Every finding on record at Catherine Kariuki and Ernest Mwangi

A recertification survey was initiated on 10/28/24 with the Administrator. Agency census: L&C-56 LHH-0 Total agency census: 56 Abbreviations: L&C-Licensed and Certified Home Health LHH-Licensed Home Health No deficiencies were cited.

A recertification survey was initiated on 10/28/24 with the Administrator. Agency census: L&C-56 LHH-0 Total agency census: 56 Abbreviations: LCHH-Licensed and Certified Home Health LHH-Licensed Home Health OASIS-Outcome and Assessment Information Set RN-Registered Nurse CMS-Centers for Medicare & Medicaid Service HHA-Home Health Agency NOMNC-Notice of Medicare Non-Coverage POC-Plan of Care SOC – Start of Care cm-centimeter abd./ABD-abdominal pad HH-home health L-left R-right PA-physician assistant FNP-family nurse practitioner wk-week

Written notice for non-covered care CFR(s): 484.50(c)(8) Receive proper written notice, in advance of a specific service being furnished, if the HHA believes that the service may be non-covered care; or in advance of the HHA reducing or terminating on-going care. The HHA must also comply with the requirements of 42 CFR 405.1200 through 405.1204. This ELEMENT is not met as evidenced by: Based on record review and interview, the agency failed to ensure the patient’s right to receive the NOMNC written notice at least two days in advance of terminating on-going care in 3 (Patient #8, #9, and #10) of 3 discharged records reviewed whose reason for discharge was “goals met.” The failure of the agency to protect the rights of the patient by informing in advance of their right to appeal the discontinuation of home health services prevented the identified patient from exercising their right to appeal the discharge decision, if they chose to appeal. Findings include: On 10/28/24 at 12:25 pm the Administrator/Supervising Nurse/RN provided the surveyor with a discharge roster. The discharge roster indicated that Patient #8, #9, and #10 were discharged with “goals met.” An interview was conducted on 10/31/24 at 9:45 am with the Administrator/Supervising Nurse/RN. The surveyor requested discharge charts for Patient #8, #9, and #10. The Administrator/Supervising Nurse/RN stated, “I might as well tell you, I have the 5 day discharge, but I do not have the Notice of Medicare Non-Coverage. Me and RN A forgot about giving the NOMNC notice.” The surveyor asked the Administrator/Supervising Nurse/RN who was responsible for providing the NOMNC. The Administrator/Supervising Nurse/RN said, “For those 3 patients, it was RN A. The surveyor asked the Administrator/Supervising Nurse/RN how not providing the NOMNC could affect the patients. The Administrator/Supervising Nurse/RN said, “They would not know they could appeal the discharge.” Patient 8: Record review of the contained a POC dated 7/15/24-9/12/24 with a SOC date of 1/17/24. The record contained a discharge OASIS assessment dated 9/12/24 and signed by RN A. The record failed to contain a NOMNC. Patient 9: Record review of the contained a POC dated 3/31/24-5/29/24 with a SOC date of 8/4/24. The record contained a discharge OASIS assessment dated 5/29/24 and signed by RN A. The record failed to contain a NOMNC. Patient 10: Record review of the contained a POC dated 6/26/24-8/24/24 with a SOC date of 3/4/23. The record contained a discharge OASIS assessment dated 8/20/24 and signed by RN A. The record failed to contain a NOMNC. An interview was conducted on 11/1/24 at 10:21 am with RN A. The Surveyor reviewed the discharge chart findings in that Patient #8, #9, and #10 charts failed to include the NOMNC with RN A. RN A said, “I give the 5 day discharge notice, I forgot about that notice (NOMNC)” The surveyor asked RN A who was responsible for providing the NOMNC. RN A said, “Me.” The surveyor asked RN A how not providing the NOMNC could affect the patients. RN A said, “They couldn’t appeal the discharge. Agency Policy: PE.6 Patient Discharge/Discharge Planning revised 7/1/21 read in part:… Purpose…To allow patient to appeal the Agency’s decisions to discharge…Policy…J. Agency will deliver the generic CMS notice NOMNC (Notice of Medicare Non Coverage) to the patient (or authorized representative), no less than two (2) days prior to the day of anticipated discharge, or as soon as the Agency determines coverage will end.”… According to OMG Form Instructions 10123-NOMNC: The NOMNC must be delivered at least two calendar days before Medicare covered services end or the second to last day of service if care is not being provided daily. Note: The two-day advance requirement is not a 48 hour requirement. This notice fulfills the requirement at 42 CFR 405.1200(b)(1) and (2) and 42 CFR 422.624(b)(1) and (2). Additional guidance for Original Medicare and Medicare Advantage can be found, respectively, at Chapter 4, Section 260 of the Medicare Claims Processing Manual and Chapter 13, Sections 90.2-90.9 of the Medicare Managed Care Manual.

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 record review and interview, the agency failed to ensure the plan of care included patient specific interventions. In 2 (Patient 2 and 3) of 3 records reviewed where the Patients had a diagnosis of heart failure, the plan of care failed to include specific interventions for the skilled nurse to assess for fluid retention with abnormal parameters to report to the physician. This failure placed the Patients at risk of not receiving adequate care, exacerbation of heart failure and possible hospitalization. Findings include: Patient 2: The record included a plan of care for episode 7/14/24 through 9/11/24 with a start of care date of 11/17/23. The plan of care included a diagnosis of hypertensive heart disease with heart failure (a serious condition that occurs when high blood pressure [hypertension] damages the heart and causes it to weaken and fail) and chronic systolic (congestive) heart failure (a type of heart failure that occurs when the left ventricle of the heart is weak and enlarged, making it unable to pump enough oxygenated blood throughout the body.) The plan of care was signed and dated by Administrator/Supervising Nurse/RN on 7/11/24. The plan of care did not include appropriate interventions for the skilled nurse to assess for fluid retention with abnormal parameters to report to the physician.[RG(1] Patient 3: The record included a plan of care for episode 8/26/24 through 10/24/24 with a start of care date of 3/5/23. The plan of care included a diagnosis of chronic systolic (congestive) heart failure chronic systolic (congestive) heart failure (a type of heart failure that occurs when the left ventricle of the heart is weak and enlarged, making it unable to pump enough oxygenated blood throughout the body.) The plan of care was signed and dated by RN A on 8/21/24. The plan of care did not include appropriate interventions for the skilled nurse to assess for fluid retention with abnormal parameters to report to the physician. An interview was conducted on 10/29/24 at 12:15 pm with the Administrator/Supervising Nurse/RN. The surveyor reviewed Client #2’s and 3’s plan of care with the diagnosis of heart failure with no interventions to assess for fluid retention and parameters for reporting to the physician. The Administrator/Supervising Nurse/RN said, “I must have missed that, I’m usually very careful about that.” The surveyor asked the Administrator/Supervising Nurse/RN who was responsible for ensuring the interventions and parameters for heart failure were included in the plan of care. The Administrator/Supervising Nurse/RN said, ‘I am.” The surveyor asked the Administrator/Supervising Nurse/RN how the plan[RG(2] of care not including the interventions to monitor for heart failure/fluid retention could affect the patient. The Administrator/Supervising Nurse/RN said, “The patient could end up in the hospital with and exacerbation of heart failure.” An interview was conducted on 10/30/24 at 8:30 am via phone with RN A. The Surveyor reviewed Patient #2’s and 3’s plan of care in that both had a diagnosis of heart failure, but their plans of care did not include interventions to monitor for fluid retention or parameters for reporting to the physician. RN A said, “I missed making sure the interventions and parameters were included in the plan of care.” The surveyor asked RN A who was responsible for the plan of care to include all interventions necessary to care for the patients. RN A said, “I am.” The surveyor asked how the plan of care not including interventions to monitor for fluid retention with parameters for reporting to the physician could affect the patients. RN A said, “The patient could go back into the hospital.” According to, https://heart-failure.net/symptoms/swelling, worsening signs and symptoms of heart failure that should be reported to the physician include a weight gain of 2-3 pounds in a single day or 5+ pound in one week, increased swelling in the feet or ankles or swelling or pain in the abdomen. Agency policy: TX.6 Plan of Care last revised 12/29/22 read in part:…” Purpose To develop an individualized plan of care which specifies the care and services necessary to meet the patient specific needs and according to state and federal regulations… Policy A. Each patient will receive an individualized written plan of care…Procedure…C. The individualized Plan of Care will specify the care and services necessary to meet the patient specific needs…The POC will contain he following elements:…14. Patient-specific interventions and education…”

A Recertification Survey entrance conference was conducted on 10/13/2021 at 11:35 AM with the Adm/DON and the LVN/QA Reviewer. Census: LCHH: 60 LHH: 0 An exit conference was conducted on 10/19/2021 at 3:25 PM with the Adm/DON and the LVN/QA Reviewer. The preliminary findings were discussed. The agency was afforded the opportunity to provide additional information. The agency was found in compliance with 42 CFR Part 484.22 Medicare Conditions of Participation and no deficiencies were cited.

A Recertification Survey entrance conference was conducted on 10/13/2021 at 11:35 AM with the Adm/DON and the LVN/QA Reviewer. Census: LCHH: 60 LHH: 0 An exit conference was conducted on 10/19/2021 at 3:25 PM with the Adm/DON and the LVN/QA Reviewer. The preliminary findings were discussed. The agency was afforded the opportunity to provide additional information. Written instructions were provided for submitting a plan of correction within 10 days of the receipt of the Statement of Deficiencies. Deficiencies cited at standard level. ABBREVIATIONS Adm - Administrator AM - ante meridiem CFR - Code of Federal Regulations CHF – Congestive Heart Failure cm - Centimeters DON - Director of Nurses/Supervising Nurse EMR - electronic medical record HF – Heart Failure LCHH- Licensed and Certified Home Health LHH - Licensed Home Health LVN - Licensed Vocational Nurse mg – milligram N/A – Not Applicable PM - post meridiem POC - plan of care QA- Quality Assurance RN - registered nurse rt - Right SN - skilled nurse

Plan of care CFR(s): 484.60(a)(1) Each patient must receive the home health services that are written in an individualized plan of care that identifies patient-specific measurable outcomes and goals, and which is established, periodically reviewed, and signed by a doctor of medicine, osteopathy, or podiatry acting within the scope of his or her state license, certification, or registration. If a physician or allowed practitioner refers a patient under a plan of care that cannot be completed until after an evaluation visit, the physician or allowed practitioner is consulted to approve additions or modifications to the original plan. This STANDARD is not met as evidenced by: Based on record review and interview, the agency failed to ensure that patients received home health services written in the individualized POC. In three of seven active patient records reviewed (Patient 2, 5 and 7), SN visits were not made as ordered. In one of one active patient record reviewed (Patient 4), the nurse failed to report significant changes in a wound to the physician, to report a new wound to the physician and to follow wound care orders. This failure placed the patients at risk of not receiving interventions as needed and could potentially cause complications and a decline in health status. Findings Include: Definitions: Mepilex®: a self-adherent, soft silicone foam dressing that minimizes trauma to the wound and pain to the patient during dressing changes. Mepilex® Border is designed for a wide range of exuding wounds such as pressure injuries, leg and foot ulcers, and traumatic wounds such as skin tears and surgical wounds. Resource: https://www.woundsource.com/product/mepilex-border. Medipore Soft Cloth Adhesive Wound Dressing: a gentle, all-in-one sterile dressing that is breathable, absorbent and conforms to body contours, providing comfort. Unique non-adherent absorbent pad. Resource: https://www.woundsource.com/product/3m-medipore-pad-soft-cloth-adhesive-wound-dressing. Debridement: the process of removing nonliving tissue from pressure ulcers, burns, and other wounds. Resource: https://medical dictionary.thefreedictionary.com/debridement. Patient 2: Record review of the EMR included a POC dated 07/31/2021 to 09/28/2021 that included an order for the SN to visit the patient one time a week for nine weeks beginning the week of 08/01/2021. The record did not include an SN visit the week of 08/22/201 to 08/28/2021. During an interview with the Adm/DON and the LVN/QA Reviewer on 10/19/2021 at approximately 12:32 PM, the surveyor presented the above findings of why an SN visit was not conducted the week of 08/22/2021 to 08/28/2021. The Adm/DON stated she did not know but it must have been because the nurse did not put the note in the EMR. Patient 4: Record review of the EMR included a POC dated 06/27/2021 to 08/25/2021 that read in part, “…Skilled nurse for skilled assessment and instructions of…integumentary status…SN to report to physician…any skin breakdown to reduce the risk of infections SN to assess the patient lesions every visit…” The POC included a supplemental physician order dated 07/12/2021 that read in part, “…Orders: Clean area with wound cleanser pat dry with 4x4 cut small piece of calcium alginate and apply to wound cover with Medipore dressing x 3 days a week until healed…” The POC included a supplemental physician order dated 08/26/2021 that read in part, “…Orders: SN to cleanse right posterior ankle with wound cleanser pat dry with 4x4 cut small piece of calcium alginate, and Medihoney, and apply to wound, cover with Medipore dressing 3 x week until healed…” SN visits were conducted on 07/12/2021 and 07/14/2021 by LVN that read in part, “…WOUND CARE: SITE 01/LOCATION…Right posterior ankle…Width: 1.5 cm Length: 1.8cm Depth: 0.5cm…Dressing Change: Yes…Clean area with wound cleanser pat dry with 4x4 cut small piece of calcium alginate and apply to wound cover withmedipore (sic) dressing x3 days a week until healed… WOUND CARE: SITE 02/LOCATION…Abrasion Left buttocks…Width: 0.5 cm Length: 0.3 cm…Dressing Change: Yes… Clean area with wound cleanser pat dry with 4x4 cut small piece of calcium alginate and apply to wound cover withmedipore (sic) dressing x3 days a week until healed…” An SN visit was conducted on 07/16/2021 by RN that read in part, “…Physician Contact…N/A…SITE 01/LOCATION…RIGHT ANKLE…Width: 1.8 CM Length: 2.8 CM Depth: 0.3 CM…Cleanse wound with wound cleanser pat dry using 4x4 apply calcium alginate and secure with Mepilex three times a week…” There was no documentation that the physician was notified the ankle would was worsening. The EMR included three SN visits on 07/19/2021 by RN as follows: Note 1: Time Arrival: [blank] Departed: [blank]; Note 2: Time Arrival: [blank] Departed: 10:10; Note 3: Time Arrival: [blank] Departed: 10:10. Note 1, 2 and 3 read in part, “…Care Given…WOUND: using aseptic technique…WOUND CARE: SITE 01/LOCATION…rt ankle…Dressing Change: Yes…Wound cleansed with…wound cleanser…Applied…Alginate…Covered with…Non-Adherent Dressing…” SN visits were conducted on 07/27/2021 and 07/30/2021 by LVN that read in part, “…SITE 01/LOCATION…RIGHT ANKLE No Problem Width: 1.8 CM Length: 2.8 CM Depth: 0.3 CM…Cleanse wound with wound cleanser pat dry using 4x4 apply calcium alginate and secure with Mepilex…” The order was for Medipore, not Mepilex. An SN visit was conducted on 08/02/2021 by LVN that read in part, “…Physician Contact…N/A…SITE 01/LOCATION…Right posterior ankle…Width: 1.5 cm Length: 1.8cm Depth: 0.5cm Clean area with wound cleanser pat dry with 4x4 cut small piece of calcium alginate and apply to wound cover withmedipore (sic)dressing x3 days a week until healed…WOUND CARE: SITE 02/LOCATION…Abrasion Left buttocks…Width: 0.5 cm Length: 0.3 cm…Dressing Change: Yes… Clean area with wound cleanser pat dry with 4x4 cut small piece of calcium alginate and apply to wound cover withmedipore (sic) dressing x3 days a week until healed…” SN visits were conducted on 08/04/2021 and 08/06/2021 by LVN that read in part, “…Physician Contact…N/A…SITE 01/LOCATION…Right posterior ankle…Width: 4 cm Length: 2.5cm Depth: 0.8cm Clean area with wound cleanser pat dry with 4x4 apply medihoney and cover with medipore dressing x3 days a week until healed…” There was no documentation that the physician was notified the ankle would was worsening. There was no documentation the agency obtained a physician order for the ankle wound care that occurred on 08/04/2021. An SN visit was conducted on 08/09/2021 by LVN that read in part, “…SITE 01/LOCATION…Left posterior ankle No Problem Width: 4 cm Length: 2.5cm Depth: 0.8cm…Clean area with wound cleanser pat dry with 4x4 apply medihoney and cover with medipore dressing x3 days a week until healed…” SN visits were conducted on 08/11/2021, 08/13/2021, 08/16/2021, 08/18/2021, 08/20/2021 and 08/23/2021 by LVN that read in part, “…SITE 01/LOCATION…Right posterior ankle…Width: 4 cm Length: 2.5cm Depth: 0.8cm…Clean area with wound cleanser pat dry with 4x4 apply medihoney and cover with medipore dressing x3 days a week until healed…” A recertification SN visit was conducted on 08/25/2021 by RN that read in part, “…The patient has a wound on right outer ankle…SITE 01/LOCATION Width: 3.8 Length: 3.5 cm Depth: 0.3 cm…Cleanse wound with wound cleanser pat dry using 4x4 apply medic-honey and secure with Mepilex… Physician contacted to approve additional orders not on referral…” During an interview with the Adm/DON and the LVN/QA Reviewer on 10/19/2021 at approximately 12:48 PM, the surveyor presented the above findings and asked how many and where wounds were located on Patient 4. The Adm/DON stated there was one wound located on the rt ankle. The Adm/DON stated [LVN] thought Patient 4 had a Stage 1 decubitus ulcer located on her left buttock but after the Adm/DON assessed the area, it was determined it was not a decubitus ulcer. The surveyor asked when the right ankle wound developed. The Adm/DON stated 07/12/2021. The surveyor asked why the supplemental physician order dated 07/12/2021 did not include the location of the wound. The LVN/QA Reviewer stated the order was corrected after coming to QA to include the wound location. The Adm/DON stated the correct wound care order was the supplemental physician order dated 08/26/2021 which included Medihoney. The surveyor asked why the corrected wound care order was dated 08/26/2021 instead of 07/12/2021. The Adm/DON stated she guessed the 08/26/2021 order was dated wrong. The surveyor asked why the LVN performed wound care on the 07/12/2021, 07/14/2021 and 08/02/2021 SN visit to the left buttock. The Adm/DON stated LVN thought it was a wound, but after the Adm/DON assessed the area on 07/12/2021, the Adm/DON determined it was not a wound. The surveyor asked why the LVN documented wound measurements to the left buttock if a wound did not exist. The LVN/QA Reviewer stated the agency told the nurses to document any skin lesion so the measurements must have been the length and width of the red area. The surveyor asked why the physician was not notified of the wound to the left buttock. The Adm/DON stated she didn’t feel it was a wound but she guessed the LVN documented it as a wound. The surveyor asked if the agency obtained a physician order for the wound care LVN performed on the left buttock. The Adm/DON stated the agency only obtained an order for the wound care to the ankle but not for the buttock. The surveyor asked why the physician was not notified the ankle wound increased in size from Width: 1.5 cm Length: 1.8cm Depth: 0.5cm on 07/14/2021 to Width: 1.8 CM Length: 2.8 CM Depth: 0.3 CM on 07/16/2021. The Adm/DON stated the visit on 07/16/2021 was conducted by a different nurse than the visit on 07/14/2021 and the nurses probably measured the wound differently. The surveyor asked why wound care was not performed on the buttock on 07/16/2021 but wound care was performed on the buttock on 07/12/2021 and 07/14/2021. The Adm/DON stated the buttock was a reddened area and not necessarily a wound. The surveyor asked why the nurse did not follow wound care orders for the ankle on 07/16/2021, 07/27/2021 and 07/30/2021 by using Mepilex instead of Medipore. The Adm/DON stated the products are similar. The surveyor asked why the EMR included three SN visit notes on 07/19/2021 that did not include the arrival time on any note. The Adm/DON stated a new agency nurse conducted only one visit on 07/19/2021 and the nurse didn’t realize she created three SN notes, but the agency had since done training with the new nurse on using the EMR. The surveyor asked why the physician was not notified that the depth of the ankle wound increased in size from 0.3 cm on 07/30/2021 to 0.5 cm on 08/02/2021. The Adm/DON stated the physician should have been notified. The surveyor asked why the physician was not notified that the depth of the ankle wound increased in size from Width: 1.5 cm Length: 1.8 cm Depth: 0.5 cm on 08/02/2021 to Width: 4.0 cm Length: 2.5 cm Depth: 0.8 cm on 08/04/2021. The Adm/DON stated the physician was not notified but the agency had a physician order for 08/04/2021. The Adm/DON searched the EMR and found an order dated 08/26/2021. The surveyor asked if the agency obtained a physician order for the ankle wound change that occurred on 08/04/2021. The Adm/DON stated no but the reason the wound size increased was because the wound started debriding. Patient 5: Record review of the EMR included a POC dated 07/30/2021 to 09/27/2021 that included an order for the SN to visit the patient one time a week for nine weeks. The record included two SN visits the week of 08/01/2021 to 08/07/2021; 08/15/2021 to 08/21/2021 and; 08/22/2021 to 08/28/2021. During an interview with the Adm/DON and the LVN/QA Reviewer on 10/19/2021 at approximately 1:42 PM, the surveyor presented the above findings of why the ordered SN frequency was not followed. The Adm/DON stated Patient 5 may have had a change in her condition. Patient 7: Record review of the EMR included a POC dated 06/22/2021 to 08/20/2021 that included an order for the SN to visit the patient two times a week for nine weeks. The record included one SN visit the week of 06/22/2021 to 06/26/2021; 07/11/2021 to 07/17/2021; 07/25/2021 to 07/31/2021; 08/08/2021 to 08/14/2021 and 08/15/2021 to 08/20/2021. The record included zero SN visits the week of 08/18/2021 to 08/24/2021. The record included three SN visits the week of 08/01/2021 to 08/07/2021. During an interview with the Adm/DON and the LVN/QA Reviewer on 10/19/2021 at approximately 12:32 PM, the surveyor presented the above findings of why the ordered SN frequency was not followed. The Adm/DON stated she did not know but maybe because the nurse that usually made visits for Patient 7 was off work during that time period. Agency Policy titled, "TX.6 PLAN OF CARE" with a revision date of 07/01/21, read in part, "PURPOSE To develop an individualized Plan of Care which specifies the care and services necessary to meet the patient specific needs and according to state and federal regulations…POLICY A. Each patient will receive an individualized written plan of care, including any revisions or additions…PROCEDURE C. The individualized Plan of Care will specify care and services necessary to meet the patient specific needs…E. Modifications to the plan of care are indicated by: reassessments, patient condition/needs, changes in orders…F. The physician is promptly alerted…to any relevant changes in the patient’s condition or needs that suggest that outcomes are not being achieved and/or that the plan of care should be altered. There will be supporting documentation in the discipline’s progress notes or communication notes regarding contact with the physician…P. All services will be furnished in accordance with accepted standards of practice. Q. The patient will receive all services outlined in the POC…” Agency Policy titled, "TX.5 ORDERS FOR CARE" with a revision date of 07/01/21, read in part, ""PURPOSE To ensure patient care is provided in accordance with federal and state regulations…POLICY A. Agency will obtain orders and provide care in accordance with orders…D. Physician or allowed practitioner orders are needed to provide any care requiring the administration of…treatment(s), on going assessments or other activities governed by state law. P. All patient orders, including verbal orders are part of the Plan of Care…PROCEDURE…D. The physician or allowed practitioners is notified for any changes in Plan of Care and orders obtained as applicable when the patient’s condition or needs occur that indicate outcomes were not being and/or that the Plan of Care should be altered…G. The original Plan of Care may be modified or additions made only after consultation and approval of any modifications by the attending physician or allowed practitioner. J. Supplemental verbal orders must be obtained before care is provided for any changes to the Plan of Care…”

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 record review and interview, the agency failed to develop a POC that covered all required elements for all patients. In three of four (Patient 1, 5 and 6) records reviewed where the patient had a diagnosis of HF, the POC did not include appropriate interventions for the SN to assess for fluid retention with abnormal parameters to report to the physician. In one of one (Patient 2) record reviewed where the patient had a diagnosis of HF and received Xarelto (a blood thinner), the POC did not include appropriate interventions for the SN to assess for fluid retention with abnormal parameters to report to the physician or bleeding safety precautions for the anticoagulant medication. In one of one (Patient 3) record reviewed where the patient had a Foley catheter, the POC did not include safety measures for the catheter. Failure of the agency to ensure that the POC included all patient-specific orders resulted in patients being placed at risk of harm for failure of agency staff to address the patients' risk factors and type of services needed for appropriate care. Findings Include: Definition: “Foley catheter : a thin, flexible catheter used especially to drain urine from the bladder by way of the urethra. The Foley catheter is often referred to as an indwelling catheter because it can be left in place for extended periods of time.” Resource: www.merriam-webster.com/dictionary/Foley%20catheter. Patient 1: Record review of the EMR included a POC dated 07/31/2021 to 09/28/2021 that included a diagnosis of hypertensive heart disease with HF and chronic systolic HF. The POC did not include appropriate interventions for the SN to assess for fluid retention with abnormal parameters to report to the physician. According to, “https://heart-failure.net/symptoms/swelling”, worsening signs and symptoms of HF that should be reported to the physician include a weight gain of 2–3 pounds in a single day or 5+ pounds in one week, increased swelling in the feet or ankles or swelling or pain in the abdomen. During an interview with the Adm/DON and the LVN/QA Reviewer on 10/19/2021 at approximately 12:25 PM, the surveyor presented the above findings of why the POC did not include appropriate interventions for the SN to assess for fluid retention with abnormal parameters to report to the physician. The Adm/DON stated they should have put that information on the POC. Patient 2: Record review of the EMR included a POC dated 07/31/2021 to 09/28/2021 that included a diagnosis of hypertensive heart disease with HF and chronic systolic HF. The POC indicated his medications included Xarelto (a blood thinner) 15 mg once daily. The POC did not include appropriate interventions for the SN to assess for fluid retention with abnormal parameters to report to the physician or bleeding safety precautions for the anticoagulant medication. According to, "www.medsnews.com/blood-thinners/xarelto-safety-precautions/”, bleeding precautions while taking Xarelto include: avoid activities that may put you at risk for traumas and injuries; protect hands and arms by wearing gloves or other similar protections when using sharp utensils such as knives, scissors, razors; use toothbrushes with soft bristles and waxed floss; carefully chew any crisp or crunchy food to reduce the risk of gum bleeding; and limit your alcohol consumption. During an interview with the Adm/DON and the LVN/QA Reviewer on 10/19/2021 at approximately 12:25 PM, the surveyor presented the above findings of why the POC did not include appropriate interventions for the SN to assess for fluid retention with abnormal parameters to report to the physician. The Adm/DON stated they should have put that information on the POC. The LVN/QA Reviewer stated that the agency normally puts visit weights on the POC. The Adm/DON further reviewed the POC and stated, “I guess it’s not on there.” The surveyor asked why the POC did not include bleeding safety precautions for the anticoagulant medication. The Adm/DON stated they did not put that information on the POC. Patient 3: Record review of the EMR included a POC dated 08/07/2021 to 10/05/2021 that included a diagnosis of urine retention. The POC read in part, “…SN for Foley Catheter management… SN to check foley catheter for patency, blockage or bleeding every visit and report any issues with the catheter to the provider. SN to change foley catheter…every 30 days…” The POC did not include safety measures for the catheter. According to," https://my.clevelandclinic.org", safety measures for the catheter include: wash your hands thoroughly with soap and water before and after handling the catheter or bag; empty the leg bag every two to three hours or every eight hours for a larger bag; attach the leg bag to your thigh with slack in the catheter so it does not pull and cause discomfort or hook to a bed frame; do not put the leg bag on the floor; and keep the bag below the level of your bladder. During an interview with the Adm/DON and the LVN/QA Reviewer on 10/19/2021 at approximately 12:41 PM, the surveyor presented the above findings of why the POC did not include safety measures for the Foley catheter. The Adm/DON stated the patient was bed bound and the patient’s caregivers had been taught by the agency but the information may not have been included on the POC. Patient 5: Record review of the EMR included a POC dated 07/30/2021 to 09/27/2021 that included a diagnosis of hypertensive heart and chronic kidney disease with HF and chronic systolic HF. The POC read in part, “…The patient has been experiencing some exacerbations of CHF and she was started on medication to help manage her symptoms…” The POC did not include appropriate interventions for the SN to assess for fluid retention with abnormal parameters to report to the physician. Patient 6: Record review of the EMR included a POC dated 07/07/2021 to 09/04/2021 that included a diagnosis of hypertensive heart disease with HF and chronic systolic HF. The POC read in part, “…The patient has been experiencing some exacerbation of CHF and she is on medication to help manage her symptoms…” The POC did not include appropriate interventions for the SN to assess for fluid retention with abnormal parameters to report to the physician. During an interview with the Adm/DON and the LVN/QA Reviewer on 10/19/2021 at approximately 1:40 PM, the surveyor presented the above findings of why the POC for Patient 5 and 6 did not include appropriate interventions for the SN to assess for fluid retention with abnormal parameters to report to the physician. The Adm/DON stated they should have put that information on the POC. Agency Policy titled, "TX.6 PLAN OF CARE" with a revision date of 07/01/21, read in part, "PURPOSE To develop an individualized Plan of Care which specifies the care and services necessary to meet the patient specific needs and according to state and federal regulations…POLICY A. Each patient will receive an individualized written plan of care…PROCEDURE C. The individualized Plan of Care will specify care and services necessary to meet the patient specific needs…The POC will contain the following elements: 10. All medications and treatments...11. Safety measures to protect against injury…14. Patient-specific interventions and education…”