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

An onsite recertification survey was conducted 2/3/25-2/5/25. No deficiencies to the Emergency Preparedness Program were identified.

An onsite recertification survey was conducted 2/3/25-2/5/25. Deficiencies to the Medicare Conditions of Participation were identified.

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 policy review, observation, client record review, and staff interviews, the agency failed to include all medications on the plan of care for 3 of 7 home visits conducted (12,11,and 14 ). Findings included: 2. Patient # 11 had a Start of Care date of 5/1/24 and an admitting diagnosis of hypertensive heart disease [complications of high blood pressure that affective the heart] with heart failure [heart does not pump effectively]. Review of the plan of care for the certification period 12/27/24-2/24/25 included orders for SN [skilled nurse] 2 times a week for 1 week, 1 time a week for 7 weeks and “skilled nurse to review medication profile and reconcile medications as needed...” On 2/3/25 at approximately 12 pm, a joint visit was conducted with RN # 5. During the visit a medication review was conducted using a medication profile provided by the agency. The following discrepancy was noted: The patient presented a tube of Betamethasone cream [steroid medication] with the following directions “May use BID [2 times a day] PRN [as needed] for itching. The patient reported she used this medication for her eczema [dry itchy skin often with a rash] on her back. The medication profile did not include the Betamethasone. During an interview with the RN, the RN confirmed the POC did not include all the medications the patient was using. 3. Patient # 14 had a Start of Care date of 1/19/24 with admitting diagnoses of encounter for fitting and adjustment of urinary device and benign prostatic hyperplasia with lower urinary tract symptoms [enlarged prostate]. Review of the plan of care [POC] for the certification period 1/13/25-3/13/25 included orders for SN [skilled nursing] 2 times a week for 9 weeks and “skilled nurse to review medication profile and reconcile medications as needed...” A joint visit was conducted with RN # 4 on 2/3/25 at approximately 10:30 am. During the visit a medication review was conducted using a medication profile provided by the agency. The following discrepancy was noted: The medication profile listed Zinc [supplement] 30 mg. Take 1 capsule daily. The patient presented a bottle of Zinc 50 mg and advised this is the medication he currently takes. During an interview with the RN, it was confirmed the POC did not include all the current/correct medications the patient was taking. Review of a policy “MM 017 AH AH Medication Reconciliation”, revised 8/7/2024 was received from the agency director on 2/5/25 at 11:05 AM. The policy stated, “… at the time of comprehensive assessment, the clinician will create and document a complete list of medications that patient is taking including dose, route and frequency…”. 1.Patient #12 was admitted on 1/22/25 with diagnoses of secondary malignant neoplasm of right kidney and renal pelvis, chronic obstructive pulmonary disease, chronic diastolic heart failure, and hyperlipidemia (high cholesterol). Orders were for occupational therapy 1 time a week for 3 weeks. A home visit was conducted on 2/3/25 at 1:30 PM with the occupational therapist. A review of the current medications was conducted with the patient/caregiver during the home visit. The review revealed the following discrepancy: triamcinolone acetonide cream 0.1% (steroid cream). Per interview with the wife the patient has using the cream for a while if his skin gets irritated with radiation.

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 agency failed to include wound measurements for 2 of 8 records reviewed with wounds (6 and 16). Findings included: Review of policy “Wound Assessment, home care”, revised 2/20/24 was received from the agency director on 2/5/25 at 11:05 AM. The policy stated,” …a thorough wound assessment should consist of objective criteria and measurements that promote accurate, consistent comparisons to determine the extent of the wound and the effectiveness of wound healing…” 1.Patient #6 was admitted on 12/23/23 with diagnoses of encounter for orthopedic aftercare following surgical amputation, paroxysmal arial fibrillation, heart failure, type 2 diabetes, and acquired absence of left leg. Review of the plan of care for 12/17/24-2/14/25 had orders for skilled nursing were 2 times a week for 1week, and 3 times a week for 5 weeks. Skilled nursing wound care orders were to clean site with wound cleanser, apply adaptic, cover with dry gauze/ABD pad, wrap with roll gauze and secure with tape. Review of skilled nursing notes revealed wound measurements were missing for the weeks of 12/30/24, 1/6/25, 1/13/25, 1/20/25, and 1/27/25. Interview with the Accreditation Coordinator on 2/3/25 at 3:55 PM confirmed no other wound measurements were in the medical record. 2. Patient #16 was admitted on 12/22/24 with diagnoses of special stenosis (spinal narrowing), type 2 diabetes, abrasion left lower leg and blister of left foot. Review of the plan of care for 12/22/24-2/19/25 had orders for skilled nursing 3 times a week for 1 week, 2 times a week for 1 week, and 1 time a week for 7 weeks. Skilled nursing wound care orders were to cleanse wound with wound cleanser, apply aquacel AG (silver), cover with gauze, secure with tape or wound retention sheets. Review of the skilled nursing notes revealed wound measurements were missing for the week of 12/30/24. Interview with the Accreditation Coordinator on 2/4/25 at 3:35 PM confirmed no measurements were documented for the week of 12/30/24.

An onsite recertification survey was conducted 02/28/22 to 03/01/22. No deficiencies to the Emergency Preparedness Program were identified. ABH

An onsite recertification survey was conducted 02/28/22 to 03/01/22. 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 4 of 7 patients that received a virtual home visit (#1,#2,#3,and #4). Findings included: 1.Patient #1 was admitted on 01/24/22 with diagnoses of COVID-19, pressure ulcer right buttock stage 2, pressure ulcer left buttock stage 2, hypokalemia (low potassium), and type 2 diabetes . The plan of care for 01/24/22 to 03/24/22 included the following orders: skilled nursing 1 time a week for 1 week, physical therapy 2 times a week for 8 weeks, 1 time a week for 1 week, and occupational therapy 1 time a week for 1 week. A virtual home visit was conducted on 02/28/22 at 12:48p.m. with the nurse. A review of current medications was conducted with the patient during the home visit. The review revealed the following discrepancies: loratadine (allergy medicine) 10 mg 1 tablet by mouth daily was not listed on the medication profile and goody’s powder 2 packets as needed for migraines. Per interview with the caregiver “ he has been taking the loratadine for a while, and he uses 2 packets of goody’s instead of 1 packet for the migraines. 2.Patient #2 was admitted on 01/27/22 with diagnoses of encounter for surgical aftercare following surgery on the circulatory system, parksinson’s disease, other chronic pain, and essential hypertension. The plan of care for 01/27/22 to 03/27/22 included the following orders: skilled nursing 1 time a week for 1 week, physical therapy 1 time a week for 1 week, 2 times a week for 6 weeks, occupational therapy 2 times a week for 1 week, and social work 1 time a week for 1 week. A virtual home visit was conducted on 02/28/22 at 1:44 p.m. with the physical therapist. A review of current medications was conducted with the patient/caregiver during the home visit. The review revealed the following discrepancy: lubrication eye drops use daily to eyes as directed. Per interview with the caregiver “he has been using these drops for years, he uses them 2 times a day”. 3. Patient #3 was admitted on 01/13/22 with diagnoses of encounter for orthopedic aftercare following a surgical amputation, type 2 diabetes, gout, and obesity. The plan of care for 01/13/22 to 03/13/22 included the following orders: skilled nursing 1 time a week for 2 week, 2 times a week for 7 weeks, and social work 1 time a week for 2 weeks. A virtual home visit was conducted on 02/28/22 at 3:30 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: normal saline flush 0.9% (percent) 10 ml (milliliter) daily intravenous (in the vein) and heparin flush 5 ml (100 unit/ml) daily intravenous were not included on the medication profile. Interview with the nurse manager on 02/28/22 at 4:00 p.m. confirmed that both of these medications should have been included on the medication profile. 4. Patient #4 was admitted on 02/15/22 with diagnoses of unspecified cirrhosis of liver, ascites (fluid in abdomen), chronic heart failure, and type 2 diabetes. The plan of care for 02/15/22 to 04/15/22 included the following orders: skilled nursing 2 times a week for 3 weeks, 1 time a week for 6 weeks, physical therapy 1 time a week for 1 week, 2 times a week for 2 week, 1 time a week for 2 week, and occupational therapy 1 time a week for 1 week. A virtual home visit was conducted on 03/01/22 at 10:30 a.m. with the physical therapy assistant. A review of current medications was conducted with the patient during the home visit. The review revealed the following discrepancies: Xifaxan (used to treat stomach issues) 550mg (milligram) take 1 tablet twice a day was not included in the medication profile. Interview with the patient on 03/01/22 at 11:12 a.m. confirmed she got this medicine filled on 02/21/22. Rosuvastatin (cholesterol medication) 5 mg 1 tablet daily by mouth was included on the medication profile but the dosage was not accurate. Interview with the patient revealed she has 10 mg tablets and it is not cut in half in her medication planner.

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 and procedure, clinical record review, and staff interview the agency failed to coordinate care with the physician regarding wound drainage and odor for 1 of 4 wound records reviewed (#8). Findings included: A policy, “Coordination of Care”, approved 02/15/2021 was received from Employee #4 on 03/01/22 at 8:46 a.m. The policy stated…reportable changes in a patient’s condition should be communicated to the patient’s physician…coordination communication will be documented in the patient record…”. Patient #8 had a SOC (start of care) of 01/06/22 and included diagnoses of encounter for surgical aftercare following surgery on skin, personal history of COVID-19, and obesity. Review of the skilled nursing visit note for 02/17/22 revealed the wound had serosanguinous, purulent (containing pus) drainage, and the wound had an odor. No documentation was in the record that the physician was notified of these findings. Interview with Employee #3 on 02/28/22 at 4:30 p.m. revealed, “she said she told the doctor about the drainage, but it’s not documented”.

Supervision of home health aides CFR(s): 484.80(h) Standard: Supervision of home health aides. This STANDARD is not met as evidenced by: Based on policy review, client record review, and staff interview the agency failed to provide home health aide supervision for 1 of 1 home health aide records reviewed (#10). Findings included: Review of policy “Home Health Aide Supervision”, approved 03/25/2020 was received from Employee #3 on 03/01/22 at 8:46 a.m. The policy stated,”…home health aides are closely supervised to ensure their competence in providing care at least every 14 days…” Patient #10 had a SOC (start of care) of 01/28/22 and included diagnoses of hypertensive chronic kidney disease, major depressive disorder, hypothyroidism (low thyroid), hyperlipidemia (high cholesterol), and gerd (gastro esophageal reflux disease). Home health aide orders were for 1 time a week for 4 weeks. Review of home health aide visits for 02/02/22, 02/09/22, 02/16/22, and 02/23/22 revealed a supervision visit was not done the week of 02/21/22. Interview with Employee #3 on 2/28/22 at 2:04 p.m. stated “the nurse did do supervisory visit on 2/24/22 but failed to document it”.

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 wound measurements for 1 of 4 records with wounds (#8). Findings included: Review of policy “Wound Assessment”, approved 04/13/2020 was received from Employee #3 on 03/01/22 at 8:46 a.m. The policy stated,” …frequency of assessment start of care, resumption of care, and weekly thereafter… size using head to toe method length x width x depth in centimeters”. Patient #8 had a SOC (start of care) of 01/06/22 and included diagnoses of encounter for surgical aftercare following surgery on skin, personal history of COVID-19, and obesity. Skilled nursing frequency orders were 1 time a week for 1 week, and 2 times a week for 8 weeks. Orders for skilled nursing were for assessment, management of long term non-healing midline sacral wound cleanse wound with normal saline, soapy water apply anasept gel wet to dry dressing, cover with gauze secure with tape or wound retention sheets, may apply skin prep. Review of skilled nursing notes for dates of 01/06/22, 01/10/22, 01/13/22, 01/19/22, 01/21/22, 01/24/22, 01/27/22, 02/02/22, 02/04/22, 02/09/22, 02/17/22 and 02/25/22 revealed measurements were not obtained for the weeks of 01/10/22, 01/19/22, 01/24/22, 02/02/22, 02/09/22, 02/17/22, and 02/25/22. Interview with Employee #3 on 02/28/22 at 4:30 p.m. revealed, “the nurse didn’t measure the wound she said wasn’t able to see the wound bed…”.