Every finding on record at Chi National Home Care, LLC

CHI Health At Home- Omaha is in compliance with the requirements of 42 CFR 484.102 Condition of Participation for Home Health Agencies.

5 calendar days after start of care CFR(s): 484.55(b)(1) The comprehensive assessment must be completed in a timely manner, consistent with the patient's immediate needs, but no later than 5 calendar days after the start of care. This ELEMENT is not met as evidenced by: Based on record review, policy and procedure review, and staff interview, the home health agency failed to complete a comprehensive assessment of the patient's physical therapy (PT) and/or occupational therapy (OT) needs no later than 5 days of the start of care (SOC) for 6 of 14 patients (Pt- 1, 3, 9, 10, 13, and 16) whose plan of care included orders for physical therapy (PT) and/or occupational therapy (OT) services. The total sample size was 17, the census was 318. A. Review of the agency policy and procedure titled, 33.43, Comprehensive Patient Assessment, last reviewed 4/15/2022, revealed: 1. A comprehensive assessment was to be completed in a timely manner, consistent with the patient's immediate needs, but no later than five calendar days after the start of care (SOC). 2. The assessment was to include other needed information that could impact the level of services required to meet the patient and family needs. B. Review of Patient 1's clinical record revealed: 1. Home Health Certification and Plan of Care (POC) for the certification period 12/17/24 through 2/14/25, included orders for Occupational Therapy (OT) to evaluate and treat. 2. The SOC was 12/17/24. 3. An OT evaluation visit was completed on 12/23/24 (6 calendar days after the SOC). 4. There was no documentation in the clinical record that the patient or the physician requested a delay in the OT comprehensive assessment beyond 5 calendar days after the SOC. C. Review of Patient 3's clinical record revealed: 1. Home Health Certification and Plan of Care for the certification period 12/19/24 through 2/16/25, included orders for Occupational Therapy (OT) to evaluate and treat. 2. The SOC was 12/19/24. 3. An OT evaluation visit was completed on 12/26/24 (7 calendar days after the SOC). 4. There was no documentation in the clinical record that the patient or the physician requested a delay in the OT comprehensive assessment beyond 5 calendar days after the SOC. D. Review of Patient 9's clinical record revealed: 1. Home Health Certification and Plan of Care for the certification period 12/10/24 through 2/7/25, included orders for Occupational Therapy (OT) to evaluate and treat. 2. The SOC was 12/10/24. 3. An OT evaluation visit was completed on 12/17/24 (7 calendar days after the SOC). 4. There was no documentation in the clinical record that the patient or the physician requested a delay in the OT comprehensive assessment beyond 5 calendar days after the SOC. E. Review of Patient 10's clinical record revealed: 1. Home Health Certification and Plan of Care for the certification period 12/18/24 through 2/15/25, included orders for Occupational Therapy (OT) to evaluate and treat. 2. The SOC was 12/18/24. 3. An OT evaluation visit was completed on 12/27/24 (9 calendar days after the SOC). 4. There was no documentation in the clinical record that the patient or the physician requested a delay in the OT comprehensive assessment beyond 5 calendar days after the SOC. F. Review of Patient 13's clinical record revealed: 1. Home Health Certification and Plan of Care for the certification period 9/24/24 through 11/22/24, included orders for Occupational Therapy (OT) to evaluate and treat. 2. The SOC was 9/24/24. 3. An OT evaluation visit was completed on 9/30/24 (6 calendar days after the SOC). 4. There was no documentation in the clinical record that the patient or the physician requested a delay in the OT comprehensive assessment beyond 5 calendar days after the SOC. G. Review of Patient 16's clinical record revealed: 1. Home Health Certification and Plan of Care for the certification period 12/27/24 through 2/24/25, included orders for Physical Therapy (PT) to evaluate and treat. 2. The SOC was 12/27/24. 3. An PT evaluation visit was completed on 1/3/25 (7 calendar days after the SOC). 4. There was no documentation in the clinical record that the patient or the physician requested a delay in the PT comprehensive assessment beyond 5 calendar days after the SOC. H. During an interview on 2/13/25 at 9:00 AM, the Administrator, Market Director of Operations, and the Manager of Clinical Services confirmed the comprehensive assessment of the patient's physical therapy (PT) and/or occupational therapy (OT) needs were not completed within 5 days of the SOC for Pt- 1, 3, 9, 10, 13, and 16.

Only as ordered by a physician CFR(s): 484.60(b)(1) Drugs, services, and treatments are administered only as ordered by a physician or allowed practitioner. This ELEMENT is not met as evidenced by: Based on record review, policy and procedure review, and staff interview, the agency failed to ensure treatments and services were completed as ordered on the plan of care (POC) for 2 of 17 clinical records reviewed (Pt 2 and Pt 7). The census was 318. A. Review of the agency policy and procedure titled, 33.24, Plan of Care and Physician and Allowed Practitioner Orders, last revised 3/5/24, revealed: 1. All care and services provided are according to current physician or allowed practitioners orders. 2. Clinicians are responsible for alerting the physician and if indicated, the allowed practitioner, to any changes in patient care or condition that suggest a need to alter the POC. B. Review of Patient 2's clinical record revealed: 1. The Home Health Certification and Plan of Care for the certification period of 10/26/24 through 12/24/24 Skilled Nurse (SN) 1 time a week for 1 week, then 2 times a week for 2 weeks, then 2 times every 3 weeks, then 2 times a week for 1 week, then 3 times a week for 2 weeks, then 1 times a week for 1 week, and 3 as needed (PRN) visits for wound care using a negative pressure wound therapy device (NPWT) (a device that utilized negative pressure through dressings and tubing to treat a wound). The physician order instructs the nurse to count and document the number of sponges removed from the wound. 2. The Home Health Certification and Plan of Care for the certification period of 12/25/24 through 2/22/25 included orders for SN 1 times a week for 1 week then 2 times a week for 2 weeks, then 3 times a week for 8 weeks, and 3 PRN visits for wound care using a negative pressure wound therapy device (NPWT) (a device that utilized negative pressure through dressings and tubing to treat a wound). The physician order instructs the nurse to count and document the number of sponges removed from the wound. 3. SN Visit Note Report revealed the SN completed NPWT dressing change with visits on 12/9/24, 12/11/24, 12/13/24, 12/16/24, 12/18/24, 12/20/24, 12/26/24, 12/30/24, 1/2/25, 1/10/25, 1/13/25, 1/15/25, 1/17/25, 1/21/25, 1/23/25, 1/27/25, 1/29/25, 1/31/25, 2/3/25, and 2/5/25. The SN did not document the number of sponges removed from the wound during the NPWT dressing changes. C. Review of Patient 7's clinical record revealed: 1. The Home Health Certification and Plan of Care for the certification period of 1/8/25 through 3/8/25 included orders for SN 1 time a week for 9 weeks and 3 PRN visits to observe and assess respiratory system and to identify changes and to intervene to minimize complications. 2. A Visit Note Report dated 1/29/25 revealed the SN identified and documented the following: a temperature of 100.3, a cough, to be weak and lethargic, had recent pulmonary tests done on 1/27/25, and the patient reported [gender] felt like [gender] had the flu. 3. There was no documentation in the clinical record that the physician was notified by the patient or the SN of the change to allow the physician to potentially provide new interventions for the patient. D. During an interview on 2/13/25 at 9:00 AM, the Administrator, the Market Director of Operations, and the Manager of Clinical Services confirmed, the SN providing cares failed to follow orders as written on the physician approved plan of care for Pt 2 and Pt 7.

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 record review, policy and procedure review, the observation of the provision of cares, and staff interview, 3 of 7 agency staff (Staff D, H, and I) failed to use proper hand hygiene, glove use, bag technique, and/or reusable equipment care during the provision of cares to 3 of 7 patients (Patient 1, 5, and 7) respectively. The total sample size was 17. The census was 318. A. Review of the agency policy and procedure titled, 33.900, Hand Hygiene, revised 8/10/22, revealed: 1. Staff are to perform hand hygiene using soap and water or alcohol based hand rub when entering and leaving the patient's home, before and after direct patient contact, when hands are visibly soiled, before entering/re-entering the clinician's bag, before handling patient's clean supplies, after contact with non-intact skin and wound dressings, when moving from contaminated body site to clean body site, between task procedures on the same patient to prevent cross-contamination of different body sites, and after removing gloves. 2. The use of gloves does not eliminate the need to perform hand hygiene. Gloves should be worn whenever there is anticipated contact with blood, body fluids, secretions, excretions, contaminated items, contact with mucous membranes, and non-intact skin. Gloves are to be changed between tasks and procedures on the same patient and when visibly soiled. B. Review of the agency policy and procedure titled, 33.83, Bag Technique, revised 5/7/24, revealed staff are to: 1. Perform hand hygiene prior to entering/re-entering the clinician's bag, before and after patient and/or equipment contact. 2. Remove necessary items for the visit and keep bag closed during the visit. 3. Reusable equipment (for example- stethoscope, blood pressure cuffs, tablets, thermometers) was to be cleaned with alcohol or cleansing agent, or disinfectant wipe after use and prior to returning items to the clinician's bag. 4. This policy does not include steps to ensure equipment was cleaned between contaminated tasks and clean tasks such as cleaning scissors used for cutting soiled dressing and prior to cutting clean/sterile dressing. C. Review of the agency policy and procedure titled, Focus on Care, Home Care and Hospice, Wound Cleansing and Dressing, no date indicated, revealed staff are to: 1. Consider wounds with separate dressing as a separate wound and must be for independently. 2. Perform hand hygiene and glove changes between the care of each individual wound. 3. This policy does not include steps to ensure equipment is cleaned between contaminated tasks and clean tasks such as cleaning scissors used for cutting soiled dressing and prior to cutting clean/sterile dressing on the same patient. D. Review of clinical records revealed: 1. Patient 1's Home Health Certification and Plan of Care for the certification period of 12/17/24 through 2/14/25 included orders for Skilled Nurse (SN) 2 times a week for 9 weeks and 3 as needed (PRN) visits for central venous catheter (a thin tube inserted in a vein near the heart and is used for administering medications, fluids, blood products, or drawing blood samples), lab draws, and wound care to wounds on the left and right lower extremities. 2. Patient 5's Home Health Certification and Plan of Care for the certification period of 1/17/25 through 3/17/25 included orders for SN 1 time a week for 5 weeks, then 3 times a week for 1 week, and then 1 time a week for 3 weeks for evaluate and assess any condition that presents itself and will impact the plan of care. 3. Patient 7's Home Health Certification and Plan of Care for the certification period of 1/8/25 through 3/8/25 included orders for Occupational Therapy (OT) 1 time a week for 2 weeks, then 1 time every 2 weeks for 6 weeks to assess, evaluate, and train the patient in functional activities. E. Observation of wound care provided to Patient 1, on 2/4/25 at 2:30 PM, revealed Staff D failed to: 1. Sanitize hands after cleansing the patients right foot wound and prior to prepping and applying clean dressing to the same wound. 2. Sanitize hands and change gloves after cleansing a wound on the patient’s right foot and prior to providing wound care to the left foot ulcer. 3. Sanitize the scissors between use to cut soiled dressing from wounds and prior to cutting clean dressing on 2 occasions during wound cares. F. Observation of the provision of nursing assessment to Patient 5, on 2/5/25 at 3:00 PM, revealed Staff H failed to: 1. Remove gloves and sanitize hands after contact skin with patient and prior to entering the clinician's bag to obtain [gender] phone. 2. Sanitize phone after use as a flashlight during the patient assessment and prior to returning the phone back to the clinician's bag. 3. Sanitize the tablet (electronic device used for documentation) after use by the patient and prior to returning the tablet to the clinician's bag. G. Observation of the provision of assessment to Patient 7, on 2/11/25 at 11:00 AM, revealed Staff I failed to sanitize the electronic tablet after use by the patient and prior to leaving the patient's home. H. During an interview on 2/13/25 at 9:00 AM, the Administrator, the Market Director of Operations, and the Manager of Clinical Services confirmed Staff D, H, and I, failed to use proper hand hygiene, glove use, bag technique, and/or reusable equipment care during the provision of cares to Patient 1, 5, and 7 respectively.

CHI- Health At Home-Omaha is in compliance with the requirements of 42 CFR 484.102 Condition of Participation for Home Health Agencies.

An unannounced recertification survey and complaint investigation were completed on 3/29/22. The allegations were substantiated and deficiencies were cited related to the allegations at G578 and G590. The agency census was 172.

Participate in care CFR(s): 484.50(c)(4)(i,ii,iii,iv,v,vi,vii,viii) Participate in, be informed about, and consent or refuse care in advance of and during treatment, where appropriate, with respect to-- (i) Completion of all assessments; (ii) The care to be furnished, based on the comprehensive assessment; (iii) Establishing and revising the plan of care; (iv) The disciplines that will furnish the care; (v) The frequency of visits; (vi) Expected outcomes of care, including patient-identified goals, and anticipated risks and benefits; (vii) Any factors that could impact treatment effectiveness; and (viii) Any changes in the care to be furnished. This ELEMENT is not met as evidenced by: Based on record review, policy and procedure review, grievance file review, and staff interview, the agency failed to notify the patient/patient representative in advance of a reduction in the frequency of services provided for 1 of 17 patient records reviewed (Pt-7). The census was 172. A. Review of the agency policy and procedure titled Advanced Beneficiary Notice and Home Health Change of Care Notice, Number 33.115, revised 8/30/17, revealed the appropriate Advanced Beneficiary Notice (ABN) or Home Health Change of Care Notice (HHCCN) is to be provided when the agency believes services or supplies will not be covered by Medicare, will be reduced, or will be terminated. The policy also revealed the forms are to be provided far enough in advance so the beneficiary may pursue alternatives to continue receiving the care. B. Review of the clinical record for Patient-7 revealed: 1. The patient‘s start of care date was 8/30/21. 2. An Explanation of Service Coverage (a form provided during the initial assessment that explains the services to be provided, the frequency of the services, and the expected patient cost for services) indicated the plan was for the patient to receive home health aide services (HHA) 3 times per week. It was signed by the patient’s spouse on 8/30/21. 3. A Client Coordination Note Report dated 8/30/21 (used to relay information to team members) indicated the family participated and understands the patient’s plan of care. The note also indicated the plan was for HHA services 3 times per week. 4. A Visit Note Report dated 8/30/21 for the initial comprehensive assessment revealed the plan was for HHA services 3 times per week. 5. The Home Health Certification and Plan of Care dated 8/30/21 included orders for HHA services 2 times per week. 6. There was no documentation in the clinical record the patient or patient representative was notified in advance of the decrease in services from the planned 3 times a week to 2 times per week. 7. An Explanation of Service Coverage signed by the patient’s spouse on 10/26/21 agreeing to HHA services 2 times per week. C. Review of the agency complaint log/grievance file revealed a complaint filed by the patient’s spouse on 9/23/21 of the reduction of HHA services without notice. D. During an interview on 3/24/22 at 1:15 PM the Director of Clinical Services (DCS) confirmed the agency did not provide the patient/patient representative an advance notice of the reduction of HHA services prior to the change.

Update of the comprehensive assessment CFR(s): 484.55(d) Standard: Update of the comprehensive assessment. The comprehensive assessment must be updated and revised (including the administration of the OASIS) as frequently as the patient's condition warrants due to a major decline or improvement in the patient's health status, but not less frequently than- This STANDARD is not met as evidenced by: Based on record review, policy and procedure review, and staff interview, the agency failed to complete a comprehensive assessment for 1 of 17 patient records reviewed (Patient-7) who had a change of condition. The census was 172. A. Review of the policy and procedure titled, Comprehensive Patient Assessment, number 33.43, 2/4/20, revealed the agency was to complete a comprehensive patient assessment on start of care, resumption of care, following an inpatient stay, and every 60 days. The policy does not include the regulatory requirement to update and revise the comprehensive assessment as frequently as the patient’s condition warrants due to a major decline or improvement the patient’s health status. Is used to develop the patient’s plan of care. B. Review of the clinical record for Patient-7 revealed: 1. The patient’s start of care date was 8/30/21. 2. A Client Coordination Note Report dated 8/30/21 (used to relay information to team members), revealed the patient was admitted with an indwelling catheter (a catheter which is inserted into the bladder, through the urethra and remains in place to drain urine). 3. A Client Coordination Note dated 1/18/22, revealed the patient’s spouse called to report the patient had a suprapubic catheter (a tube inserted into your bladder through a small hole in your belly to drain urine) two weeks ago and the patient was scheduled to have a mastectomy on 1/27/22. 4. A Home Health Aide visit was conducted on 1/30/22. 5. There was no documentation in the clinical record of an updated comprehensive assessment until 2/21/22. C. During an interview on 3/24/22 at 1:15 PM, the Director of Clinical Services confirmed a comprehensive assessment was not completed after the agency was notified of the changes in the patient health status and until 2/21/22.

Conformance with physician orders CFR(s): 484.60(b) Standard: Conformance with physician or allowed practitioner orders. This STANDARD is not met as evidenced by: Based on record review, policy and procedure review, review of the agency's investigative notes, and staff interview, the agency failed to ensure staff followed the patients’ physician-approved plan of care for 1 of 17 patient records reviewed (Patient- 15). The census was 172. A. Review of the agency policy and procedure titled, Plan of Care and Physicians Orders, number 33.24, revised 3/8/21, revealed all care and services are to be provided according to the current physicians orders and clinicians are responsible for alerting the physician to any changes in patient care or condition that suggests a need to alter the plan of care. B. Review of the agency policy and procedure titled, Nursing Services, number 33.08, revised 8/7/20, revealed duties of the registered nurse are to follow a written plan of care, initiate appropriate preventative and rehabilitative nursing procedures. C. Review of Patient 15’s clinical record revealed: 1. The Home Health Certification and Plan of Care for the certification period of 9/19/21 through 11/17/21 included an order for the skilled nurse (SN) to assess/evaluate any conditions that present themselves and that will impact the plan of care to identify changes and intervene to minimize complications. 2. SN visit notes for 11/12/21 and 11/15/21 revealed the patient’s suprapubic catheter was not draining properly and was leaking urine outside of the tubing. The patient reported skin breakdown during the 11/15/21 visit. The nurse documented no skin breakdown observed. 3. Hospital visit record from infectious disease and wound consults revealed the patient presented to the emergency room on 11/16/21 with wounds present to the right hip, perirectal area and left ischium (the bone at the lower part of the pelvis; the sitter bone). D. Review of the agency's investigative note revealed an email from the Manager of Clinical Services to the Administrator, dated 11/19/21 documenting an interview with registered nurse (RN)-R who conducted the 11/12/21 and 11/15/21 skilled nurse visits. The email documentation revealed RN-R failed to look at the patient’s skin under the clothing during the visits leading to the failure to identify the presence of wounds. E. During an interview on 3/24/22 at 1:15 PM the Director of Clinical Services confirmed the agency nurse failed to assess the patients according to agency policies and procedures, failed to identify changes in the patients skin condition due to failure to complete a skin assessment, and failed to notify the physician of the change in skin condition due to the failure to complete a skin assessment. This failure resulted in the failure to follow the plan of care order to assess/evaluate any conditions that present themselves and that will impact the plan of care to identify changes and intervene to minimize complications.

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 record review, policy and procedure review, review of the agency's investigative notes, and staff interview, the agency failed to update the physician of a change in condition for 1 of 17 patient records reviewed (Patient-15). The census was 172. A. Review of the agency policy and procedure titled, Nursing Services, number 33.08, revised 8/7/20, revealed the nurse was to promptly alert the physician to any changes that suggest a need to alter the plan of care. B. Review of Patient-15’s clinical record revealed: 1. The Home Health Certification and Plan of Care for the certification period of 9/19/21 through 11/17/21 included an order for the skilled nurse (SN) to assess/evaluate any conditions that present themselves and that will impact the plan of care to identify changes and intervene to minimize complications. 2. SN visit notes for 11/12/21 and 11/15/21 revealed the patient’s suprapubic catheter was not draining properly and was leaking urine outside of the tubing. The patient reported skin breakdown during the 11/15/21 visit. The nurse documented no skin breakdown observed. 3. SN note on 11/15/21 revealed the nurse left a message for the physician’s office. There was no documentation in the clinical record that the physician’s office returned the message or received notification of the patient’s catheter continuing to leak or the skin breakdown reported by the patient. 4. Hospital visit record from infectious disease and wound consults revealed the patient presented to the emergency room on 11/16/21 with wounds present to the right hip, perirectal area and left ischium (the bone at the lower part of the pelvis; the sitter bone). C. Review of the agency's investigative notes revealed an email from the Manager of Clinical Services to the Administrator, dated 11/19/21 documenting an interview with Registered Nurse (RN)-R who conducted the 11/12/21 and 11/15/21 skilled nurse visits. The email documentation revealed RN-R failed to look at the patient’s skin under the clothing during the visits leading to the failure to identify the presence of wounds. D. During an interview on 3/24/22 at 1:15 PM the Director of Clinical Services (DCS) confirmed RN-C did not ensure the physician was updated regarding the continued leaking of the suprapubic catheter and the skin breakdown reported by the patient to enable the physician to make potential changes to the plan of care.

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 record review, policy and procedure review, and staff interview, the agency failed to include the progress towards the patient and agency identified measurable outcomes and goals on the plan of care for 6 of 6 patient records reviewed who had a revised/updated plan of care (Patient- 5, 6, 7, 9, 10, and 15). The total sample size was 17. The census was 172. A. Review of the agency policy and procedure titled, Plan of Care And Physician Orders, number 33.24, revised 3/8/21, revealed the policy lists items required on the plan of care but does not include the regulatory requirement to include the patient’s progress towards the patient and agency identified measurable outcomes and goals on the plan of care. B. Review of clinical records revealed: 1. Patient-5’s revised/updated Home Health Certification and Plan of Care for the certification periods of 12/11/21 through 2/8/22 and 2/9/22 through 4/9/22 did not included the progress towards the patient and agency identified measurable outcomes and goals. 2. Patient-6’s revised/updated Home Health Certification and Plan of Care for the certification period of 1/31/22 through 3/31/22 did not included the progress towards the patient and agency identified measurable outcomes and goals. 3. Patient-7’s revised/updated Home Health Certification and Plan of Care for the certification periods of 10/29/21 through 12/27/22 and 12/28/21 through 2/25/22 and 2/26/22 through 4/26/22 did not included the progress towards the patient and agency identified measurable outcomes and goals. 4. Patient-9’s revised/updated Home Health Certification and Plan of Care for the certification period of 3/15/22 through 5/13/22 did not included the progress towards the patient and agency identified measurable outcomes and goals. 5. Patient-10’s revised/updated Home Health Certification and Plan of Care for the certification periods of 12/2/21 through 1/30/22 and 1/31/22 through 3/31/22 did not included the progress towards the patient and agency identified measurable outcomes and goals. 6. Patient-15’s revised/updated Home Health Certification and Plan of Care for the certification periods of 7/18/21 through 9/18/21 and 9/19/21 through 11/17/21 did not included the progress towards the patient and agency identified measurable outcomes and goals. C. During an interview on 3/24/22 at 1:15 PM the Director of Clinical Services (DCS) confirmed the agency did not include the patient’s progress towards the patient and agency identified measureable outcomes and goals on the patient plan of care to ensure the physician is aware of the patient’s progress with the services ordered.

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 record review, policy and procedure review, agency’s investigative note review, and staff interview, the agency failed to ensure all staff follow the policy and procedure when documenting in the clinical notes for 1 of 17 patient records reviewed (Patient-15). The census was 172. A. Review of the agency policy and procedure titled, Documentation in the Clinical Record, number 33.21, revised 12/28/16, revealed all who participate in patient care, treatment and services are responsible for documentation in accordance with generally accepted professional standards of documentation. B. Review of Patient-15’s clinical record revealed: 1. A Visit Note Report dated 11/15/21 by registered nurse (RN)-R. RN-R documented the skin was assessed and no skin issues were identified. 2. Hospital visit record from infectious disease and wound consults revealed the patient presented to the emergency room on 11/16/21 with wounds present to the right hip, perirectal area and left ischium (the bone at the lower part of the pelvis; the sitter bone). C. Review of the agency investigative note revealed an email from the Manager of Clinical Services to the Administrator, dated 11/19/21 documenting an interview with RN-R who conducted the 11/15/21 skilled nurse visit. The email documentation revealed RN-R confirmed [gender] failed to look at the patient’s skin under the clothing during the visit on 11/15/21. D. During an interview on 3/24/22 at 1:15 PM the Director of Clinical Services confirmed RN-R provided inaccurate documentation in Patient-15 clinical visit note. This was also confirmed by the Administrator during an interview on 3/29/22 at 9:00 AM.

Home health aide assignments and duties CFR(s): 484.80(g)(1) Standard: Home health aide assignments and duties. Home health aides are assigned to a specific patient by a registered nurse or other appropriate skilled professional, with written patient care instructions for a home health aide prepared by that registered nurse or other appropriate skilled professional (that is, physical therapist, speech-language pathologist, or occupational therapist). This STANDARD is not met as evidenced by: Based on record review, the observation of the provision of cares, policy and procedure review, and staff interview, the agency failed to ensure the supervising registered nurse (RN) updated the home health aide care plan with written, clear, complete and individualized patient care instruction when changes in patient’s health status occurred for 1 of 2 patient records reviewed who receive home health aide services (HHA) (Patient-7). The total sample size was 17. The census was 172. A. Review of the agency policy and procedure titled, Home Health Aide and Homemaker Plan of Care, number 33.37, revised 6/29/17, revealed the plan of care was to be updated by a qualified clinician as needed, with significant changes in patient condition. B. Review of the clinical record for Patient-7 revealed: 1. The Home Health Certification and Plan of Care for the certification period of 12/28/21 through 2/25/21 included orders for HHA services 2 times a week for assistance with personal care, hygiene, and activities of daily living. It also revealed the patient had an indwelling catheter (a catheter which is inserted into the bladder, through the urethra and remains in place to drain urine). 2. An Aide Care Plan Report dated 12/28/21 through 2/25/22 with patient care instructions. The plan of care included the task of catheter care but did not specify what type of care was present or any specific catheter related precautions that needed to be taken during cares. 3. A Client Coordination Note dated 1/18/22, revealed the patient’s spouse called to report the patient had a suprapubic catheter (a tube inserted into your bladder through a small hole in your belly to drain urine) two weeks ago and the patient was scheduled to have a mastectomy on 1/27/22. 4. There was no evidence the Aide Care Plan was revised to include changes related to the new suprapubic catheter or the mastectomy incision. 5. An Aide Care Plan report dated effective 3/23/22 for the certification period of 2/26/22 through 4/26/22, included the same catheter care task. This updated care plan did not include changes related to the new suprapubic catheter or the precautions needed to be taken related to the new mastectomy incision. C. During the observation of the provision of cares to Patient-7 by the HHA on 3/23/22 at 10:30 AM, the HHA was observed to provide a shower to the patient. The patient was observed to have a suprapubic catheter in place and a healed mastectomy incision of the right chest area. D. During an interview on 3/24/22 at 1:15 PM, the Director of Clinical Services (DCS) confirmed the HHA plan of care had not been updated to include changes related to the new suprapubic catheter or the precautions needed to be taken related to the new mastectomy incision.