Every finding on record at Concerned Care Home Health, Inc

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

Recertification Survey Abbreviations ALF- Assisted Living Facility CFR- Code of Federal Regulations CMS- Center for Medicare and Medicaid Services DR- Delayed Release ER- Extended Release mg- milligram ml- milliliter PoC- Plan of Care SOC- Start of Care SN- Skilled Nurse OASIS- Outcome and Assessment Information Set

Encoding and transmitting OASIS CFR(s): 484.45(a) Standard: An HHA must encode and electronically transmit each completed OASIS assessment to the CMS system, regarding each beneficiary with respect to which information is required to be transmitted (as determined by the Secretary), within 30 days of completing the assessment of the beneficiary. This STANDARD is not met as evidenced by: Based on record review and interviews, the agency failed to encode and electronically transmit each completed OASIS (Outcome and Assessment Information Set) as evidenced by failing to ensure the agency successfully completed and transmitted OASIS data within 30 days of completion of the assessment of the beneficiary. Findings: Findings: Review of CMS’s (Center for Medicare and Medicaid Services) Standard Regulation Text titled “CFR (Code of Federal Regulations) Section 484.45(a)” revealed: A home health agency must encode and electronically transmit each completed OASIS assessment to the CMS system, regarding each beneficiary with respect to which information is required to be transmitted (as determined by the Secretary), within 30 days of completing the assessment of the beneficiary. Review of the agency’s Oasis Detail Error Report dated 04/01/2024 to 06/18/2024 revealed 20 Oasis assessments with error code -3330 were submitted more than 30 days after the date of completion on the record, which was late. On 06/27/2024 at 3:00 p.m., a phone interview was conducted with S7OM. S7OM confirmed she was responsible for all OASIS submissions. She verified the aforementioned Oasis records reviewed were submitted more than 30 days after the completion date on the record and were late. On 06/27/2024 at 3:05 p.m., an interview was conducted with S1DCS. S1DCS confirmed S7OM was responsible for the submission of all Oasis data. S1DCS further confirmed she did not review the validation reports for accuracy, including if any submissions were late, or > 30 days of the completion date. SIDCS reviewed the validation reports dated 04/01/2024- 06/18/2024 and confirmed the OASIS assessments on these dates with error code -3330 were submitted more than 30 days after the completion date on record and were late.

A review of all current medications CFR(s): 484.55(c)(5) A review of all medications the patient is currently using in order to identify any potential adverse effects and drug reactions, including ineffective drug therapy, significant side effects, significant drug interactions, duplicate drug therapy, and noncompliance with drug therapy. This ELEMENT is not met as evidenced by: Based on observations, record reviews, and interviews, the agency failed to ensure the medication profile accurately reflected all medications patients were using, and/or did not reflect medications the patients were no longer using, for 4 (Patient #1, #2, #6 and #7) of 7 (Patients #1- #7) sampled patients reviewed who received home visits. Findings: Patient #1 Review of the clinical record revealed the patient had a SOC (Start of Care) date of 06/08/2024. The patient's current diagnoses included Type 2 Diabetes Mellitus with Diabetic Chronic Kidney Disease. A review of the 485/PoC (Plan of Care) for the certification period of 06/08/2024-08/06/2024 revealed Orders and Treatments, which included the following: SN 1day1, then 1w9. A current medication profile list was provided by the agency on 06/25/2024. On 06/25/2024 at 9:05 a.m., a visit and interview were conducted at Patient #1’s home with S2LPN present. Patient #1 stated his daughter setup his medications. His daughter was unavailable and not present during the home visit. The current medication profile list provided by the agency for Patient #1 was reviewed with S2LPN and revealed the following discrepancies: 1. Zyrtec 10mg one tablet by mouth daily. This medication was listed as a current medication on the patient's medication list provided by the agency. There were no Zyrtec tablets available in the home. 2. Bupropion HCL ER (XL) 300mg one tablet by mouth daily. This medication was listed as a current medication on the patient’s medication list provided by the agency. There were no Bupropion tablets available in the home. A review of SN visit documentation revealed SN visits were conducted with Patient #1 on the following dates during the current Certification Period of 06/08/2024 to present: 06/15/2024 and 06/21/2024. S2LPN verified Patient #1’s medication list had not been updated to reflect the current medications he was taking and should have. Patient #2 Review of the clinical record revealed a start of care date of 04/17/2024. A review of the Home Health Certification and Plan of Care/485 for the Certification Period of 06/16/2024- 08/14/2024 revealed a primary diagnosis of Hypertensive Heart and Chronic Kidney Disease Stage 1-4 and orders, which included SN 1w8 effective week of 08/01/2021. A current medication profile list was provided by the agency on 06/25/2024. On 06/25/2024 at 10:05 a.m., a visit and interview were conducted at Patient #2’s home with S2LPN present. The current medication profile list provided by the agency for Patient #2 was reviewed with the Assisted Living facility (ALF) nurse and S2LPN and revealed the following discrepancies: 1. A bottle of Zinpep DR 20,000 units 1 capsule by mouth three times daily, with a prescription fill date of 06/13/2024 was provided by the ALF nurse. This medication was not listed as a current medication on Patient #2’s medication profile list. A review of SN visit documentation revealed SN visits were conducted with Patient #2 on the following dates during the current Certification Period of 06/16/2024 to present: 06/18/2024 and 06/25/2024. The ALF nurse verified she administered Patient #2’s medications daily and stated Patient #1’s new Zinpep DR medication was started on 06/13/2024. S2LPN verified Patient #2’s medication list had not been updated to reflect the current medications she was taking and should have been. Patient #6 Review of the clinical record revealed a start of care date of 12/16/2023. A review of the Home Health Certification and Plan of Care/485 for the Certification Period of 06/13/2024 to 08/11/2024 revealed a primary diagnosis of Hypertensive Heart and Chronic Kidney Disease with Heart Failure and Stage 1-4 Chronic Kidney Disease and orders which included SN 1w1, 3w8. A current medication profile list was provided by the agency on 06/25/2024. Review of the physician’s order dated 06/21/2024 for Patient #6 signed by S3RN revealed: Problem: Rash to lower extremities New order: Apply barrier cream to skin as needed for rash or irritation. On 06/26/2024 at 8:52 a.m., a visit and interview were conducted at Patient #6’s home with S3RN and Patient #6’s sitter present. Patient #6’s spouse was not present in the home. Patient #6 stated her husband prepared all of her medications weekly. Patient #6’s sitter stated she was not familiar with the patient's medications and did not prepare her medications. The current medication profile list provided by the agency for Patient #6 was reviewed with S3RN and revealed the following discrepancies: 1. Boudreaux’s Butt Paste a.k.a. Barrier Cream was not listed on the current medication list provided by the agency. A review of SN visit documentation revealed SN visits were conducted with Patient #6 on the following dates during the current Certification Period of 06/13/2024 to present: 06/14/2024, 06/18/2024, 06/19/2024, 06/22/2024, and 06/26/2024. S3RN verified Patient #6’s medication list had not been updated to reflect the current medications she was taking and should have been. Patient #7 Review of the clinical record revealed a start of care date of 02/23/2024. A review of the Home Health Certification and Plan of Care/485 for the Certification Period of 06/22/2024 to 08/20/2024 revealed a primary diagnosis of Pressure Ulcer of Other Site, Stage 4 and orders which included SN 2w2, 3w3 effective 06/13/2024. A current medication profile list was provided by the agency on 06/25/2024. On 06/26/2024 at 9:25 a.m., a visit and interview were conducted at Patient #7’s home with S3RN present. Patient #7 verified he was familiar with his medications and managed them himself. Review of the medications listed on Patient #7’s current medication profile list provided by the agency revealed the following discrepancies when compared with medications in the home: 1. Ozempic 2mg/1.5ml Inject 1ml daily. The patient stated he has no longer is taking this medication due to cost and has not taken this medication in several weeks. 2. Doxcycline Hyclate 100mg tablet by mouth every 12 hours. The patient stated he no longer is taking this medication and has not taken this medication in several weeks. 3. Metoprolol 100mg one tablet twice a day. There was no medication bottle to review in the home, and the patient stated he has been taking this medication for over 3 years. A review of SN visit documentation revealed SN visits were conducted with Patient #7 on the following dates during the current Certification Period of 06/22/2024 to present: 06/26/2024. Review of prior cert period 04/23/2024-06/21/2024 revealed SN visit was last conducted on 06/21/2024 for recertification. S3RN verified Patient #7's medication list had not been updated to reflect the current medications he was taking and should have been. On 06/27/2024 at 3:05 p.m., an interview was conducted with S1DCS. She was notified of the medication discrepancies found during the home visits for Patients #1, #2, #6, and #7. She verified the medication profiles were not up to date. S1DCS confirmed nurses should reconcile medications during each SN visit and update the medication profiles accordingly.

Infection Prevention CFR(s): 484.70(a) Standard: Infection Prevention. The HHA must follow accepted standards of practice, including the use of standard precautions, to prevent the transmission of infections and communicable diseases. This STANDARD is not met as evidenced by: Based on observations, interviews, and record reviews, the HHA failed to ensure staff followed accepted standards of infection control practices for 3 (Patients #1, #6, #7) of 7 (Patients #1, #2, #3, #4, #5, #6, and #7) patients observed during home visits. The agency staff failed to: 1. Ensure staff properly disinfected reusable equipment used during home visits with Patients #1, #6, #7; and 2. Practice proper bag barrier technique while providing care to Patients #6 and #7. Findings: Review of the undated Agency's Competency Training titled “Bag Technique” included the following, in part: Purpose: to decrease spread of infection from patient to patient. Expectations: All supplies that have touched a patient/unclean surface will be considered dirty until they have been cleaned with an antimicrobial wipe. (ex. B.P. cuff, thermometer, etc). All employees will equip themselves with a disposable waterproof barrier to protect bags. Visit Process: Place bag on waterproof barrier in home. Remove B.P. cuff, thermometer and other supplies needed for visit from bag and place on clean barrier. Take patient vitals and proceed with assessment. Clean all supplies (B.P. cuff, stethoscope, thermometer, etc.) with antimicrobial wipe and place back into clean portion of bag. 1. Patient #1 Review of the clinical record revealed the patient had a SOC (Start of Care) date of 06/08/2024. A review of the 485/PoC (Plan of Care) for the certification period of 06/08/2024 – 08/06/2024 revealed Orders and Treatments, which included the following: SN (Skilled Nurse) 1day1, then 1w9. On 06/25/2024 at 9:05 a.m., an observation and interview were conducted in the home of Patient #1 with S2LPN present. S2LPN was observed taking the patient's blood pressure, temperature, and pulse oximetry reading. After completing the vital sign assessment, S2LPN returned her reusable blood pressure cuff, stethoscope, thermometer, and pulse oximeter to her bag without properly disinfecting her equipment. S2LPN verified she did not have any antimicrobial wipes on hand and did not clean her reusable equipment before returning them to her bag. Patient #6 Review of the clinical record revealed the patient had a SOC (Start of Care) date of 12/16/2023. A review of the 485/PoC for the certification period of 06/13/2024- 08/11/2024 revealed Orders and Treatments, which included the following: SN 1w1, 3w8. On 06/26/2024 at 8:52 a.m., an observation and interview were conducted in the home of Patient #6 with S3RN present. S3RN was observed taking the patient's blood pressure, temperature and performing a pulse oximetry reading. After completing the vital sign assessment, S3RN returned her reusable blood pressure cuff, stethoscope, thermometer and pulse oximeter to her bag/box without properly disinfecting her equipment. S3RN verified she did not have any antimicrobial wipes on hand and did not clean her reusable equipment before returning them to her bag/box. Patient #7 Review of the clinical record revealed the patient had a SOC date of 02/23/2024. A review of the 485/PoC for the certification period of 06/22/2024- 08/20/2024 revealed original Orders and Treatments which included the following: SN 2w2, 3w3. On 06/26/2024 at 9:25 a.m., an observation and interview were conducted in the home of Patient #7 with S3RN present. S3RN was observed taking the patient's blood pressure, temperature, and pulse oximetry reading. After completing the vital sign assessment, S3RN returned her reusable blood pressure cuff, stethoscope, thermometer, and pulse oximeter to her bag/box without properly disinfecting her equipment. S3RN confirmed she had not properly disinfected her equipment using antimicrobial wipes before returning them to her bag/box and should have. On 06/27/2024 at 2:55 p.m., an interview was conducted with S1DCS. S1DCS confirmed all staff should clean reusable equipment with antimicrobial wipes before returning them to their bag. 2. Patient #6 Review of the clinical record revealed the patient had a SOC date of 12/16/2023. A review of the 485/PoC for the certification period of 06/13/2024- 08/11/2024 revealed Orders and Treatments, which included the following: SN 1w1, 3w8. On 06/26/2024 at 8:52 a.m., an observation and interview were conducted in the home of Patient #6 with S3RN present. S3RN was observed placing her equipment box on the patient’s dining table without a barrier between the box and table. S3RN verified she did not use a barrier between her box and patient’s table and should have. Patient #7 Review of the clinical record revealed the patient had a SOC date of 02/23/2024. A review of the 485/PoC for the certification period of 06/22/2024- 08/20/2024 revealed original Orders and Treatments which included the following: SN 2w2, 3w3. On 06/26/2024 at 9:25 a.m., an observation and interview were conducted in the home of Patient #7 with S3RN present. S3RN was observed placing her equipment box on the patient’s side table without a barrier between the box and table. S3RN verified she did not use a barrier between her box and patient’s table and should have. On 06/27/2024 at 2:55 p.m., an interview was conducted with S1DCS. S1DCS confirmed all staff should use a waterproof barrier to place their bag/box on during patient visits.

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: Findings: Review of the agency’s policy titled “Care Planning Process” dated November 2017 revealed the following, in part: Policy: The care planning process will be documented on the plan of care, individualized discipline specific care plans, and clinical notes. 3. Based on the assessment and conclusions, the plan of care will include: A. Patient specific interventions and education. D. Specific services and treatments to be provided. 5. Will be based on physician’s orders and will encompass the equipment, supplies, and services required to meet the patient’s needs. Review of the agency’s undated policy titled “Wound Care Protocol” revealed, in part: Wounds must match Physician’s Orders. Measurements should be done at least weekly. Prescribing physician or NP (Nurse Practitioner) must be notified of any changes in wounds. 1. Patient #4 Review of Patient #4’s Clinical Record revealed she was admitted to the agency on 05/14/2024 with diagnoses, which included Infection/Inflammation Reaction Due to Internal Right Knee Prosthesis, Initial Encounter and Type 2 Diabetes Mellitus with Foot Ulcer, and Non-Pressure Chronic Ulcer Other Part Right Foot. Review of Patient #4’s Plan of Care for certification period of 05/14/2024 to 07/12/2024 revealed Physician Orders, which included the following, in part: Skilled Nurse (SN): 2w2, 1w7. SN to perform and instruct wound care on the right third toe: paint with Betadine, cover with island dressing/border daily. Caregiver may perform on alternate days of skilled nurse visit. SN to perform and instruct wound care on the right third toe: cleanse with soap and water, pat dry, and apply antifungal skin barrier ointment 2 times a day and as needed soilage. Caregiver may perform on alternate days of skilled nurse visit. SN to perform and instruct wound care to right knee: Surgical dressing in place. Remove dressing after 7 days (05/19/2024). After removal, clean with alcohol and place silver dressing to site. Review of the Client Calendar Report for Patient #4 revealed Skilled Nurse visits were conducted on: 05/14/2024, 05/16/2024, 05/20/2024, 05/24/2024, 05/30/2024, 06/07/2024, 06/10/2024, 06/13/2024, 06/19/2024, and 06/26/2024. Review of Patient #4’s clinical nursing notes dated 05/24/2024, 05/30/2024, and 06/13/2024 revealed no wound care had been provided per Physician’s Orders and no wound measurements were performed. No documentation provided by the agency indicated the patient’s caregiver had provided the wound care on those dates. On 06/27/2024 at 3:15 p.m., an interview was conducted with S1DCS. She reviewed Patient #4’s Clinical Record and confirmed wound care should have been provided per physician’s orders/Plan of care and wounds measured at least weekly on the aforementioned dates and was not. 2. Patient #6 Review of Patient #6’s Clinical Record revealed she was admitted to the agency on 12/16/2023 with diagnoses, which included Hypertensive Heart and Chronic Kidney Disease with Heart Failure and Stage 3 Chronic Kidney Disease. Review of Patient #6’s Plan of Care for certification period of 04/14/2024 to 06/12/2024 revealed Physician Orders, which included the following, in part: Skilled Nurse (SN) effective week of 04/15/2024 2w8, 1w1. SN to perform wound care on the left lower extremity: Cleanse with Hibiclens, wrap with unna boot and Coban, wound care to be performed 3 times a week. Caregiver may perform wound care on alternate days of skilled nurse visit. Review of the Client Calendar Report for Patient #6 revealed Skilled Nurse visits were conducted on 04/29/2024, 05/03/2024, 05/06/2024, 05/10/2024, 05/13/2024, 05/17/2024- Missed visit, 05/20/2024, 05/24/2024, 05/31/2024, 06/03/2024, 06/05/2024, 06/07/2024, and 06/10/2024. Review of Nurses notes dated 04/29/2024 by S3RN revealed, in part: Seen by [Wound Care Clinic Provider]. Will discontinue unna boots temporarily and see if blisters and redness return to bilateral lower extremities. Edema still 2+. Further record review revealed there was no written, signed Physician Orders provided by the agency for unna boot discontinuation on 04/29/2024. Review of Nurses notes dated 05/03/2024 by S3RN revealed in part: Wound assessment: left lower extremity skin lesion. Treatment: cleansed with normal saline, applied unna boot and covered with Coban. Further record review revealed no written, signed Physician Orders provided by the agency for unna boots to be resumed on 05/03/2024. Review of Nurses notes dated 05/06/2024 by S3RN revealed in part: Wound assessment: left lower extremity skin lesion. Status: Closed. Further review revealed there was no written Physician Orders provided by the agency for the discontinued wound care as of 05/06/2024. Review of Nurses notes dated 05/31/2024 by S3RN revealed in part: There are two areas of concern to patient’s left and right leg. Re-evaluate at next visit. Further record review revealed there was no communication documented in the clinical record Patient #6’s physician had been notified of the skin changes. Review of Nurses notes dated 06/03/2024 by S3RN revealed in part: Right leg has several blisters. SN cleaned with normal saline and applied barrier cream to site. Further record review revealed there were no updated wound care orders approved by Patient #6’s physician for wound care provided by S3RN to Patient #6’s right leg on 06/03/2024. Review of Patient #6’s Plan of Care for certification period of 06/13/2024 to 08/11/2024 revealed there were no Physician Orders for wound care. Review of the Client Calendar Report for Patient #6 revealed Skilled Nurse (SN) visits were conducted on: 06/14/2024, 06/18/2024, 06/19/2024, 06/22/2024, and 06/26/2024. Review of Nurses notes dated 06/19/2024 by S3RN revealed, in part: Wound assessment: Buttocks, Open, onset 06/14/2024, Rash. Treatment: Cleansed with normal saline, barrier cream applied. Further record review revealed there were no updated wound care orders approved by Patient #6’s physician for wound care provided by S3RN to Patient #6’s buttocks on 06/19/2024. Review of Nurses notes dated 06/22/2024 by S3RN revealed, in part: Wound assessment: Buttocks, Open, onset 06/14/2024, Rash, Treatment: cleansed with normal saline, barrier cream applied. Further record review revealed no updated wound care order provided by the agency to apply barrier cream to Patient #6’s buttocks or bilateral lower extremities. Review of Physician’s Orders provided by the agency on 06/26/2024, dated 06/21/2024, and written by S3RN revealed: Problem: Rash to lower extremities New Order: Apply barrier cream to skin as needed for rash or irritation 06/21/2024. Further review revealed there was no updated wound care order provided by the agency to apply barrier cream to Patient #6’s buttocks. On 06/26/2024 at 9:00 a.m., an interview was conducted with S3RN during a home visit with Patient #6. S3RN confirmed Patient #6’s unna boots were discontinued recently after a visit to the wound care physician’s clinic but she had not received or written Physician Order to discontinue the unna boots, and she did not clarify the orders. S3RN confirmed she had not written or requested updated wound care orders for wound care provided after 04/29/2024 on the aforementioned dates to Patient #6’s lower extremities or buttocks and should have. On 06/27/2024 at 3:00 p.m., an interview was conducted with S1DCS. S1DCS reviewed the Physician Orders for wound care for Patient #6. She confirmed there was no documentation available in Patient #6’s clinical record indicating the discontinuation of unna boots on 04/29/2024, resumption of unna boots on 05/03/2024, or discontinuation of unna boots on 05/06/2024. S1DCS confirmed S3RN should have notified Patient #6’s physician when skin changes were identified during her assessment 05/31/2024. S1DCS confirmed there were no approved physician orders available for wound care provided by S3RN on 06/03/2024 for application of barrier cream to Patient #6’s right lower extremity or for wound care provided by S3RN on 06/19/2024 for barrier cream application to Patient #6’s buttocks as needed for rash. S1DCS confirmed S3RN should have requested physician approval of wound care orders provided to Patient #6 prior to performing wound care on the aforementioned dates and did not.

Documentation of inservice training CFR(s): 484.80(d)(2) The HHA must maintain documentation that demonstrates the requirements of this standard have been met. This ELEMENT is not met as evidenced by: Based on interview and record reviews, the agency failed to maintain documentation of annual abuse and neglect training for 11 of 11 (S1DCS, S2LPN, S3RN, S4RN, S5OT, S6PT, S8HHA, S9HHA, S10HHA, S11HHA and S12HHA) employee personnel files reviewed, in accordance with federal regulation requirements. Findings: Record review of the agency’s undated policy titled, “Assessment of Possible Abuse and Neglect” revealed, in part: Policy This policy will be reviewed annually with each employee. Each employee will sign an attestation of acknowledgement. Record Review of S1DCS’s personnel file revealed a hire date of 08/16/2021. There was no documented evidence of annual abuse and neglect training completed since 08/11/2022. Record Review of S2LPN’s personnel file revealed a hire date of 04/17/2023. There was no documented evidence of annual abuse and neglect training completed since date of hire. Record Review of S3RN’s personnel file revealed a hire date of 11/23/2020. There was no documented evidence of annual abuse and neglect training completed since 08/11/2022. Record Review of S4RN’s personnel file revealed a hire date of 02/09/2024. There was no documented evidence of annual abuse and neglect training completed upon date of hire. Record Review of S5OT’s personnel file revealed a hire date of 02/01/2017. There was no documented evidence of annual abuse and neglect training completed since 08/11/2022. Record Review of S6PT’s personnel file revealed a hire date of 09/10/2019. There was no documented evidence of annual abuse and neglect training completed since 08/11/2022. Record Review of S8HHA’s personnel file revealed a hire date of 12/16/2022. There was no documented evidence of annual abuse and neglect training completed since 12/16/2022. Record Review of S9HHA’s personnel file revealed a hire date of 10/03/2016. There was no documented evidence of annual abuse and neglect training completed since 08/11/2022. Record Review of S10HHA’s personnel file revealed a hire date of 01/17/2023. There was no documented evidence of annual abuse and neglect training completed upon date of hire and at least annually. Record Review of S11HHA’s personnel file revealed a hire date of 12/05/2022. There was no documented evidence of annual abuse and neglect training completed upon date of hire and at least annually. Record Review of S12HHA’s personnel file revealed a hire date of 10/25/2021. There was no documented evidence of annual abuse and neglect training completed since 08/11/2022. On 06/27/2024 at 3:00 p.m., an interview was conducted with S1DCS. S1DCS stated she was unaware abuse and neglect training was required at least annually and was unable to provide any documented evidence of abuse and neglect training provided to any newly hired employees in the last 12 months or to any existing employees since 2022. S1DCS confirmed the aforementioned employees had not received annual abuse and neglect training and should have.

Complaint Survey #LA00099256

Integrate all services CFR(s): 484.60(d)(3) Integrate services, whether services are provided directly or under arrangement, to assure the identification of patient needs and factors that could affect patient safety and treatment effectiveness and the coordination of care provided by all disciplines. This ELEMENT is not met as evidenced by: Based on record review and interview, the agency failed to integrate services to identify patient needs and coordinate care provided by all disciplines for 1 (#1) of 5 (#1-5) patients reviewed that had wounds. The agency failed to ensure the CNA (Certified Nursing Assistant) communicated with the nurse when she noticed a change in a patient’s wound. Review of Patient #1's Plan of Care for the certification period 04/13/2023 – 06/08/2023 revealed a Primary Diagnosis of Malignant Neoplasm of Right Kidney. Additional diagnoses included Secondary Malignant Neoplasms of Bone/Right Lung/Left Lung, Morbid Obesity, and Dependence on Wheelchair. The Plan of care revealed Orders and Treatments which included the following, in part: SN (Skilled Nurse): 1 time a week for 8 weeks effective week of 04/16/2023. HHA (Home Health Aide): 2 times a week for 8 weeks. HCA (Home Care Aide) Order: HCA to assist patient with personal care and ADLs (Activities of Daily Living). SN Interventions included the following, in part: SN to assess skin for breakdown each visit. SN to instruct the patient/CG (caregiver) on methods to reduce friction and shear. SN to instruct patient/CG to apply moisture barrier cream to all skin folds and wet areas in perineal area daily, after baths and all bowel movements. Review of a Physician’s Order dated 05/15/2023 revealed the following: New wounds noted under bilateral abdomen skin folds. Wound care orders: cleanse with wound cleanser of choice, pat dry, apply antifungal powder, and cover with silicone dressing. Dressing to be changed 3 times a week and as needed. SN to perform wound care every visit and PRN (as needed), family able to do on other days. May use equivalent of any supplies ordered. Review of SN Visit documentation for Patient #1 revealed the following documentation, in part: 05/15/2023 – Full assessment done. Pt. complained of rash under his abdomen folds. Area was assessed. Patient had open areas present likely due to fungal infection from area staying moist. RN (Registered Nurse) instructed patient on applying antifungal powder and covering the area with a dressing to help keep the area dry and clean. Wound care orders sent to MD (Medical Doctor). Wounds addressed on visit: Wound #1 – right abdomen skin fold. Open. Onset date: 05/12/2023. Skin lesion. 10 cm (centimeters L (Length) x 3 cm W (Width) x 0.2 cm D (Depth). Wound bed red. No drainage. No odor. Erythema. Cleaned with wound cleanser, pat dried, applied antifungal powder, and covered with silicone dressing. Wound #2 – left abdomen skin fold. Open. Onset date: 05/12/2023. 4 cm L x 2 cm W x 0.2 cm D. Wound bed red. Moderate amount serosanguineous drainage. No odor. Cleaned with wound cleanser, pat dried, applied antifungal powder and covered with silicone dressing. No complaints of pain at wound sites. Documented by S2RN. 05/25/2023 – No change noted in measurements or characteristics of wounds from previous visit. Same wound care performed as last visit on 5/15/23. Documented by S3LPN. 05/30/2023 – No change noted in measurements or characteristics of wounds from previous visit. Same wound care performed as last visit on 5/25/23. Documented by S3LPN. Review of the HHA Visit Notes from 05/15/2023 – 05/30/2023 for Patient #1's certification period of 04/13/2023 – 06/08/2023 revealed no documentation the LPN (Licensed Practical Nurse) or RN was notified by the CNA of a change in status of Patient #1’s abdominal wounds. All HHA Visit Notes from 05/15/2023 – 05/30/2023 revealed a Skin Condition comment of “No change to skin” documented by S4CNA. Review of a Transfer Summary dated 06/01/2023 revealed the patient was hospitalized on 05/30/2023. On 07/20/2023 at 11:20 a.m., a telephone interview was conducted with Patient #1. He was alert, oriented and talkative. He verified he had received SN and HHA services from the agency. He verified he had long-standing problems with redness and irritation between skin folds of his abdomen. He stated Nystatin powder was used daily and applied to his abdominal folds with the help of his son. Patient #1 verified he was transferred to the ER on 05/30/2023 after S4CNA contacted his sister because S4CNA told Patient #1 she felt like the rash area was not looking good. He stated, “They called the ambulance and said I had to go.” He verified his sister and S4CNA told him he had to go to the ER. On 07/20/2023 at 1:35 p.m., a telephone interview was conducted with S3LPN. He verified the patient was receiving SN visits 1 time a week during the most recent plan of care period. He verified the patient was receiving wound care to a fungal rash between the abdominal folds. S3LPN stated he usually alternated weekly visits with S2RN and assessed the patient’s skin every visit. He verified Patient #1 was mentally intact; and the patient, nor the son, had ever voiced any complaints to him regarding his care. S3LPN verified he saw the patient the morning he was transferred out to the hospital. S3LPN stated he never received a notification of the CNA reporting a change in the patient’s skin condition on 05/30/2023. On 07/20/2023 at 1:50 p.m., a telephone interview was conducted with S2RN. She stated she was familiar with the patient and usually made home visits every other week, alternating with S3LPN for once a week visits. She stated the resident was a very large man and was always in the bed. She stated he sweated a lot and had large skin folds in the abdominal area. S2RN verified she assessed Patient #1’s skin every visit. She stated the patient made her aware of redness in his abdominal folds on the visit of 5/15/2023. S2RN stated Patient #1 told her the redness started a couple days before her visit. She stated she received orders and started care to the abdominal folds that day. S2RN stated she did not recall being notified of a decline in Patient #1’s skin condition on 05/30/2023 and did not know until a couple of days later that he had been transferred to the hospital on 05/30/2023. She stated she would normally receive a text message from the CNA or LPN if there was a change in a patient’s condition, including skin conditions, and would make a PRN visit to assess the patient. On 07/20/2023 at 1:35 p.m., a telephone interview was conducted with S4CNA. She verified she was familiar with Patient #1 and saw him 2 times a week when he was a patient of the agency. She stated she would give him a bed bath and sometimes wash his hair. She stated she was aware the patient had a skin rash between his abdominal folds. S4CNA stated when she made a visit to the patient’s home on 05/30/2023, the rash seemed worse. She stated the patient did not want her to call the HHA office about it. She stated she called his sister and told her about it, at which time his sister asked S4CNA to take a picture of the rash area and text it to her. She stated she did text a picture to Patient #1’s sister. She stated the sister was adamant about Patient #1 going to the hospital. S4CNA verified she called 911 for an ambulance to transfer Patient #1 to the hospital. She stated she would normally call the case manager in the office or her supervisor if there were any changes in a patient’s condition. She verified she did not call the LPN, RN, or anyone at the office about Patient #1’s rash and stated she knew she should have. On 07/20/2023 at 3:15 p.m., an interview was conducted with S1DON. She verified there was no documentation showing the CNA communicated with the LPN or RN regarding the status of Patient #1’s abdominal wounds on 05/30/2023. She verified the CNA should have made a nurse aware so the wound could be properly assessed when the wound was found to have a decline. S1DON further verified a CNA should not initiate transfer of a patient to the ER without direction from a nurse.

Recertification Survey COVID-19 Focused Infection Control Survey with no related deficiencies cited. Abbreviations: HCl Hydrochloride IU International Units mg milligrams OT Occupational Therapist PT Physical Therapist SN Skilled Nurse wk week

A review of all current medications CFR(s): 484.55(c)(5) A review of all medications the patient is currently using in order to identify any potential adverse effects and drug reactions, including ineffective drug therapy, significant side effects, significant drug interactions, duplicate drug therapy, and noncompliance with drug therapy. This ELEMENT is not met as evidenced by: Based on observations, record reviews, and interviews, the agency failed to ensure the medication profile accurately reflected all medications patients were using and/or did not reflect medications the patients were no longer using, for 5 (#4, #6, #7, #11, #12) of 7 (#4, #6, #7, #8, #10, #11, #12) sampled patients reviewed who received home visits. Findings: Patient #4 Review of the clinical record revealed a start of care date of 06/29/2021. The patient's primary diagnosis was Sepsis, unspecified organism. A review of the Home Health Certification and Plan of Care/485 for the Certification Period of 06/29/2021 to 08/27/2021 revealed orders for Frequency/Duration of Visits which included: SN 2wk1, 1wk8. Review of the Visit Note Reports for the Certification Period of 06/29/2021 to 08/27/2021 revealed SN visits were conducted on the following dates: 06/29/2021, 07/06/2021, 07/14/2021, 07/20/2021, 07/27/2021, and 08/05/2021. On 08/17/2021 at 2:15 p.m., a home visit was conducted in the home of Patient #4. Review of the patient's current medication list provided by the agency revealed the following discrepancies during the home visit: 1. Metoprolol Tartrate 50 mg twice daily. There was none of this medication observed in the home. 2. Lasix 20 mg one time daily. The patient verified she only takes this medication as needed for fluid in her lower extremities, but not daily. 3. RisaQuad 1 capsule daily. There was none of this medication observed in the home. 4. Ferrous Sulfate 325 mg daily. Prescription fill date was 07/18/2021. This medication was not listed on the current medication list provided by the agency. 5. Vitamin D3 1000 IU once daily. Prescription fill date was 07/18/2021. This medication was not listed on the current medication list provided by the agency. 6. Magnesium Oxide 400 mg daily. Prescription fill date was 07/18/2021. This medication was not listed on the current medication list provided by the agency. During the home visit, Patient #4 stated she was familiar with her medications and managed her own medications. She verified she no longer took Metoprolol or RisaQuad. She further verified she has been taking Ferrous Sulfate, Vitamin D3, and Magnesium Oxide since 07/18/2021. Patient #6 Review of the clinical record revealed a start of care date of 06/29/2021. The patient's diagnoses included Urinary Tract Infection. A review of the Home Health Certification and Plan of Care/485 for the Certification Period of 06/29/2021 to 08/27/2021 revealed orders for Frequency/Duration of Visits which included: SN 1wk9. Review of the Visit Note Reports for the Certification Period of 06/29/2021 to 08/27/2021 revealed SN visits were conducted on the following dates: 06/29/2021, 07/06/2021, 07/13/2021, 07/22/2021, 07/27/2021, 08/03/2021, and 08/10/2021. On 08/17/2021 at 9:00 a.m., a home visit was conducted in the home of Patient #6. The patient provided her medications and stated she was familiar with the medicines she was taking. Review of the patient's current medication list provided by the agency revealed the following discrepancies during the home visit: 1. Trospium Chloride 20 mg by mouth daily. The prescription in the home had a fill date of 04/19/2021 with instructions to take the medication twice a day. 2. Furosemide 20 mg by mouth every other day on M-W-F. The prescription in the home had a fill date of 07/15/2021 with instructions to take the medication daily. 3. MegaCoQ10 100 mg. This medication was not listed on the current medication list provided by the agency. The patient stated she took one tablet once a day. Patient #7 Review of the clinical record revealed a start of care date of 06/27/2021. The patient's diagnoses included Parkinson's Disease. A review of the Home Health Certification and Plan of Care/485 for the Certification Period of 06/27/2021 to 08/25/2021 revealed orders for Frequency/Duration of Visits which included: SN 2wk1, 1wk8. A review of the Visit Note Reports for the Certification Period of 06/27/2021 to 08/25/2021 revealed SN visits were conducted on the following dates: 06/27/2021, 07/01/2021, 07/08/2021, 07/15/2021, 07/21/2021, 07/30/2021, 08/04/2021, and 08/10/2021. On 08/17/2021 at 12:00 p.m., a home visit was conducted in the home of Patient #7. The patient's wife stated she managed the patient's medicines and was familiar with all the medication doses and frequencies. Review of the patient's current medication list provided by the agency revealed the following discrepancies during the home visit: 1. Pantoprazole Sodium 40 mg by mouth two times a day. The patient's wife stated this medication was decreased by his physician to only once a day about 2 weeks ago. Patient #11 Review of the clinical record revealed a start of care date of 06/23/2021. The patient's diagnoses included Age-related Osteoporosis. A review of the Home Health Certification and Plan of Care/485 for the Certification Period of 06/23/2021 to 08/21/2021 revealed orders for Frequency/Duration of Visits which included: SN evaluation only; PT 1wk1, 2wk4; OT 1wk5. A review of the Visit Note Reports for the Certification Period of 06/23/2021 to 08/21/2021 revealed a SN visit was conducted on the following date: 06/23/2021. PT visits were conducted on the following dates: 06/23/2021, 06/28/2021, 07/02/2021, 07/06/2021, 07/08/2021, 07/13/2021, 07/16/2021, 07/19/2021, 07/26/2021, 07/30/2021, 08/02/2021, 08/05/2021, 08/09/2021, and 08/11/2021. OT visits were conducted on the following dates: 06/24/2021, 07/01/2021, 07/09/2021, 07/14/2021, 07/21/2021, 07/28/2021, 08/04/2021, 08/13/2021. On 08/18/2021 at 11:30 a.m., a home visit was conducted in the home of Patient #11. The patient's daughter stated she managed the patient's medicines and was familiar with all the medication doses and frequencies. Review of the patient's current medication list provided by the agency revealed the following discrepancies during the home visit: 1. Amlodipine Besylate 5 mg daily by mouth. The bottle of medication in the home has instructions to take 2 tablets for a total of 10 mg daily. The prescription fill date was 08/12/2021. The patient's daughter stated the patient had taken this dose for at least a year. 2. Aspirin 81 mg by mouth 2 times a day. The patient's daughter stated the patient had taken 81 mg once daily for at least a year. Patient #12 Review of the clinical record revealed a start of care date of 07/17/2021. The patient's diagnoses included Chronic Combined Systolic and Diastolic Heart Failure. A review of the Home Health Certification and Plan of Care/485 for the Certification Period of 07/17/2021 to 09/14/2021 revealed orders for Frequency/Duration of Visits which included: SN 1day1, 2wk2, 1wk7. A review of the Visit Note Reports for the Certification Period of 06/23/2021 to 08/21/2021 revealed a SN visit was conducted on the following date: 06/23/2021. PT visits were conducted on the following dates: 06/23/2021, 06/28/2021, 07/02/2021, 07/06/2021, 07/08/2021, 07/13/2021, 07/16/2021, 07/19/2021, 07/26/2021, 07/30/2021, 08/02/2021, 08/05/2021, 08/09/2021, and 08/11/2021. OT visits were conducted on the following dates: 06/24/2021, 07/01/2021, 07/09/2021, 07/14/2021, 07/21/2021, 07/28/2021, 08/04/2021, 08/13/2021. On 08/18/2021 at 1:00 p.m., a home visit was conducted in the home of Patient #12. The patient stated he managed his own medicines and was familiar with all the medication doses and frequencies. S3DON was present during the home visit. Review of the patient's current medication list provided by the agency revealed the following discrepancies during the home visit: 1. Cetirizine HCl 10 mg daily by mouth. This medication was not in the home. Patient #12 stated he did not take this medication. 2. Colchicine-Probenecid 0.5-500 mg one tablet daily. This medication was not in the home. The patient stated he was not familiar with that medication. 3. Trazodone HCl 300 mg one tablet daily at bedtime. The prescription in the home was for 150 mg daily with a fill date of 07/30/2021. The patient verified this dose was what he was currently taking. 4. Allopurinol 300 mg by mouth daily. This medication was not included on the current medication list provided by the agency. The patient stated he had been on this medication for gout for at least 1 year. The fill date on the medicine bottle was dated 2018, but the patient verified he had refilled this bottle with a more recent refill of the medication. 5. Indomethacine 50 mg one by mouth three times a day as needed. This medication was not included on the current medication list provided by the agency. The prescription fill date was 04/22/2021. An interview was conducted with S3DON during the home visit. She verified the medication discrepancies. She further verified she would expect the nurses to review and reconcile the patients' medications during every SN visit. An interview was conducted on 08/19/2021 at 1:45 p.m. with S2AltADM. S1ADM was present for the interview. They were both notified of the medication discrepancies found during home visits with Patients #4, #6, #7, #11, and #12. S2AltADM verified medications were to be reviewed during every SN visit and updated accordingly. She further verified a patient's medications should also be reviewed during every visit if the patient was only receiving therapy services.

Verbal orders CFR(s): 484.60(b)(3)(4) (3) Verbal orders must be accepted only by personnel authorized to do so by applicable state laws and regulations and by the HHA's internal policies. (4) When services are provided on the basis of a physician or allowed practitioner's verbal orders, a nurse acting in accordance with state licensure requirements, or other qualified practitioner responsible for furnishing or supervising the ordered services, in accordance with state law and the HHA's policies, must document the orders in the patient's clinical record, and sign, date, and time the orders. Verbal orders must be authenticated and dated by the physician or allowed pracitioner in accordance with applicable state laws and regulations, as well as the HHA's internal policies. This ELEMENT is not met as evidenced by: Based on interview and record review, the agency failed to ensure the total plan of care was signed and dated by the patient's physician in a timely manner for 5 (Patients #3, #6, #11, #13, and #17) of 17 (Patients #1-#17) sampled patient records reviewed. Cross-referenced with State Regulations 9123. Patient Care Standards: C. Plan of Care. The plan of care for each patient must be individualized to address the patient's problems, goals, and required services. 1. The Plan of Care, telephone and/or verbal orders must be signed by the physician within a timely manner, not to exceed 30 days. Findings: Patient #3 Review of the clinical record for Patient #3 revealed a start of care date of 02/23/2021. Review of the plan of care for the certification period 06/23/2021 to 08/21/2021 for the patient revealed a principal diagnosis of Hypertensive Heart Disease with Heart Failure. Further review of the plan of care for the certification period revealed it was not signed until 08/17/2021. The Resumption of Care dated 07/08/2021 was also not signed by the physician until 08/17/2021. Patient #6 Review of the clinical record for Patient #6 revealed a start of care date of 06/29/2021. Review of the plan of care for the certification period 06/29/2021 to 08/27/2021 for the patient revealed a principal diagnosis of Urinary Tract Infection. Further review of the plan of care for this certification period revealed it was not signed by the physician until 08/17/2021. Patient #11 Review of the clinical record for Patient #11 revealed a start of care date of 06/23/2021. Review of the plan of care for the certification period 06/23/2021 to 08/21/2021 for the patient revealed a principal diagnosis of Age-related Osteoporosis. Further review of the plan of care for this certification period revealed it was not signed by the physician until 07/28/2021. Patient #13 Review of the clinical record for Patient #13 revealed a start of care date of 03/18/2021. Review of the plan of care for the certification period 03/18/2021 to 05/19/2021 for the patient revealed a principal diagnosis of Type 2 Diabetes Mellitus with Diabetic Chronic Kidney Disease. Further review of the plan of care for this certification period revealed it was not signed by the physician until 05/04/2021. Patient #17 Review of the clinical record for Patient #17 revealed a start of care date of 01/29/2021. Review of the plan of care for the certification period 01/29/2021 to 03/10/2021 for the patient revealed a principal diagnosis of Malignant Neoplasm of Prostate. Further review of the plan of care for this certification period revealed it was not signed by the physician until 03/10/2021. On 08/19/2021 at 1:45 p.m., an interview was conducted with S2AltADM. S1ADM was also present during the interview. After reviewing the clinical records for Patients #3, #6, #11, #13, and #17, S2AltADM verified the physicians' orders were not signed for the patients within the required time frame of 30 days.