week for 3 weeks. Review of the clinical record revealed PT #4 completed the Start Of Care (SOC) OASIS (Outcome and Assessment Information Set-collection of data elements that home health agencies use to assess and report on patient quality) on 5/12/25. Review of the OASIS question NO415 [high risk medications] indicated the patient’s only high-risk medication was a hypoglycemic (used to reduce blood sugar level). Review of the POC revealed the patient was also using Morphine extended release (opioid) 30 mg 1 tablet every 12 hours and Morphine 15mg 1 tablet every 4 hours as needed for pain. NO415 did not capture the use of an opioid. During an interview with the agency director on 5/21/25 at approximately 2:00 pm, the director confirmed the OASIS information was not accurate. 1. Patient # 1 had a Start of Care [SOC] date of 2/11/24 with an admitting diagnosis of encounter for fitting and adjustment of urinary device. Review of the clinical record revealed RN # 10 completed the SOC OASIS [Outcome and Assessment Information Set-assessment tool used to collect data on patient’s demographics, clinical status, functional status and service needs] on 2/11/24. Review of OASIS question N0415 related to high-risk medications indicated the patient was receiving an antipsychotic [psychiatric medication] medication. Review of the Plan of Care for the certification period 2/11/24-4/10/24 revealed no antipsychotic medication was ordered for the patient. During an interview with RN # 9 on 5/21/25 at approximately 2 pm, RN # 9 confirmed the OASIS [N0415] was answered incorrectly. 2. Patient # 3 had a Start of Care date of 2/6/24 with an admitting diagnosis of age-related osteoporosis [condition related to aging where bone density and strength decline]. Review of the clinical record revealed RN # 2 completed the SOC OASIS [Outcome and Assessment Information Set-assessment tool used to collect data on patient’s demographics, clinical status, functional status and service needs] on 2/6/24. Review of OASIS question N0415 revealed RN # 2 indicated the patient was not taking any high risk medications. Review of the Plan of Care for the certification period 2/6/24-4/5/24 revealed the patient was ordered an antiplatelet [aspirin 81 mg two times per day]. During an interview with RN # 9 on 5/21/25 at approximately 2 pm, RN # 9 confirmed the OASIS [N0415] was answered incorrectly. 3. Patient # 15 had a Start of Care [SOC] date of 5/7/25 with an admitting diagnosis of infection/inflammation response due to internal fixator of right femur. Review of the clinical record revealed RN # 8 completed the SOC OASIS [Outcome and Assessment Information Set-assessment tool used to collect data on patient’s demographics, clinical status, and service needs] on 5/7/25. Review of OASIS question N0415 revealed RN # 8 indicated the patient was taking an antibiotic and hypoglycemic medication. The OASIS did not indicate the patient was ordered an opioid [pain medication] or antiplatelet medication [medication that reduces the blood’s ability to form platelets. Review of the Plan of Care for the certification period 5/7/25-7/5/25 indicated the patient was ordered children’s aspirin [antiplatelet] 81 mg two times a day and oxycodone [opioid] 5 mg every 6 hours. During an interview with RN # 9 on 5/21/25 at approximately 2 pm, RN # 9 confirmed the OASIS [N0415] was answered incorrectly. 4. Patient # 16 had a Start of Care [SOC] date of 4/23/25 with an admitting diagnosis of intrahepatic bile duct carcinoma [cancer]. Review of the clinical record revealed RN # 6 completed the SOC OASIS [Outcome and Assessment Information Set-assessment tool used to collect data on patient’s demographics, clinical status, functional status and service needs] on 4/23/25. Review of OASIS question N0415 related to high-risk medications indicated the patient was receiving an antipsychotic [psychiatric medication]. Review of the Plan of Care [POC] for the certification period 4/23/25-6/21/25 revealed no antipsychotic medications were ordered. Further review of the OASIS question N0415 revealed RN # 6 did not include the patient being ordered an opioid [pain medication]. Review of the POC revealed the patient was ordered Fentanyl 25 mcg/hr. transdermal patch. During an interview with RN # 9 on 5/21/25 at approximately 2 pm, RN # 9 confirmed the OASIS [N0415] was answered incorrectly.

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, observations, and staff interviews, the agency failed to perform proper hand hygiene for 1 of 7 home visits (#8); and failed to use a thermometer sheath for a thermometer used for other patients for 1 of 7 home visits (#8). Findings included: Patient #8 had an admission date of 5/12/2025 with a diagnosis of Acute and chronic respiratory failure with hypoxia (long-term “chronic” severe impairment of the respiratory system causing low blood oxygen levels and a sudden “acute” worsening of symptoms including shortness of breath). The plan of care for 5/12/2025 – 7/10/2025 included orders for skilled nurse (SN) visits 2 times a week for 2 weeks, 1 time a week for 4 weeks. During a joint visit on 5/19/2025 at approximately 2:30pm with RN #2 and the clinical team lead, RN #2 applied an excessive amount of hand sanitizer to her hands and then wiped the excess sanitizer off on her scrubs. RN #2 was observed using a thermometer without a sheath (clear, sanitary cover) while obtaining a temperature by mouth. During an interview conducted on 04/30/2025 at approximately 3:10 pm, the clinical team lead was asked what the expectations were in this situation. She acknowledged that based on agency policy, RN #14 should not have wiped her hands on her scrubs and should have used a protective sheath on the thermometer.

An unannounced, onsite recertification survey was conducted 5/31/22-6/1/22. No deficiencies to the Emergency Preparedness Plan was identified.

An unannounced onsite recertification survey was conducted 5/31/22-6/1/22. Standard level deficiencies to the Medicare CoP 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 clinical record review, observation of virtual visits, interviews with staff and patients/caregivers the clinical record did not include all/correct medications the patient was using for 4 of 7 virtual visits [#11, 7, 12 , 9 ]. The findings included: 4.Patient #9 was admitted on 05/15/22 with diagnoses of encounter for other orthopedic aftercare, essential hypertension, spinal stenosis (pressure on the nerves of the spinal cord), and anxiety. The plan of care for 05/15/22 to 07/13/22 included the following orders: skilled nursing 2 times a week for 1 week, 1 time a week for 4 weeks; physical therapy 1 time a week for 1 week, 2 times a week for 6 weeks, occupational therapy 1 time a week for 1 week and 2 times a week for 6 weeks. A virtual home visit was conducted on 05/31/22 at 2:20 p.m. with the physical therapist. A review of current medications was conducted with the patient during the home visit. The review revealed the following discrepancy: Tylenol 500 mg (milligram) 2 tablets by mouth every 6 hours as needed for pain. Per interview with the patient, “I’ve been taking this medicine off and on since I got out of the hospital”. 2. Patient #7 had a Start of Care date of 05/08/2022. Diagnoses on the Plan of care included, Encounter for surgical after care following surgery on circulatory system; Type II Diabetes Mellitus with diabetic peripheral angiopathy without gangrene; Atherosclerosis native artery of left leg with ulcer other part of lower leg; Non- pressure chronic ulcer other part left lower leg with unspecified severity; chronic respiratory failure with hypoxia. The certification of 05/08/2022 to 07/06/2022 included orders for Skilled nurse visits 2 times per week for 2 weeks; 1 time per week for 4 weeks with 1 as needed visit for exacerbation of disease process. A virtual home visit was conducted on 06/01/2022 at 10:00 a.m. with skilled nurse #8 and patient. A review of the active medication list provided by the agency clinical manager on 06/01/2022, revealed the following discrepancy in duplication of the same medication: Albuterol sulfate HFA 90 mcg (microgram)/actuation aerosol inhaler take 2 puffs as needed for SOB (shortness of breath) and Ventolin (a brand name for albuterol) HFA 90 mcg/actuation aerosol inhaler 2 puffs every 4 to 6 hours as needed for wheezing or shortness of breath. In an interview with the skilled nurse #8 on 06/01/2022 at 10:13 a.m., the nurse stated “it (albuterol sulfate) needs to be discontinued, will remove it so it is correct.” 3. Patient #12 had a Start of Care of 05/14/2022. Diagnoses on the Plan of Care for the certification period 05/14/2022 to 07/12/2022 included Diverticulosis of Large intestine without perforation or abscess without bleeding, other impaction of intestine, and Dementia with Lewy Bodies. Physical therapy [PT] was ordered 1 time per week for 1 week; 2 times every 2 weeks for 2 weeks; 2 times per week for 2 weeks. Occupational therapy [OT] was ordered beginning 05/15/2022 for 1 time per week for 1 week then 2 times per week for 3 weeks. A virtual home visit was conducted on 06/01/2022 at 1:00 p.m. with patient, primary caregiver (PCG) and an agency physical therapy assistant ­­­­#7. A review of the medications with the primary caregiver revealed the following discrepancies: Omeprazole ER (extended release) 40mg (milligram) taken by mouth daily [for Gastroesophageal reflux disease], the Omeprazole was omitted on the POC. Aspirin 81 mg taken by mouth daily [ taken as a blood thinning medication]. The PCG stated the patient “has been taking for years.” The Aspirin was omitted on the POC. Tylenol Arthritis 650 mg taken by mouth daily as needed for pain, the PCG stated patient, “takes 1 tablet every morning.” The Tylenol Arthritis was omitted on the POC. Fibercon 2 tsp (teaspoons) mixed in liquid of choice taken by mouth daily for constipation. Fibercon was omitted on the POC. Duloxetine 30 mg capsule delayed release taken by mouth daily and Duloxetine 60 mg capsule delayed release taken by mouth daily [for nerve pain; antidepressant]. The PCG stated she had “only been giving the patient [#12] Duloxetine 60 gm capsule because she was confused over the prescription on the bottle.” Stated the patient had an appointment with the doctor on 07/07/2022 and would ask about the medications and she would continue only the Duloxetine 60 mg capsule.” An interview on 06/01/2022 with the agency Clinical nurse manager, which was present at time of the home- visit, stated she would follow up with the Physician for clarification of orders for Duloxetine. 1. Patient # 11 had a Start of Care [SOC] date of 4/25/22and an admitting diagnosis of Paraplegia. A review of the Plan of Care {POC] for the certification period 4/25/22 to 6/23/22 included orders for SN [skilled nursing] 1 time a week for 1 week, 2 times every 2 weeks for 2 weeks, 1 time a week for 4 weeks, 1 PRN [as needed] for exacerbation of disease process and “Skilled nurse to review medication profile and reconcile medications as needed…” A virtual visit was conducted with RN # 1 on 6/1/22 at 11 am. During the virtual visit a medication review was conducted using the Client Medication Report provided by the agency. The following discrepancies were noted: During an interview with the patient after during the visit the patient presented a bottle of Amitriptyline [antidepressant] 25 mg 1 tablet every day. The start date for the Amitriptyline was 4/13/22 and a bottle of Aspirin 81 mg 1 tablet each day. During the interview with the patient he stated he had been taking both medications since before his admission to home health. An interview was conducted with RN # 2 on 6/1/22 at approximately 12 noon. During the interview the RN confirmed the the clinical record did not include all medications/correct medications the patient was using.