Every finding on record at Chase Health Care Inc.

The entity is in compliance with the federal emergency preparedness requirements.

Recertification Survey Abbreviations: CMS-Centers for Medicare and Medicaid Services gm- gram HFAHydrofluoroalkane-134a mg-milligram mcg-microgram MEQ-milliequivalent

Encoding and transmitting OASIS CFR(s): 484.45(a) Standard: An HHA must encode and electronically transmit each completed OASIS assessment to the CMS system, regarding each beneficiary with respect to which information is required to be transmitted (as determined by the Secretary), within 30 days of completing the assessment of the beneficiary. This STANDARD is not met as evidenced by: Based on record review and interview, the agency failed to ensure each OASIS (Outcome and Assessment Information Set) was successfully transmitted to the CMS system within 30 days of completion. Findings: Review of the agency’s undated policy titled “Oasis Policy” revealed the following, in part: The Oasis collection and reporting- All OASIS collection and reporting will be guided by the timeframes set by CMS. Review of the agency's OASIS Agency Final Validation Report with a submission date of 02/17/2025 revealed 10 records were processed with 2 records receiving a message the record was submitted late due to a submission date of more than 30 days after date on the record. Review of the agency's OASIS Agency Final Validation Report with a submission date of 02/25/2025 revealed 8 records were processed with 2 records receiving a message the record was submitted late due to a submission date of more than 30 days after date on the record. Review of the agency's OASIS Agency Final Validation Report with a submission date of 02/27/2025 revealed 4 records were processed with 1 record receiving a message the record was submitted late due to a submission date of more than 30 days after date on the record. Review of the agency's OASIS Agency Final Validation Report with a submission date of 03/06/2024 revealed 3 records were processed with 1 record receiving a message the record was submitted late due to a submission date of more than 30 days after date on the record. Review of the agency's OASIS Agency Final Validation Report with a submission date of 03/13/2025 revealed 2 records were processed with 1 record receiving a message the record was submitted late due to a submission date of more than 30 days after date on the record. Review of the agency's OASIS Agency Final Validation Report with a submission date of 03/21/2025 revealed 30 records were processed with 1 record receiving a message the record was submitted late due to a submission date of more than 30 days after date on the record. Review of the agency's OASIS Agency Final Validation Report with a submission date of 05/13/2025 revealed 7 records were processed with 1 record receiving a message the record was submitted late due to a submission date of more than 30 days after date on the record. Review of the agency's OASIS Agency Final Validation Report with a submission date of 05/14/2025 revealed 11 records were processed with 1 record receiving a message the record was submitted late due to a submission date of more than 30 days after date on the record. Review of the agency's OASIS Agency Final Validation Report with a submission date of 05/16/2025 revealed 23 records were processed with 1 record receiving a message the record was submitted late due to a submission date of more than 30 days after date on the record. An interview was conducted with S2AADM on 05/20/2025 at 12:24 p.m. She confirmed she was responsible for submitting the agency’s OASIS Assessments. She reviewed and confirmed the above listed OASIS Agency Final Validation Reports and confirmed the OASIS was submitted late. She stated the requirement was to submit the OASIS within 30 days of the assessment date.

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 observations during home visits, interviews, and record review, the agency failed to ensure each patients’ comprehensive assessment included a review of all medications the patients were currently using. The agency failed to ensure skilled nursing and therapy staff reconciled patients’ medications for 3 (#1, #2, and #4) of 5 (#1, #2, #3, #4, #5) patients reviewed with home visits. Findings: Review of the agency’s undated policy, titled “Medication Information Policy” revealed the following, in part: Purpose: To ensure agency staff have access to and are knowledgeable of the effects, side effects, indications and contraindications of all the medications a patient is taking. Procedure: 1. The Medication Profile is completed on admission; 5. Medication reconciliation is to occur with each skilled nurse visit. Patient #1 Review of Patient #1’s Clinical Record revealed she began receiving services from the agency on 03/15/2025 and had a current Certification Period of 05/14/2025 through 07/12/2025. Patient #1 had diagnoses, which included Pressure Ulcer of Right Buttock – Stage 4 and Hypertension. Patient #1 was ordered to receive Skilled Nursing Visits once weekly for one week then twice weekly for eight weeks. A home visit was conducted with Patient #1 on 05/20/2025 at 9:00 a.m. with S5RN present in the home. Patient #1 stated he managed his own medications. Patient #1’s medications were reviewed during the home visit and the following discrepancies were identified when compared to the current medication profile provided by the agency: Hydrocodone 10 mg 1 tab twice daily – listed on the medication profile and the patient was currently taking Hydrocodone-Acetaminophen 10-325 mg by mouth twice daily; and Olmesartan Medoxomil 40 mg by mouth daily – not listed as a current medication on the medication profile but present in the home and the patient was currently taking. An interview was conducted with Patient #1 during the home visit. He stated he had never taken Hydrocodone 10mg without the Acetaminophen. He stated he had been taking Olmesartan Medoxomil 40 mg daily for years and since the start of his current episode. An interview was conducted with S5RN during the home visit. He confirmed the above medication discrepancies. Patient #2 Review of Patient#2’s Clinical Record revealed he began receiving services from the agency on 07/25/2024 and had a current Certification Period of 03/23/2025 through 05/21/2025. Patient #2 had diagnoses, which included Pressure Ulcer of Sacral Region- Stage 3, Hypertensive Chronic Kidney Disease, Anemia in Chronic Kidney Disease, Atrial Fibrillation, and Colostomy Status. A home visit was conducted with Patient#2 on 05/19/2025 at 12:46 p.m. with S4RN present in the home. Patient #1 stated he managed his own medications and took them as prescribed on the bottles. Patient #2’s medications were reviewed during the home visit and the following discrepancies were identified when compared to the current medication profile provided by the agency: Cyanocobalamin 1200mcg oral, extended release 1 tablet by mouth daily- listed on the medication profile and the patient reported he was no longer taking this medication; Metoprolol Tartrate 25mg oral take 0.5 tablet by mouth twice daily- listed on the medication profile and the patient was currently taking Metoprolol Tartrate 25mg 1 tablet by mouth twice daily; Miralax 17gm once daily or as needed by mouth for constipation- listed on the medication profile and patient was no longer taking; Mupirocin 2% External Ointment apply small amount to scrotum twice a day- listed on the medication profile and patient was no longer taking; Potassium Chloride 20 MEQ one tablet by mouth once daily- listed on the medication profile and patient was no longer taking for at least six months; Ferrous Sulfate 325mg one tablet by mouth once daily with a start date of 5/12/2025- not listed as a current medication on the medication profile but present in the home and the patient was currently taking. An interview was conducted with S4RN during the home visit. She confirmed the above medication discrepancies. Patient #4 Review of Patient#4’s Clinical Record revealed she began receiving services from the agency on 05/10/2025 and had a current Certification Period of 5/10/2025 through 07/08/2025. Patient #4 had diagnoses, which included Aftercare Following Joint Replacement Surgery, Presence of Right Artificial Knee Joint, Hypertensive Heart Disease with Heart Failure, Anxiety Disorder, Major Depressive Disorder, and Gastroesophageal Reflux Disease. A home visit was conducted with Patient #4 on 05/19/2025 at 3:20 p.m. with S6LPN present in the home. Patient#4 stated her sister assisted her with her medications and she took them as prescribed on the bottles. Patient #4’s medications were reviewed during the home visit and the following discrepancies were identified when compared to the current medication profile provided by the agency: Synthroid 125mcg one tablet by mouth every morning- not listed as a current medication on the medication profile but present in the home and patient was currently taking; Omeprazole Delayed Release 40mg one capsule by mouth twice daily- not listed as a current medication on the medication profile but present in the home and patient was currently taking; Tylenol 500mg capsule one capsule by mouth twice daily as needed for pain- not listed as a current medication on the medication profile but present in the home and patient was currently taking; Duloxetine HCL Delayed Release 60 mg capsule one by mouth daily- not listed as a current medication on the medication profile but present in the home and patient was currently taking; Gabapentin 300mg one capsule by mouth twice daily- not listed as a current medication on the medication profile but present in the home and patient was currently taking; Fluticasone 50mcg 2 sprays each nostril once daily- not listed as a current medication on the medication profile but present in the home and patient was currently taking; Asprin 81 mg one tablet by mouth once daily was on the medication profile, but patient was one tablet by mouth twice daily with a prescribed date of 05/12/2025; Oxycodone/ Acetaminophen 5/325mg one tablet by mouth every 4-6 hours as needed for pain- not listed as a current medication on the medication profile but present in the home and patient was currently taking; Promethazine 12.5mg one tablet by mouth every 6 hours as needed for nausea with a prescribed date of 05/12/2025- not listed as a current medication on the medication profile but present in the home and patient was currently taking; Lasix 40mg one tablet by mouth daily- not listed as a current medication on the medication profile but present in the home and patient was currently taking; Docusate sodium with Senna 50mg/8.6mg one tablet by mouth twice daily-was not listed on the medication profile but present in the home and patient was currently taking; Coreg 3.125mg tablet one tablet by mouth twice daily- not listed as a current medication on the medication profile but present in the home and patient was currently taking; Albuterol HFA 90mcg 1-2 puffs inhaled every 4 hours as needed for shortness of breath- not listed as a current medication on the medication profile but present in the home and patient was currently taking; Hydrocodone-Acetaminophen 10/325mg one tablet by mouth every 4 hours as needed for pain- was listed on the medication profile but patient was no longer taking; Docusate sodium 50mg one capsule by mouth as needed was on the medication profile but patient was no longer taking. An interview was conducted with Patient #4 who reported when she was admitted to the home health agency on 05/10/2025 the admitting nurse did not request her medications to be reviewed during the admission process. An interview was conducted with S6LPN during the home visit. She confirmed the above medication discrepancies. She confirmed medications should be reconciled each visit, but was not completed due to all the discrepancies found. An interview was conducted with S3DON on 05/20/2025 at 2:55 p.m. She was made aware of the above medication discrepancies for Patients #1, #2, and #4. She stated each patients’ medications should have been reconciled each Skilled Nursing Visit. She confirmed every patient’s medication profile should have reflected the current medications they were taking.

All orders recorded in plan of care CFR(s): 484.60(a)(3) All patient care orders, including verbal orders, must be recorded in the plan of care. This ELEMENT is not met as evidenced by: Based on record review and interview the agency failed to ensure all patient care orders were recorded in the Plan of Care (POC) for 1 (#2) of 13 (#1-#13) patient records reviewed. The agency failed to ensure Patient #2’s POC was revised to reflect current wound treatment orders. Findings: Review of Patient #2’s Clinical Record revealed he began receiving services with the Home Health Agency on 07/26/2024 and had a current Certification Period of 03/23/2025 through 05/21/2025. Review of Patient #2’s Plan of Care for current certification period revealed, in part: Wound Care Orders- Skilled Nurse perform Pressure Ulcer care to stage 3 Sacrum Ulcer. Cleanse with wound cleanser, apply hydrofiber dressing with silver, cover and secure with border dressing, using aseptic technique. Review of Patient #2’s current wound care orders dated 05/06/2025 revealed the following: Skilled Nurse to perform treatment to Pressure Ulcer to Sacrum 3 times weekly: Cleanse with wound cleanser and pat dry, apply an antiseptic to peri-wound, then apply medical-grade honey and Collagen to the wound bed, and secure with dry dressing. An interview was conducted on 05/21/2025 at 11:00 a.m. with S3DON. She reviewed Patient #2’s POC and confirmed his wound care orders were not updated. She reported that the Plan of Care is only updated with a Resumption of Care or Recertification. She confirmed that the Plan of Care should be updated with current orders to prevent any errors in patient care.

Infection Prevention CFR(s): 484.70(a) Standard: Infection Prevention. The HHA must follow accepted standards of practice, including the use of standard precautions, to prevent the transmission of infections and communicable diseases. This STANDARD is not met as evidenced by: Based on observations, interviews, and record review, the agency failed to ensure staff followed accepted standards of infection control practices for 1 (#2) of 5 (#1, #2, #3, #4, and #5) patients observed during home visits. The agency staff failed to practice proper hand hygiene while providing wound care for Patient #2. Findings: Review of the agency’s undated policy, titled “Standard Precautions” revealed the following, in part: 1. Hand Hygiene- Perform hand hygiene before having direct contact with a patient. Perform hand hygiene after touching blood, body fluids, secretions, excretions, and contaminated items whether or not gloves are worn. Perform hand hygiene immediately after gloves are removed. 2. Gloving- Change gloves during patient care if the hands move from a contaminated site to a clean site. Remove gloves after contact with a patient and/ or the surrounding environment. Review of Patient #2’s Clinical Record revealed he began receiving services with the Home Health Agency on 07/26/2024 and had a current Certification Period of 03/23/2025 through 05/21/2025. Patient #2 had a diagnosis which included Pressure Ulcer of Sacral Region, Stage 3. A home visit was conducted with Patient #2 on 05/19/2025 at 12:46 p.m. with S4RN present. Upon entering the home S4RN was observed applying gloves to her hands without performing hand hygiene prior to assessing Patient #2. After patient #2’s assessment she applied a second pair of clean gloves over the gloves used to assess Patient #2. She assisted Patient #2 into a standing position with his walker by holding the walker and patient’s left arm with her gloved hands, and S4RN removed Patient #2’s soiled dressings to his Sacrum. Patient’s legs became weak and he sat down in his recliner onto a washable pad. While patient was sitting in his recliner she removed the top pair of soiled gloves and applied a new pair of clean gloves. S4RN assisted patient back into a standing position holding his walker and left arm with her clean gloves, and without changing gloves S4RN cleansed his sacral wound with wound cleanser and gauze. Without performing hand hygiene or changing gloves she applied collagen to wound bed and covered the wound with a dry cover dressing. She removed the top pair of gloves and finished assisting patient to a comfortable position. After she removed the bottom gloves she was not observed washing her hands or performing hand hygiene. On 05/19/2025 at 1:15 p.m., an interview was conducted with S4RN. She confirmed she did not perform appropriate hand hygiene. On 05/20/2025 at 11:30 a.m., an interview was conducted with S3DON who stated staff were expected to perform appropriate hand hygiene and not washing hands with soap and water or changing gloves when going from soiled to clean dressings was not appropriate infection control practices.

Services by skilled professionals CFR(s): 484.75(a) Standard: Provision of services by skilled professionals. Skilled professional services are authorized, delivered, and supervised only by health care professionals who meet the appropriate qualifications specified under §484.115 and who practice according to the HHA's policies and procedures. This STANDARD is not met as evidenced by: Based on interviews and record reviews, the home health agency failed to ensure the Registered Nurse (RN) provided home health agency services in accordance with current clinical practice guidelines and accepted professional standards for 2 (#2 and #12) of 5 (#1, #2, #6, #10, and #12) patients reviewed with Pressure Ulcers. The agency failed to ensure the RN assessed and measured wounds at least weekly for Patients #2 and #12. Findings: Review of the agency’s undated policy titled, “Wound Care” revealed the following, in part: Policy: A RN, or Physical Therapist (PT) will see all patients with a wound at least once weekly unless patient is seen by the Physician (MD) or Nurse Practitioner (NP) for wound assessment. Procedure: 1. Measurements and new orders are to be obtained from visit and followed. Review of the Louisiana State Board of Nursing, Declaratory Statement Scope of Practice for Registered Nurses - Wound Care Management revealed, in part, the following: Registered nurses render care that is directed towards the prevention and the treatment of wounds. Scope of Practice - The Louisiana State Board of Nursing recognizes that assessment, planning, intervention, teaching, evaluation, and supervision are the major responsibilities of the registered nurse in the practice setting. The Registered Nurse initiates appropriate wound prevention measures, stages wounds and collaborates with the wound care team in the implementation and evaluation of nursing interventions as prescribed by the authorized prescriber. Wound care management requires the registered nurse to collaborate with other members of the interdisciplinary team to ensure that the individual's nutritional and psychosocial needs are being met and to provide for preventive and therapeutic measures. The Registered Nurse should consult with the physician and/or CWCN (certified wound care nurse) to assure safe, quality nursing measures that facilitate appropriate skin and wound management. Review of the National Pressure Ulcer Advisory Panel Prevention and Treatment of Pressure Ulcers: Quick Reference Guide revealed, in part, the following: Pressure Ulcer Assessment 1. Assess the pressure ulcer initially and re-assess it at least weekly. 1.1. Document the results of all wound assessments. Assess and document physical characteristics including: location, Category/Stage, size, tissue type(s), color, peri-wound condition, wound edges, sinus tracts, undermining, tunneling, exudate, and odor. Patient #2 Review of the Clinical Record revealed Patient #2 began receiving services with the agency on 07/26/2024 and had a current Certification Period of 03/23/2025 through 05/21/2025. Patient #2 had a diagnosis of Pressure Ulcer of Sacral Region – Stage 3. Patient #2 was ordered to receive skilled nursing visits twice weekly for 5 weeks then once weekly for 1 week. Review of Patient #2’s skilled nursing visits conducted for the Certification Period of 03/23/2025 through 05/21/2025 revealed he was seen by a RN on the following dates: 04/17/2025, 04/19/2025, 04/23/2025, 04/25/2025, and 05/02/2025. Further review revealed no documented evidence Patient #2’s Stage 3 Sacral Pressure Ulcer was measured. The RN documented “patient refused wound measurements” on the above dates. Review of Patient #2’s Wound History for his Stage 3 Sacral Pressure Ulcer revealed an onset sate of 04/17/2025 and no documented measurements. A home visit was conducted on 05/19/2025 at 12:46 p.m. with Patient #2, and S4RN was present. An observation was conducted of S4RN performing wound care on Patient #2’s Stage 3 Sacral Pressure Ulcer. S4RN did not perform wound measurements or ask Patient #2 for permission to measure the wound. An interview was conducted on 05/19/2025 at 3:27 p.m. with Patient #2. Patient #2 reported he had never refused to allow the RN to measure his Sacral Pressure Ulcer. He confirmed the RN had not been measuring the wound. An interview was conducted on 05/20/2025 at 11:30 a.m. with S3DON. S3DON reviewed Patient #2’s Clinical Record and confirmed there was no documented evidence of wound measurements for Patient #2’s Stage 3Sacral Pressure Ulcer. She confirmed the RN should have measured the wound at least once weekly or obtained measurements from the Certified Wound Care Nurse Practitioner weekly for documentation in the Clinical Record. S3DON confirmed the agency was not following the progression of the wound via measurements from an RN, NP or MD. Patient #12 Review of the Clinical Record revealed Patient #12 began receiving services with the agency on 12/23/2024 and had a current Certification Period of 04/12/2025 through 06/10/2025. Patient #12 had a diagnosis of Pressure Ulcer of Sacral Region – Stage 4. Patient #12 was ordered to receive skilled nursing visits three times weekly for eight weeks then once weekly for one week. Review of Patient #12’s skilled nursing visit notes dated 04/13/2025 through 04/19/2025 revealed a RN made no documented evidence the RN, NP or MD measured Patient #12’s Stage 4 Sacral Pressure Ulcer. An interview was conducted on 05/20/2025 at 2:17 p.m. with S3DON. She reviewed Patient #12’s Clinical Record and confirmed there was no documented evidence of wound measurements between 04/13/2025 through 04/19/2025. She confirmed the RN made a nursing visit on 04/18/2025 and should have measured Patient #12’s wound.

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 observation, record review, and interviews, the agency failed to provide wound care as ordered by the physician or allowed practitioner as indicated in the Plan of Care for 1 (#2) of 2 (#1, and #2) patients wound care observed during home a visit. Findings: Review of Patient #2’s Clinical Record revealed he began receiving services with the Home Health Agency on 07/26/2024 and had a current Certification Period of 03/23/2025 through 05/21/2025. Patient #2 had a diagnosis of Pressure Ulcer of Sacral Region, Stage 3. Patient #2 was ordered to receive skilled nursing visits twice weekly for 5 weeks then once weekly for 1 week. Review of Patient #2’s current wound care orders dated 05/06/2025 revealed the following: Skilled Nurse to perform treatment to Pressure Ulcer to Sacrum 3 times weekly: Cleanse with wound cleanser and pat dry, apply an antiseptic to peri-wound, then apply medical-grade honey and Collagen to the wound bed, and cover and secure with dry dressing. A home visit was conducted with Patient #2 on 05/19/2025 at 12:46 p.m. with S4RN present. S4RN was observed providing wound care for Patient #2. S4RN removed the soiled dressing, cleansed wound bed with wound cleanser and gauze, and applied Collagen and a dry dressing. S4RN did not apply an antiseptic to the peri-wound or medical grade honey to the wound bed. An interview was conducted on 05/20/2025 at 10:00 a.m. with Patient #2’s wound care Nurse Practitioner (NP). He confirmed Patient #2’s current wound care order was to cleanse with wound cleanser and pat dry, apply an antiseptic to peri-wound, then apply medical-grade honey and Collagen to the wound bed, and cover and secure with dry dressing. He stated he expected the nurses to follow the current wound treatment orders. An interview was conducted on 05/20/2025 at 11:30 a.m. with S3DON. She reviewed Patient #2’s Clinical Record. She confirmed Patient #2’s current wound care order was to cleanse with wound cleanser and pat dry, apply an antiseptic to peri-wound, then apply medical-grade honey and Collagen to the wound bed, and cover and secure with a dry dressing. She was made aware of the observation of Patient #2’s wound care on 05/19/2025 and stated Patient #2’s wound care should have been completed as ordered.

Communication with physicians CFR(s): 484.75(b)(7) Communication with all physicians involved in the plan of care and other health care practitioners (as appropriate) related to the current plan of care; This ELEMENT is not met as evidenced by: Based on interviews and record review, the agency failed to ensure a patient’s physician was notified when physician ordered Home Health Aide services were refused for 1 (#7) of 4 (#2, #7, #11, and #13) patients reviewed with Home Health Aide services. Findings: Review of Patient #7’s Clinical Record revealed he began receiving services from the agency on 04/01/2025 and had a current Certification Period of 04/01/2025 through 05/30/2025. Further review revealed Patient #7 had diagnoses, which included Type 2 Diabetes Mellitus and Hemiplegia. Patient #7 was ordered to receive a Home Health Aide evaluation effective the week of 04/07/2025. Review of Patient #7’s Visit Notes and Coordination Notes for Certification Period of 04/01/2025 through 05/30/2025 revealed no documented evidence a Home Health Aide visit was conducted. Further review revealed no documentation Patient #7’s ordering physician was notified Patient #7 did not receive or refused Home Health Aide services. An interview was conducted with S7RN on 05/20/2025 at 3:14 p.m. She stated Patient #7 refused services from the Home Health Aide. She confirmed the refusal was not communicated with the physician and should have been. An interview was conducted with S3DON on 05/20/2025 at 2:25 p.m. She reviewed Patient #7’s clinical record. She confirmed Patient #7 had Home Health Aide services ordered effective the week of 04/07/2025. She stated Patient #7 notified S7RN he did not want the Home Health Aide services. She confirmed Patient #7’s physician was not notified of the refusal and should have been.

The entity is in compliance with the federal emergency preparedness requirements.

Recertification Survey

A review of all current medications CFR(s): 484.55(c)(5) A review of all medications the patient is currently using in order to identify any potential adverse effects and drug reactions, including ineffective drug therapy, significant side effects, significant drug interactions, duplicate drug therapy, and noncompliance with drug therapy. This ELEMENT is not met as evidenced by: Based on observation, interviews, and record review, the agency failed to ensure the medication profile accurately reflected all medications the patient was using for 1 (#3) of 4 (#1, #2, #3, and #4) patients reviewed who received home visits. Findings: Review of the policy titled, “Medication Information Policy” revealed the following, in part: Purpose: To ensure the Agency staff have access to and are knowledgeable of the effects, side effects, indications and contraindications of all the medications a patient is taking. Procedure: 5. Medication reconciliation is to occur with each skilled nurse visit. Review of the Clinical Record revealed Patient #3 had a start of care date of 04/28/2022 and diagnoses which included Chronic Obstructive Pulmonary Disease Exacerbation, Displaced Intertrochanteric Fracture Right Femur, Muscle Wasting and Atrophy, Type 2 Diabetes Mellitus, Atherosclerotic Heart Disease of Native Coronary Artery, Hypertensive Heart and Chronic Kidney Disease with Heart Failure; Chronic Kidney Disease – Stage 3, Gastro-Esophageal Reflux Disease, and History of Falling. Review of the Home Health Certification and Plan of Care for Patient #3 revealed the following, in part: Orders for Discipline and Treatment: Skilled Nurse Frequency: once a week for one week, twice a week for one week, and once weekly for four weeks. Skilled Nurse to perform medication review each skilled nursing visit and reconcile medications as indicated. A home visit was conducted with Patient #3 on 06/14/2022 at 10:15 a.m. Patient #3’s medications were reviewed with her husband. An interview was conducted with Patient #3’s husband at that time. Patient #3’s husband verified he prepared and administered her medications. He stated Patient #3 had not taken the following medications since 05/14/2022: Tramadol 50 mg, Lovenox 30 mg/0.3 mL, Lactulose 10 G/15 mL, and Hydrocodone – Acetaminophen 5 mg – 325 mg. He stated Patient #3 had been out of Methocarbamol 500 mg since 05/24/2022. He verified none of the above medications were available in Patient #3’s home. Patient #3 had the following medications available in her home, and her husband stated she was receiving them as described on the medication bottle (filled on: 05/09/2022) Lisinopril – Hydrochlorothiazide 12.5 – 20 mg by mouth daily and (filled on: 06/03/2022) Cephalexin 250 mg by mouth daily. An interview was conducted with S1DON on 06/14/2022 at 11:40 a.m. She verified the following medications were listed as active medications on Patient #3’s current Medication Profile: Tramadol 50 mg, Lovenox 30 mg/0.3 mL, Lactulose 10 G/15 mL, Hydrocodone – Acetaminophen 5 mg – 325 mg, and Methocarbamol 500 mg. S1DON confirmed Lisinopril –Hydrochlorothiazide 12.5 – 20 mg by mouth daily and Cephalexin 250 mg by mouth daily were not listed on Patient #3’s current Medication Profile. She stated Patient #3’s medications should have been reconciled with each nurse visit and if she was no longer taking a medication and/or it was not available, it should have been removed from Patient #3’s medication profile. She stated if Patient #3 was currently taking a medication, it should have been on the medication profile.

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 home health agency failed to ensure the patient's written Plan of Care was followed as evidenced by the following: Physical Therapy visits not conducted as ordered for 2 (#6 and #7) of 8 (#3, #4, #5, #6, #7, #8, #9, #10) sampled patient records reviewed with orders for Physical Therapy services. Home Health Aide visits not conducted as ordered for 1(#7) of 3(#3, #4, and #7) sampled patient records reviewed with orders for Home Health Aide services. Skilled Nurse visits not conducted as ordered for 1(#8) of 10(#1 - #10) sampled patient records reviewed with orders for Skilled Nurse services. Patient #6 Review of Patient #6's Home Health Certification and Plan of Care for Certification Period 05/21/2022 – 07/19/2022 revealed diagnoses that included Embolism and Thrombus of Proximal Lower Extremity and Unspecified Dementia without Behavioral Disturbance. Further review of the Plan of Care revealed Patient #6's orders of Discipline and Treatments included Physical Therapy 2 times a week for 3 weeks and 1 time a week for 1 week. Review of visit note reports for Certification Period 05/21/2022 – 07/19/2022 revealed no documented Physical Therapy visits the week of 05/23/2022. Patient #7 Review of Patient #7’s Home Health Certification and Plan of Care for Certification Period 05/18/2022- 07/16/2022 revealed diagnoses that included Essential Hypertension, Polyneuropathy, Unspecified Glaucoma, Chronic Pain Syndrome, and Hyperlipidemia. Further review of the Plan of Care revealed Patient #7's orders of Discipline and Treatments included Physical Therapy 1 time a week for 1 week and 2 times a week for 3 weeks and Home Health Aide 2 times a week for 8 weeks. Review of visit note reports for Certification Period 05/18/2022- 07/16/2022 revealed no documented Physical Therapy visits the week of 05/23/2022 and no documented Home Health Aide visits during the certification period. An interview was conducted on 06/14/2022 at 9:00 a.m. with S1DON. She verified Patient #6 and Patient #7 did not receive Physical Therapy visits the week of 05/23/2022 as ordered. She said the Physical Therapist that provided care to Patient #6 and Patient #7 was on vacation and there were no other therapists available. She said it was her responsibility to ensure Patient #6 and Patient #7 received Physical Therapy care as ordered by the physician. She said Patient #7 did not receive any Home Health Aide services because the agency did not have a Home Health Aide that was willing to go out to the rural area to provide Home Health Aide services to Patient #7. She said the weekly case conference team decided Patient #7 did not need Home Health Aide services. Patient #8 Review of Patient #8’s Home Health Certification and Plan of Care for Certification Period 12/19/2021- 02/16/2022 revealed diagnoses that included Acute Cystitis without Hematuria, Syncope and Collapse, Essential Hypertension, and Atrial Fibrillation. Further review of the Plan of Care revealed Patient #8's orders of Discipline and Treatments included Skilled Nurse visits 2 times a week for 1 week and 1 time a week for 3 weeks. Review of visit note reports for Certification Period 12/19/2021- 02/16/2022 revealed 1 missed Skilled Nurse visit the week of 12/20/2021 and 1 missed Skilled Nurse visit the week of 01/03/2022. An interview was conducted on 06/14/2022 at 9:20 a.m. with S1DON. She verified Patient #8 had a missed Skilled Nurse visits the weeks of 12/20/2021 and 01/03/2022. She said she was unsure why the Skilled Nurse did not provide these visits. She said it was her responsibility to ensure Patient #8 received the visits ordered by the physician.

Verbal orders CFR(s): 484.60(b)(3)(4) (3) Verbal orders must be accepted only by personnel authorized to do so by applicable state laws and regulations and by the HHA's internal policies. (4) When services are provided on the basis of a physician or allowed practitioner's verbal orders, a nurse acting in accordance with state licensure requirements, or other qualified practitioner responsible for furnishing or supervising the ordered services, in accordance with state law and the HHA's policies, must document the orders in the patient's clinical record, and sign, date, and time the orders. Verbal orders must be authenticated and dated by the physician or allowed pracitioner in accordance with applicable state laws and regulations, as well as the HHA's internal policies. This ELEMENT is not met as evidenced by: Based on interview and record reviews, the agency failed to ensure the Plan of Care was signed and dated by the patient's physician in a timely manner for 2 (#8 and #9) of 10 (#1- #10) sampled patients. Cross-referenced with State Regulations 9123. Patient Care Standards: C. Plan of Care. The plan of care for each patient must be individualized to address the patient's problems, goals, and required services. 1. The Plan of Care, telephone and/or verbal orders must be signed by the physician within a timely manner, not to exceed 30 days. Patient #8 Review of the Clinical Record for Patient # 8 revealed a start of care date of 12/19/2021. Review of the Plan of Care for the certification period 12/19/2021- 02/16/2022 for the patient revealed a principal diagnosis of Acute Cystitis without Hematuria. Further review of the Plan of Care revealed a physician signature dated 01/28/2022 which was greater than 30 days from the start of the certification period. Patient #9 Review of the Clinical Record for Patient # 9 revealed a start of care date of 04/08/2022. Review of the Plan of Care for the certification period 04/07/2022 – 06/05/2022 for the patient revealed a principal diagnosis of Chronic or Unspecified Gastric Ulcer with Hemorrhage. Further review of the Plan of Care revealed a physician signature dated 05/16/2022 which was greater than 30 days from the start of the certification period. An interview was conducted on 06/14/2022 at 10:00 a.m. with S1DON. After reviewing the Plan of Care for Patient #8 and Patient #9, she verified the Physician’s Orders were not signed within the required time frame of 30 days. She said she was responsible for ensuring the patient's Plan of Care was signed by the physician timely.