Every finding on record at Community Care, Inc.

Based on the findings of an onsite unannounced Medicare Recertification and State Re-licensure survey completed on May 10, 2024, Community Care Inc. was found not to be in compliance with the requirements of 42 CFR, Part 484.22, Subpart B, Condition of Participation: Home Health Agencies-Emergency Preparedness.

EP Training Program CFR(s): 484.102(d)(1) §403.748(d)(1), §416.54(d)(1), §418.113(d)(1), §441.184(d)(1), §460.84(d)(1), §482.15(d)(1), §483.73(d)(1), §483.475(d)(1), §484.102(d)(1), §485.68(d)(1), §485.542(d)(1), §485.625(d)(1), §485.727(d)(1), §485.920(d)(1), §486.360(d)(1), §491.12(d)(1). *[For RNCHIs at §403.748, ASCs at §416.54, Hospitals at §482.15, ICF/IIDs at §483.475, HHAs at §484.102, REHs at §485.542, "Organizations" under §485.727, OPOs at §486.360, RHC/FQHCs at §491.12:] (1) Training program. The [facility] must do all of the following: (i) Initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles. (ii) Provide emergency preparedness training at least every 2 years. (iii) Maintain documentation of all emergency preparedness training. (iv) Demonstrate staff knowledge of emergency procedures. (v) If the emergency preparedness policies and procedures are significantly updated, the [facility] must conduct training on the updated policies and procedures. *[For Hospices at §418.113(d):] (1) Training. The hospice must do all of the following: (i) Initial training in emergency preparedness policies and procedures to all new and existing hospice employees, and individuals providing services under arrangement, consistent with their expected roles. (ii) Demonstrate staff knowledge of emergency procedures. (iii) Provide emergency preparedness training at least every 2 years. (iv) Periodically review and rehearse its emergency preparedness plan with hospice employees (including nonemployee staff), with special emphasis placed on carrying out the procedures necessary to protect patients and others. (v) Maintain documentation of all emergency preparedness training. (vi) If the emergency preparedness policies and procedures are significantly updated, the hospice must conduct training on the updated policies and procedures. *[For PRTFs at §441.184(d):] (1) Training program. The PRTF must do all of the following: (i) Initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles. (ii) After initial training, provide emergency preparedness training every 2 years. (iii) Demonstrate staff knowledge of emergency procedures. (iv) Maintain documentation of all emergency preparedness training. (v) If the emergency preparedness policies and procedures are significantly updated, the PRTF must conduct training on the updated policies and procedures. *[For PACE at §460.84(d):] (1) The PACE organization must do all of the following: (i) Initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing on-site services under arrangement, contractors, participants, and volunteers, consistent with their expected roles. (ii) Provide emergency preparedness training at least every 2 years. (iii) Demonstrate staff knowledge of emergency procedures, including informing participants of what to do, where to go, and whom to contact in case of an emergency. (iv) Maintain documentation of all training. (v) If the emergency preparedness policies and procedures are significantly updated, the PACE must conduct training on the updated policies and procedures. *[For LTC Facilities at §483.73(d):] (1) Training Program. The LTC facility must do all of the following: (i) Initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected role. (ii) Provide emergency preparedness training at least annually. (iii) Maintain documentation of all emergency preparedness training. (iv) Demonstrate staff knowledge of emergency procedures. *[For CORFs at §485.68(d):](1) Training. The CORF must do all of the following: (i) Provide initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles. (ii) Provide emergency preparedness training at least every 2 years. (iii) Maintain documentation of the training. (iv) Demonstrate staff knowledge of emergency procedures. All new personnel must be oriented and assigned specific responsibilities regarding the CORF's emergency plan within 2 weeks of their first workday. The training program must include instruction in the location and use of alarm systems and signals and firefighting equipment. (v) If the emergency preparedness policies and procedures are significantly updated, the CORF must conduct training on the updated policies and procedures. *[For CAHs at §485.625(d):] (1) Training program. The CAH must do all of the following: (i) Initial training in emergency preparedness policies and procedures, including prompt reporting and extinguishing of fires, protection, and where necessary, evacuation of patients, personnel, and guests, fire prevention, and cooperation with firefighting and disaster authorities, to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles. (ii) Provide emergency preparedness training at least every 2 years. (iii) Maintain documentation of the training. (iv) Demonstrate staff knowledge of emergency procedures. (v) If the emergency preparedness policies and procedures are significantly updated, the CAH must conduct training on the updated policies and procedures. *[For CMHCs at §485.920(d):] (1) Training. The CMHC must provide initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles, and maintain documentation of the training. The CMHC must demonstrate staff knowledge of emergency procedures. Thereafter, the CMHC must provide emergency preparedness training at least every 2 years. This STANDARD is not met as evidenced by: Based on review of agency personnel files (PF), the agency failed to maintain documentation that demonstrated staff knowledge of emergency procedures initially for three (3) of six (6) PF reviewed (PF#1, 5 and 6). Findings included: Review of PF on January 3, 2024, at approximately 9:15am revealed: Findings include: PF reviewed 5/7/24 at approximately 9:00am revealed: PF #1, date of hire (DOH)/ start of services (SOS) 2/20/24: PF contained undated Emergency Preparedness test. PF#5, DOH/SOS 5/31/23: PF contained undated Emergency Preparedness test. PF#6, DOH/SOS 1/4/23: PF contained undated Emergency Preparedness test. Interview with agency Administrator and Director of Nursing completed on May 9, 2024, at approximately 2:00 pm confirmed the above findings.

Based on the findings of an onsite unannounced Medicare Recertification and State Re-licensure survey completed on May 10, 2024, Community Care Inc. was found not to be in compliance with the requirements of 42 CFR, Part 484, Subparts B and C, Conditions of Participation: Home Health Agencies.

Program scope CFR(s): 484.65(a)(1),(2) Standard: Program scope. (1) The program must at least be capable of showing measurable improvement in indicators for which there is evidence that improvement in those indicators will improve health outcomes, patient safety, and quality of care. (2) The HHA must measure, analyze, and track quality indicators, including adverse patient events, and other aspects of performance that enable the HHA to assess processes of care, HHA services, and operations. This STANDARD is not met as evidenced by: Based on review of policies and procedures, agency Quality Assurance and Performance Improvement (QAPI) documentation, and staff (EMP) interview, the agency QAPI failed to measure, analyze, and track quality indicators, including adverse patient events, and other aspects of performance that enable the HHA to assess processes of care, HHA services, and operations for six (6) of six (6) QAPI meeting minutes reviewed. Findings include: Review of QAPI meeting minutes on 5/7/24 at approximately 1:00pm revealed: QAPI meeting minutes dated 3/31/23 addressed a concern called from a facility related to multiple calls related to leaking foley catheter. No data, adverse events, or quality indicators tracked. No additional information in meeting minutes. QAPI meeting minutes dated 4/28/23 addressed chart audit findings that OASIS SOC date failed to match physician ordered start of care (SOC) date. No data, adverse events, or quality indicators tracked. Prior documented issue related to foley concerns not updated or addressed. No additional information in meeting minutes. QAPI meeting minutes dated 7/21/23 addressed chart audit findings that nursing documentation does not reflect top 3 diagnosis. No data, adverse events, or quality indicators tracked. Prior documented issue related to foley concerns or SOC dates not updated or addressed. No additional information in meeting minutes. QAPI meeting minutes dated 12/4/23 addressed chart audit findings that nursing documentation continues not to reflect top 3 diagnosis and also goals are not being documented as met. No data, adverse events, or quality indicators tracked. Prior documented issue related to foley concerns or SOC dates not updated or addressed. No additional information in meeting minutes. Interview with agency Administrator and Director of Nursing completed on May 9, 2024, at approximately 2:00 pm confirmed the above findings.

Based on the findings of an unannounced on-site State Re-licensure and Medicare Re-certification survey completed on January 13, 2022, Community Care Inc. was found not to be in compliance with the requirements of 42 CFR, Part 484.22, Subpart B, Condition of Participation: Home Health Agencies- Emergency Preparedness.

Local, State, Tribal Collaboration Process CFR(s): 484.102(a)(4) §403.748(a)(4), §416.54(a)(4), §418.113(a)(4), §441.184(a)(4), §460.84(a)(4), §482.15(a)(4), §483.73(a)(4), §483.475(a)(4), §484.102(a)(4), §485.68(a)(4), §485.625(a)(4), §485.727(a)(5), §485.920(a)(4), §486.360(a)(4), §491.12(a)(4), §494.62(a)(4) [(a) Emergency Plan. The [facility] must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least every 2 years [annually for LTC facilities]. The plan must do the following:] (4) Include a process for cooperation and collaboration with local, tribal, regional, State, and Federal emergency preparedness officials' efforts to maintain an integrated response during a disaster or emergency situation. * * [For ESRD facilities only at §494.62(a)(4)]: (4) Include a process for cooperation and collaboration with local, tribal, regional, State, and Federal emergency preparedness officials' efforts to maintain an integrated response during a disaster or emergency situation. The dialysis facility must contact the local emergency preparedness agency at least annually to confirm that the agency is aware of the dialysis facility's needs in the event of an emergency. This STANDARD is not met as evidenced by: Based on a review of the facility Emergency Preparedness Plan (EPP) and staff (EMP) interview, the facility failed to ensure the EPP included documentation of the facility efforts to contact, cooperate, and collaborate with emergency preparedness officials (local, tribal, regional, state, federal) in order to facilitate an integrated response during a disaster situation. Findings Included: Review conducted January 11, 2022 at approximately 10:00AM of facility Emergency Preparedness Plan (EPP). Facility EPP did not contain documented evidence to confirm local, regional, State or Federal emergency officials were contacted and made aware of the facility's requirements during an emergency or disaster. In interview on January 11, 2022 at approximately 10:15AM, Director of Professional Services stated, "we were not aware of everything we needed to have included..." Findings confirmed at exit conference on January 13, 2022 at approximately 3:00PM with Office Manager and Compliance Officer. Repeat deficiency. Previously cited: 1/14/19

Homebound HHA/Hospice Inform EP Officials CFR(s): 484.102(b)(2) §418.113(b)(2), §460.84(b)(4), §484.102(b)(2) [(b) Policies and procedures. The [facilities] must develop and implement emergency preparedness policies and procedures, based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, and the communication plan at paragraph (c) of this section. The policies and procedures must be reviewed and updated at least every 2 years. At a minimum, the policies and procedures must address the following:] *[For homebound Hospice at §418.113(b)(2), PACE at §460.84(b)(4), and HHAs at §484.102(b)(2):] The procedures to inform State and local emergency preparedness officials about [homebound Hospice, PACE or HHA] patients in need of evacuation from their residences at any time due to an emergency situation based on the patient's medical and psychiatric condition and home environment. This STANDARD is not met as evidenced by: Based on a review of the agency Emergency Preparedness Plan (EPP) and staff (EMP) interview it was determined the agency failed to include policies and procedures to informed State and local emergency preparedness officials about homebound patients in need of evacuation from their residence based on patients medical and psychiatric conditions and home environments. Findings Included: Review of agency EPP completed on January 11, 2022 at approximately 10:00AM revealed the agency developed EPP failed to contain policies and procedures to inform State and local emergency preparedness officials about homebound patients in need of evacuation from their residence based on patients medical and psychiatric conditions and home environments. In interview on January 11, 2022 at approximately 10:15AM,Director of Professional Services stated, "we were not aware of everything we needed to have included..." Findings confirmed at exit conference on January 13, 2022, at approximately 3:00PM with Office Manager and Compliance Officer.

Policies/Procedures-Volunteers and Staffing CFR(s): 484.102(b)(5) §403.748(b)(6), §416.54(b)(5), §418.113(b)(4), §441.184(b)(6), §460.84(b)(7), §482.15(b)(6), §483.73(b)(6), §483.475(b)(6), §484.102(b)(5), §485.68(b)(4), §485.625(b)(6), §485.727(b)(4), §485.920(b)(5), §491.12(b)(4), §494.62(b)(5). [(b) Policies and procedures. The [facilities] must develop and implement emergency preparedness policies and procedures, based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, and the communication plan at paragraph (c) of this section. The policies and procedures must be reviewed and updated at least every 2 years [annually for LTC facilities]. At a minimum, the policies and procedures must address the following:] (6) [or (4), (5), or (7) as noted above] The use of volunteers in an emergency or other emergency staffing strategies, including the process and role for integration of State and Federally designated health care professionals to address surge needs during an emergency. *[For RNHCIs at §403.748(b):] Policies and procedures. (6) The use of volunteers in an emergency and other emergency staffing strategies to address surge needs during an emergency. *[For Hospice at §418.113(b):] Policies and procedures. (4) The use of hospice employees in an emergency and other emergency staffing strategies, including the process and role for integration of State and Federally designated health care professionals to address surge needs during an emergency. This STANDARD is not met as evidenced by: Based on review of agency emergency preparedness plan (EPP) and interview with staff (EMP), the agency failed to incorporate emergency staffing strategies for use of volunteers or a process and role for integration of State and Federally designated health care professionals to address surge needs to sustain operations during an emergency. Findings included: Review conducted January 11, 2022 at approximately 10:00AM of facility Emergency Preparedness Plan (EPP). Plan did not identify a process or role for volunteers/state or federally designated health care professionals if needs arose to require staffing surge. In interview on January 11, 2022 at approximately 10:15AM, Director of Professional Services stated, "we were not aware of everything we needed to have included..." Findings confirmed at exit conference on January 13, 2022, at approximately 3:00PM with Office Manager and Compliance Officer. Repeat deficiency. Previously cited: 1/14/19

EP Training Program CFR(s): 484.102(d)(1) §403.748(d)(1), §416.54(d)(1), §418.113(d)(1), §441.184(d)(1), §460.84(d)(1), §482.15(d)(1), §483.73(d)(1), §483.475(d)(1), §484.102(d)(1), §485.68(d)(1), §485.625(d)(1), §485.727(d)(1), §485.920(d)(1), §486.360(d)(1), §491.12(d)(1). *[For RNCHIs at §403.748, ASCs at §416.54, Hospitals at §482.15, ICF/IIDs at §483.475, HHAs at §484.102, "Organizations" under §485.727, OPOs at §486.360, RHC/FQHCs at §491.12:] (1) Training program. The [facility] must do all of the following: (i) Initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles. (ii) Provide emergency preparedness training at least every 2 years. (iii) Maintain documentation of all emergency preparedness training. (iv) Demonstrate staff knowledge of emergency procedures. (v) If the emergency preparedness policies and procedures are significantly updated, the [facility] must conduct training on the updated policies and procedures. *[For Hospices at §418.113(d):] (1) Training. The hospice must do all of the following: (i) Initial training in emergency preparedness policies and procedures to all new and existing hospice employees, and individuals providing services under arrangement, consistent with their expected roles. (ii) Demonstrate staff knowledge of emergency procedures. (iii) Provide emergency preparedness training at least every 2 years. (iv) Periodically review and rehearse its emergency preparedness plan with hospice employees (including nonemployee staff), with special emphasis placed on carrying out the procedures necessary to protect patients and others. (v) Maintain documentation of all emergency preparedness training. (vi) If the emergency preparedness policies and procedures are significantly updated, the hospice must conduct training on the updated policies and procedures. *[For PRTFs at §441.184(d):] (1) Training program. The PRTF must do all of the following: (i) Initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles. (ii) After initial training, provide emergency preparedness training every 2 years. (iii) Demonstrate staff knowledge of emergency procedures. (iv) Maintain documentation of all emergency preparedness training. (v) If the emergency preparedness policies and procedures are significantly updated, the PRTF must conduct training on the updated policies and procedures. *[For PACE at §460.84(d):] (1) The PACE organization must do all of the following: (i) Initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing on-site services under arrangement, contractors, participants, and volunteers, consistent with their expected roles. (ii) Provide emergency preparedness training at least every 2 years. (iii) Demonstrate staff knowledge of emergency procedures, including informing participants of what to do, where to go, and whom to contact in case of an emergency. (iv) Maintain documentation of all training. (v) If the emergency preparedness policies and procedures are significantly updated, the PACE must conduct training on the updated policies and procedures. *[For LTC Facilities at §483.73(d):] (1) Training Program. The LTC facility must do all of the following: (i) Initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected role. (ii) Provide emergency preparedness training at least annually. (iii) Maintain documentation of all emergency preparedness training. (iv) Demonstrate staff knowledge of emergency procedures. *[For CORFs at §485.68(d):](1) Training. The CORF must do all of the following: (i) Provide initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles. (ii) Provide emergency preparedness training at least every 2 years. (iii) Maintain documentation of the training. (iv) Demonstrate staff knowledge of emergency procedures. All new personnel must be oriented and assigned specific responsibilities regarding the CORF's emergency plan within 2 weeks of their first workday. The training program must include instruction in the location and use of alarm systems and signals and firefighting equipment. (v) If the emergency preparedness policies and procedures are significantly updated, the CORF must conduct training on the updated policies and procedures. *[For CAHs at §485.625(d):] (1) Training program. The CAH must do all of the following: (i) Initial training in emergency preparedness policies and procedures, including prompt reporting and extinguishing of fires, protection, and where necessary, evacuation of patients, personnel, and guests, fire prevention, and cooperation with firefighting and disaster authorities, to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles. (ii) Provide emergency preparedness training at least every 2 years. (iii) Maintain documentation of the training. (iv) Demonstrate staff knowledge of emergency procedures. (v) If the emergency preparedness policies and procedures are significantly updated, the CAH must conduct training on the updated policies and procedures. *[For CMHCs at §485.920(d):] (1) Training. The CMHC must provide initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles, and maintain documentation of the training. The CMHC must demonstrate staff knowledge of emergency procedures. Thereafter, the CMHC must provide emergency preparedness training at least every 2 years. This STANDARD is not met as evidenced by: Based on review of agency emergency preparedness training program, personnel files (PF) and interview with staff (EMP), the facility failed to provide initial training in emergency preparedness (EP) policies and procedures to staff under arrangement, consistent with their expected roles in emergency preparedness training for two (2) of two (2) staff under arrangement reviewed (PF5 & 6.) Findings included: Review of personnel files conducted January 10, 2022 at approximately 1:00PM failed to reveal documentation of initial training in emergency preparedness (EP) policies and procedures to staff under arrangement, consistent with their expected roles in emergency preparedness training. PF 5, date of hire 8/2/2021, lacked documentation of training with demonstrated staff knowledge of emergency procedures. Interview with employee on 1/13/22 at approximately 9:55AM confirmed that the only education provided is from therapy company. States, "We only do training with Allstar, we never go to the agency, I'd think they would be in communication with the agency." Confirms no Emergency preparedness training specific to agency. PF 6, date of hire 7/12/2021, lacked documentation of training with demonstrated staff knowledge of emergency procedures. In interview on January 11, 2022, at approximately 10:15AM, Director of Professional Services stated, "we do not provide the contracted therapy with specific EPP training, I'm sure Allstar has some they provide..." Findings confirmed at exit conference on January 13, 2022, at approximately 3:00PM with Office Manager and Compliance Officer. Repeat deficiency. Previously cited: 1/14/19

Based on the findings of an unannounced on-site State Re-licensure and Medicare Re-certification survey completed on January 13, 2022, Community Care Inc. was found not to be in compliance with the requirements of 42 CFR, Part 484, Subparts B and C, Conditions of Participation: Home Health Agencies.

Plan of care must include the following CFR(s): 484.60(a)(2)(i-xvi) The individualized plan of care must include the following: (i) All pertinent diagnoses; (ii) The patient's mental, psychosocial, and cognitive status; (iii) The types of services, supplies, and equipment required; (iv) The frequency and duration of visits to be made; (v) Prognosis; (vi) Rehabilitation potential; (vii) Functional limitations; (viii) Activities permitted; (ix) Nutritional requirements; (x) All medications and treatments; (xi) Safety measures to protect against injury; (xii) A description of the patient's risk for emergency department visits and hospital re-admission, and all necessary interventions to address the underlying risk factors. (xiii) Patient and caregiver education and training to facilitate timely discharge; (xiv) Patient-specific interventions and education; measurable outcomes and goals identified by the HHA and the patient; (xv) Information related to any advanced directives; and (xvi) Any additional items the HHA or physician or allowed practitioner may choose to include. This ELEMENT is not met as evidenced by: Based on review of Agency Policy/Procedure, Clinical Records (CR), Home Visit Observation, and staff (EMP) interview the agency failed to ensure the Plan of Treatment (POT) included supplies and equipment for three (3) of seven (7) CR's reviewed (CR5, 6, & 7), medications for three (3) of seven (7) CR's reviewed (CR3, 4, & 6,) and orders/interventions for four (4) of seven (7) CR's reviewed (CR2, 4, 5,& 7.) Findings included: Review of Agency Policy and Procedure on January 10, 2022, at approximately 10:30AM revealed: "PHYSICIAN ORDERS...Policy...4.0 The plan of care/medical order includes: Pertinent diagnosis, prognosis, Mental status, Service(s) required, Supplies and equipment needs, Medications (all...Rx, OTC, herbals), Treatments, Frequency of visits by discipline/service and reason for visits, Other appropriate items based on patient's condition, Rehabilitation potential, Functional limitations, Activities permitted, Nutritional requirements, Safety measures, Anticipated discharge..." Review of CR on January13, 2022 between approximately 9:30AM and 1:30PM revealed: CR2, start of service (SOS)9/1/2021, period reviewed 9/1/2021-10/29/2021, POT included straight catheter on supplies and goal for for patient to be "independent in catheter care and management for straight catheterization procedure within this plan of care. POT failed to include orders or interventions for catheterization process, frequency, and teaching. CR3, SOS 11/23/2021, period reviewed 11/23/2021-1/21/2022, Clinical note on SOS noted patient "...is currently on treatment with Zometa and Keytruda..." No evidence of these medications on POT or patient medication list. CR4, SOS 11/1/2021, period reviewed 12/31/2021-2/28/2022, POT included suction machine and oxygen concentrator on supply list. Interventions included on POT for "...oxygen 1-2L/M via nasal canula when patient is sleeping, has labored breathing, or saturations below 93%..." Oxygen not included in medication profile. Intervention on POT to "...change and clean suction machine and tubing every shift and as needed..." Clarification with Compliance officer on 1/14/2021 at 8:11AM revealed that the patient's suction, "is a bulb suction, used for extra secretions" No interventions on POT for bulb suctioning. No suction machine or tubing required for bulb suctioning. CR5, SOS 12/28/2021, period reviewed 12/28/2021-2/25/2022, Home visit observation on 1/21/2022 at approximately 9:00AM revealed patient has C-PAP machine and trapeze apparatus on hospital bed. Patient confirmed this equipment and routine use of C-PAP nightly and trapeze for positioning and assist with transfers. POT failed to include CPAP and trapeze in supplies/equipment. POT also failed to include orders/interventions for use of C-PAP nightly. CR6, SOS 12/5/2021, period reviewed 12/5/2021-2/2/2022, Home visit observation on 1/21/2022 at approximately 12:00PM revealed oxygen concentrator and portable tanks in patient home. Patient confirmed use of oxygen nightly and when short of breath. Oxygen running in home when arrived and patient smoking cigarette. POT failed to include oxygen on medication profile and supplies, also failed to include smoking and oxygen precautions for safety on POT. Hospital bed also present in home upon visit and patient reports having a prosthetic leg that is currently being repaired. Both OT and Pt assessed patient for use of prosthetic on 12/9/2021. Both prosthetic and hospital bed failed to be included in equipment/supplies on POT. Patient POT notes diabetes and primary diagnosis and patient confirms diagnosis and direction by doctor to check blood sugar. Diabetic supplies failed to be included in equipment/supplies on POT. CR7, SOS 12/14/2021, period reviewed 12/14/2021-2/11/2022, Home visit observation on 1/21/2022 at approximately 10:30AM reveal tubigrip as compression wit wound care. Supply list failed to include tubigrip on POT. Medication profile included "Cephalexin Oral Tablet 500mg-1 tab-QID (4 times a day) until gone-PO (by mouth), POT failed to include end date for antibiotic treatment. POT included interventions for teaching of hyper/hypoglycemia and actions to take. No diagnosis of diabetes or orders for monitoring of blood sugar on POT. Findings confirmed at exit conference on January 13, 2022, at approximately 3:00PM with Office Manager and Compliance Officer. Repeat deficiency. Previously cited: 1/14/19

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 review of Agency Policy/Procedure, Clinical Records (CR), Home Visit Observation, and staff (EMP) interview the agency failed to ensure orders were performed per doctors’ orders for two (2) of two (2) patients reviewed receiving wound care (CR5&7) and two (2) of three (3) CR reviewed with lab orders (CR1&3.) Findings included: Review of Agency Policy and Procedure on January 10, 2022, at approximately 10:30AM revealed: “ Review of CR on January13, 2022 between approximately 9:30AM and 1:30PM revealed: "PHYSICIAN ORDERS...5.0 The orders are reviewed for appropriateness and accuracy prior to providing care...", "...WOUND CARE:POLICIES...GENERALPOLICIES...2...the patient or responsible caregiver must be willing and able t assume responsibility for learning the required care including emergency measures and dressing changes... CR1, start of service (SOS) 10/30/2021, period reviewed 10/30/2021-12/22/2021, Plan of Treatment (POT) dated 10/30/2021 included order for labs to be drawn. Documentation revealed labs not obtained until 3 nursing visits later on 11/8/2021. Additional lab order written on 11/10/2021 for labs to be obtained 11/17/2021. Documentation revealed labs obtained 11/16/2021. CR3, SOS 11/23/2021, period reviewed 11/23/2021-1/21/2022, Plan of Treatment (POT) dated 11/23/2021 included order for labs to be drawn. Documentation revealed labs not obtained until 2 nursing visits later on 12/3/2021. CR5, SOS 12/28/2021, period reviewed 12/28/2021-2/25/2022, POT included wound care to right hip to be completed daily and as needed. Home visit observation on 1/21/2022 at approximately 9:00AM confirmed with patient and caregiver that the wound care is only completed 2 times a week by the nurse during scheduled visits. Order states "caregiver to complete dressing change in SN absence" Confirmed with patient/caregiver that this instruction has not been taught/given. CR7, SOS 12/14/2021, period reviewed 12/14/2021-2/11/2022, POT included wound care to be completed daily and as needed. Home visit observation on 1/21/2022 at approximately 10:30AM confirmed with patient and nurse that the wound care is only completed 3 times a week by the nurse during scheduled visits. Order states "caregiver to complete dressing change in SN absence" Confirmed with patient/nurse that this instruction has not been taught/given. At this time nurse stated, "I have not taught anyone since I have been coming. I just do it at each visit." Findings confirmed at exit conference on January 13, 2022, at approximately 3:00PM with Office Manager and Compliance Officer.