Every finding on record at Citizens Memorial Home Health and Hospice

The Emergency Preparedness regulations were reviewed as part of the Medicare recertification survey completed on 11/01/2023. 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.

A partial extended survey for Medicare recertification for the home health provider was completed on 11/01/2023. The provider had 181 current patients.

Written notice within 4 business days CFR(s): 484.50(a)(4) Provide written notice of the patient's rights and responsibilities under this rule and the HHA's transfer and discharge policies as set forth in paragraph (d) of this section to a patient-selected representative within 4 business days of the initial evaluation visit. This ELEMENT is not met as evidenced by: Based on review of the home health provider's patient rights information and interview, the home health provider failed to ensure the patient rights information included the verbiage that the provider would provide written notice of the patient's rights and responsibilities and the provider's transfer and discharge policies to a patient-selected representative within 4 business days of the initial evaluation visit. This deficient practice has the potential to affect all patients served by the provider. Review of the provider's patient rights information failed to include that they would provide written notice of the patient's rights and responsibilities and the provider's transfer and discharge policies to a patient-selected representative within 4 business days of the initial evaluation visit. During an interview on 10/31/2023 at 2:35 PM, the clinical manager stated that he/she did not see this verbiage in the patient rights information.

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 maintain an updated medication profile in, but not limited to, two of five full records reviewed (Records/Patients #1 and #3). This deficient practice has the potential to affect all patients served by the provider. Review of the patient's record showed in part that the patient was admitted to home health care on 06/24/2023. Diagnoses included right lower extremity (RLE) abrasion-infected, diabetic charcot (condition that affects the bones, joints, and soft tissue in the feet and ankles) foot, staph infection (bacteria infection commonly found on the skin), obstructive sleep apnea (OSA) (person frequently stops breathing during sleep), hypothyroid (thyroid gland doesn’t make enough thyroid hormones), atrial fibrillation (Afib) (abnormal heart rhythm), and left lower extremity (LLE) cellulitis (deep infection of the skin caused by bacteria). The patient received skilled nursing (SN) services. Observation and interview on 10/31/2023, beginning at 10:05 AM, during the patient’s home visit showed the following discrepancies: - The SN asked the patient about medication changes and the patient stated no changes; - The patient was taking Breo Ellipta (asthma combination treatment) 100-25 micrograms (mcg)/dose one inhalation two to three times per a week due to the cost of the medication. The hospice providers Medication Profile printed on 10/30/2023 showed one inhalation daily; - The patient had not been taking Plavix (antiplatelet to prevent blood clots) for about three months. The hospice providers Medication Profile printed on 10/30/2023 showed Plavix 75 milligrams (mg) one tablet daily; - The patient was taking potassium chloride (supplement to treat low levels of potassium) 10 milliequivalents (mEq) extended release (ER) four capsules twice a day (BID). The hospice providers Medication Profile printed on 10/30/2023 showed three capsules BID. Total of 6 capsules daily; - The patient was using Refresh tears 0.5 percent ophthalmic (eye) drops (gtts) three to four gtts daily in each eye. The hospice providers Medication Profile printed on 10/30/2023 showed one gtt each eye daily; - The patient was taking bumetanide (diuretic) 1 mg four tablets BID. The hospice providers Medication Profile printed on 10/30/2023 showed three tablets BID. Total of 6 mg daily; - The patient was not using sulfacetamide (antibiotic) sodium 10 percent ophthalmic gtts, he/she had been out for a month or longer. The hospice providers Medication Profile printed on 10/30/2023 showed one gtt to each eye daily. Findings included: Review of the provider’s policy titled, “Patient Medication Schedule Worksheet/Medication Reconciliation,” approved 10/2023, showed in part: - Upon admission to home care services, a medication list is completed; - If discrepancies are identified between the medications found in the home and the medication list received from the discharging inpatient facility or physician, the physician will be notified to reconcile medications. Medications will be reconciled within the first 24 hours of the patient being admitted to home health; - When the nurse determines that a patient needs a written schedule of his/her medications so that he/she can take their medications correctly, the nurse will prepare the medication schedule worksheet and give the original to the patient at the time of completion; - When changes with medications occur, the nurse will complete a new medication schedule worksheet for the patient and dispose of the old worksheet to avoid patient confusion about his/her medication schedule; - If skilled nursing services have been discontinued and the patient is only receiving therapy services, the following approach will be used to reconcile new medications found in the home; - Therapist will notify home health nurse or designee of the medication change if the medication change was the result of a physician appointment and was a change in current medication. If the medication was a new medication and the patient gave the medication bottle to the therapist, the therapist will enter the medication and the prescription number in the medication list; - Home health nurse or designee will call physician and obtain order for medication if needed; and - Medication order will be entered into the computer system. RECORD/PATIENT #3: Review of the patient's record showed in part that the patient was admitted to home health care on 10/16/2023. Diagnoses included atrial fibrillation (abnormal heart rhythm), high blood pressure, and benign prostatic hyperplasia (enlarged prostate), and urinary retention. The patient received skilled nursing (SN) and physical therapy (PT) services. Observation and interview on 10/30/2023, beginning at 2:20 PM, during the patient’s home visit showed: - The PT failed to review/ask the patient about medication changes; - The surveyor requested to review the patient’s medications; and - The patient had a bottle dated 10/19/2023, of benzonatate (used to treat cough) 200 milligrams (mg) one capsule three times a day as needed. This was not included on the patient’s current medication profile. The patient's spouse stated that the patient last took this medication three or four days ago. Review of the patient’s medication profile dated 10/31/2023, failed to show this medication had been added to the profile. During an interview on 10/31/2023, at 9:18 AM, the assistant director of home care stated that the therapists should ask if the patients have had any medication changes. If any teaching needed to be done, they would send a nurse to do the teaching. During an interview on 10/31/2023, at 3:15 PM, the director of home care stated that their process for medication reconciliation included for the nurse on admission to review the discharge medication list with the patient’s medication bottles. If there were discrepancies, they would call the physician. The staff should ask about medication changes at every visit and perform a medication reconciliation at least weekly. The therapists would ask about medication changes, then call the nurse if there were changes. If the patient has the bottle, they can take the prescription number off of that and enter it into their computer system.

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 that the physician was notified of changes in one of five full records reviewed (Record/Patient #5). This deficient practice has the potential to affect all patients served by the provider. Findings included: Review of the provider's policy titled, "Responsibilities of Physician and Home Health/Hospice," revised 09/2023, showed in part: - "Changes in the patient's condition will be called to the physician/provider; and - The physician/provider will be contacted when changes occur in the patient's expected response to treatment or medications, or changes in the caregiver support or the environment." RECORD/PATIENT #5: Review of the clinical record showed: - The patient was admitted to home health services on 09/07/2023 with a diagnosis of Type II Diabetes (a group of diseases that results in too much sugar in the blood) with the use of insulin; - The referring provider ordered that blood sugars be monitored; - Review of the admission assessment, dated 09/07/2023, showed that the patient's caregiver checked the blood sugar multiple times per day and that the caregiver was educated on the home health provider's parameters to report blood sugars (70 to 250); - Review of the skilled nurse (SN) note, dated 09/12/2023, showed that the registered nurse (RN) documented a blood sugar of 271 and failed to notify the physician; - Review of the SN note, dated 09/19/2023, showed that on 09/18/2023 at 7:00 PM the caregiver reported a blood sugar of 301 after dinner and on 09/19/2023 at 8:00 AM the caregiver reported a blood sugar of 68 before breakfast and the RN failed to notify the physician; - Review of the SN discharge summary, dated 09/26/2023, showed that the patient's blood sugar was 270 and the RN failed to notify the physician; and - Review of a physical therapy (PT) reassessment visit, dated 10/04/2023, showed that the patient's caregiver checked the patient's blood sugar at the end of the treatment session and the blood sugar was 366 and the PT failed to notify the physician or a nurse. During an interview on 11/01/2023 beginning at 10:45 AM, the clinical manager stated that he/she would expect that blood sugars outside of the provider's parameters to be reported to the physician and that there was no documentation to show that the blood sugars on 09/12/2023, 09/19/2023, 09/26/2023, and 10/04/2023 were reported.

Patient medication schedule/instructions CFR(s): 484.60(e)(2) Patient medication schedule/instructions, including: medication name, dosage and frequency and which medications will be administered by HHA personnel and personnel acting on behalf of the HHA. This ELEMENT is not met as evidenced by: Based on policy review, observation, and interview the home health provider failed to ensure all patients received a written medication schedule in two of three home visits conducted (Records/Patients #1 and #3). This deficient practice has the potential to affect all patients served by the provider. RECORD/PATIENT #1: Observation and interview on 10/31/2023, beginning at 10:05 AM, during the patient’s home visit, the patient’s admission folder was reviewed. The admission folder failed to include a medication list for the patient. Registered nurse (RN) A stated there was no medication list in the patient’s folder. Findings included: Review of the home health provider’s policy titled, “Patient Medication Schedule Worksheet/Medication Reconciliation,” approved 10/2023, showed in part: - Patient medication schedule worksheets will be used as needed per individual patient as a teaching tool to provide the patient with a clear and concise written schedule about his/her medications so that the patient will know the name of, times to take, amount to take, purpose of, and special instructions for a medication; - The purpose is to assure optimal medication compliance and benefits for the patient; and - When changes with medications occur, the nurse will complete a new medication schedule worksheet for the patient. RECORD/PATIENT #3: Observation and interview on 10/30/2023, beginning at 2:20 PM, during the patient’s home visit, the patient’s admission folder was reviewed. The admission folder failed to include a medication list for the patient. The patient’s spouse stated that the only medication list he/she had was from the nursing home. During an interview on 10/31/2023, at 3:15 PM, the director of home care stated that staff should provide a medication schedule for the patients.

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 that wound measurements were completed in one of two discharged records (Record/Patient #6). This deficient practice has the potential to affect all patients served by the provider. Findings included: Review of the provider's policy titled, "Pressure Ulcer/Wound Assessment and Treatment," revised 10/2023, showed that the policy failed to state a timeframe for measurements of wounds in the home health setting. RECORD/PATIENT #6: Review of the clinical record showed the following: - The patient was admitted on 09/13/2023 for wound care to the left heel and the admission assessment contained measurements for the patient's wound; - Review of the routine nursing assessment dated 09/22/2023, showed that a dressing change was completed and contained measurements for the patient's wound; and - Review of the routine nursing assessments dated 09/28/2023, 10/02/2023, and 10/06/2023 showed that dressing changes were completed and failed to contain measurements for the patient's wound (the wound was not measured for two weeks). During an interview on 11/01/2023 beginning at 10:45 AM, the clinical manager stated that the expectation was that wound measurements would be done with dressing changes and he/she would expect wound measurements to be done weekly, but it is not in the policy that way.

Discharge and transfer summaries CFR(s): 484.110(a)(6)(i-iii) (i) A completed discharge summary that is sent to the primary care practitioner or other health care professional who will be responsible for providing care and services to the patient after discharge from the HHA (if any) within 5 business days of the patient's discharge; or (ii) A completed transfer summary that is sent within 2 business days of a planned transfer, if the patient's care will be immediately continued in a health care facility; or (iii) A completed transfer summary that is sent within 2 business days of becoming aware of an unplanned transfer, if the patient is still receiving care in a health care facility at the time when the HHA becomes aware of the transfer. This ELEMENT is not met as evidenced by: Based on policy review, record review, and interview the home health provider failed to complete a discharge summary for one of two discharge records reviewed (Record/Patient #6). This deficient practice has the potential to affect all patient's served by the provider. Findings included: Review of the provider's policy titled, "Medical Records," revised 10/2023, showed, in part: - "A discharge summary is prepared when a patient is discharged; - The discharge summary report will include: date of discharge, length of time patient was on service, summary of services rendered, condition upon discharge, reason for discharge, and disposition after discharge; and - Upon discharge from the agency, the last discipline in the home will have 5 business days to complete a discharge summary." RECORD/PATIENT #6: Review of the clinical record showed that the patient was discharged from the provider on 10/19/2023 and that a discharge summary was not completed. During an interview on 10/31/2023 at 1:50 PM, the assistant clinical manager stated that a discharge summary was not completed for the patient and that he/she would expect that one should have been completed.

Authentication CFR(s): 484.110(b) Standard: Authentication. All entries must be legible, clear, complete, and appropriately authenticated, dated, and timed. Authentication must include a signature and a title (occupation), or a secured computer entry by a unique identifier, of a primary author who has reviewed and approved the entry. 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 documentation in the clinical record was submitted in a timely manner in, but not limited to, two of six records reviewed (Records/Patients #5 and #6). This deficient practice has the potential to affect all patients served by the provider. Findings included: Review of the provider's policy titled, "Medical Records," revised 10/2023, showed in part: - "The clinical record will contain clinical notes from a discipline seeing the patient, which are detailed, accurate, and reflects the care or services provided as well as changes in the patient's condition; - These notes are generated in the medical record by home care services (HCS) clinician with first initial, surname, and title; and - These clinical notes are forwarded, exported, or received to the HCS business office within two working days." RECORD/PATIENT #5: Review of the clinical record showed that: - The skilled nurse (SN) admission note dated 09/07/2023 was signed as complete on 09/16/2023 (nine days later); - The SN discharge note dated 09/26/2023 was signed as complete on 10/01/2023 (five days later); - The physical therapy (PT) admission note dated 09/08/2023 was signed as complete on 09/12/2023 (four days later); - The certified occupational therapy assistant (COTA) note dated 09/18/2023 was signed as complete on 09/26/2023 (eight days later); - The PT routine visit note dated 09/20/2023 was signed as complete on 09/24/2023 (four days later); - The PT routine visit note dated 09/22/2023 was signed as complete on 09/25/2023 (three days later); - The PT reassessment visit dated 10/04/2023 was signed as complete on 10/11/2023 (seven days later); and - The PT routine visit note dated 10/13/2023 was signed as complete on 10/17/2023 (four days later). RECORD/PATIENT #6: Review of the clinical record showed that: - The SN routine visit dated 10/06/2023 was signed as complete on 10/09/2023 (three days late); - The SN routine visit dated 10/13/2023 was signed as complete on 10/16/2023 (three days late); and - The OASIS (Outcome and Assessment Information Set; a standardized data collection tool) discharge visit dated 10/13/2023 was signed as complete on 10/30/2023 (seventeen days late). During an interview on 11/01/2023 beginning at 10:45 AM, the clinical manager stated that he/she expected documentation to be completed in 48 hours according to the provider's policy.

The Emergency Preparedness regulations were reviewed as part of the Medicare certification survey completed on 01/27/21. During the survey it was determined Citizens Memorial Home Health is in compliance with the requirements of 42 CFR 484.102 Condition of Participation: Emergency Preparedness for Home Health Agencies.

A partial extended survey for Medicare certification for Citizens Memorial Home Health was completed on 01/27/21. The agency had 169 current patients. A COVID-19 Focused Infection Control survey was completed in conjunction with the survey and no deficiencies were identified related to the Focused Infection Control 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 policy review, home visit observation, and interview, the agency failed to review all medications the patient was 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 in three (Records/Patients #2, #1, and #3 listed in order of significance) of three home visit observations. This deficient practice has the potential to affect the medication management of all patients served by the agency. Findings included: Review of the agency policy dated 08/2020 and titled, "Patient Medication Schedule Worksheet/Medication Reconciliation," showed: - The purpose of the policy was to assure optimal medication compliance and benefits for the patient. to be an instructional tool for the nurse to use during the patient teaching. To facilitate early detection of possible non-compliance or side effects and reports to the physician of such. To provide a clear and concise written medication schedule for the patient to use for reference between skilled nurse visits to reinforce teaching; - The completed medication schedule worksheet shall include the medication name and dosage and the times of the day that a medication is to be taken; and - When changes with medications occur, the nurse will complete a new medication schedule worksheet for the patient and dispose of the old worksheet to avoid patient confusion about his/her medication. RECORD/PATIENT #2: Review of the clinical record showed the patient was admitted to home health services on 12/01/2020 for the primary diagnosis of care of a burn on the right buttock from a heating pad used to treat right hip pain, and secondary diagnoses of hypertensive heart disease with heart failure (Hypertensive heart disease refers to heart conditions caused by high blood pressure. The heart working under increased pressure causes the heart to fail to pump blood efficiently). During the home visit observation on 01/27/21 at 10:00 AM, the licensed practical nurse (LPN) performed a review of the patient's medications by comparing the medication bottle to the medication profile. The LPN found: - A prescription bottle for Eliquis (an anticoagulant medication used to prevent blood clots) 5 milligram (mg) tablets, take one tablet two times per day, and with the refill date of 01/18/21; - The medication profile showed the patient was to take one Eliquis 2.5 mg tablet two times per day. During an interview on 01/27/21 at 10:00 AM the patient stated that he/she does not break the Eliquis tablets in half to take a 2.5 mg dose, but takes a full tablet two times per day. During an interview on 01/247/21 at 10:00 AM the LPN stated that the medication profile did not contain the dose of Eliquis at 5 mg two times per day. RECORD/PATIENT #1: Review of the clinical record showed the patient was admitted to home health services on 12/28/2020 for pressure ulcer (sore) of sacral (buttocks) region. During the home visit observation on 01/25/21 at 4:30 PM, the primary care giver (CG) performed a review of the patient's medications by comparing the medication containers to agency medication profile. The CG found: - The agency medication profile showed the patient on Konsyl sugar free 0.52g (gram) capsule (cap) daily for constipation. CG stated that patient was not taking this medication; - The agency medication profile showed the patient used super duper diaper doo one application every one hour as needed. CG stated that this medication was discontinued on 01/05/21; - The agency medication profile showed terbinafine HCL (yeast treatment) 250 mg daily. CG stated that the patient was not taking this medication; - The agency medication profile failed to show: Acidophilus (used to restore healthy gut bacteria) one cap twice a day. CG stated patient had been taking since admission to the group facility; and - The agency medication profile failed to show: Robitussin two teaspoon as needed for cough every four to six hours. CG stated that the patient had been taking this medication as needed. During home visit observation, the director of home care observed medication discrepancies and confirmed drug medication observation. RECORD/PATIENT #3: Review of the clinical record showed the patient was admitted to home health services on 01/05/21 for a fracture (break) of his/her right femur (leg bone). During the home visit observation on 01/26/21 at 11:00 AM the clinical coordinator (CO) performed a review of the patient's medications by comparing the medication containers to the agency medication profile. - The agency medication profile showed Calcium 600 + Minerals 600 mg Calcium-200 unit (mineral supplement) one tablet twice daily. CO found Calcium Citrate 630 mg +D3 500 IU (international unit). The patient stated that the medication in the pill box was what he/she took each day; - The medication pill box contained Vitamin D 50,000 units. This medication was not listed on the agency medication profile. The patient stated that he/she had been taking this medication weekly since 01/15/2021; and - The medication pill box contained Iron 65 mg daily. This medication was not listed on the agency medication profile. The patient stated that he/she had been taking this medication for a while. During an interview with the CO following the home visit, the CO confirmed the medication discrepancies and offered no further information on the medication discrepancies.

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 nationally recognized standards, policy review, clinical record review, and home visit observation, the agency failed to assure the staff followed accepted standards of practice, including the use of standard precautions, to prevent the transmission of infections and communicable diseases in one (Record/Patient #2) of three home visits performed. This deficient practice has the potential to affect the standard precautions taken for all patients served by the agency. Findings included: Review of the Centers for Disease Control (CDC) publication dated 01/08/21 and titled, "Hand Hygiene in Healthcare Settings," showed the following clinical indications for hand hygiene: - Immediately before touching a patient; - Before performing an aseptic task (i.e., placing an indwelling device) or handling invasive medical devices; - Before moving from work on a soiled body site to a clean body site on the same patient; - After contact with blood, body fluids, or contaminated surfaces; and - Immediately after glove removal. Review of the agency policy dated 05/2020 and titled, "Home Care Bag, Bag Cleaning and Care," showed: - Prior to visits, check bag and restock routine items as needed; - Carry bag and other needed supplies into home setting; - Set bag on clean surface out of reach of children, pets, and confused patients. Do not place bag on floor surface. When cleanliness of work area is questionable, place bag and supplies on area protected by a barrier; - Perform hand hygiene; - Open bag. Remove needed supplies and/or equipment and place them on a clean work area. Close bag. If additional supplies are needed during the visit, perform hand hygiene before removing them from the bag; - Proceed with appropriate care; - Contaminated items will be handled and disposed of according to appropriate policies and procedures; and - After performing hand hygiene, unused clean supplies and equipment may be returned to the bag. RECORD/PATIENT #2: Review of the clinical record showed the patient was admitted to home health services on 12/01/2020 for the primary diagnosis of care of a burn on the right buttock from a heating pad used to treat right hip pain, and secondary diagnoses of hypertensive heart disease with heart failure (Hypertensive heart disease refers to heart conditions caused by high blood pressure. The heart working under increased pressure causes the heart to fail to pump blood efficiently). During a home visit observation on 01/27/21 at 10:00 AM, the licensed practical nurse: - Performed hand hygiene, put on clean gloves, and cleaned the patient's wound; and - Failed to removed his/her soiled gloves, or perform hand hygiene, before he/she applied the clean foam dressing, gauze cover dressing, and tape. Home observation findings were reviewed with the director of home care on 01/27/21 at 10:30 AM. No additional information or findings were provided at that time.

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, clinical record review, and home visit observation, the agency failed to complete an ongoing interdisciplinary assessment of the patient in two (Record/Patient #2 and #5) of six records. This deficient practice has the potential to affect the interdisciplinary assessment of all patients served by the agency. Findings included: Review of agency policy dated 07/2020 and titled, "Initial Comprehensive/Oasis Assessment and Initial Therapy Evaluation," showed: - This assessment will include the following as applicable: * The patient's problems, needs, and strengths; * Pertinent physical findings; * Patient's medical history; * Identified symptoms of pain; * Patient's wishes regarding care, treatment, and end of life decisions; and * Medication history, including drug allergies, sensitivities, past medication compliance history and past adverse drug reaction; and - For pain assessment, home care considers a level 7 or above to be considered severe pain. Review of agency policy dated 07/2019 and titled, "Pain Management," showed: - Definitions; * Acute Pain (distinguished by acute onset, transient, and usually from an identifiable cause); * Chronic Pain (ongoing or recurrent pain lasting beyond the usual course of acute illness or injury or more than 3 to 6 months and which adversely affects the individual's well-being ); and * Breakthrough or flare-up pain (a transitory increase in pain in someone who has relatively stable and adequately controlled baseline pain). - Assessment of pain shall include: * Circumstances of onset; * Location; * Description of pain; * Aggravating/alleviating factors; and * Intensity, using the linear scale of 0-10, where "0" indicates no pain and "10" indicates severe pain; and * The patient's individualized pain level goal regarding an acceptable level of pain. - On-going assessment of patients should include: * Documentation of pain intensity; * Progress toward therapeutic goals; * Presence of adverse reactions; * Adherence to prescribed therapies; and * Patients who are high-risk or who have engaged in aberrant drug-related behaviors should have a periodic urine drug screen performed. RECORD/PATIENT #2: Review of the clinical record showed the patient was admitted to home health services on 12/01/2020 for the primary diagnosis of care of a burn on the right buttock from a heating pad used to treat right hip pain, and secondary diagnoses of hypertensive heart disease with heart failure (Hypertensive heart disease refers to heart conditions caused by high blood pressure. The heart working under increased pressure causes the heart to fail to pump blood efficiently). Review of the start of care (SOC) comprehensive visit dated 12/01/2020 showed that the registered nurse failed to document the medications (including name and frequency) used to manage pain. Review of the plan of care (POC) dated 12/01/2020 failed to include patient specific goals for pain management. Review of nursing visits dated 12/03/2020, 12/04/2020, 12/07/202, and 12/09/2020 failed to contain documentation of a complete pain assessment including: - Progress toward therapeutic goals; - Presence of adverse reactions; and - Adherence to prescribed therapies, including the use of opioid medications. During an interview on 01/26/2021 at 11:00 AM, the director of home care stated they would expect the pain assessment documentation to reflect what was required in the policy. RECORD/PATIENT #5: Review of the clinical record showed the patient was admitted to home health services on 09/27/2020 with a primary diagnosis of ataxia (lack of voluntary coordination of muscle movements) following cerebral infarction (a stroke), and secondary diagnoses of diabetes (a disease in which the body's ability to produce or respond to the hormone insulin is impaired, resulting in elevated sugar in the blood), dementia (a chronic or persistent disorder of the mental processes caused by brain disease or injury), chronic obstructive pulmonary disease (a condition in which the air sacs of the lungs are damaged and enlarged, causing breathlessness), and long term use of anticoagulants (blood thinners). Review of the SOC comprehensive assessment dated 09/27/2020 showed conflicting pain assessment documentation in the following areas: - The pain overview assessment showed documentation that: * The patient denies experiencing pain; and * The patient has pain that does interfere with activity or movement; - The assessment of pain management documentation showed that the patient's pain was controlled, the patient was very satisfied with pain control, and the patient's goal for pain control was to be 3 or below on the pain scale; and - The patient did not take anything for pain at the time of the assessment and did not have any pain that caused distress. Review of the physical therapy evaluation performed on 10/08/2020 showed that the patient reported having some pain and taking pain medication two times per day. The clinician failed to document: - The circumstances of the onset of the pain; - The location of the pain; - A description of pain; and - Factors that aggravated or alleviated the pain. Review of the documentation for the 11/04/2020 physical therapy visit showed the patient had pain at a four on the pain scale and used Tylenol (a non-narcotic pain medication) for pain control. The visit failed to contain documentation: - That the physician was notified of the patient experiencing pain outside of his/her stated goal on the SOC visit; - A listing of Tylenol on the medication profile; and - The frequency of use for the Tylenol. Review of the physical therapy discharge showed that: - The patient was discharged with chronic pain rated at a five on the pain scale; - The patient did not use pain medication; and - The patient was satisfied with his/her pain management. The findings were reviewed with the director of home care on 01/26/21 at 5:35 PM. No further documentation was provided.

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 policy review, record review, and interview, the registered nurse (RN) failed to provide an individualized, patient specific home health aide plan of care in one (Record/Patient #3) of three records reviewed. This deficient practice has the potential to affect all patients served by agency. Findings included: Review of the agency's policy dated 01/2021 and titled, "Aide Assignment Sheet, HHA09-12" showed that the RN will complete the Aide Assignment sheet. RECORD/PATIENT #3: Review of the Plan of Care (POC) dated 01/05/2021 showed: - The patient was admitted for a fracture (break) of the right femur (leg bone); - Aide services were ordered for twice a week for four weeks - to assist with shower and activities of daily living (ADL's); and - The POC stated the patient was walker dependent and requires hands on assistance for transfers. Review of the aide assignment sheet prepared by the RN showed: - Aide personal care - dressing - upper/lower body - one-person assistance; and - Aide personal care - dressing - upper/lower body - two person assistance. Review of the aide charting showed on five of five aide visits, the aide charted both one person assistance and two person assistance with dressing. During an interview on 01/26/2021 at 2:00 PM, the clinical coordinator (CO) verified the duplicate charting related to one and two person assistance with dressing.