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

An onsite recertification survey was conducted 1/13/25-1/15/25. No deficiencies to the Emergency Preparedness Program were identified.

An onsite recertification survey was conducted 1/13/25-1/15/25. 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 6 home visits conducted (16,12, and 15). Findings included: Patient # 12 had a Start of Care [SOC] date of 12/18/24 with admitting diagnoses of orthostatic hypotension [a condition that causes a drop in blood pressure when standing up or sitting down], and permanent atrial fibrillation [abnormal heart rhythm]. Review of the Plan of Care [POC] for the certification period 12/16/24-2/15/25 included orders for OT [occupational therapy] 1 time a week for 1 week, 1 time every other week for 2 weeks, 1 time a week for 6 weeks and “...therapist to monitor and follow-up regarding management of medication...” A joint visit was made with OT # 7 pm 1/14/25 at approximately 12 pm. During the visit a medication review was conducted using a medication profile provided by the agency. The following discrepancies were noted: The medication profile listed Midodrine [used to treat low blood pressure] 5 mg every 8 hours. During an interview with the patient she stated, “I am not taking that right now”. The patient presented a bottle of Docusate Sodium [stool softener] 100 mg and Miralax [stool softener] 17 grams per capful. Neither medication was listed on the POC. During the interview with the patient she stated, “I use both of those, but only when I need them.” Patient # 15 had a Start of Care date of 10/9/24 and an admitting diagnosis of fracture unspecified part of neck of right femur [thigh bone]. Review of the Plan of Care [POC] for the certification period 12/8/24-2/5/25 included orders for SN [skilled nursing] 1 time a week for 9 weeks and “...review medication profile and reconcile medications as needed...” On 1/14/25 at approximately 9 am a joint visit was made with RN # 8. During the visit a medication preview was conducted using a medication profile provided by the agency. The following discrepancies were noted: The patient’s caregiver provided a bottle of pioglitazone [Actos- diabetic medication] 15 mg daily. Take daily with a start date of 11/12/24 and Escitalopram [antidepressant] 20 mg. Take 1 daily with a start date of 12/9/24. Neither medication was listed on the POC. During an interview with employee # 2 on 1/15/25 at approximately 10:30 am employee # 2 confirmed the POC was not complete with all medications. Review of a policy “MM 017 AH AH Medication Reconciliation”, revised 8/7/2024 was received from the agency director on 1/15/25 at 11:11 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 #16 was admitted on 1/4/25 with diagnoses of malignant neoplasm of hypopharynx (cancer of the lower throat), type 2 diabetes, unspecified atrial fibrillation and tracheostomy status (opening in the neck for airflow). Orders were for skilled nursing 1 time a week for 1 week, 2 times a week for 1 week and 1 time a week for 6 weeks; physical therapy 2 times a week for 4 weeks, and 1 time a week for 2 weeks; and occupational therapy 1 time a week for 4 weeks. A virtual home visit was conducted on 1/14/25 at 9:20 AM 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: latanoprost eye drops use 1 drop in both eyes every morning for glaucoma and dorzolamide/timolol 1 drop in both eyes 2 times a day for glaucoma were not included on the current medication list. Per interview with the patient “I have been using these drops for about 15 years”.

All orders recorded in plan of care CFR(s): 484.60(a)(3) All patient care orders, including verbal orders, must be recorded in the plan of care. This ELEMENT is not met as evidenced by: Based on agency policy review, clinical record review, direct observation, and staff interviews the Plan of Care [POC] failed to include wound care orders for 1 of 2 home visits which included wound care [#11]. The findings included: The policy, Plan of Care and Provider Orders, was provided by employee # 2 on 1/15/25 at 8:30 am. The policy stated, "Services will be provided in accordance with a Plan of Care..." Patient # 11 had a Start of Care date of 9/28/24 and admitting diagnoses of disruption of external operation wound [wound reopens], infection following a procedure, and chronic obstructive pulmonary disease [COPD-lung disease]. Review of the Plan of Care [POC] for the certification 11/27/24-1/25/25 included orders for SN [skilled nursing] 2 times a week for 1 week, 3 times a week for 8 weeks and “Cleanse wound with anasept, place white foam to wound bed...wound care is 3 times per week...” On 1/13/35 at approximately 12 pm a joint visit was made with RN # 4 to observe wound care. During the visit the surveyor noted an open area on the right side of the midline wound. The RN cleaned the area and applied telfa and secured it with a piece of drape provided with the negative pressure kit. Review of the clinical record revealed no order related to the open area [right side of midline wound]. During an interview with employee # 2 on 1/15/24 at approximately 10 am it was confirmed the POC did not include an order for the wound care to the wound.

Only as ordered by a physician CFR(s): 484.60(b)(1) Drugs, services, and treatments are administered only as ordered by a physician or allowed practitioner. This ELEMENT is not met as evidenced by: Based on policy review, client record review, and staff interviews, the agency failed to include all vital signs as ordered for 4 of 17 records reviewed (16, 6, 7, and 14). Findings included: 2. Patient # 6 had a Start of Care date of 12/19/24 and an admitting diagnosis of muscle spasm of back. Review of the Plan of Care [POC] for the certification period 12/19/24-2/16/25 included orders for PT [physical therapy] 1 time a week for 4 weeks and “Licensed professional to report vital signs falling outside the following established parameters...temperature less than 95 or greater than 100 degrees...” Review of the clinical record revealed PT # 6 conducted routine visits on 12/23/24 and 12/30/24. Review of visit documentation revealed PT # 6 failed to obtain a temperature on the patient. During an interview with employee # 2 on 1/15/25 at approximately 10 am employee # 2 confirmed PT # 6 failed to follow the POC related to vital signs. 3. Patient # 7 had a Start of Care date of 12/9/24 with an admitting diagnosis of paroxysmal atrial fibrillation [irregular heart rhythm]. Review of the Plan of Care [POC] for the certification period 12/9/24-2/6/25 included orders for PT [physical therapy] 1 time a week for 1 week, 2 times a week for 1 week, 1 time a week for 2 weeks, 2 times a week for 1 week and “...Licensed professional to report vital signs falling outside the following established parameters...temperature less than 95 or greater than 100 degrees...” Review of the clinical record revealed PT # 6 conducted routine visits on 12/0/24 and 12/31/24. PT # 6 conducted a reassessment visit on 1/10/25. PT # 6 failed to obtain a temperature during these visits. During an interview with employee # 2 on 1/15/25 at approximately 10 am employee # 2 confirmed PT # 6 failed to follow the POC related to vital signs. 4. Patient # 14 had a Start of Care date of 10/20/24 and admitting diagnoses of fracture unspecified part of neck of left femur [thigh bone. Review of the Plan of Care [POC] for the certification period 12/9/24-2/16/25 included orders for PT [physical therapy] 2 times a week for 4 weeks and “Licensed professional to report vital signs falling outside the following established parameters...temperature less than 95 or greater than 100 degrees...” Review of the clinical record revealed PT # 6 conducted routine visits on 12/26/24, 1/2/25, 1/6/25, and 1/10/25. Review of the documentation or those dates revealed PT # 6 did not obtain a temperature. During an interview with employee # 2 on 1/15/25 at approximately 10 am employee # 2 confirmed PT # 6 failed to follow the POC related to vital signs. Review of a policy “PC 014 AH AH Plan of Care and Provider Orders”, revised 10/15/2024 was received from the agency director on 1/15/25 at 11:11 AM. The policy stated, “…care and services, including drugs and treatments, will be provided according to provider orders…” 1. Patient #16 was admitted on 1/4/25 with diagnoses of malignant neoplasm of hypopharynx (cancer of the lower throat), type 2 diabetes, unspecified atrial fibrillation and tracheostomy status (opening in the neck for airflow). Orders were for skilled nursing 1 time a week for 1 week, 2 times a week for 1 week and 1 time a week for 6 weeks; physical therapy 2 times a week for 4 weeks, and 1 time a week for 2 weeks; and occupational therapy 1 time a week for 4 weeks. Review of the skilled nursing visit on 1/9/25 did not include a blood pressure as ordered by the physician. Interview with the agency director on 1/15/25 at 9:52 AM revealed, “the nurse said she must have forgotten to document the blood pressure”.

Infection Prevention CFR(s): 484.70(a) Standard: Infection Prevention. The HHA must follow accepted standards of practice, including the use of standard precautions, to prevent the transmission of infections and communicable diseases. This STANDARD is not met as evidenced by: Based on clinical record review, direct observation, and staff interviews the registered nurse failed to follow acceptable infection control practices when completing wound care for 1 of 2 patients receving a home visit for wound care [#11]. The findings included: Patient # 11 had a Start of Care date of 9/28/24 and admitting diagnoses of disruption of external operation wound [wound reopens], infection following a procedure, and chronic obstructive pulmonary disease [COPD-lung disease]. Review of the Plan of Care [POC] for the certification 11/27/24-1/25/25 included orders for SN [skilled nursing] 2 times a week for 1 week, 3 times a week for 8 weeks and “Cleanse wound with anasept, place white foam to wound bed...wound care is 3 times per week...” On 1/13/35 at approximately 12 pm a joint visit was made with RN # 4 to observe wound care. The RN removed all supplies from the nursing bag and placed the items on a clean barrier. After removing the soiled dressing, the RN proceeded to measure the midline incision. The RN removed the paper measuring device from the barrier and placed it on the arm of a visible soiled couch arm without a barrier. The RN then used the paper measuring device [which was previous placed on the arm of the couch] to measure the wound [touching the paper measuring device directly to the open wound]. During an interview with employee # 2 on 1/13/25 at approximately 3 pm it was confirmed the RN should not have placed the measuring device on the couch arm without a barrier.

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 clinical record review, and staff interviews the agency failed to document a wound assessment in the clinical record for 1 of 2 patients receiving a home visit for wound care [#11]. The findings included: Patient # 11 had a Start of Care date of 9/28/24 and admitting diagnoses of disruption of external operation wound [wound pulls apart], infection following a procedure, and chronic obstructive pulmonary disease [COPD-lung disease]. Review of the Plan of Care [POC] for the certification 11/27/24-1/25/25 included orders for SN [skilled nursing] 2 times a week for 1 week, 3 times a week for 8 weeks and “Cleanse wound with anasept, place white foam to wed...wound care is 3 times per week...” Review of the clinical record revealed the following documentation: Routine visit dated 12/2/24 by RN # 4, “...Patient continues to areas of maceration/skin breakdown to hernia/right side of wound...” 12/18/24 by RN # 4, “...Several areas of skin breakdown, unchanged since last RN visit...” 12/30/24 by RN # 4, “...Patient continues to have multiple areas of skin breakdown and maceration to periwound, especially on hernia side...” 1/6/25 by RN # 4, “...Patient continues to have multiple areas of skin breakdown and maceration to periwound, especially on hernia side...” 1/13/25 by RN # 4, “Multiple small areas of skin breakdown...”Review of the clinical record revealed no wound assessment or measurements completed related to the breakdown on the right side of the hernia. During an interview with RN # 2 on 1/15/25 at approximately 10 am RN # 2 confirmed the RN failed to document an assessment of the skin breakdown.

An onsite recertification survey was conducted 02/21/22 to 02/22/22. No deficiencies to the Emergency Preparedness Program were identified. ABH

An onsite recertification survey was conducted 02/21/22 to 02/22/22. 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 2 of 6 patients that received a virtual home visit (#12 and #17) Findings included: 1.Patient #12 was admitted on 12/25/21 with diagnoses of multiple fracture of ribs right side, wedge compression fracture third thoracic vertebrae, nonrheumatic mitral valve insufficiency, alcohol abuse, and uncomplicated heart failure. The plan of care for 12/25/21 to 02/22/22 included the following orders: skilled nursing 1 time a week for 3 weeks, physical therapy 2 times a week for 4 weeks, 1 time a week for 2 weeks, occupational therapy 1 time a week for 1 week, 2 times a week for 2 weeks and 1 time a week for 2 weeks. A virtual home visit was conducted on 02/21/22 at 2:37 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: levothyroxine 25 mcg (micrograms) 1 tablet daily by mouth. The patient stated, “ I stopped taking that medicine a couple of weeks ago, it was hurting my stomach”. 2. Patient #17 was admitted on 01/21/22 with diagnoses of COVID-19, hypertensive heart disease with heart failure, type 2 diabetes with hyperglycemia, chronic kidney disease stage 4, and unspecified atrial fibrillation. The plan of care for 01/21/22 to 03/21/22 included the following orders: physical therapy 1 time a week for 2 weeks, 2 times a week for 2 weeks, 1 time a week for 3 weeks, and occupational therapy 1 time a week for 1 week. A virtual home visit was conducted on 02/22/22 at 3:43 p.m. with the occupational therapist. A review of current medications was conducted with the patient/caregiver during the home visit. The reviewed revealed the following discrepancy: travoprost (eye drop) 0.004% (percent) eye drops 1 drop daily in each eye. The caregiver stated” she’s not using those anymore she’s using latanoprost 0.005 % 1 drop into each eye as directed at bedtime.” The caregiver stated” she’s been using these drops for a long time”.

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 a reported fall for 1 of 1 records reviewed (#5). Findings included: A policy, “Coordination of Care”, approved 02/15/2021 was received from Employee #3 on 02/21/22 at 4:45 p.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 #5 had a SOC (start of care) of 01/11/22 and included diagnoses of COVID-19, pneumonia, acute respiratory failure with hypoxia, chronic kidney disease, and type 2 diabetes. Review of the skilled nursing visit note for 01/13/22 revealed Patient #5 had reported a fall to the skilled nurse. No documentation was in the record that the physician was notified of the fall. Interview with the agency director and quality specialist on 2/21/22 at 1:24 p.m. stated, “the protocol is a falls report is completed and the doctor is notified; nothing is in the record of this being done for this visit on 1/13/22.”.

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 CVC (central venous catheter) measurements for 1 of 2 charts with central line catheter (#11). Findings included: Review of policy “Central Line Dressing Change and Care”, approved 04/13/2020 was received from Employee #3 on 02/21/22 at 4:45 p.m. The policy stated,” …record length of catheter from skin-catheter junction site to hub of catheter…”. Patient #1 was admitted on 07/15/21 with diagnoses of intestine transplant rejection, inflammatory liver disease, fatty liver, supraventricular tachycardia, encounter and adjustment and management of VAD (vascular access device), and other long term drug therapy. The plan of care for 01/11/22 to 03/11/22 had orders for skilled nursing 1 time a week for 9 weeks with 2 as needed visits. Orders for skilled nursing were to perform site care to infusion access device 1 time a week and as needed for loose or soiled dressing as follows: clean with chlorhexidine using friction scrub x 3 seconds allow to dry apply skin prep, apply biopatch apply external securement device and cover with transparent dressing. Change extension tubing and injection cap weekly and after blood draws. Review of skilled nursing notes for dates of 01/12/22, 01/19/22, 02/02/22, 02/09/22, 02/16/22, and 02/21/22 revealed measurements were not obtained for the week of 01/26/22. Interview with the agency director on 2/22/22 at approximately 9:00 a.m. confirmed no measurements were documented on the visit of 1/26/22 by the registered nurse.