Every finding on record at Companion Home Health, LLC

The Oklahoma State Department of Health conducted an unannounced Medicare Emergency Preparedness Program survey at the agency on 06/03/25 to 06/04/25. No deficiency was cited as a result of the Emergency Preparedness Program survey.

The Oklahoma State Department of Health conducted an unannounced Medicare re-certification survey at the agency on 06/03/25 to 06/04/25. An entrance conference was conducted with Staff A and B. The survey process was explained. Questions were answered. Staff A was identified as the contact person for clinical issues, and Staff B was identified as the contact person for administrative issues. Findings were discussed during an informal exit conference with Staff A, B and C. Standard level deficiencies were cited as a result of the Medicare re-certification survey. Glossary: ABN advance beneficiary notice BS blood sugar HHCOC home health change of care notice MSW medical social work PT physical therapy POC plan of care QAPI Quality Assessment Performance Improvement SN skilled nurse SOC Start of Care

HHA administrator contact information CFR(s): 484.50(a)(1)(ii) (ii) Contact information for the HHA administrator, including the administrator's name, business address, and business phone number in order to receive complaints. This ELEMENT is not met as evidenced by: Based on record review and interview, the agency failed to ensure the administrator’s name and contact information for complaint and grievance procedures was a part of the admission packet information for three (Patients #2, 3 and #6) of 11 patients. Findings: A review of start of care packets showed no agency administrator’s name and contact information for complaint and grievance procedures for the agency. Patient #2 On 06/04/25 at 8:30 a.m., during an in-home visit, the patient was unable to identify the agency administrator’s name or contact information. Review of the in-home folder (patient information packet for the agency) showed no administrator’s name and contact information related to complaint and grievance procedures. Patient #3 On 06/04/25 at 8:45 a.m., during an in-home visit, the patient was unable to identify the agency administrator’s name or contact information. Review of the in-home folder (patient information packet for the agency) showed no administrator’s name and contact information related to complaint and grievance procedures. Patient #6 On 06/04/25 at 9:00 a.m., during an in-home visit, the patient was unable to identify the agency administrator’s name or contact information. Review of the in-home folder (patient information packet for the agency) showed no administrator’s name and contact information related to complaint and grievance procedures. On 04/04/25 at 1:20 p.m., Staff B reviewed the start of care patient information and stated the administrator’s name and contact information was not in the information given to patients at the time of admission to the agency for patients #2, 3 and #6.

HHA can no longer meet the patient's needs CFR(s): 484.50(d)(1) The transfer or discharge is necessary for the patient's welfare because the HHA and the physician or allowed practitioner, who is responsible for the home health plan of care agree that the HHA can no longer meet the patient's needs, based on the patient's acuity. The HHA must arrange a safe and appropriate transfer to other care entities when the needs of the patient exceed the HHA's capabilities; This ELEMENT is not met as evidenced by: Based on record review and interview, the agency failed to ensure: 1. Physician notification the agency could no longer meet the patient needs prior to discharge for three (Patients #9, 10 and #11) of 11 patients. 2. Arrange transfer of care to another care entity for three (Patients #9, 10 and #11) of 11 patients. Findings: Patient #9 A review of a POC for 11/30/24 to 01/20/25 showed a SN visit frequency of one time a week for one week, effective 11/30/25 and one time a day for one day, effective 01/22/25 for assessment, monitoring and teaching of blood sugar and pain management. The POC showed orders for SN to conduct foley catheter change 18 French/10 cubic centimeters every month due week of 01/31/25. The POC showed a physical therapy visit frequency of one time a week for one week, two times a week for two weeks, then one time a week for one week for physical therapy evaluation and treatment. A review of a communication note dated 01/22/25 stated the patient was being discharged to hospice care services. A review of clinical documentation showed no communication with the ordering provider of discharge from home care services and showed no coordination of care with the hospice to continue the patient’s care prior to the patient’s discharge from HHA services on 01/22/25. On 06/04/25 at 1:48 p.m., Staff C stated: 1. The SN did not communicate with the ordering provider that the patient was being discharged from the agency to hospice services. 2. The agency showed no coordination of care with the hospice to continue the patient’s care prior to the patient’s discharge from HHA services on 01/22/25. Patient #10 A review of a POC for 02/19/25 to 04/04/25 showed a SN visit frequency of one time a week for one week, then one time a week for eight weeks for assessment, monitoring and teaching of blood sugar and pain management; and physical therapy visit frequency of one time a week for one week, two times a week for four weeks, one time a week for one week, then two times a week for two weeks for physical therapy evaluation and treatment. Documentation showed a discharge reason as “other”, showed no communication with the ordering medical provider to notify the patient was being discharged from home care services and showed no arrangement with another care entity to continue the patient’s care prior to the patient’s discharge from HHA services on 04/04/25. On 06/04/25 at 1:56 p.m., Staff C stated: 1. The SN did not communicate with the physician that the patient was being discharged from the agency. 2. The agency did not arrange care with another care entity to continue the patient’s care after the patient’s discharge from HHA services on 04/04/25. Patient #11 A review of a POC for 11/08/24 to 01/06/25 showed a SN visit frequency of one time a week for three weeks, then one to two times a month for two months for assessment, monitoring and teaching of pain management; and physical therapy visit frequency of one time a week for five weeks for physical therapy evaluation and treatment. A review of a quick note (a communication note) dated 01/02/25 stated the patient was being discharged due to a change in payor source. Documentation showed no communication with the ordering medical provider to notify the patient was being discharged from home care services and showed no arrangement with another care entity to continue the patient’s care prior to the patient’s discharge from HHA services on 01/02/25. On 06/04/25 at 2:00 p.m., Staff C stated: 1. The SN did not communicate with the physician that the patient was being discharged from the agency. 2. The agency did not arrange care with another care entity to continue the patient’s care after the patient’s discharge from HHA services on 04/04/25.

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 record review and interview, the agency failed to ensure individualized patient POC included: 1. A a specific SN visit frequency and duration for one (Patient #2) of 11 patients. 2. Blood sugar reporting parameters for one (Patient #5) of 11 patients. 3. pain reporting parameters for one (Patients #5, 6, 7 and #11) of 11 patients. 4. wound site goals for one (Patient #6) of 11 patients. 5. SN catheter treatment/interventions or last changed/treatment due date for urinary catheter management for one (Patient #7) of 11 patients. Findings: Patient #2 A review of the POC dated 03/28/25 to 05/26/25 showed orders for SN to conduct assessment and teaching of patient health conditions and medications every visit. A review of clinical documentation showed a SN visit range with a frequency and duration of one to two times a month times two months on the POC. Documentation showed SN visits were conducted on 04/24/25 (SOC) and on 05/21/25. Documentation showed no patient refusal of visits, no physician notifications and no change in orders. On 06/04/25 at 11:55 a.m., Staff C stated the POC for patient #2 should have included an individualized SN visit frequency and duration to meet the patient’s care needs. Patient #5 A review of the POC dated 04/06/25 to 06/04/25 showed orders for SN one time a week for nine weeks to conduct assessment, monitoring and teaching of patient blood sugar and pain levels every visit. A review of clinical documentation showed no blood sugar or pain physician reporting parameters on the POC. Documentation showed SN visits were conducted on 04/11/25, 04/16/25, 04/29/25, 05/06/25, 05/12/25, 05/20/24 and on 05/27/25 and showed no patient blood sugar monitoring results and no reported pain levels. Documentation showed no patient/caregiver refusal of SN assessment and monitoring of the patient’s blood sugar or pain levels during the SN visits, no physician notifications and no change in orders. On 06/04/25 at 12:07 p.m., Staff C stated the POC for patient #5 should have included blood sugar and pain physician reporting parameters. Patient #6 A review of the POC dated 04/13/25 to 06/11/25 showed orders for SN one time a week for eight weeks to conduct assessment, monitoring, intervention and teaching of patient pain levels and wound site care every visit. A review of clinical documentation showed no pain physician reporting parameters or wound site goals on the POC. Documentation showed SN visits were conducted on 04/14/25, 04/30/25, 05/06/25, 05/13/25, 05/21/24 and on 05/28/25 showed no patient reported pain levels and showed the patient complained of increased pain. Documentation showed no patient/caregiver refusal of SN assessment and monitoring of the patient’s pain levels during the SN visits, no physician notifications and no change in orders. On 06/04/25 at 1:05 p.m., Staff C stated the POC for patient #6 should have included pain physician reporting parameters and wound site goals for patient #6. Patient #7 A review of the POC dated 05/10/25 to 07/08/25 showed orders for SN one time a day for one day, one time a week for two weeks then one to two times a week for eight weeks to conduct assessment, monitoring, intervention and teaching of patient pain levels every visit and SN to conduct foley catheter 16 French/10 cubic centimeters every month. A review of clinical documentation showed SN visits were conducted on 05/13/25, 05/15/25, 05/19/25, 05/23/25 and on 05/28/25 showed no patient reported pain levels and no foley catheter intervention was conducted. Documentation showed no pain physician reporting parameters or foley catheter intervention last changed or monthly change due date on the POC. Documentation showed no patient/caregiver refusal of SN assessment and monitoring of the patient’s pain levels during the SN visits, no physician notifications and no change in orders. On 06/04/25 at 1:08 p.m., Staff C stated the POC should have included pain physician reporting parameters and foley catheter intervention last changed or monthly change due date for patient #7. Patient #11 A review of the POC dated 11/08/24 to 01/06/25 showed orders for SN to conduct assessment and teaching of patient pain management every visit. A review of clinical documentation showed no physician pain management reporting parameters on the POC. Documentation showed SN visits were conducted on 11/12/25, 11/20/24, 12/06/24 and on 12/19/24 showed no patient reported pain levels. Documentation showed no patient/caregiver refusal of SN assessment and monitoring of the patient’s pain levels during the SN visits, no physician notifications and no change in orders. On 06/04/25 at 1:10 a.m., Staff C stated the POC should have included physician pain management reporting parameters for patient #11.

Performance improvement projects CFR(s): 484.65(d)(1)(2) Standard: Performance improvement projects. Beginning July 13, 2018 HHAs must conduct performance improvement projects. (1) The number and scope of distinct improvement projects conducted annually must reflect the scope, complexity, and past performance of the HHA's services and operations. (2) The HHA must document the quality improvement projects undertaken, the reasons for conducting these projects, and the measurable progress achieved on these projects. This STANDARD is not met as evidenced by: Based on record review and interviews, the agency failed to ensure performance improvement project for the agency in calendar year 2024 and 01/01/25 to 06/03/25 showed baseline or threshold measurements to identify measurable outcomes in PIP activity for 11 (Patients #1, 2, 3, 4, 5, 6, 7, 8, 9, 10 and #11) and all employees. Findings: A review of QAPI Program documentation showed no performance improvement project measurable goals (baseline or threshold levels) for calendar year 2024 and 01/01/25 to 06/03/25 QAPI activities. On 06/04/25 at 1:15 p.m., Staff B stated the agency had no QAPI PIP documentation which showed baseline or threshold measurements for calendar year 2024 and 01/01/25 to 06/03/25 QAPI activities.

Provide services in the plan of care CFR(s): 484.75(b)(3) Providing services that are ordered by the physician or allowed practitioner as indicated in the plan of care; This ELEMENT is not met as evidenced by: Based on record review and interview, the agency failed to ensure: 1. SN monitored the patient’s blood pressure every visit as ordered for one (Patient #1) of 11 patients. 2. SN monitored a patient’s blood sugar every visit as ordered for one (Patient #1) of 11 patients. 3. PT conducted visits as ordered for one (Patient #2) of 11 patients. 4. SN conducted visits as ordered for three (Patients #5, 6 and #8) of 11 patients. 5. MSW conducted a visit as ordered for one (Patient #7) of 11 patients. 6. SN conducted foley catheter change intervention as ordered for one (Patient #9) of 11 patients. Findings: Patient #1 A review of the POC dated 03/28/25 to 05/26/25 showed orders for SN one time a week for eight weeks to assess and instruct the patients’ blood pressure and blood sugar every visit. SN to report to physician blood pressure of greater than 160/90. · A review of SN visits on 04/02/25, 04/03/25, 04/08/25, 04/15/24, 04/22/25, 04/29/25, 05/06/25 and on 05/13/25 showed no blood sugar monitoring interventions. · 04/08/25 blood pressure reading of 174/80, 04/10/25 blood pressure reading of 178/72 and on 04/17/25 blood pressure reading of 162/70 were not reported to the physician. Documentation showed no patient or caregiver refusal of blood pressure result reporting or blood sugar monitoring, no physician notification and no changes in orders. On 06/04/25 at 11:42 a.m., Staff C stated: 1. The SN visit notes dated 04/02/25, 04/03/25, 04/08/25, 04/15/24, 04/22/25, 04/29/25, 05/06/25 and 05/13/25 showed no blood sugar monitoring interventions. 2. The SN visit notes dated 04/08/25 blood pressure reading of 174/80, 04/10/25 blood pressure reading of 178/72 and 04/17/25 blood pressure reading of 162/70 were not reported to the physician. Patient #2 A review of the POC dated 04/24/25 to 06/22/25 showed orders for PT to evaluate and treat with a frequency and duration of two times a week for five weeks. A review of visit notes for the week of 05/18/25 to 05/24/25 showed a missed PT visit on 05/23/25 (two visits ordered, no visit conducted) and during the week of 05/25/25 to 05/31/25 no PT visits were conducted (two visits ordered, no visit conducted). Documentation showed no patient or caregiver refusal, no physician notification and no changes in orders. On 06/04/25 at 11:55 a.m., Staff A stated the PT visits should have been conducted as ordered on the POC. Patient #5 A review of the POC dated 04/06/25 to 06/04/25 showed orders for SN one time a week for nine weeks. A review of visit notes for the week of 04/20/25 to 04/26/25 showed no SN visit (one visit ordered, no visit conducted). Documentation showed no patient or caregiver refusal of a visit, no physician notification and no changes in orders. On 06/04/25 at 12:07 p.m., Staff C stated the SN visits should have been conducted as ordered on the POC. Patient #6 A review of the POC dated 04/13/25 to 06/11/25 showed orders for SN one time a week for eight weeks. A review of visit notes for the week of 04/20/25 to 04/26/25, showed no SN visit (one visit ordered, no visit conducted). Documentation showed no patient or caregiver refusal of a visit, no physician notification and no changes in orders. On 06/04/25 at 1:05 p.m., Staff D stated the SN visits should have been conducted as ordered on the POC. Patient #7 A review of the POC dated 05/10/25 to 07/08/25 showed orders for MSW one time a day for one day on 05/20/25. A review of visit notes showed no MSW visit on 05/20/25 (one visit ordered, no visit conducted). Documentation showed no patient or caregiver refusal of a visit, no physician notification and no changes in orders. On 06/04/25 at 1:37 p.m., Staff A stated no MSW visits had been conducted for patient #7. Patient #8 A review of the POC dated 01/24/25 to 03/24/25 showed orders for SN one time a week for nine weeks. A review of visit notes for the week of 03/02/25 to 03/08/25, showed no SN visit (one visit ordered, no visit conducted). Documentation showed no patient or caregiver refusal of a visit, no physician notification and no changes in orders. On 06/04/25 at 1:44 p.m., Staff C stated the SN visits should have been conducted as ordered on the POC. Patient #9 A review of the POC dated 11/30/24 to 01/28/25 showed orders for SN to conduct foley catheter intervention monthly, due on 01/31/25 (two months). A SN visit note dated 12/02/24 stated the monthly foley catheter change was completed. SN visit notes dated 12/10/24, 12/16/24, 12/24/24, 12/31/24, 01/07/25, 01/13/25, and 01/21/25 showed no foley catheter change was conducted. Documentation showed no patient or caregiver refusal, no physician notification and no changes in orders. On 06/04/25 at 1:48 p.m., Staff C stated monthly foley catheter change should have been conducted by the SN as ordered on the POC.

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 record reviews and interviews, the agency failed to ensure completed transfer/discharge summaries were provided to receiving providers for two (Patients #8 and #9) of 11 patients. Findings: Patient #8 A review of the clinical record showed transfer from the agency on 03/19/25 to inpatient hospital services with subsequent discharge from the agency on 03/23/25. A review of clinical documentation showed no transfer and/or discharge summary was provided to the receiving inpatient hospital service provider. Patient #9 A review of the clinical record showed discharge from the agency on 01/22/25 to hospice services. A review of clinical documentation showed no discharge summary was provided to the receiving hospice provider and no discharge summary was provided to the ordering physician. On 06/04/25 at 1:48 p.m., Staff C stated no transfer or discharge summaries for patients #8 and #9 were sent to the receiving providers or the ordering physician.

The Oklahoma State Department of Health conducted an unannounced Medicare Emergency Preparedness Program survey at the agency on 07/12/22 to 07/13/22. Standard deficiency was cited as a result of the Emergency Preparedness Program survey.

Names and Contact Information CFR(s): 484.102(c)(1) §403.748(c)(1), §416.54(c)(1), §418.113(c)(1), §441.184(c)(1), §460.84(c)(1), §482.15(c)(1), §483.73(c)(1), §483.475(c)(1), §484.102(c)(1), §485.68(c)(1), §485.625(c)(1), §485.727(c)(1), §485.920(c)(1), §486.360(c)(1), §491.12(c)(1), §494.62(c)(1). [(c) The [facility must develop and maintain an emergency preparedness communication plan that complies with Federal, State and local laws and must be reviewed and updated at least every 2 years [annually for LTC facilities]. The communication plan must include all of the following:] (1) Names and contact information for the following: (i) Staff. (ii) Entities providing services under arrangement. (iii) Patients' physicians (iv) Other [facilities]. (v) Volunteers. *[For Hospitals at §482.15(c) and CAHs at §485.625(c)] The communication plan must include all of the following: (1) Names and contact information for the following: (i) Staff. (ii) Entities providing services under arrangement. (iii) Patients' physicians (iv) Other [hospitals and CAHs]. (v) Volunteers. *[For RNHCIs at §403.748(c):] The communication plan must include all of the following: (1) Names and contact information for the following: (i) Staff. (ii) Entities providing services under arrangement. (iii) Next of kin, guardian, or custodian. (iv) Other RNHCIs. (v) Volunteers. *[For ASCs at §416.45(c):] The communication plan must include all of the following: (1) Names and contact information for the following: (i) Staff. (ii) Entities providing services under arrangement. (iii) Patients' physicians. (iv) Volunteers. *[For Hospices at §418.113(c):] The communication plan must include all of the following: (1) Names and contact information for the following: (i) Hospice employees. (ii) Entities providing services under arrangement. (iii) Patients' physicians. (iv) Other hospices. *[For HHAs at §484.102(c):] The communication plan must include all of the following: (1) Names and contact information for the following: (i) Staff. (ii) Entities providing services under arrangement. (iii) Patients' physicians. (iv) Volunteers. *[For OPOs at §486.360(c):] The communication plan must include all of the following: (2) Names and contact information for the following: (i) Staff. (ii) Entities providing services under arrangement. (iii) Volunteers. (iv) Other OPOs. (v) Transplant and donor hospitals in the OPO's Donation Service Area (DSA). This STANDARD is not met as evidenced by: Based on record review and interview, the agency failed to ensure an Emergency Preparedness Communication Plan included updated required information related to the staff contact information for the agency. Findings: A review of administrative records showed the Emergency Preparedness Communication Plan included staff contact information for former staff members who no longer worked for the agency and did not include staff contact information for current staff members who worked for the agency. On 07/13/22 at 1:30 p.m., Staff A stated the active staff member call list was not updated with current contact information in the Emergency Preparedness Communication Plan for the agency.

The Oklahoma State Department of Health conducted an unannounced Medicare re-certification survey at the agency on 07/12/22 through 07/13/22 An entrance conference was conducted with Staff A and B. The survey process was explained. Questions were answered. Staff A and Staff C was identified as the contact persons for administrative issues and Staff B was identified as the contact person for clinical issues. Findings were discussed during an informal exit conference with Staff A, B and C. Standard level deficiencies were cited as a result of the Medicare re-certification survey. Glossary: OT Occupational Therapy PT Physical Therapy POC Plan of Care PRN as needed SN Skilled Nurse

Before discharge for cause HHA must: CFR(s): 484.50(d)(5) The HHA determines, under a policy set by the HHA for the purpose of addressing discharge for cause that meets the requirements of paragraphs (d)(5)(i) through (d)(5)(iii) of this section, that the patient's (or other persons in the patient's home) behavior is disruptive, abusive, or uncooperative to the extent that delivery of care to the patient or the ability of the HHA to operate effectively is seriously impaired. The HHA must do the following before it discharges a patient for cause: This ELEMENT is not met as evidenced by: Based on record review and interview, the agency failed to ensure advance notice of discharge was provided prior to being discharged from the agency for one (Patient #8) of 10 patients. Findings: Patient #8 A review of the clinical record showed no advance notice of discharge prior to discharge from the agency on 03/11/22 for non-compliance. On 07/13/22 at 2:50 p.m., Staff B stated Patient #8 should have received an advanced notice of discharge but did not for non-compliance prior to being discharged from the agency.

Advise the patient of discharge for cause CFR(s): 484.50(d)(5)(i) (i) Advise the patient, representative (if any), the physician(s) or allowed practitioner(s), issuing orders for the home health plan of care, and the patient's 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) that a discharge for cause is being considered; This ELEMENT is not met as evidenced by: Based on record review and interview, the agency failed to ensure: 1. Patient education on potential health outcomes related to refusal of OT visits for one (Patient #8) of 10 patients and; 2. Pysician notification of the patient's continued refusal of OT visits for one (Patient #8) of 10 patients. Findings: Patient #13 A review of a plan of care for 01/31/22 to 03/31/22 showed an OT visit frequency of one week one, then two times a week for three weeks. A review of visit notes showed missed OT visits on 02/08/22, 02/16/22, 02/17/22 and on 02/23/22 with a subsequent OT discipline discharge on 02/25/22. The patient was discharged from agency services on 03/11/22 for non-compliance. Continued review of clinical documentation showed no communication or education attempts to the patient for potential health outcomes related to refusal of OT visits and no documentation to the physician of the patient's continued refusal of OT visits or discharge from the agency for non-compliance prior to the discharge date of 03/11/22. On 07/13/22 at 2:50 p.m., Staff B stated there was no documentation of: 1. Attempts to educate the patient of potential health outcomes related to refusal of OT visits and; 2. No physician notification of the patient's refusal of OT visits with subsequent discharge from the agency for non-compliance.

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 record review and interview, the agency failed to ensure: The medication profile was reviewed, updated and the physician was notified of an allergy alert for an ordered medication for one (Patient #1) of 10 patients and;The medication profile was reviewed and updated with an ordered medication for one (Patient #4) of 10 patients. Findings: Patient #1 A review of a POC dated 05/24/22 to 07/22/22 showed the patient was allergic to hydrocodone (a pain medication). Documentation showed hydrocodone / acetaminophen 7.5/325 milligram every 6 hours as needed for pain. Documentation showed no system allergy auto-alert, no physician notification and no change in orders. On 07/13/22 at 1:42 p.m., Staff B stated the clinical record showed no documentation of a system allergy auto-alert, no physician notification and no change in orders. Patient #4 A review of a POC dated 06/10/22 to 08/10/22 showed no documentation the patient was on a course of oral antibiotics. A clinical SN visit note dated 06/06/22 documented the patient was on antibiotics. Documentation showed no update to the medication profile, no physician coordination of care to verify the antibiotics and no changes in orders. On 07/13/22 at 2:08 p.m., Staff B stated: 1. the antibiotic medication should have been added to the medication profile to be reviewed for allergy and medication interactions and end dated on the date of the last ordered dose and 2. The medication was not added to the medication profile or reviewed for allergies or interaction.

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 record review and interview, the agency failed to ensure the individualized patient POC included: pain reporting parameters for six (Patients #1, 2, 3, 5, 9 and #10) of 10 patients and;Recurring urinary catheter change due dates were documented for one (Patient #4) of 10 patients. Findings: Patient #1 A review of the plan of care dated 05/24/22 to 07/22/22 showed a principal diagnosis of fracture of the tibia. Documentation showed instructions for SN to assess and teach intervention to monitor and mitigate pain and teach medication use with a goal of pain will be controlled. Documentation showed no pain reporting parameter for physician notification of the patient’s pain levels and no acceptable patient pain level to indicate pain was controlled. Patient #2 A review of the plan of care dated 06/01/22 to 07/30/22 showed a principal diagnosis of epilepsy. Documentation showed instructions for SN to assess and teach intervention to monitor and mitigate pain and teach medication use with a goal of pain will be controlled. Documentation showed no pain reporting parameter for physician notification of the patient’s pain levels and no acceptable patient pain level to indicate pain was controlled. Patient #3 A review of the plan of care dated 06/04/22 to 08/02/22 showed a principal diagnosis of dysphagia. Documentation showed instructions for SN to assess and teach intervention to monitor and mitigate pain and teach medication use with a goal of pain will be controlled. Documentation showed no pain reporting parameter for physician notification of the patient’s pain levels and no acceptable patient pain level to indicate pain was controlled. Patient #4 A review of the plan of care dated 06/10/22 to 08/08/22 showed a principal diagnosis of cirrhosis and a secondary diagnosis of cystostomy. POC orders instructed SN to change suprapubic Foley catheter every two weeks. POC documentation showed no treatment due date or treatment date the indwelling Foley catheter change was last conducted. Patient #5 A review of the plan of care dated 06/04/22 to 08/02/22 showed a principal diagnosis of dysphagia. Documentation showed instructions for SN to assess and teach intervention to monitor and mitigate pain and teach medication use with a goal of pain will be controlled. Documentation showed no pain reporting parameter for physician notification of the patient’s pain levels and no acceptable patient pain level to indicate pain was controlled. Patient #9 A review of the plan of care dated 06/04/22 to 08/02/22 showed a principal diagnosis of dysphagia. Documentation showed instructions for SN to assess and teach intervention to monitor and mitigate pain and teach medication use with a goal of pain will be controlled. Documentation showed no pain reporting parameter for physician notification of the patient’s pain levels and no acceptable patient pain level to indicate pain was controlled. Patient #10 A review of the plan of care dated 06/04/22 to 08/02/22 showed a principal diagnosis of dysphagia. Documentation showed instructions for SN to assess and teach intervention to monitor and mitigate pain and teach medication use with a goal of pain will be controlled. Documentation showed no pain reporting parameter for physician notification of the patient’s pain levels and no acceptable patient pain level to indicate pain was controlled. On 07/13/22 at 1:50 p.m., Staff B stated individualized POCs should have documented: Pain reporting parameters for Patients #1, 2, 3, 5, 9 and #10;Recurring urinary catheter treatment due dates for Patient #4 andThe POC for Patients #1, 2, 3, 5, 9, and 10 did not document pain reporting parameters and the POC for Patient #4 did not show due dates for catheter changes.

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 reviews and interview, the agency failed to ensure: SN visits were conducted as ordered by the physician for three (Patients #1, 2 and #7) of 10 patients;SN staff perform wound care as ordered by the physician for one (Patient #4) of 10 patients. Findings: Patient #1 A review of the POC dated 05/24/22 to 07/22/22 showed a SN visit frequency of one time a week for seven weeks. Documentation showed during the week of 05/29/22 to 06/04/22 a SN visit was conducted on 05/31/22 and on 06/01/22 (two visits conducted, one visit ordered). Documentation showed no patient or caregiver request for a PRN visit, physician notification of the additional visit and no change in orders. On 07/13/22 at 1:44 p.m., Staff B stated the physician should have been notified of the need for additional SN visit for Patient #1 but was not. Patient #2 A review of the POC dated 06/01/22 to 07/30/22 showed a SN visit frequency of one time a day for one day, one time a week for three weeks, one time a day for one day, then one time a week for four weeks. Documentation showed during the week of 06/12/22 to 06/18/22 SN visits were conducted on 06/13/22, 06/14/22, 06/15/22, 06/17/22 and a PRN visit on 06/18/22 for a lab draw (five visits conducted, two visits ordered). Documentation showed no patient or caregiver request for additional visits, physician notification of the need for additional visits and no change in orders. On 07/13/22 at 1:52 p.m., Staff B stated the physician should have been notified of the need for additional SN visits for Patient #2 but was not. Patient #4 A review of the POC dated 06/10/22 to 08/08/22 showed a SN frequency of two times a week for nine weeks for SN to assess wound sites and conduct wound care to the right lower extremity and left great toe. Documentation showed during the SN visit on 06/24/22 hydrofera blue (a wound care material) was applied to the wound sites (material not ordered by the physician). Documentation showed no physician notification of change in wound care materials, no change in orders and no patient or caregiver refusal of the ordered wound care to the wound sites. On 07/13/22 at 2:08 p.m., Staff B stated the SN should not have used the hydrofera blue wound care material to conduct the wound site care for Patient #4. Patient #7 A review of the POC dated 05/23/22 to 07/21/22 showed a SN visit frequency of one time a week for four weeks. Documentation showed during the week of 06/19/22 to 06/25/22 a SN visit was conducted on 06/24/22 (one visit conducted, no visit ordered). Documentation showed no patient or caregiver request for a PRN visit, physician notification of the need for the additional visit and no change in orders. On 07/13/22 at 2:44 p.m., Staff B stated the physician should have been notified of the need for additional SN visit for Patient #7 but was not.

Coordination of Care CFR(s): 484.60(d) Standard: Coordination of care. The HHA must: This STANDARD is not met as evidenced by: Based on record review and interview, the agency failed to ensure care was coordinated between the agency and physician for three (Patient #2, 4 and #8) of 10 patients. Findings: Patient #2 A review of the POC dated 06/01/22 to 07/30/22 showed an OT visit frequency of one time a week for one week, then two times a week for three weeks. Documentation showed during the week of 06/12/22 to 06/18/22 an OT visit was conducted on 06/16/22 (one visit conducted and one visit missed). Documentation showed no physician notification of the missed visit, no change in orders, and no patient or caregiver refusal of the visit. On 07/13/22 at 1:52 p.m., Staff B stated the physician should have been notified of the missed OT visit for Patient #2 but was not. Patient #4 A review of the POC dated 06/10/22 to 08/08/22 showed a SN frequency of two times a week for nine weeks for SN to monitor and educate on disease management with skilled observation and assessment of blood sugar per home glucose monitoring and to notify physician of blood sugar levels below 60 and above 350. Documentations showed on SN visit notes dated 06/16/22, 06/20/22, 06/22/22 and on 06/24/22 the patient did not monitor his blood sugar levels. Documentation showed no SN performed blood sugar monitoring, no physician notification communications the patient’s blood sugar levels were not being monitored and no changes in orders. On 07/13/22 at 2:08 p.m., Staff B stated the physician should have been notified Patient #4 was not conducting blood sugar testing and the SN was not monitoring the blood sugar levels and that the physician was not notified. Patient #8 A review of the POC dated 01/31/22 to 03/31/22 showed a OT visit frequency of one time a week for one week then two times a week for three weeks and a PT visit frequency of one time a week for four weeks; then effective week of 02/28/22 one time a week for two weeks. Documentation showed OT visit were missed on 02/08/22, 02/16/22, 02/17/22 and on 02/23/22 and showed no physician notification communications of the OT missed visits. Documentation showed the patient was discharged from PT service on 03/08/22, and from agency services on 03/11/22 for non-compliance. PT visit notes dated 02/02/22, 02/04/22, 02/11/22, 02/23/22, 02/24/22 and on 03/02/22 documented no patient non-compliance with the PT treatment plan or refused PT visits. Documentation showed no physician notification communications of treatment plan non-compliance, no patient advance notice of discharge from agency services for non-compliance and no change in orders. On 07/13/22 at 2:52 p.m., Staff B stated the physician should have been notified but was not of OT missed visits and therapy treatment plan non-compliance prior to discharge from therapy services on 03/08/22 and discharge from agency services on 03/11/22.

Program activities CFR(s): 484.65(c) Standard: Program activities. The HHA's performance improvement activities must-- This STANDARD is not met as evidenced by: Based on record review and interview, the agency failed to ensure conduction of patient centered QAPI Program activities for all patients and employees. Findings: A review of administrative records showed no ongoing QAPI program activities to include meetings to analyze data and review the QAPI program plan for changes to improve the care, services, and operations of the agency for 3rd quarter calendar year 2020 and 2nd quarter calendar year 2021. On 07/13/22 at 4:00 p.m., Staff C stated: 1. the agency combined QAPI meeting activities for 3rd quarter in the 4th quarter meeting in calendar year 2020 and the meeting activity for 2nd quarter in the 3rd quarter meeting in calendar year 2021; 2. QAPI documentation did not accurately show QAPI activity.

Provide services in the plan of care CFR(s): 484.75(b)(3) Providing services that are ordered by the physician or allowed practitioner as indicated in the plan of care; This ELEMENT is not met as evidenced by: Based on record review and interview, the agency failed to ensure services were provided as ordered on the POC’s: SN to conduct wound site assessments and perform wound care for three (Patient #1, 4 and #6) of 10 patients;SN to conduct assessments of patient weight every visit and notify the physician of change in patient weight for one (Patient #7) of 10 patients;SN conducted visit frequencies as ordered for two (Patient #9 and #10) for 10 patients and;Home Health Aide conducted visit frequency for one (Patient #10) of 10 patients. Findings: Patient #1 A review of the POC dated 05/24/22 to 07/22/22 showed orders for SN to conduct wound site assessment and care every visit. Documentation showed no wound site care was performed on 05/31/22 SN visit. Documentation showed no patient/caregiver refusal of wound site assessment and care, no physician notification of the wound site assessment and care and no change in orders. Patient #4 A review of the POC dated 06/10/22 to 08/08/22 showed orders for SN to conduct wound site assessment and care every visit. Documentation showed no wound site care was performed on 06/16/22 and on 06/22/22 SN visits. Documentation showed no patient/caregiver refusal of wound site assessment and care, no physician notification of the wound site assessment and care and no change in orders. Patient #6 A review of the POC dated 06/22/22 to 08/20/22 showed orders for SN to conduct wound site assessment and care every visit. Documentation showed no wound site care was performed on 06/28/22 and on 07/01/22 SN visits. Documentation showed no patient/caregiver refusal of wound site assessment and care, no physician notification of the wound site assessment and care and no change in orders. Patient #7 A review of the POC dated 05/23/22 to 07/21/22 showed orders for SN to conduct assessment of patient weight every visit and notify the physician of change in patient weight of greater than three pounds. Documentation showed no patient weight assessment was conducted during SN visits on 05/27/22, 06/0322, 06/09/22, 06/16/22, 06/24/22, 06/29/22 and on 07/06/22. Documentation showed no patient/caregiver refusal of patient weight assessment, no physician notification of the weight and no change in orders. Patient #9 A review of the POC dated 04/08/22 to 06/06/22 showed a SN visit frequency of two times a week for nine weeks. Documentation showed during the week of 04/10/22 to 04/16/22 a SN visit was conducted on 04/15/22 (one visit conducted, two visit ordered); during the week of 04/24/22 to 04/30/22 a SN visit was conducted on 04/29/22 (one visit conducted, two visit ordered). Documentation showed no patient/caregiver refusal of SN visits, no physician notification of missed SN visits and no change in orders. Patient #10 A review of the POC dated 06/06/22 to 08/04/22 showed a SN visit frequency of one time a day for one day, then one time a week for eight weeks and a Home health Aide visit frequency of two times a week for six weeks. Documentation showed during the week of 06/11/22 to 06/17/22 no SN visit was conducted (one visit ordered, no visit conducted) and home health aide visits on 06/08/22, 06/09/22 and on 07/06/22 were documented as missed visits with no physician notification. Documentation showed no patient/caregiver refusal of SN visit, no physician notification of missed SN visit or missed home health aide visits and no change in orders. On 07/13/22 at 3:30 p.m., Staff B stated: SN should have conducted wound site assessment and care for Patients #1, 4 and #6 but did not;SN should have conducted patient weight assessments and monitoring for Patient #7 every SN visit and notified the physician of patient weight gain greater than three pounds but did not;SN visits should have been conducted as ordered for Patients #9 and #10 but was not and;Home Health Aide missed visits should have been reported to the physician for Patient #10 but was not.

Participate in the HHA's QAPI program; CFR(s): 484.75(b)(8) Participation in the HHA's QAPI program; and This ELEMENT is not met as evidenced by: Based on a record review and interview, the agency failed to ensure multi-discipline professional staff were available to participate and provide input into the agency’s QAPI program for all patients and employees. Findings: A review of administrative records showed no multi-discipline professional staff participation to improve the care, services, and operations of the agency during QAPI meeting activities documented for calendar year 2020, and 1st and 2nd quarters calendar year 2021. Additional administrative records were requested, no additional records were provided. On 07/13/22 at 4:00 p.m., Staff C stated the agency had no documentation that showed multi-discipline professional staff participation during QAPI program meeting activities for calendar year 2020, and 1st and 2nd quarters calendar year 2021 and no additional administrative records were available for review.

Governing body CFR(s): 484.105(a) Standard: Governing body. A governing body (or designated persons so functioning) must assume full legal authority and responsibility for the agency's overall management and operation, the provision of all home health services, fiscal operations, review of the agency's budget and its operational plans, and its quality assessment and performance improvement program. This STANDARD is not met as evidenced by: Based on record review and interview the agency failed to ensure governing body oversite of: A patient centered QAPI Program for calendar years 2020 and 2021;Agency program evaluation for calendar years 2020 and 2021 and;An operating budget and allocation of resources activities for calendar year's 2020 and 2021 effecting all patients and staff. Findings: A review of administrative records showed no governing body oversite of an ongoing patient centered QAPI program, agency program evaluation or operating budget and allocation of resource activities for calendar year's 2020 and 2021. On 07/13/22 at 4:30 p.m., Staff C stated there was no documentation which showed governing body oversight for the agency’s QAPI program, agency program evaluation or operating budget and allocation of resource activities for calendar year's 2020 and 2021.