Every finding on record at Centerwell Certified Healthcare Corp.

Creve Coeur, Missouri · CCN 267290

23 findings across 2 surveys, in the inspector's own words.

The inspector’s own words from form CMS-2567, unedited, including CMS’s own spacing. Names and some dates are redacted by CMS.

Survey of June 18, 2026

6 findings

E0000

The Emergency Preparedness regulations were reviewed as part of the Medicare recertification survey completed on 06/18/2026. During the survey it was determined the home health provider is in compliance with the requirements of 42 CFR 484.102 Condition of Participation: Emergency Preparedness for Home Health Providers.

G0000

A partial extended survey for Medicare recertification for the home health provider was completed on 06/18/2026. The provider had 117 current patients.

G0536

G0572

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 policy review, record review, observation, and interview, the home health provider failed to ensure that each patient received the home health services that were written in the individualized plan of care (POC), in one of five records reviewed (Record/Patient #2). This deficient practice has the potential to affect all the patients served by the provider. Findings included: Review of the provider’s policy titled, "Care Planning,” reviewed 03/2026, showed in part the following: - Each patient must receive an individualized written POC, including updates based on patient's findings; and - The POC covered the patient’s 60-day episode of care and included treatments that were to be provided/administered by home health agency (provider) clinical associates. RECORD/PATIENT #2: Review of the clinical record showed the patient was admitted to home health services on 05/10/2026 with a primary diagnosis of a non-pressure chronic ulcer of left calf with fat layer exposed (a full thickness skin wound where the subcutaneous tissue is visible). The patient resided in his/her home with paid caregivers during waking hours to assist with care. Review of the POC dated 05/10/2026 to 07/08/2026, showed: - Physical therapy (PT) 1wk 1 (once a week for one week), 2 wk 3 (twice a week for three weeks), then 1 wk 5 (once a week for five weeks); and - Skilled nurse (SN) 2 wk 8 (twice a week for eight weeks), then 1 wk 1 (once a week for one week) to perform/teach wound care to the lower left leg. Cleanse with VASHE (a professional-grade, saline-based wound cleanser that effectively removes bacteria, fungi, and spores while helping to reduce wound odor), apply Santyl (chemical agent used to remove dead tissue from a wound), cover was Xeroform (a sterile, non-adhering medical dressing made of fine mesh gauze infused with petroleum (Vaseline) and 3% Bismuth Tribromophenate) and a non-adherent pad, secure with rolled gauze, and tape, then apply Tubigrip (a multi-purpose, elasticated tubular bandage used to provide lasting, even compression and tissue support). Further review of week one of the clinical record showed: - A PT evaluation on 05/15/2026 (week one); - A missed visit note dated 05/29/2026, with reason for missed visit: “Patient was agreeable to one time this week” (week three); and - PT failed to perform a second visit for the week of 05/24/2026 to 05/30/2026 (week three), as ordered in the POC. Observation on 06/16/2026 at 12:44 PM, showed licensed practical nurse (LPN)-A failed to apply Tubigrip after the wound care was performed and the dressing was applied. During an interview on 06/18/2026 beginning at 8:35 AM, the administrator stated that: - The physical therapy assistant (PTA) that documented the missed visit 05/29/2026 was a “newer” employee; - It was discussed with him/her that the physician was to be contacted for orders to update frequency on the POC; and - The POC visit frequency and wound care orders should have been followed.

G0590

Promptly alert relevant physician of changes CFR(s): 484.60(c)(1) The HHA must promptly alert the relevant physician(s) or allowed practitioner(s) to any 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. This ELEMENT is not met as evidenced by: Based on policy review, record review, observation, and interview, the home health provider failed to ensure clinicians promptly notified the patient's physician/allowed practitioner of any changes in the patient's condition or needs that suggested that outcomes were not being achieved and/or that the plan of care should be altered in one of five full records reviewed (Record/Patient #2). This deficient practice has the potential to affect all the patients served by the provider. Findings included: Review of the provider’s policy titled, "Care Planning,” reviewed 03/2026, showed in part the following: - Each patient must receive an individualized written plan of care (POC), including updates based on patient's findings; and - The home health agency (provider) will notify the physician/allowed practitioner and the patient/caregiver/authorized representative of any identified changes in the patient's condition, and will notify the physician/ allowed practitioner of the change; if a patient for caregiver/ representative refuses care that could negatively impact the patient's clinical well-being, the clinical associate must attempt to identify the reason for refusal, document in the electronic medical record (EMR), and notify the physician/allowed practitioner ordering the care. Review of the provider’s policy titled, "Physician/Allowed Practitioner Orders,” reviewed 01/2026, showed in part the following: - The physician/allowed practitioner will be contacted for any change in condition that may require a change in medications, treatment, or home health services; - Revisions to the patient's POC due to a change in the patient's health status must be communicated to all physicians/allowed practitioners issuing orders related to the patients POC; and - The home health agency provider will notify the physician/allowed practitioner if a patient and/or caregiver/authorized representative refuses any services or treatments ordered and will document that refusal within the patient's medical record. RECORD/PATIENT #2: Review of the clinical record showed the patient was admitted to home health services on 05/10/2026 with a primary diagnosis of a non-pressure chronic ulcer of left calf with fat layer exposed (a full-thickness skin wound where the subcutaneous tissue is visible). The patient resided in his/her home with paid caregivers during waking hours to assist with care. Review of the POC dated 05/10/2026 to 07/08/2026, showed: - Physical therapy (PT) 1wk 1 (once a week for one week), 2 wk 3 (twice a week for three weeks), then 1 wk 5 (once a week for five weeks); - Skilled nurse (SN) 2 wk 8 (twice a week for eight weeks), then 1 wk 1 (once a week for one week) to perform/teach wound care to the lower left leg. Cleanse with VASHE (a professional-grade, saline-based wound cleanser that effectively removes bacteria, fungi, and spores while helping to reduce wound odor), apply Santyl (chemical agent used to remove dead tissue from a wound), cover was Xeroform (a sterile, non-adhering medical dressing made of fine mesh gauze infused with petroleum (Vaseline) and 3% Bismuth Tribromophenate) and a non-adherent pad, secure with rolled gauze, and tape, then apply Tubigrip (a multi-purpose, elasticated tubular bandage used to provide lasting, even compression and tissue support); and - The POC failed to show a knee brace documented for use to the left knee. Further review of the clinical record showed: - A PT evaluation on 05/15/2026 (week one); - A missed visit note dated 05/29/2026 with reason for missed visit: “Patient was agreeable to one time this week” (week three); and - PT failed to perform a second visit for the week of 05/24/2026 to 05/30/2026 (week three), as ordered in the POC, or request a decrease in visit frequency to update the POC. Observation on 06/16/2026 at 12:44 PM, showed: - Licensed practical nurse (LPN)-A failed to apply Tubigrip after the wound care was performed and the dressing was applied; and - A brace was present to the patient’s left knee (this failed to be documented on the POC). During an interview on 06/18/2026 beginning at 8:35 AM, the administrator stated that: - The physical therapy assistant (PTA) that documented the missed visit 05/29/2026 was a “newer” employee; - It was discussed with him/her that the physician was to be contacted for orders to update frequency on the POC; - Both the SN that routinely saw the patient and the LPN reported that the patient had been refusing the Tubigrip; - The nurse was instructed to notify the physician of the Tubigrip refusal and there was now an updated order without the Tubigrip; - The nurse was instructed to contact the physician about the knee brace which the patient had been using since admission. The physician was notified and the POC was updated.

G0606

Integrate all services CFR(s): 484.60(d)(3) Integrate services, whether services are provided directly or under arrangement, to assure the identification of patient needs and factors that could affect patient safety and treatment effectiveness and the coordination of care provided by all disciplines. This ELEMENT is not met as evidenced by: Based on policy review, record review, and interview, the home health provider failed to ensure the clinicians integrated services to assure the identification of patient needs and factors that could affect patient safety and treatment effectiveness and the coordination of care provided by all disciplines in one of five full records reviewed (Record/Patient #2). This deficient practice has the potential to affect the coordination of all patients served by the provider. Findings included: Review of the provider’s policy titled, "Coordination of Care - Case Conferences," reviewed 03/2026, showed the following: - All healthcare providers, whether internal or external to the company, associated with direct patient care, must maintain close communication to ensure each patient receives coordinated care that meets their needs and supports the objectives identified in the plan of care (POC); - Communication between team members may be face to face, via phone, other telecommunication technology and/or secure email, including but not limited to, changes in the patient's condition resulting in a need to revise/update the POC; and - All communication will be documented in the patient’s medical record. RECORD/PATIENT #2: Review of the clinical record showed the patient was admitted to home health services on 05/10/2026 with a primary diagnosis of a non-pressure chronic ulcer of left calf with fat layer exposed (a full-thickness skin wound where the subcutaneous tissue is visible). The patient resided in his/her home with paid caregivers during waking hours to assist with care. Review of the POC dated 05/10/2026 to 07/08/2026, showed cardiovascular exacerbations (a sudden worsening of heart failure symptoms including, but not limited to breathing difficulties and fluid retention (edema) are identified promptly and interventions initiated to minimize risks. Further review of the clinical record showed: - A physical therapy (PT) evaluation on 05/15/2026 with documented 1+ (A +1 grade (mild) means the skin barely indents (about 2 millimeters (mm) deep) and the skin bounces back and rebounds almost immediately) edema (swelling of the tissues) to right and left lower extremities; - A PT reassessment visit dated 06/09/2026 with documented 2+ (A +2 grade (moderate) means when pressure is applied to the swollen area, it creates an indentation about 4 mm deep that takes up to 15 seconds to disappear) edema (swelling of the tissues) to right and left lower extremities; and - There failed to be any documentation of coordination with nursing regarding the increase in the edema noted on the reassessment visit. During an interview on 06/18/2026 beginning at 8:35 AM the administrator stated that: - The nurse had already contacted the physician on 06/08/2026 about the edema; and - The PT did not document notification to anyone about the increase in the edema.

Survey of September 26, 2023

17 findings

E0000

The Emergency Preparedness regulations were reviewed as part of the Medicare recertification survey completed on 9/26/2023. During the survey it was determined the home health provider is in compliance with the requirements of 42 CFR 484.102 Condition of Participation: Emergency Preparedness for Home Health Providers.

G0000

An extended survey for Medicare recertification for the home health provider was completed on 09/26/2023. The provider had 174 current patients. Two condition-level deficiencies were identified during this survey: - 484.60 Condition of Participation: Care planning, coordination of services, and quality care; and - 484.75 Condition of Participation: Skilled professional services. A home health agency that is found out of compliance with any Condition of Participation evaluated as part of a standard survey may not train or competency evaluate their home health aides for a period of two (2) years following the date of this survey. A deficiency has been cited at 484.80(f) (3) - see Tag G788.

G0528

Health, psychosocial, functional, cognition CFR(s): 484.55(c)(1) The patient's current health, psychosocial, functional, and cognitive status; This ELEMENT is not met as evidenced by: Based on policy review, record review, and interview the home health provider failed to ensure the comprehensive assessment accurately reflected the patient's status in one of six full records reviewed (Record/Patient #2). This deficient practice has the potential to affect all patients served by the provider. Findings included: Review of the provider’s policy titled, "Initial and Comprehensive Assessments," revised 04/2023, showed in part that the initial assessment must accurately reflect the patient’s status. Each patient’s current health, psychosocial, functional and cognitive status will be accurately assessed. RECORD/PATIENT #2: Review of the registered nurse (RN) OASIS (outcome assessment and information set) dated 08/15/2023, showed diagnoses that included diabetes mellitus (a condition that affects how the body processes blood sugar). The patient was not receptive to education. The narrative portion of the assessment showed that the patient was not cooperative with the medication reconciliation. He/she used Humalog (lispro,fast acting) insulin per sliding scale (the amount of insulin taken is based upon the blood sugar reading) and would not disclose the sliding scale he/she used (the discharge medication order showed insulin lispro 12 units three times daily with meals). The physician was notified and is aware of the above. No documentation of whether the patient had previous issues with symptoms of hypoglycemia (low blood sugar) or hyperglycemia (high blood sugar). The patient used a glucose meter to monitor his/her blood sugar. The patient took his/her insulin as prescribed and was compliant with all medication administration (the narrative portion showed the patient was not compliant with medications). During an interview on 09/20/2023, beginning at 10:25 AM, the administrator and clinical manager stated the assessment of the patient being compliant with medications would not be accurate. The clinical manager stated that he/she would expect the nurse to assess whether the patient had a history of symptoms of hypoglycemia and hyperglycemia.

G0536

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 policy review, record review, observation, and interview the home health provider failed to ensure staff maintained an accurate/updated medication profile for two of six full records reviewed (Records/Patients #2 and #6). This deficient practice has the potential to affect all patients served by the agency. RECORD/PATIENT #6: Review of the referring hospital's medical records showed the patient had active diagnoses of cerebral vascular accident (CVA; stroke), atrial fibrillation (an irregular, often rapid heart rate), and iron-deficiency anemia (too few healthy red blood cells due to too little iron in the body). Review of the referring hospital’s discharge medications, dated 09/01/2023, showed the patient was to be discharged on: -Apixaban (anticoagulant) 5 mg (milligram)-per tube (a tube placed in the stomach to provide nutrition) two times per day; -Aspirin (anticoagulant) 81 mg chewable tablet- per tube one time a day; -Atorvastatin (statin drug used to treat high cholesterol and triglyercides) 40 mg tablet per tube nightly; and -Iron polysaccharides (mineral supplement used to treat and prevent iron-deficiency anemia) 150 mg per tube daily. Review of the home health provider’s plan of care (POC), dated 09/01/2023, failed to show orders for the apixaban, aspirin, atorvastatin, and iron polysaccharides. During an interview on 09/20/2023, beginning at 10:25 AM, the clinical manager stated that he/she would expect those medications to be on the home health provider's POC. Findings included: Review of the provider’s policy titled, “Medication Review and Documentation,” revised 10/2022, showed in part the provider will assess all medications the patient is taking – both prescription and over-the-counter to include all routes of administration during each patient visit. Medication assessment will be performed each clinical associate visit to ensure medications are current, accurate, and documented on the medication profile within the patient’s electronic medical record. A drug regimen review and medication reconciliation will include all medications and be performed during the initial comprehensive assessment, each comprehensive assessment thereafter, and when a new medication is added to the patient plan of care (POC). Examine medication bottles, prescriptions, and current medication lists provided by the patient. Review medication lists from the physician/allowed practitioner and/or inpatient facility within the last 30 days and compare to home medications found to ensure complete accurate medication availability to the patient. Clinical associate follow-up with the physician/allowed practitioner is required for all medication discrepancies. Medication orders related to a range of dosages or frequency, that is, sliding scale will include criteria for changing the dosage/frequency for the patient. When performing resumption of care for a patient who is discharged from a hospital and returns to the provider for skilled care, clinical associates will contact the physician/allowed practitioner for specific medication orders for the provider or patient administration. RECORD/PATIENT #2: Review of the registered nurse (RN) resumption of care assessment dated 09/07/2023, showed the nurse documented he/she used the patient’s medication bottles to perform the medication reconciliation. There were differences found during the medication review, and the physician was contacted. There was no documentation that showed what issues/discrepancies were found. Observation and interview on 09/19/2023, beginning at 11:10 AM, during the patient’s home visit, showed the following medication discrepancies with the hospital discharge medication list dated 09/02/2023 and the provider’s current medication profile: -The hospital discharge list showed orders for hydrocodone/acetaminophen (pain medication) 5-325 mg one tablet every six hours as needed, oxycodone HCL (pain medication) 15 mg one tablet two times a day as needed, oxycodone HCL/acetaminophen 10-325 mg one tablet every six hours as needed and alprazolam (anti-anxiety) 1 mg three times a day as needed. These were not included with the medications provided by the patient and was not included on the medication profile; -The patient had a bottle dated 07/17/2023 of acetaminophen/codeine (pain medication) #3 one every eight hours as needed for pain. This was not included on the medication profile; -The medication profile showed an order for Florastor (probiotic) 250 mg one capsule daily. The patient’s bottle dated 09/02/2023, showed one capsule two times a day for 10 days. The patient stated that he/she had finished this; -The medication profile showed an order for Lispro (insulin, fast acting) use per sliding scale (the amount of insulin taken is based on the blood sugar level), sliding scale not available, patient would not inform nurse of the actual scale). The medication label dated 09/03/2023, showed 10-20 units three times a day after meals. The hospital discharge medication list showed an order for 10-20 units three times a day after meals. There was no documentation of a specific physician ordered sliding scale dose. The patient stated that if his/her blood sugar was around 200 then he/she took 12 units. The patient stated that he/she knew what he/she was doing and had been doing this a long time; -The medication profile showed an order for Lantus insulin 50 units daily. The hospital discharge medication list dated 09/02/2023, showed an order for 30-40 units at bedtime. There was no clarification to show when the patient was to take 30 or 40 units. The patient stated that he/she took 30 or 40 units; -The medication profile showed an order for vitamin D3 125 mcg (microgram) 5000 units one tablet weekly. The hospital discharge medication list showed an order for 50,000 units daily. The patient could not find this medication; -The patient had a bottle dated 12/09/2022, of gabapentin (used for nerve pain) 800 mg one tablet three times a day. The patient stated that he/she had taken this for a long time. The hospital discharge medication list showed an order for 100 mg three times a day. The medication profile did not include this medication; and -The patient had an albuterol inhaler (dilates the lung passages to make it easier to breathe). The patient stated that he/she took 2 puffs three to four times a day ever since he/she came home from the hospital. This was not included on the hospital medication list or the provider’s medication profile. During an interview on 09/20/2023, beginning at 10:25 AM, the clinical manager stated that he/she would expect the nurse to clarify and obtain specific sliding scale insulin orders and clarify the Lantus insulin order. He/she would prefer the nurse document what specific issues were found during the drug regimen reviews. The administrator stated that staff should reconcile medications with the discharge medication list and compare it with the bottles in the home. The nurse should contact the physician during the visit to discuss any discrepancies. He/she would like to have a response within 24 hours. If staff find a new medication in the home, they should update the medication profile at that time then enter the order from the label on the medication bottle.

G0570

Care planning, coordination, quality of care CFR(s): 484.60 Condition of participation: Care planning, coordination of services, and quality of care. Patients are accepted for treatment on the reasonable expectation that an HHA can meet the patient's medical, nursing, rehabilitative, and social needs in his or her place of residence. Each patient must receive an individualized written plan of care, including any revisions or additions. The individualized plan of care must specify the care and services necessary to meet the patient-specific needs as identified in the comprehensive assessment, including identification of the responsible discipline(s), and the measurable outcomes that the HHA anticipates will occur as a result of implementing and coordinating the plan of care. The individualized plan of care must also specify the patient and caregiver education and training. Services must be furnished in accordance with accepted standards of practice. This CONDITION is not met as evidenced by: Based on policy review, record review, observation, and interview the home health provider failed to: -Ensure patients received services as ordered by the physician (G572); -Develop a complete, individualized Plan of Care (G574); -Promptly alert the physician to changes in the patient’s condition (G590); -Develop a complete revised POC (G592); and -Provide written information and other pertinent information to the patient (G620). The cumulative effect of these deficient practices has the potential to affect the care and services provided to all the home health provider’s patients.

G0572

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 policy review, record review, and interview the home health provider failed to ensure that all visits were performed according to the individualized plan of care for the patient in one of six full records reviewed (Record/Patient #1). This deficient practice has the potential to affect all patients served by the provider. Findings included: Review of the provider’s policy titled, “Physician/Allowed Practitioner Orders,” revised 04/2023, showed in part that: - If fewer visits are provided during the week than ordered, the physician/allowed practitioner will be notified unless a patient’s plan of care (POC) indicates the home health provider may miss visits for specific reasons, that is, nursing visits on the days of physician/allowed practitioner visits; or home health aide visits may be missed when a patient’s caregiver is in the patient’s residence and is available to provide personal care; and - All missed visits must be documented in the patient’s medical record to include the reason for missing the visit and physician/allowed practitioner notification unless authorized under specific circumstances that are documented on the POC. RECORD/PATIENT #1: Review of the clinical record showed: - The patient’s start of care date was 08/21/2023; - The plan of care dated 08/21/2023 to 10/19/2023, showed that the home health aide (HHA) visit frequency was ordered for two times per week for eight weeks; - A missed visit report for the HHA dated 08/22/2023, showed “awaiting authorization;” - A HHA visit was completed on 08/24/2023; and - The HHA failed to complete another visit during the week of 08/21/2023 to 08/26/2023. During an interview on 09/19/2023 at 4:50 PM, the clinical manager stated that there was not a HHA coordination note available and that the physician had not been notified of the missed visit. During an interview on 09/20/2023 at 9:40 AM, the clinical manager stated that the information in the missed visit report was not accurate and that no other information was available for the patient.

G0574

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, record review, and interview the home health provider failed to ensure staff developed a complete/individualized plan of care (POC) in four of six full records reviewed (Records/Patients #1, #2, #5, and #6). This deficient practice has the potential to affect all patients served by the provider. Review of the provider’s procedure titled, “Enteral tube feeding home care,” dated as revised 11/28/2022, showed in part the following: -Assist the patient to an upright or a semi-Fowler (a position in which a person lies on their back in bed with the head of bed elevated 30 to 45 degrees); -Assist the patient with oral care, as needed, to promote comfort and reduce bacterial burden in the mouth; -If the patient or a family member will manage home enteral nutrition independently, provide additional instruction, including hands-on training and return demonstration. Teach the patient and family member how to: * Verify tube placement; * Flush and irrigate the tube; * Administer enteral feedings via the tube, including formula preparation and storage; * Administer medications via the tube (as appropriate); * Clean and store reusable supplies and equipment; * Inspect the exit site for fluid leakage or other discharge and resulting skin irritation; * Perform hand hygiene and other infection control measures; and * Provide comfort measures for the patient, including oral care and exit site skin care. RECORD/PATIENT #6: Review of the referring hospital record, dated 08/29/2023, showed the following: -The patient had a current medical history of cerebral vascular accident (CVA; stroke), atrial fibrillation (abnormal heart rhythm characterized by rapid and irregular heartbeat), congestive heart failure (CHF; a decrease in the ability of the heart to pump blood, resulting in an accumulation of fluid in the lungs and other areas of the body), neurogenic dysphagia (difficulty in swallowing food caused by a disease or impairment of the nervous system, including stroke and traumatic brain injury) status post percutaneous endoscopic gastrostomy (PEG; a procedure to place a feeding tube is passed into a patient’s stomach through the abdominal wall to provide nutrition). The patient had recently been discharged from the hospital on 08/03/2023 to an inpatient rehabilitation (rehab) facility. The patient was sent to the emergency room from rehab due to leakage around the PEG tube. Upon admission the patient was started on intravenous (IV) antibiotics. The patient had an abdominal wall abscess (a pocket of infected fluid and pus located inside the abdominal cavity). Status post incision and drainage complex abdominal wall abscess. The patient was admitted back to the inpatient rehabilitation for continuation of physical therapy (PT)/occupational therapy (OT)/speech therapy (ST); -Diet (dated 08/28/2023): Nothing by mouth (NPO); -Medications were given per PEG tube; -The patient had an open surgical incision adjacent to his/her PEG tube with an order (dated 08/24/23) to cleanse with wound cleanser and cover with a dry dressing; and -Discharge medications included: Apixaban (anticoagulant) 5 mg (milligram)-per tube (a tube placed in the stomach to provide nutrition) two times per day, aspirin (anticoagulant) 81 mg chewable tablet- per tube one time a day, atorvastatin (statin drug used to treat high cholesterol and triglyercides) 40 mg tablet per tube nightly, and iron polysaccharides (mineral supplement used to treat and prevent iron deficiency anemia) 150 mg per tube daily. Review of the RN OASIS admission assessment, dated 09/01/2023, showed the following: -Had no skin issues identified; -Had no surgical wound (the patient had a PEG tube); -At moderate risk for developing pressure ulcers; -Incontinent of bladder; -Totally dependent for toileting; -Feeding tube listed as nutritional approach; -Had no hematopoietic (of, relating to, or involved in the formation of blood cells) condition (had diagnosis of anemia (lack of red blood cells in the body)); and -DME available: Bedside commode, hospital bed, hoyer lift, walker, and sock assist. Review of the POC, dated 09/01/2023 to 10/30/2023, showed the following: -Diagnoses included: Dysphagia (difficulty swallowing) following cerebral infarction (stroke), atrial fibrillation, and iron-deficiency anemia; -Medications were to be given per tube; -Nutritional Requirements: Isosource 1.5 cal (brand of enteral supplement) 320 milliliter (ml) four times a day. Flush before and after with 150 ml of warm water; and -DME and supplies: Hospital bed. The POC failed to be individualized and include the following: -Goals or interventions for pressure ulcers, incontinence, and anemia; -Orders for NPO status, apixaban, aspirin, atorvastatin, iron polysaccharides (as ordered on hospital discharge medication list), to crush medications and if the medications could be administered together once crushed, and dressing site orders for the PEG tube; -Teaching interventions to include: assist the patient to an upright or a semi-Fowler prior to tube feeding or medication administration, to assist the patient with oral care, as needed, to promote comfort and reduce bacterial burden in the mouth, to verify tube placement prior to tube feeding or medication administration, to clean and store reusable supplies and equipment, and to perform hand hygiene and other infection control measures regarding tube feeding and medication administration (as per procedure); and -DME: Bedside commode, hoyer lift, walker, and sock assist. During an interview on 09/20/2023, beginning at 10:25 AM, the clinical manager stated that the POC should be individualized and include the above listed failures. Review of the provider's policy titled, "Care Planning," dated 9/2022, showed, in part: - Each patient must receive an individualized Plan of Care (POC) including ongoing revisions and/or additions related to the patient findings. The individualized POC must be specify: - Care and services to meet patient –specific needs as identified in the comprehensive assessment and provided in accordance with accepted standards of practice. - - Identification of the responsible disciplines and measurable outcomes the home health agency anticipates will occur as a result of implementing and coordinating the POC. - - Patient /caregiver education and training associated with care and services ordered. - The POC serves as a patient care-planning document. The POC will be developed in collaboration with the physician / allowed practitioner and home health agency following the initial /comprehensive assessment. The Clinical Manager or designee will review and ensure appropriateness of the POC prior to submission for the physician /allowed practitioner signature. - The individualized POC must include pertinent diagnosis relevant to the patient, types of services, equipment and supplies required, frequency and duration of visits to be made, all medication and treatments, safety measures to protect against injury, Description of the patient’s risk for emergency department visits and hospital re- admissions; and all necessary interventions to address the underlying risk factors, Patient and caregiver education and training to facilitate timely discharge, patient –specific interventions and measurable outcomes/goals. - The Registered Nurse Therapist, or Social Worker will develop the patient’s POC in conjunction with the physician /allowed practitioner, patient, patient representative (if any) caregiver, and other team member involved in the care. RECORD/PATIENT #5: Review of the Plan of Care (POC) dated 09/05/2023 to 11/03/2023, showed: - Diagnoses which included Type 2 diabetes with Chronic Kidney Failure; - Cardiovascular Accident (CVA/stroke) with left side hemiparesis (weakness or the inability to move on one side of the body; and, - A history of falls; - Long term use of anti-coagulant medication (a family of medications that stop blood from clotting too easily. Review of the POC dated 09/05/2023 to 11/03/20233, failed to show: - Individualized interventions for fall prevention / high risk medications (patient is a diabetic, has had previous falls and is prescribed rivaroxaban (Xarelto) - an anti-coagulant medication. Review of a Skilled Nursing (SN) visit dated 9/12/2023, showed staff documented the patient was prescribed an anticoagulant medication, had been “drinking beer”, and had an unsteady gait. Records failed to show documentation of staff attempting to educate the patient regarding medication safety, and /or fall prevention measures. During an interview on 09/20/2023 at 11:40 AM, the clinical manager stated: - Patient #5 was on long term anticoagulant medication, and should have been addressed in the initial POC, but was not addressed. - The POC for patient #5 failed to include documentation of regarding patient education of high risk medications (anticoagulants), and should have been addressed at the patient’s Start Of Care (SOC). RECORD/PATIENT #2: Review of the registered nurse (RN) OASIS assessment dated 08/15/2023, showed diagnoses that included diabetes mellitus (a condition that affects how the body processes blood sugar). The narrative portion of the assessment showed that the patient used Humalog (lispro, fast acting) insulin per sliding scale (the amount of insulin taken is based upon the blood sugar reading) and would not disclose the sliding scale he/she used (the discharge medication order showed insulin lispro 12 units three times daily with meals). The physician was notified and is aware of the above. The patient used a glucose meter to monitor his/her blood sugar. No documentation of whether the patient had previous issues with symptoms of hypoglycemia (low blood sugar) or hyperglycemia (high blood sugar). The DME (durable medical equipment) available showed elevated toilet seat, long handled reacher, tub chair and rolling walker. Review of the POC dated 08/15/2023, showed diagnoses that included diabetes mellitus. The skilled nurse (SN) was to teach related to diabetes management including disease process, nutrition, medications, activities, and personal/environmental. Biometrics out of parameters and significant changes in status will be reported to the physician. The POC did not include specific interventions for monitoring and assessment for signs of hypoglycemia and hyperglycemia and physician ordered parameters for reporting blood sugar levels. The DME and supplies section listed the patient’s dressing change supplies but did not include the elevated toilet seat, long handled reacher, tub chair, and rolling walker. During an interview on 09/20/2023, beginning at 10:25 AM, the clinical manager stated that the POC should include monitoring for signs and symptoms of hypoglycemia (low blood sugar) and hyperglycemia (high blood sugar) and parameters for reporting blood sugars. The administrator stated that all DME should be included on the POC. Findings included: Review of the provider’s policy titled, “Care Planning,” revised 09/2022, showed in part that each patient must receive an individualized POC including ongoing revisions and/or additions related to patient findings. The individualized POC must specify care and services to meet patient needs as identified in the comprehensive assessment, identification of the responsible disciplines and measurable outcomes the provider anticipates will occur as a result of implementing and coordinating the POC, and patient/caregiver education and training associated with care and services ordered. The individualized POC must include types of services, supplies and equipment required. RECORD/PATIENT #1: Review of the clinical record showed: - The patient was admitted to home health services on 08/21/2023; - The registered nurse (RN) OASIS (outcome assessment and information set) admission assessment dated 08/21/2023, showed the following: * The durable medical equipment (DME) recommended for the patient included: a cane, a long-handled reacher, a tub chair, and a rolling walker; * The DME available in the home included: a long-handled reacher, a tub chair, and a rolling walker; * The patient was identified as at high nutritional risk and had lost over 10 pounds in the past six months; and - The plan of care dated 08/21/2023 to 10/19/2023, failed to include any DME supplies needed or available in the home and failed to include any interventions related to weight loss. During an interview on 09/19/2023 at 4:50 PM, the clinical manager stated that he/she would expect DME to be listed on the plan of care and that if the patient was receiving any interventions related to weight loss it would be found on the plan of care.

G0590

Promptly alert relevant physician of changes CFR(s): 484.60(c)(1) The HHA must promptly alert the relevant physician(s) or allowed practitioner(s) to any 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. This ELEMENT is not met as evidenced by: Based on policy review, record review, and interview the home health provider failed to ensure staff notified the physician of a change in condition that could alter the plan of care (POC) in two of six full records reviewed (Records/Patients #1 and #2). This deficient practice has the potential to affect all patients served by the provider. RECORD/PATIENT #2: Review of the RN OASIS assessment dated 08/15/2023, showed the patient’s respiratory assessment was within normal limits (WNL), and the patient was not short of breath. The cardiovascular (pertaining to the heart and lungs) assessment showed 1+ (slight indentation when you press on the skin) edema (swelling) to the lower right and trace edema in the left lower (did not specify whether this was the lower extremities). Review of the skilled nurse (SN) visits showed: - On 08/16/2023, the patient had abnormal heart sounds (irregular heartbeat) and shortness of breath with exertion and at night. The licensed practical nurse (LPN) documented he/she coordinated with his/her supervisor regarding the start of wound care, but no documentation that the registered nurse case manager (RNCM) or physician was notified of the patient’s irregular heartbeat and shortness of breath; - On 08/18/2023, the cardiopulmonary assessment was WNL; and - On 08/21/2023, the LPN documented the patient had episodes of shortness of breath at night and while lying down. The patient used an albuterol (dilates the lung passages so you can breathe easier) inhaler and it was effective. The LPN documented coordination with the physician/allowed practitioner regarding increasing nursing visits due to wound treatment, but no documentation that the physician was notified of the patient’s shortness of breath. Review of the hospital discharge dated 09/02/2023, showed the patient presented to the emergency department on 08/23/2023, with shortness of breath, bilateral leg edema, and orthopnea (difficulty breathing when lying down). The patient was found to be in new acute heart failure (the heart does not pump as well to deliver blood/oxygen to meet the body’s needs). Review of a physical therapy (PT) visit note dated 09/13/2023, showed the patient experienced signs and symptoms of high or low blood glucose (sugar), and cannot always maintain usual activity level. Observed/reported hypoglycemic (low blood sugar)/hyperglycemic (high blood sugar) symptoms showed fatigue. Follow-up actions related to hypo/hyperglycemic symptoms showed snacks or juice. No documentation the PT notified the RNCM or physician of the patient’s symptoms. During an interview on 09/20/2023, beginning at 10:25 AM, the clinical manager stated that the LPN should have communicated to the RNCM regarding the patient’s shortness of breath and irregular heartbeat. The PT should have called the RNCM regarding symptoms of hypo/hyperglycemia. The RNCM would then follow up with the physician and they would do follow up calls and extra visits with the patient. Findings included: Review of the provider’s policy titled, “Coordination of Care – Case Conferences,” revised 11/2022, showed in part that: -Communication with other team members may be face-to-face, via phone, other telecommunication technology and/or secure email including but not limited to: * contact between clinical associates, involved in the patient's care; * all contact with the patient's physician/allowed practitioner; * review of clinical care and supportive documentation to ensure medical necessity; * effectiveness of treatment plan; * changes in the patient's condition resulting in a need to revise/update plan of care; * safety concerns impacting patient well-being and plan of care; * review of the plan of care to support recertification or discharge; -All communication will be documented in the patient's medical records; and -Communication with the patient’s physician/allowed practitioner must occur regarding significant changes in condition and identification of new problems. RECORD/PATIENT #1: Review of the clinical record showed: - The registered nurse (RN) OASIS (outcome and assessment information set, a federally mandated assessment) admission assessment dated 08/21/2023, showed that the patient had a pulse rate of 62 beats per minute (BPM), pulse characteristics were WNL (within normal limits), and no heart sounds were noted as assessed; - The skilled nurse (SN) visit dated 08/28/2023, was completed by a licensed practical nurse (LPN) and showed that the patient had a pulse rate of 68 BPM, pulse characteristics showed regularly irregular, and the heart sounds were described as abnormal and irregular heartbeat; - The SN visit dated 08/31/2023, was completed by an LPN and showed that the patient had a pulse rate of 60 BPM, pulse characteristics showed regularly irregular, and the heart sounds were described as abnormal and irregular heartbeat; - The SN visit dated 09/06/2023, was completed by an LPN and showed that the patient had a pulse rate of 44 BPM, pulse characteristics showed regularly irregular, and the heart sounds were described as abnormal and irregular heartbeat with bradycardia (a slower than expected heart rate generally beating fewer than 60 BPM) episode at time of visit; and - The LPN failed to notify the RN of changes in the patient’s condition on 08/28/2023, 08/31/2023, and 09/06/2023. The LPN also failed to notify the physician of changes in the patient’s condition on 08/28/2023 and 08/31/2023. During an interview on 09/19/2023 at 1:20 PM, the clinical manager stated that there were no coordination notes found to show that the LPN had reported changes in the heart sounds to the RN. During an interview on 09/20/2023 at 9:40 AM, the clinical manager stated that there was no other information available for the patient.

G0592

Revised plan of care CFR(s): 484.60(c)(2) A revised plan of care must reflect current information from the patient's updated comprehensive assessment, and contain information concerning the patient's progress toward the measurable outcomes and goals identified by the HHA and patient in the plan of care. This ELEMENT is not met as evidenced by: Based on policy review, record review, and interview the home health provider failed to ensure staff developed a complete revised plan of care (POC) after a hospitalization in one of six full records reviewed (Record/Patient #2). This deficient practice has the potential to affect all patients served by the provider. Findings included: Review of the provider’s policy titled, “Care Planning,” revised 09/2022, showed in part that each patient must receive an individualized written plan of care including ongoing revisions and/or additions related to patient findings. The individualized POC must specify the care and services to meet patient-specific needs as identified in the comprehensive assessment, identification of the responsible disciplines and measurable outcomes the provider anticipates will occur as a result of implementing and coordinating the POC. The individualized POC must include all pertinent diagnoses relevant to the patient, description of the patient’s risk for emergency department visits and hospital readmissions, patient-specific interventions and measurable outcomes/goals. RECORD/PATIENT #2: Review of the hospital discharge summary dated 09/02/2023, showed in part on 08/29/2023, the patient presented to the emergency department with shortness of breath, bilateral leg edema (swelling of the tissues), and orthopnea (difficulty breathing when lying down). The patient was found to be in new acute heart failure (your heart does not work as well to pump enough blood/oxygen to meet the body’s needs). Review of the registered nurse (RN) resumption of care visit dated 09/07/2023, showed in part: -No diagnosis of heart failure; -2+ edema in the lower left and lower right (did not specify this was the lower extremities); -Respiratory assessment within normal limits (WNL); -Shortness of breath with moderate exertion; -The OASIS (outcome assessment and information set, a federally mandated assessment) item number (M1011) section to list inpatient diagnoses actively treated during an inpatient stay having a discharge date within the last 14 days failed to include a diagnosis of heart failure; -The patient was recently hospitalized for complications to right foot amputation. No mention of the patient’s heart failure. The patient had a history of heart disease and diabetes mellitus. The patient stated that he/she felt much better; and -Reviewed and instructed on recent exacerbation of co-morbid conditions (did not indicate what conditions or what instructions were provided such as monitoring for increased shortness of breath, increased swelling, irregular heartbeat, or daily weights with parameters to report to the nurse or physician). Review of the resumption of care physician orders/plan of care dated 09/07/2023, failed to show a diagnosis of heart failure. There were no specific interventions and goals to address the patient’s heart failure. During an interview on 09/20/2023, beginning at 10:25 AM, the administrator and clinical manager stated that the POC should include the patient’s diagnosis of heart failure with interventions, goals, and education.

G0620

Other pertinent instructions CFR(s): 484.60(e)(4) Any other pertinent instruction related to the patient's care and treatments that the HHA will provide, specific to the patient's care needs. This ELEMENT is not met as evidenced by: Based on policy review, record review, observation, and interview the home health provider failed to ensure the patient received pertinent written instructions in one of three home visit observations (Record/Patient #2). This deficient practice has the potential to affect all patients served by the provider. Findings included: Review of the provider’s policy titled, “Care Planning,” revised 09/2022, showed the patient or caregiver will be provided a copy of the POC (plan of care) and/or other form of written instructions outlining pertinent instruction related to the patient’s care and treatments that the home health provider will provide. RECORD/PATIENT #2: Review of the resumption of care physician orders dated 09/07/2023 showed an order for the skilled nurse (SN) to provide wound care two times a week and as needed. Observation and interview on 09/19/2023, beginning at 11:10 AM, during the patient’s home visit, showed the home folder did not include written instructions for wound care. The patient stated that he/she did not have anything like that but did have instructions from the physical therapist. The nurse was not able to find wound care instructions. The nurse wrote down wound care instructions at that time and placed them in the home folder. The findings were reviewed with the administrator, clinical manager, and area director of operations on 09/20/2023 at approximately 11:00 AM. No further information was provided.

G0700

Skilled professional services CFR(s): 484.75 Condition of participation: Skilled professional services. Skilled professional services include skilled nursing services, physical therapy, speech-language pathology services, and occupational therapy, as specified in §409.44 of this chapter, and physician or allowed practitioner and medical social work services as specified in §409.45 of this chapter. Skilled professionals who provide services to HHA patients directly or under arrangement must participate in the coordination of care. This CONDITION is not met as evidenced by: Based on policy review, procedure review, record review, and interview, the home health provider failed to: -Ensure ongoing interdisciplinary assessment of the patient (G706); -Provide services which were ordered by the physician (G710); and -Provide patient and caregiver education (G714). The cumulative effect of these deficient practices has the potential to affect all patients served by the provider.

G0706

Interdisciplinary assessment of the patient CFR(s): 484.75(b)(1) Ongoing interdisciplinary assessment of the patient; This ELEMENT is not met as evidenced by: Based on policy review, record review, and interview the home health provider failed to ensure staff documented ongoing assessments in two of six full records reviewed (Records/Patients #2 and #4). This deficient practice has the potential to affect all patients served by the provider. Findings included: Review of the provider's policy titled, "Care Planning," revised 09/2022, showed in part that the professional disciplines (included registered nurse (RN) and physical therapist (PT) must assume responsibility for but not restricted to ongoing interdisciplinary assessment of the patient. RECORD/PATIENT #2: Review of the RN OASIS (outcome and assessment information set, a federally mandated assessment) dated 08/15/2023, showed the patient's respiratory assessment was within normal limits (WNL), and the patient was not short of breath. The cardiovascular (pertaining to the heart and blood vessels) assessment showed 1+ (slight indentation when you press on the skin) edema (swelling of the tissues) to the lower right and trace edema in the left lower (did not specify this was the lower extremities). Review of the licensed practical nurse (LPN) visits showed: - On 08/16/2023, the patient had abnormal heart sounds (irregular heartbeat) and shortness of breath with exertion and at night. The documentation failed to show an assessment of lung sounds or edema; - On 08/18/2023, the cardiopulmonary (pertaining to the heart and lungs) assessment was WNL; and - On 08/21/2023, the LPN documented the patient had episodes of shortness of breath at night and while lying down. The patient used an albuterol inhaler (opens the lung passages so you can breathe easier) and it was effective. The documentation failed to show an assessment of lung sounds or edema. Review of the hospital discharge summary dated 09/02/2023, showed the patient went to the emergency department on 08/23/2023, with shortness of breath, bilateral leg edema, and orthopnea (difficulty breathing when lying down). The patient was found to be in new acute heart failure. Review of the RN resumption of care visit dated 09/07/2023, showed in part: -No diagnosis of heart failure; -2+ edema in the lower left and lower right (did not specify whether this was lower extremity); -Respiratory assessment within normal limits (WNL); and -Shortness of breath with moderate exertion. Review of the resumption of care physician orders/plan of care dated 09/07/2023, failed to show a diagnosis of heart failure. The plan of care failed to show specific interventions and goals to address the patient’s heart failure. Review of the skilled nurse (SN) visits showed: -On 09/12/2023, the cardiopulmonary assessment was WNL; and -On 09/15/2023, the cardiopulmonary assessment showed shortness of breath. The documentation failed to show an assessment of lung sounds, and edema. Observation and interview on 09/19/2023, beginning at 11:10 AM, during the patient’s home visit, the patient stated that he/she was more short of breath. The nurse stated the patient’s lung sounds were clear. The nurse instructed the patient to weigh him/herself each day and report if he/she gained two or three pounds in a day or five pounds in a week. The nurse weighed the patient. The patient was slightly unsteady on the scales. The patient’s weight was 258 (the weight on 09/07/2023 was 240). The nurse called the physician’s office to report the weight, shortness of breath and edema. The office staff gave the nurse the physician’s direct number. The nurse left a message regarding the patient’s weight, shortness of breath, and edema. The nurse called the administrator to report the patient’s symptoms and that he/she left a message for the physician. The administrator would also attempt to call the physician. Review of the SN visit note dated 09/19/2023, showed the patient’s lung sounds were diminished (normal lung sounds are decreased and harder to hear). Heart sounds included a murmur (turbulent blood flow through the heart valves). Spoke with staff at the physician’s office. Called the physician’s direct number and left a voicemail again at 3:14 PM. The nurse requested a return call. Updated clinical manager (administrator) of the patient’s complaints and again at 3:15 PM as the physician had not called back. Spoke with the patient’s family member regarding concerns over medications, shortness of breath, weight gain, and overall visit. The patient had called for him/her to make a cardiologist appointment. He/she had concerns with the patient’s noncompliance and stated that the patient had been taking his/her medications as he/she wanted even when he/she was aware of changes. He/she also had trouble reaching the physician’s office. During an interview on 09/20/2023, beginning at 10:25 AM, the clinical manager stated that he/she would expect the nurse to document an assessment of lung sounds and edema at every visit. The administrator stated that the physician had not called back since yesterday. When asked what the plan was for the patient, he/she stated they should have a check in call and visit with the patient today. The clinical manager stated that they would make a visit today, and if any further distress they would send the patient to the hospital. RECORD/PATIENT #4: Review of the physical therapy (PT) OASIS showed the patient had pressure ulcers (a lesion caused by unrelieved pressure resulting in damage of underlying tissue) on his/her buttocks and B (unsure what this meant) feet. The wound assessment showed a Stage 2 (partial thickness loss of skin layers that presents clinically as an abrasion, blister, or shallow crater) pressure ulcer to the coccyx (tailbone), an unstageable (unable to visualize the wound bed due to presence of dead tissue or a non-removable dressing) non-rem (unsure if this meant non-removable dressing) to the right lateral (side) proximal (upper) thigh, and unstageable deep tissue injury (purplish area of intact discolored skin which can indicate tissue damage) to the left lateral, proximal thigh. The wounds were not assessed as the caregiver had completed care. The wound assessment failed to include an assessment of the patient’s feet. Review of a RN add-on evaluation dated 09/12/2023, showed the nurse assessed the patient’s coccyx, right lateral proximal thigh and left lateral proximal thigh. The wound assessment failed to include an assessment of the patient’s feet. Review of an RN visit dated 09/15/2023, showed the nurse provided wound care and teaching but failed to document an assessment of the wounds. The documentation failed to show an assessment of the patient’s feet. During an interview on 09/20/2023, at 11:00 AM, the administrator stated that he/she would expect staff to document an assessment of the patient’s wounds and feet.

G0710

Provide services in the plan of care CFR(s): 484.75(b)(3) Providing services that are ordered by the physician or allowed practitioner as indicated in the plan of care; This ELEMENT is not met as evidenced by: Based on record review and interview the home health provider failed to follow the physician ordered plan of care (POC) in three of six full records reviewed (Records/Patients #1, #2, and #6). This deficient practice has the potential to affect all patients served by the provider. RECORD/PATIENT #6: Review of the referring hospital record, dated 08/29/2023, showed the following: -The patient had a current medical history of cerebral vascular accident (CVA; stroke), atrial fibrillation (abnormal heart rhythm characterized by rapid and irregular heartbeat), congestive heart failure (CHF; a decrease in the ability of the heart to pump blood, resulting in an accumulation of fluid in the lungs and other areas of the body), neurogenic dysphagia (difficulty in swallowing food caused by a disease or impairment of the nervous system, including stroke and traumatic brain injury) status post percutaneous endoscopic gastrostomy (PEG; a procedure to place a feeding tube is passed into a patient’s stomach through the abdominal wall to provide nutrition) tube. The patient had recently been discharged from the hospital on 08/03/2023 to an inpatient rehabilitation (rehab) facility. The patient was sent to the emergency room from rehab due to leakage around the PEG tube. Upon admission the patient was started on intravenous (IV) antibiotics. The patient was admitted back to the inpatient rehabilitation for continuation of physical therapy (PT), occupational therapy (OT), and speech therapy (ST); and -OT's current functional status, dated 08/28/2023, showed that the patient would benefit from continued intensive OT to address continued barriers for safe return to prior level of function. Review of the home health provider’s home care consent, dated as signed 09/01/2023, showed the provider would provide skilled nursing once a week for the first week, then twice a week for three weeks, and then once a week for four weeks. The provider would also provide PT evaluation, OT evaluation, and ST evaluation. Review of the clinical record showed: - The patient’s start of care date was 09/01/2023; - The RN OASIS admission visit dated 09/01/2023, showed the RN reviewed the plan of care and would have PT, OT, ST, and medical social worker (MSW) evaluate the patient and they agreed; and - The plan of care dated 09/01/2023, under the section Orders of Discipline and Treatments showed that the OT was to evaluate the patient for OT services and develop a plan of care for the physician’s signature and MSW was to evaluate the patient for social and emotional factors related to the patient's illness, needs for care, response to treatment and adjustment to care, to be followed by collaboration with the physician and nurse to develop a plan of care. The skilled nurse (SN) to administer PEG tube feeding of isosource 1.5 cal (tube feeding brand) 320 milliliter (ml) four times a day per bolus (all at once). Flush the PEG tube with 150 ml of warm water before and after each feeding and medications. Do site care daily, check tube placement before each feeding, and check residual with every feeding; and -The clinical record failed to show an evaluation for OT or for MSW, and documentation that the SN was going four times a day to administer the PEG tube feeding. During an interview on 09/20/2023, beginning at 10:25 AM, the clinical manager stated that OT was to do an evaluation on 09/10/2023 (9 days after admission), but the patient was discharged on 09/07/2023 to the referring hospital. He/she did not have an evaluation for MSW and the order for the SN to administer the PEG tube feeding four times a day should not have been written like that, as the SN was not going four times a day into the patient's home. RECORD/PATIENT #2: Review of the POC dated 08/15/2023, showed an order for occupational therapy (OT) one time a week for one week. Review of the record showed no OT evaluation before the patient was re-hospitalized on 08/23/2023. During an interview on 09/20/2023, beginning at 10:25 AM, the clinical manager stated that he/she would have to run a report to see why the OT had not been started. No further information was provided. Findings included: RECORD/PATIENT #1: Review of the clinical record showed: - The patient’s start of care date was 08/21/2023; - The registered nurse (RN) OASIS (outcome and assessment information set, a federally mandated assessment) admission visit dated 08/21/2023, showed in part, that the physician was contacted for and approved an order for occupational therapy (OT) to evaluate and treat the patient and that the RN communicated with the OT; - The plan of care dated 08/21/2023, showed that the OT was to evaluate the patient for OT services and develop a plan of care for the physician’s signature; - A client coordination note report dated 08/26/2023, showed that an OT visit was missed on 08/25/2023 due to therapist unavailable and that the primary physician was to be notified on 08/28/2023; and - A verbal order was obtained from the physician by the OT on 09/01/2023 and showed that an OT evaluation was completed, and that the patient would begin receiving OT services one time per week for eight weeks beginning the week of 08/27/2023. During an interview on 09/19/2023 at 4:50 PM, the clinical manager stated that he/she would expect an OT evaluation to be completed within 24 to 48 hours of the order unless the patient or responsible party requests treatment to start later. The clinical manager also stated that he/she believed the patient’s responsible party had felt that the patient was overwhelmed and had requested the evaluation be done later but had no documentation of that.

G0714

Patient and caregiver education CFR(s): 484.75(b)(5) Patient and caregiver education; This ELEMENT is not met as evidenced by: Based on policy review, procedure review, record review, and interview, the home health provider failed to ensure the skilled nurse (SN) documented patient/caregiver education regarding percutaneous endoscopic gastrostomy (PEG; a procedure to place a feeding tube is passed into a patient’s stomach through the abdominal wall to provide nutrition) tube feeding procedures and site care in one of one record reviewed for which a patient had a PEG tube (Record/Patient #6). This deficient practice has the potential to affect any patients with a PEG tube that the home health provider has on service. Findings included: Review of the provider’s policy titled, “Care Planning,” dated as revised 09/2022, showed in part the following: -Each patient must receive an individualized written Plan of Care (POC) including revisions and/or additions related to patient findings. The individualized POC must specify: * Care and services to meet patient-specific needs as identified in the comprehensive assessment and provided in accordance with accepted standards of practice; * Patient/caregiver education and training associated with care and services ordered; -The individualized POC is developed for the patient 60-day episode of care and must include: * Patient/caregiver education and training to facilitate timely discharge; * Patient-specific interventions and measurable outcomes/goals; -The patient or caregiver will be provided a copy of the POC and/or other form of written instructions outlining: * Patient medication schedule/instructions to include medication name, dosage, frequency and which medications will be administered by the home health agency staff and personnel acting on behalf of the agency; * Pertinent instruction related to the patient’s care and treatments that the home health agency will provide; and -Care will be planned to ensure effective utilization of services and resources including the total number of visits/hours appropriate to the care required and ordered. Review of the provider’s procedure titled, “Enteral tube feeding home care,” dated as revised 11/28/2022, showed in part the following: -An enteral feeding tube allows direct administration of nutrition, fluids, or medications into the gastrointestinal (GI) system for patients who can’t ingest these substances orally but who have a functional GI tract. Enteral tube feeding also permits supplemental feedings in patients who can’t ingest enough nutrition orally to meet their metabolic requirements or who have high nutritional requirements due to illness; -Nursing care includes assessing and monitoring the patient and access device, administering home enteral nutrition, coordinating care with the interdisciplinary team and teaching the patient and family how to administer home enteral nutrition independently; -Review the referral information, plan of care, and previous visit documentation, if available; -Verify orders, noting the route of administration, enteral feeding device, prescribed formula, administration method, volume, and rate; and type, volume, and frequency of water flushes; -Ask the patient and family (if appropriate) about any recent changes in the patient’s health status, including practitioner visits, tests, and changes in medications, fluid intake, diet, activity level. Also ask about any problems with the enteral feeding tube and signs and symptoms of enteral nutrition complications, such as exit site skin irritation or breakdown, GI distress (including nausea, vomiting, abdominal bloat, and diarrhea or constipation), and respiratory distress (including coughing, choking, and shortness of breath); -Assist the patient to an upright or a semi-Fowler (a position in which a person lies on their back in bed with the head of bed elevated 30 to 45 degrees); -Assist the patient with oral care, as needed, to promote comfort and reduce bacterial burden in the mouth; -Teach the patient and family (as appropriate) about the enteral feeding tube, including the indication and goals of therapy. Instruct them on tube and site care; formula components, handling, and storage; the feeding regimen; and the use of feeding equipment and supplies. If the patient or family member will manage the tube independently, teach the proper technique and have the patient or family member perform a return demonstration to identify any learning gaps, correct any misconceptions, and determine competency; -If the patient or a family member will manage home enteral nutrition independently, provide additional instruction, including hands-on training and return demonstration. Teach the patient and family member how to: * Verify tube placement; * Flush and irrigate the tube; * Administer enteral feedings via the tube, including formula preparation and storage; * Administer medications via the tube (as appropriate); * Clean and store reusable supplies and equipment; * Inspect the exit site for fluid leakage or other discharge and resulting skin irritation; * Perform hand hygiene and other infection control measures; * Provide comfort measures for the patient, including oral care and exit site skin care; -Documentation associated with enteral tube feeding includes: * All assessment findings; * Verification of tube placement; * Amount and type of flushes used; * Type and volume of the enteral formula; * Patient’s tolerance to the procedure or patient’s response to your interventions; and * Teaching provided to the patient and family (if applicable), their understanding of that teaching, and any need for follow-up teaching. RECORD/PATIENT #6: Review of the referring hospital record, dated 08/29/2023, showed the following: -The patient had a current medical history of cerebral vascular accident (CVA; stroke), atrial fibrillation (abnormal heart rhythm characterized by rapid and irregular heartbeat), congestive heart failure (CHF; a decrease in the ability of the heart to pump blood, resulting in an accumulation of fluid in the lungs and other areas of the body), neurogenic dysphagia (difficulty in swallowing food caused by a disease or impairment of the nervous system, including stroke and traumatic brain injury) status post PEG tube. The patient had recently been discharged from the hospital on 08/03/2023 to an inpatient rehabilitation (rehab) facility. The patient was sent to the emergency room from rehab due to leakage around the PEG tube. Upon admission the patient was started on intravenous (IV) antibiotics. The patient had an abdominal wall abscess (a pocket of infected fluid and pus located inside the abdominal cavity). Status post incision and drainage complex abdominal wall abscess. The patient was admitted back to the inpatient rehabilitation for continuation of physical therapy (PT)/occupational therapy (OT)/speech therapy (ST); -Diet (dated 08/28/2023): Nothing by mouth (NPO), tube feeding of Jevity 1.5 (brand) - give 360 milliliter (ml) bolus (at once) four times a day at 6:00 AM, 12:00 PM, 4:00 PM, and 8:00 PM. Tube feeding water flush 200 ml before and after each bolus for a total of 400 ml with each feeding; -Medications were given per PEG tube; -The inpatient rehab facility nursing staff to work on skin integrity, carry over from therapies, and providing the patient and family education; -The patient had an open surgical incision adjacent to his/her PEG tube with an order (dated 08/24/23) to cleanse with wound cleanser and cover with a dry dressing; -A face-to-face encounter was completed on 08/24/23 to evaluate the patient for home health services. Clinical findings demonstrating the medical necessity for home health services include: new medication, patient requires further teaching and assessment. Decline in patient condition due to hospitalization, requires skilled services. The patient has enteral nutrition and requires continued skilled care. Based on the findings, the patient is homebound and needs intermittent skilled nursing care, physical therapy and/or speech therapy, or continues to need occupational therapy; and -A face-to-face encounter regarding durable medical equipment (DME) was completed on 08/24/2023. The patient will require a hospital bed upon discharge due to impairments as a result of a stroke. The patient requires the head of the bed to be elevated more than 30 degrees as he/she is in need of tube feeds daily due to severe dysphagia as a result of the stroke. He/she is at a significant risk of aspiration when receiving tube feeds if the head of the bed is not elevated to 30 degrees. Pillows and wedges have been ruled out. Review of the home health provider’s home care consent, dated as signed 09/01/2023, showed the provider would provide skilled nursing once a week for the first week, then twice a week for three weeks, and then once a week for four weeks. The provider would also provide PT evaluation, OT evaluation, and ST evaluation. Review of the Plan of Care (POC), showed the following: -Start of care: 09/01/2023; -Patient’s expressed goals: The patient would like to be able to eat solid foods, then he/she would like to move more by self and be a little stronger; -Diagnoses included: Dysphagia following stroke; -Frequency/Duration of Visits: Skilled nurse (SN) once a week for two weeks (this contradicts what they had the patient/family sign on consent), PT once a week for one week, OT once a week for one week, and ST once a week for one week; -SN to evaluate and develop plan of care; -SN to provide skilled teaching to minimize and manage identified risks of hospitalization and/or ER visits; -SN to observe/assess gastrointestinal system, identify changes, and intervene to minimize complications. SN to teach related to altered gastrointestinal status including disease process, nutrition, medications, activities, and personal environmental factors. Significant changes in status will be reported to physician; -SN to teach PEG tube feeding, management such as definition, symptom monitoring, site/skin care, and feeding/flushing; -SN to administer PEG tube feeding: Isosource 1.5 Cal (brand), 320 ml four times a day per bolus, flush PEG tube with 150 ml of warm water, before and after each feeding and meds, site care daily, check tube placement before each feeding and check residual (the volume of fluid remaining in the stomach at a point in time during enteral feeding) every feeding; -Goals: Patient will tolerate PEG tube feeding and care as evidenced by intact skin, improved nutritional status, and no unplanned hospitalizations by 10/15/2023; -Discharge Plans: Discharge to caregiver under supervision of physician when goals are met; -Safety Measures: Aspiration precautions, swallowing precaution, and tube feeding precautions; -Mental statuses: Oriented and forgetful; -Focus of care: (who is the primary discipline to treat the primary diagnosis): SN; -Principle Diagnosis: CVA; -Medications to be given per PEG tube; and -The POC failed to show an order to crush meds and if they could be mixed and administered all at the same time. Review of the Registered Nurse (RN) OASIS (outcome and assessment information set, a federally mandated assessment) admission assessment, dated 09/01/2023, showed the following: -The RN was in the home from 9:49 AM to 10:43 AM; -The patient lived with another person in the home; -The patient had around the clock availability of assistance in the home; -The caregiver was willing and/or able to provide the care the patient needed; -The patient was at a moderate nutritional risk; -Nutritional approaches: PEG feeding tube; -The patient was alert, but forgetful; -The patient had moderate cognitive impairment (difficulty with problem-solving, difficulty remembering names and details, and may withdraw socially as new situations and places are challenging to them); -Feeding or eating: Unable to take in nutrients orally and is fed nutrients through gastrostomy; -Dependent on eating; -No oral medications prescribed; -Patient/Caregiver compliant with all medication administration; -Clinical summary: The patient was lying in bed. The family member stated that the patient did not get home from the inpatient rehab facility until midnight. The patient was sleeping, but easily woke up and able to answer simple questions. Another family member arrived and brought medication from the pharmacy. The patient had a PEG tube. The family member asked for assistance to give the medications, so he/she could learn. Demonstrated on using pill crusher. Added to warm water and instilled. Flushed after and then the family member demonstrated on giving feeding. Reviewed several times on flushing before and after feeding and medications. The family member understood. Dressing to PEG tube intact; and -The summary failed to show documentation of teaching the need for the head of the bed to be up 30-45 degrees prior to medications and tube feeding, the need to check tube placement prior to administering the medications and tube feedings, what medications could be crushed and administered together, how to check for residual (as per order), infection control practices regarding the PEG tube, what signs and symptoms to watch for in regards to the PEG tube, PEG tube dressing care, and comfort measures for the patient, including oral care. Review of the clinical record showed no further nursing visits (as per POC for SN to administer tube feeding four times a day) until 09/06/2023. Review of SN visit, dated 09/06/2023, showed the following: -Licensed practical nurse (LPN) in the patient home from 8:33 AM to 9:23 AM; -The patient lives with other family member; -The patient receives assistance from person residing in the home; -Gastrointestinal: Gastrostomy or other type of GI tube; -Indicate type and placement of GI tube: PEG tube left upper quadrant; -Indicate surrounding tissue characteristics: within normal; -Nutritional details: Tube feeding; -Changes to the patient’s POC: No changes to frequency/duration, mediations or treatments; -Indicate summary of clinical findings this visit, including the main barriers or impairments to address and explain why skilled services are needed to support medical necessity: Education and assessment provided; -Recommended plan for next visit including specific skill/care and expected progress/outcomes: Education, assessment, and observation; -Interventions Provided: * Instruct patient/caregiver on PEG tube management including care, feeding/flushing, symptom monitoring, and intended effects. Details/comments: Introduced definition of PEG tube and for them to call the home health provider first for nausea/vomiting, pain, feeding intolerance, changes in tube stability, skin breakdown to promote clinical stability using scenario-based teach back. Educated patient/caregiver on site care, maintaining tube stability, feeding/flushing technique, and intended effects to promote treatment/monitoring adherence using task-specific return demonstration; * Instruct patient/caregiver on PEG feeding/flushing, symptom monitoring, site care, and intended effects. Details/comments: Educated patient/caregiver on feeding/flushing, site care, and intended effects to promote health awareness; -Interventions Not Provided: * Administer PEG tube flushes, tube feedings, and site care. Exception Code: Not applicable to current visit; -Goals Not Met: * Patient tolerates PEG tube flush, tube feeding, and site care without complications including: nausea/vomiting, diarrhea, or skin breakdown. Exception Code: Not applicable to current visit; * Patient/caregiver verbalizes/demonstrates PEG tube management, site/skin care technique, feeding/flushing, symptom monitoring, and intended effects. Exception Code: Additional time required to meet intervention/goal; and -The visit failed to show documentation of teaching the need for the head of the bed to be up 30-45 degrees prior to medications and tube feeding, the need to check tube placement prior to administering the medications and tube feedings, what medications could be crushed and administered together, how to check for residual (as per order), and infection control practices regarding the PEG tube, and comfort measures for the patient, including oral care. Review of the clinical record failed to show any further skilled nurse visits (as per POC, SN was to go four times a day to administer tube feeding and flushes). Review of Speech Therapy (ST) evaluation note, dated 09/07/2023 (6 days after start of care), showed the following: -Indicate oral peripheral structural exam findings: Abnormalities noted; -Indicate structure abnormalities: White coating was noted on the tongue; -Indicate signs or symptoms of aspiration: Other- specify; -Indicate other signs or symptoms of aspiration: The patient currently on PEG tube for his/her nutrition secondary to severe dysphagia. The patient remains at risk for aspiration of bacteria/saliva; -The patient is at risk for aspiration; -PEG tube is present; -Indicate current diet level: NPO; -Therapy subjective: The patient noted to wheeze after lying down past 45 degrees; -Interventions Provided: * Instruct patient/caregiver on signs/symptoms of disease that require immediate attention. Details/comments: Recommended doctor’s appointment for potential oral thrush. If patient demonstrates temperature spikes, increased congestion or respiratory difficulty to consult medical professionals; * Instruct on basic use of assistive devices to ensure patient is safe until next visit. Details/comments: Family member educated to strategies for avoiding for the respiratory difficulties such as putting patient upright or over 45 degrees during PEG tube feedings; and * Instruct on environmental safety issues to resolve immediate safety issues or concerns. Details/comments: Head of bed to at least 45 degrees during PEG tube feeding or flushes, maintenance of PEG tube site, and importance of oral care. Review of the patient’s discharge summary, dated 09/07/2023, showed the following: -The patient was discharged to the referring hospital on 09/07/2023 with shortness of breath; -Was admitted to inpatient; -Goals not met, included: * Patient tolerates PEG tube flush, feeding, and site care without complications, including nausea/vomiting, diarrhea, or skin breakdown; and * Patient/caregiver verbalizes/demonstrates PEG tube management, site/skin care technique, feeding/flushing, symptom monitoring, and intended effects. During an interview on 09/19/2023 at 10:25 AM, the clinical manager, stated that: -There should have never been an order for SN to administer PEG tube feedings and flushes four times a day and to check for residual; -There should have been an order to crush medications and if it was okay for them to be mixed all together and administered at the same time; -There should have been an order for the head of the bed to be at a 30-45 degree angle when the patient was receiving his/her medications, tube feedings, and flushes; and -He/she agreed with the missing education pieces and that the documentation should have showed what exactly was taught and to whom. During an interview on 09/21/2023 at 4:38 PM, the person whom the patient lived with, stated the following: -He/she took care of the patient; -He/she denied being educated on the need for the patient’s head of the bed to be up 30 to 45 degrees when receiving tube feedings, flushes, or medications; -He/she denied being educated on how to check PEG tube placement; -He/she denied being educated on how to crush medications and administer via the feeding tube; -He/she denied being educated on how to check for residual and did not know what that was when SA explained it; -He/she denied being educated on PEG site care; -He/she denied being educated on importance of oral care; -The nurse that came the second visit, informed him/her that he/she was just there to evaluate and not to treat; and -He/she was very upset with the care the home health provider provided and he/she had called the provider and informed them of that.

G0788

Org. had partial/extended survey CFR(s): 484.80(f)(3) Was subjected to an extended (or partially extended) survey as a result of having been found to have furnished substandard care (or for other reasons as determined by CMS or the state); or This ELEMENT is not met as evidenced by: Based on the results of this extended level survey, resulting in noncompliance with two Conditions of Participation: Care planning, coordination of services, and quality of care and Skilled professional services, the home health provider may not train, or competency evaluate their home health aides for a period of two (2) years following the date of this survey. This restriction ends 09/26/2025.

G0808

Onsite supervisory visit every 14 days CFR(s): 484.80(h)(1)(i) If home health aide services are provided to a patient who is receiving skilled nursing, physical or occupational therapy, or speech-language pathology services, a registered nurse or other appropriate skilled professional who is familiar with the patient, the patient's plan of care, and the written patient care instructions described in §484.80(g), must make an onsite visit to the patient's home no less frequently than every 14 days. The home health aide does not have to be present during this visit. This ELEMENT is not met as evidenced by: Based on policy review, record review, and interview the home health provider failed to ensure that supervisory visits were conducted for the home health aide (HHA) in one of six full records reviewed (Record/Patient #1). This deficient practice has the potential to affect all patients served by the provider. Findings included: Review of the provider’s policy titled, “Patient Care Supervision,” revised 10/2022, showed in part that: - Nursing, therapy and other allowed patient care services including services under arrangement are provided under the supervision and direction of the registered nurse (RN), qualified professional or other individual as permitted by state regulations/law; - Supervisory visits will be documented in the patient medical record; and - Supervision of home health aides will be performed when the patient is receiving skilled nursing services. An RN will make on-site supervisory visits to each patient receiving home health aide services at least every 14 days. RECORD/PATIENT #1: Review of the clinical record showed: - The patient’s start of care date was 08/21/2023; - The HHA began visits to the patient on 08/24/2023; and - The RN failed to make any supervisory visits for the HHA between 08/24/2023 and 09/18/2023. Supervisory visits for the HHA were requested on 09/19/2023 at approximately 11:00 AM and during an interview with the clinical manager at 4:50 PM. During an interview on 09/20/2023 at 9:40 AM, the clinical manager stated that no other information was available for the patient.

G0982

Skilled services furnished CFR(s): 484.105(f) Standard: Services furnished. Skilled nursing services and at least one other therapeutic service (physical therapy, speech-language pathology, or occupational therapy; medical social services; or home health aide services) are made available on a visiting basis, in a place of residence used as a patient's home. An HHA must provide at least one of the services described in this subsection directly, but may provide the second service and additional services under arrangement with another agency or organization. This STANDARD is not met as evidenced by: Based on review of the home health provider's employee list, survey report form 1572 and interview the home health provider failed to ensure that their qualifying service for Medicare was provided in its entirety by the provider’s own employees. This deficient practice has the potential to affect all patients served by the agency. Findings included: Review of the provider's employee list included one contractual registered nurse (RN) with a hire date of 01/13/2020 and one contractual RN with a hire date of 04/17/2023. Review of the provider's home health survey report form 1572 (includes direct care staff and staff under arrangement) showed two RNs hired under arrangement. During the entrance interview on 09/18/2023, at 1:23 PM, the clinical manager stated that their qualifying service for Medicare was nursing. They had two RNs that were contracted employees. During an interview on 09/19/2023, at 4:15 PM, the regional director of operations stated that they thought as long as they had more of their own staff than they did contract staff that was okay. They had two contracted RNs and four RNs that were direct employees.

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Federal survey findings only. State licensure findings for home health agencies are not shown.

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