Every finding on record at Carolinas Medical Center at Home Lllc

An onsite recertification survey was conducted 08/26/2025-08/28/2025. No deficiencies to the Emergency Preparedness Program were identified.

An onsite recertification survey was conducted 08/26/2025-08/28/2025. A deficiency to the Medicare Conditions of Participation was 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 5 home visits conducted (9,12, and 15). Findings included: Review of a policy “MM 017 AH AH Medication Reconciliation”, revised 8/7/2024 was received from Employee #3 on 08/28/2025 at 1145. 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 #9 was admitted on 07/22/2025 with diagnoses of pneumonia, copd (chronic obstructive pulmonary disease), acute and chronic respiratory failure and dependence on supplemental oxygen. 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;. A home visit was conducted on 08/27/2025 at 1100 with the registered nurse. A review of current medications was conducted with the patient during the home visit. The review revealed the following discrepancy: Flonase 50 mcg (micrograms) 1 spray each nostril daily. Interview with patient revealed she has been taking this for a while for respiratory issues. 2. Patient #12 was admitted on 07/29/2025 with diagnoses of chronic respiratory failure, atrial fibrillation, and pulmonary hypertension. Order were for physical therapy 1 time a week for 5 weeks. A home visit was conducted on 08/27/2025 with the physical therapist assistant at 1300. A review of current medication was conducted with the patient during the home visit. The review revealed the following discrepancy: Metformin daily for diabetes by mouth. Interview with the patient at 1355 confirmed that the patient has been taking this medication since the first of this year. 3. Patient #15 was admitted on 08/17/2025 with diagnoses of venous insufficiency (not enough blood supply), non-pressure chronic ulcer of lower left leg, hypertensive heart disease and permanent atrial fibrillation (heart flutter). Order were for physical therapy 1 time a week for 1 week, 2 times a week for 2 weeks and 1 time a week for 2 weeks. A home visit was conducted on 08/27/2025 with the physical therapist assistant at 1400. A review of current medication was conducted with the patient during the home visit. The review revealed the following discrepancy: miralax (used for constipation) takes as needed. Interview with the patient at 1430 confirmed she has been using this when she needs to for a while.

A recertification survey was conducted August 29, 2022-September 1, 2022. No deficiencies to the Emergency Preparedness Program was identified.

A recertification survey was conducted August 29, 2022-September 1, 2022. Standard levels 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, clinical record review, observation, and caregiver and staff interviews the Plan of Care failed to include and accurate medication list for 2 of 2 patients that had feeding tubes (#13 and 15). Findings included: A policy, Medication Reconciliation issued 3/4/20, stated, “The organization will reconcile patient’s medication at the time of admission and on an ongoing basis…At time of comprehensive assessment, the clinician will create and document a complete list of medications that patient is taking, including dose, route, and frequency…Any discrepancies will be reconciled by the clinician with the patient’s physician…” A policy, Plan of Care and Provider Orders revised 2/2022 stated, “The Plan of Care includes…All medications and treatments…” 1. Patient #13 was admitted on 8/17/22 with a diagnosis of encounter following surgery on the respiratory system. The patient also had a tracheostomy (a surgical opening into the windpipe to help the patient breathe) and gastrostomy tube (feeding tube). The Plan of Care (POC) for 8/17/22-10/15/22 included orders for skilled nursing visits weekly for five weeks to “to review medication profile and reconcile medications as needed. Instruct/reinforce medication teaching. The POC also included an order for Tramadol 50 mg every 4-6 hours as needed for pain oral. A virtual home visit observation with PTA #6 was conducted on 8/30/22 at 12:45 p.m. In an interview with the patient’s spouse, it was confirmed the patient does not take any medications by mouth. An interview was conducted with RN #12 on 9/1/22at 3:00 p.m. confirmed the patient did not take any medications by mouth. 2. Patient #15 was admitted on 3/31/22 with diagnoses of other paralytic syndrome (a group of rare muscles diseases that cause episodes of muscle weakness or paralysis) following intracerebral hemorrhage (bleeding on the brain), quadriplegia (paralysis of all four extremities), and chronic respiratory (lung) failure. The patient also had a tracheostomy (a surgical opening in the neck into the windpipe to help patient breathe) and gastrostomy tube (feeding tube). The Plan of Care (POC) for 7/29/22-9/26/22 included orders for skilled nursing visits one time for one week, then one time every three weeks for six weeks “to review medication profile and reconcile medications as needed. Instruct/reinforce medication teaching. The POC also included the following medications: · Amlodipine 10 mg daily oral—blood pressure · Ascorbic Acid (Vitamin C) 500 mg chewable tablet daily oral—supplement · Atorvastatin 80 mg daily oral oral—cholesterol · Famotidine 25 mg twice daily oral— gastroesophageal reflux · Levetiracetam 500 mg 2 tablets every 12 hours oral—seizures · Levothyroxine 125 mcg daily oral—thyroid · Oxcarbazepine 600 mg twice daily oral—seizures · Potassium Chloride 20 meg/15 ml, 15 ml daily oral—supplement A virtual home visit observation was conducted on 8/30/22 at 11:30 a.m. In an interview with the patient’s spouse, it was confirmed the patient does not take any medications by mouth. In an interview with RN #9, immediately following the observation, it was confirmed the patient’s medications should have been ordered per gastrostomy tube not orally. During the medication review, the patient’s spouse revealed the patient was also taking the following medications that were no on the POC: · Melatonin 5 mg at bedtime via gastrostomy tube—sleep · Trazadone 150 mg daily via gastrostomy tube—antidepressant · Centrum daily via gastrostomy tube—multivitamin An interview with the spouse during the home visit revealed the patient had been taking these medications daily beginning prior to the home health admission. A physician office visit note on March 11, 2022 stated, “Remains on trazadone nightly…” In an interview with RN #9, immediately following the observation, revealed the POC did not include all medications the patient was taking.

Responsibilities of skilled professionals CFR(s): 484.75(b) Standard: Responsibilities of skilled professionals. Skilled professionals must assume responsibility for, but not be restricted to, the following: This STANDARD is not met as evidenced by: Based on clinical record review, and staff interview the RN failed to assess a wound prior to discharge in 2 of 2 patients discharged with a wound (#9, 10). Findings include: Patient #9 was admitted 9/19/21 with stage 2 pressure ulcers (a wound caused by pressure with partial-thickness skin loss) of the right and left buttocks. The Plan of Care for 11/18/21-1/16/22 included orders for skilled nursing (SN) weekly for eight weeks to provide wound care and to assess, teach, and reinforce management of wounds. On the 1/5/22 skilled nurse visit, the RN identified a stage 2 pressure ulcer (a wound caused by pressure with partial-thickness skin loss) on the right buttock had reopened. The wound measured 0.3 cm (centimeters) x 0.6 cm x 0.1 cm. The physician was notified, and wound care orders were requested. Wound care orders were received on 1/6/22. The next nurse visit was on 1/12/22 when RN #1 conducted a discharge assessment. The visit note revealed wound measurements were not taken because “wife performed wound care prior to SN arrival.” An interview with RN #1 on 9/1/22 at 12:20 p.m. revealed the RN could not remember the visit. The RN confirmed the documentation stated that the patient’s wife had completed wound care before the nurse arrived at the home. 2. Patient #10 was admitted on 11/17/21 with diagnoses of malignant neoplasm of the pancreatic head, chronic obstructive pulmonary disease (COPD-a lung disease), and type 2 diabetes mellitus. The Plan of Care for 11/17/21-1/15/22 included orders for skilled nursing weekly for nine weeks. The patient was hospitalized, and a resumption of care (an assessment completed after a hospitalization) was completed on 12/21/21. The nurse visit frequency was increased to three time per week. On 1/5/22, RN #7 conducted a home visit. The nurse documented the patient had been to the wound care center and new orders for a coccyx (tailbone area) wound were received. The wound was not assessed this visit due to dressing intact and wound supplies ordered. On 1/7/22 and 1/14/22, RN #7 conducted a visit and stated, “Family able to be independent with wound care to buttocks.” The patient received no further visits. There was no evidence that a wound assessment was conducted. An interview was conducted with RN #7 on 9/1/22 at 1:30 p.m. The RN stated, “The family was independent with wound care.”

Preparing clinical notes CFR(s): 484.75(b)(6) Preparing clinical notes; This ELEMENT is not met as evidenced by: Based on clinical record review and staff interview the RN failed to document wound care for 2 of 9 patients with wounds (#1 and 4); and to document interventions and follow up for 1 of 1 patients [ #17] with complaint of pain. FIndings included: 3. Patient #4 was admitted on 7/9/21 with diagnoses of type 2 diabetes mellitus with other skin ulcer, non-pressure chronic ulcer of left ankle with fat layer exposed, and diabetic peripheral angiopathy (a blood vessel disease caused by high blood sugar levels). The Plan of Care (POC) for 7/4/22-9/1/22 included orders for skilled nursing weekly for nine weeks to provide wound care to the left ankle. On 8/9/22 an interim order was received; “CLEAN WOUND WITH WOUND CLEANSER. APPLY MEDIHONEY GEL COVER WITH DRY DRESSING. SECURE WITH TAPE. CHANGE DRESSING EVERY OTHER DAY. USE MEDIHONEY GEL UNTIL SANTYL OINTMENT BECOMES AVAILABLE. WHEN SANTYL BECOMES AVAILABLE APPLY TO WOUND BED COVER WITH SALINE MOISTENES GAUZE, COVER WITH DRY GAUZE, ROLL GAUZE AND SECURE WITH TAPE. CHANGE EVERY OTHER DAY.” The nurse conducted visits on 8/9/22, 8/12/22, and 8/19/22. There was no evidence of the type of wound care provided on these visits. An interview was conducted with RN #12 on 9/1/22 at 3:00 p.m. The RN stated that she used the Medihoney until the Santyl came in but could not confirm the dates. 1. Patient #1 had a Start of Care of 08/09/2022 which included diagnoses of cellulitis [bacterial skin infection] of right lower limb and bacteremia [presence of bacteria in the blood stream]. The Plan of Care for certification period of 08/09/2022 through 10/07/2022 included orders for Skilled nursing [SN] 2 times per week for 9 weeks. Wound care orders were, “SN… using clean technique, cleanse wound with wound cleanser … apply hydrogel to wound bed, cover with gauze or foam dressing…may apply ABD [gauze pads used to absorb discharges … from heavily draining wounds] if needed for drainage, 2 times per week and PRN [as needed]. A review of wound care documentation for SN visits on 08/12/2022, 08/16/2022, 08/23/2022 and 08/26/2022 revealed there was no evidence of the type of wound care provided. Skilled nurse #8 was interviewed on 09/01/2022 at 2:00 PM, and it was reported the dressing changes were done as per the physician’s orders. The interview also confirmed there was no evidence of the type of wound care provided in the documentation. 2. Patient #17 had a Start of Care 07/25/2022 which included diagnoses of alcoholic cirrhosis of the liver [an advanced stage of alcohol induced liver disease] and hyponatremia [a condition that occurs when the level of sodium in the blood is too low]. The Plan of Care [POC] for the certification period 07/25/2022 through 09/22/2022 included orders for skilled nursing [SN] for 2 times per week for 1 week; 1 time per week for 6 weeks with 2 PRN [as needed]. The POC included orders for “clinician to provide skilled assessment to monitor pain, effectiveness of pain management regimen and provide teaching/ reinforcement regarding methods to effectively manage pain.” A clinical record review of SN#8 visit assessment on 07/29/2022 revealed patient #17 reported pain at “11 [on a pain scale of 1-10 with 10 being the worst] … generalized aching” and asked if SN #8 “has any pain medication in the bag.” There was no evidence the nurse addressed patient #17 complaint of pain. On 08/03/2022 a visit note was entered which reported patient #17 had been transferred on 07/29/2022 to the hospital with complaint of “cramps.” Also, per the hospital record from 07/29/2022 patient reported “hands and feet cramping which happens when __sodium is low (low sodium levels in the blood can cause muscle weakness, spasms or cramps).” According to the hospital report, patient #17 sodium level was 117 mmol/l ( normal sodium level 134- 143 mmol/l; sodium is required for the human body to conduct nerve impulses, contract and relax muscles, and maintain the proper balance of water and minerals.) An interview with SN #9 on 09/01/2022 at 2:00 PM it was reported that during the SN visit with patient #17 on 07/29/2022, the patient “packed his bags and said I am going to the hospital.” SN confirmed that the full conversation with patient #17 was not documented.

Interventions and patient response CFR(s): 484.110(a)(2) All interventions, including medication administration, treatments, and services, and responses to those interventions; This ELEMENT is not met as evidenced by: Based on policy review, clinical record review, and staff interview, the agency failed to include complete wound orders for 4 of 9 patients with wounds (#2, 4, 10, and 13); to document reason an oxygen saturation level was believed to be inaccurate (#10) for 1 of 5 discharged patients. Findings included: 2. Patient #4 was admitted on 7/9/21 with diagnoses of type 2 diabetes mellitus with other skin ulcer, non-pressure chronic ulcer of left ankle with fat layer exposed, and diabetic peripheral angiopathy (a blood vessel disease caused by high blood sugar levels). The Plan of Care for 7/4/22-9/1/22 included orders for skilled nursing weekly for nine weeks to provide wound care to the left ankle. On 7/8/22 an interim order was received for wound care: “CLEANSE WOUND WITH WOUND CLEANSER. APPLY SILVASORB TO WOUND, COVER WITH FOAM, DRY DRESSING AND SECURE WITH TAPE. CHANGE DRESSING EVERY 3 DAYS PER WOUND ORDERS IN HOME.” The order did not include the site of the wound. On 8/9/22 another interim order was received; “CLEAN WOUND WITH WOUND CLEANSER. APPLY MEDIHONEY GEL COVER WITH DRY DRESSING. SECURE WITH TAPE. CHANGE DRESSING EVERY OTHER DAY. USE MEDIHONEY GEL UNTIL SANTYL OINTMENT BECOMES AVAILABLE. WHEN SANTYL BECOMES AVAILABLE APPLY TO WOUND BED COVER WITH SALINE MOISTENES GAUZE, COVER WITH DRY GAUZE, ROLL GAUZE AND SECURE WITH TAPE. CHANGE EVERY OTHER DAY.” The order did not include the site of the wound. An interview was conducted with RN #12 on 9/1/22 at 3:00 p.m. The RN confirmed the wound orders were for the left ankle. The RN stated that if the new orders were obtained for an existing wound, the site did not have to be included on the order. 3A. Patient #10 was admitted on 11/17/21 with diagnoses of malignant neoplasm of the pancreatic head, chronic obstructive pulmonary disease (COPD-a lung disease), and type 2 diabetes mellitus. The Plan of Care for 11/17/21-1/15/22 included orders for skilled nursing weekly for nine weeks. The patient was hospitalized, and a resumption of care (an assessment completed by after a hospitalization) was completed on 12/21/21. The resumption of care orders stated, “USING CLEAN TECHNIQUE, CLEANSE WOUND WITH WOUND CLEANSER, APPLY FOAM DRESSING, MAY SECURE EDGES WITH TAPE OR WOUND RETENTION SHEETS. MAY APPLY SKIN PREP. MAY WRAP WITH COBAN…LOCATION OF WOUND: TRAUMA.” Wound care to be provided three times per week. The order did not include the site of the wound. An interview with RN #7 was conducted on 9/1/22 at 1:30 p.m. The RN stated, “I missed it” related to wound care site. 3B. The Plan of Care (POC) for Patient #10 for 11/17/21-1/15/22 included orders for skilled nursing weekly for nine weeks and physical therapy (PT) one time per week for two weeks, then twice weekly for four weeks. The POC also included parameters for the physician to be notified of oxygen saturation (O2 sat) levels below 90%. RN #7 conducted a home visit on 12/10/21 and documented a O2 sat of 0%. The physician was notified of O2 sat. There was no documentation of an assessment that stated why 0% was not an accurate reading. An interview with RN #7 on 9/1/22 at 1:30 p.m. revealed the staff had difficulty obtaining accurate O2 sats because this patient’s hands were cold. On 12/15/21, PT #3 conducted a home visit. The PT documented O2 sats 81%. The note revealed the physician was not notified because the physician was aware there were problems getting an accurate reading. The note also stated, “Do not believe this was a correct reading.” There was no documented assessment that stated why this was not accurate. The visit note revealed the patient had been to the emergency department twice the previous weekend. Record review revealed the patient was admitted to the hospital on 12/19/21. An interview with PT #3 on 9/1/22 at 12:30 p.m. revealed the PT did not remember how the inaccuracy was determined and stated that the assessment that determined the inaccuracy should have been in the visit note. 4. Patient #13 was admitted on 8/17/22 with a diagnosis of encounter following surgery on the respiratory system. The Plan of Care (POC) for 8/17/22-10/15/22 included orders for skilled nursing visits weekly for five weeks to “gentle [sic] clean neck incisions and apply bacitracin [an antibiotic ointment] to two times daily…” The order did not include the cleansing solution. In an interview with RN #12 on 9/1/22 at 3:00 p.m., the RN stated, “I probably typed what was on the order.” A procedure, Orders-Guidance Document (revised 8/2022), was provided by the Accreditation Coordinator on 9/1/22 at 4:50 p.m. The document stated, “Wound orders must include location of the wound…how would [sic] will be cleaned…type of dressing being applied to wound bed…Frequency of wound care…” 1. Patient #2 had a Start of Care 8/5/2022 with diagnoses of pressure ulcer of the sacral region, stage 4 [a wound involving muscle and bone at the bottom of the spine], unstageable [an ulcer that has full thickness tissue loss but unable to see the wound bed] pressure ulcers to right heel, ankle and other sites; type 2 diabetes mellitus and bacteremia [the presence of bacteria in the bloodstream]. The certification period for the Plan of Care [POC] 8/5/2022 through 10/3/2022 included orders for skilled nursing [SN] 1 time per week for 1 week; 3 times per week for 2 weeks; 2 times per week for 4 weeks; 1 time per week for 2 weeks with 3 PRN [as needed]. The sacral region wound care frequency on the POC began 8/5/2022 was ordered “3 X weekly.” SN #9 completed the resumption of care [an assessment required any time the patient is admitted as an inpatient for 24 hours or more for other than diagnostic tests and returns to home care] on 8/25/2022. The frequency of wound care for the sacral region was documented as “X weekly.” An interview with SN #9 on 9/1/2022 at 2:25 PM confirmed the frequency of wound care was missing.