Every finding on record at County of Lewis

General Initial Statement (E 000) CHHA Emergency Preparedness: This Statement of Deficiencies report includes the results of a review of the agency's compliance with emergency preparedness requirements completed during the recertification survey conducted 09/09/24-09/12/24. Pre-survey activities consisted of a review on 08/21/24 of the agency's Health Commerce System account. The following information was reviewed during the survey: the agency's Emergency Preparedness Plan, policies and procedures, the emergency patient roster, and staff call down list. Interviews were conducted with the Administrator/Director of Patient Services and Clinical Manager. The following deficiencies are being cited as a result of the survey: Federal: E 0006 Plan Based on All Hazards Approach; E 0007 Emergency Preparedness Program Patient Population; E 0031 Emergency Officials Contact Information; E 0036 Emergency Preparedness Training and Testing State: J 1156 Governing Authority

Plan Based on All Hazards Risk Assessment CFR(s): 484.102(a)(1)-(2) §403.748(a)(1)-(2), §416.54(a)(1)-(2), §418.113(a)(1)-(2), §441.184(a)(1)-(2), §460.84(a)(1)-(2), §482.15(a)(1)-(2), §483.73(a)(1)-(2), §483.475(a)(1)-(2), §484.102(a)(1)-(2), §485.68(a)(1)-(2), §485.542(a)(1)-(2), §485.625(a)(1)-(2), §485.727(a)(1)-(2), §485.920(a)(1)-(2), §486.360(a)(1)-(2), §491.12(a)(1)-(2), §494.62(a)(1)-(2) [(a) Emergency Plan. The [facility] must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least every 2 years. The plan must do the following:] (1) Be based on and include a documented, facility-based and community-based risk assessment, utilizing an all-hazards approach.* (2) Include strategies for addressing emergency events identified by the risk assessment. * [For Hospices at §418.113(a):] Emergency Plan. The Hospice must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least every 2 years. The plan must do the following: (1) Be based on and include a documented, facility-based and community-based risk assessment, utilizing an all-hazards approach. (2) Include strategies for addressing emergency events identified by the risk assessment, including the management of the consequences of power failures, natural disasters, and other emergencies that would affect the hospice's ability to provide care. *[For LTC facilities at §483.73(a):] Emergency Plan. The LTC facility must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least annually. The plan must do the following: (1) Be based on and include a documented, facility-based and community-based risk assessment, utilizing an all-hazards approach, including missing residents. (2) Include strategies for addressing emergency events identified by the risk assessment. *[For ICF/IIDs at §483.475(a):] Emergency Plan. The ICF/IID must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least every 2 years. The plan must do the following: (1) Be based on and include a documented, facility-based and community-based risk assessment, utilizing an all-hazards approach, including missing clients. (2) Include strategies for addressing emergency events identified by the risk assessment. This STANDARD is not met as evidenced by: Based on a review of the agency’s policy and procedure and interviews with the Administrator/Director of Patient Services and Clinical Manager, it was determined the agency failed to ensure the Emergency Preparedness Plan was based on an updated and accurate facility and community hazard vulnerability risk assessment. Evidence as follows: The 06/2022 “Emergency Operations Management Plan – Lewis County Home Health Agency and Hospice” plan stated that the agency would complete an annual hazard vulnerability assessment on which to base their emergency plan and include the assessment in their plan. The hazard vulnerability assessment in the plan: - was dated 2021 - listed the top 10 vulnerabilities but was unclear which hazards posed the greatest threat - was unclear which threats would be the most disruptive - was not specific to the emergencies most impactful for the home care agency On 09/11/24 at 1:00 P.M. the Clinical Manager and Administrator/Director of Patient Services were interviewed about the hazard vulnerability assessment regarding how this tool was used to identify potential risks for the agency; both responded that they do not know. Failure to ensure the Emergency Preparedness Plan is specific to the facility and community creates the potential for unmet patient needs and possible negative patient outcomes in the event of an emergency.

EP Program Patient Population CFR(s): 484.102(a)(3) §403.748(a)(3), §416.54(a)(3), §418.113(a)(3), §441.184(a)(3), §460.84(a)(3), §482.15(a)(3), §483.73(a)(3), §483.475(a)(3), §484.102(a)(3), §485.68(a)(3), §485.542(a)(3), §485.625(a)(3), §485.727(a)(3), §485.920(a)(3), §491.12(a)(3), §494.62(a)(3). [(a) Emergency Plan. The [facility] must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least every 2 years. The plan must do the following:] (3) Address [patient/client] population, including, but not limited to, persons at-risk; the type of services the [facility] has the ability to provide in an emergency; and continuity of operations, including delegations of authority and succession plans.** *[For LTC facilities at §483.73(a):] Emergency Plan. The LTC facility must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least annually. The plan must do all of the following: (3) Address resident population, including, but not limited to, persons at-risk; the type of services the LTC facility has the ability to provide in an emergency; and continuity of operations, including delegations of authority and succession plans. *NOTE: ["Persons at risk" does not apply to: ASC, hospice, PACE, HHA, CORF, CMCH, RHC/FQHC, or ESRD facilities.] This STANDARD is not met as evidenced by: Based on a review of the agency’s policy and procedure and interviews with the Administrator/Director of Patient Services and Clinical Manager, it was determined that the agency failed to ensure the Emergency Preparedness Plan included the types of services the agency could provide during an emergency and continuity of operations to ensure patient needs would continue to be met. Evidence as follows: The 06/2022 “Emergency Operations Management Plan – Lewis County Home Health Agency and Hospice” included procedures that were not specific to maintaining home care services within the community, and was incomplete as follows: - failed to specify how the agency would ensure the health care needs of patients continued to be met in emergencies that interfere with the delivery of services - failed to specify how resources would be maximized to ensure an orderly response to an emergency situation. Examples include: - The plan stated “the home health agency will encourage patients and their families to follow their personal emergency plans and instructions. Patients and family have ultimate responsibility for planning appropriately." The agency failed to identify what services the agency will provide, what actions the home care agency will take to identify the needs of the patients, or how care will be prioritized. - The plan stated “if the agency is using an electronic documentation system, describe the method of documentation to be used during the emergency if the electronic system fails. The agency failed to include any plan for how care would be documented. Failure to ensure the Emergency Preparedness Plan includes measures to ensure continuity of care creates the potential for unmet patient needs and possible negative patient outcomes in the event of an emergency.

Emergency Officials Contact Information CFR(s): 484.102(c)(2) §403.748(c)(2), §416.54(c)(2), §418.113(c)(2), §441.184(c)(2), §460.84(c)(2), §482.15(c)(2), §483.73(c)(2), §483.475(c)(2), §484.102(c)(2), §485.68(c)(2), §485.542(c)(2), §485.625(c)(2), §485.727(c)(2), §485.920(c)(2), §486.360(c)(2), §491.12(c)(2), §494.62(c)(2). [(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: (2) Contact information for the following: (i) Federal, State, tribal, regional, and local emergency preparedness staff. (ii) Other sources of assistance. *[For LTC Facilities at §483.73(c):] (2) Contact information for the following: (i) Federal, State, tribal, regional, and local emergency preparedness staff. (ii) The State Licensing and Certification Agency. (iii) The Office of the State Long-Term Care Ombudsman. (iv) Other sources of assistance. *[For ICF/IIDs at §483.475(c):] (2) Contact information for the following: (i) Federal, State, tribal, regional, and local emergency preparedness staff. (ii) Other sources of assistance. (iii) The State Licensing and Certification Agency. (iv) The State Protection and Advocacy Agency. This STANDARD is not met as evidenced by: Based on a review of the agency’s policy and procedure and interviews with the Administrator/Director of Patient Services and Clinical Manager, it was determined the agency failed to maintain accurate contact information within the Emergency Preparedness Plan. Evidence as follows: The regional contact list for the New York State Department of Health included an outdated/inaccurate name and telephone number. On 09/11/24 at 1:00 P. M., the findings were reviewed with the Administrator and Director of Patient services. They acknowledged the findings and provided no additional information at that time. On 09/12/24 at 11:56 A. M., a revised copy of the Emergency Management Plan, dated 09/2024, was given to the surveyor. On 09/16/24 at 2:45 P.M., the surveyor interviewed the Administrator/Director of Patient Services to determine when the policy was revised, and the Administrator/Director of Patient Services reported that the document was revised following the feedback received from surveyors on 09/11/24 and had not yet been sent to committee for review or approved by the Professional Advisory Committee. The Administrator/Director of Patient Services stated that they were aware that revising the document after receiving feedback from the surveyors would not negate the findings or any potential citations but would be reflected in their plan of correction. Failure to ensure contact information for Federal, State, and/or local emergency preparedness staff creates the potential for unmet patient needs and possible negative patient outcomes in the event of an emergency.

EP Training and Testing CFR(s): 484.102(d) §403.748(d), §416.54(d), §418.113(d), §441.184(d), §460.84(d), §482.15(d), §483.73(d), §483.475(d), §484.102(d), §485.68(d), §485.542(d), §485.625(d), §485.727(d), §485.920(d), §486.360(d), §491.12(d), §494.62(d). *[For RNCHIs at §403.748, ASCs at §416.54, Hospice at §418.113, PRTFs at §441.184, PACE at §460.84, Hospitals at §482.15, HHAs at §484.102, CORFs at §485.68, REHs at §485.542, CAHs at §486.625, "Organizations" under 485.727, CMHCs at §485.920, OPOs at §486.360, and RHC/FHQs at §491.12:] (d) Training and testing. The [facility] must develop and maintain an emergency preparedness training and testing program that is based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, policies and procedures at paragraph (b) of this section, and the communication plan at paragraph (c) of this section. The training and testing program must be reviewed and updated at least every 2 years. *[For LTC facilities at §483.73(d):] (d) Training and testing. The LTC facility must develop and maintain an emergency preparedness training and testing program that is based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, policies and procedures at paragraph (b) of this section, and the communication plan at paragraph (c) of this section. The training and testing program must be reviewed and updated at least annually. *[For ICF/IIDs at §483.475(d):] Training and testing. The ICF/IID must develop and maintain an emergency preparedness training and testing program that is based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, policies and procedures at paragraph (b) of this section, and the communication plan at paragraph (c) of this section. The training and testing program must be reviewed and updated at least every 2 years. The ICF/IID must meet the requirements for evacuation drills and training at §483.470(i). *[For ESRD Facilities at §494.62(d):] Training, testing, and orientation. The dialysis facility must develop and maintain an emergency preparedness training, testing and patient orientation program that is based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, policies and procedures at paragraph (b) of this section, and the communication plan at paragraph (c) of this section. The training, testing and orientation program must be evaluated and updated at every 2 years. This STANDARD is not met as evidenced by: Based on review of personnel records and interviews with the Administrator/Director of Patient Services and Clinical Manager, it was determined the agency failed to ensure staff received emergency preparedness education during orientation and/or annually as required. Evidence as follows: 5 out of 5 employees hired after 2021 (employees #2-5 and #7) lacked evidence of training to emergency preparedness specific to the Home Health Agency during orientation. 1. Employee #2 hired by the agency on 10/31/22 2. Employee #3 hired by the agency on 07/08/24 3. Employee #4 re-hired by the agency on 03/06/23 4. Employee #5 hired by the agency on 05/21/24 5. Employee #7 hired by the agency on 07/18/22 Failure to develop and implement an adequate emergency preparedness initial and annual orientation for all employees creates the potential for unmet patient needs and possible negative patient outcomes in the event of an emergency.

The following statement of deficiencies represents the results of a partial extended recertification survey of Lewis County General Hospital Certified Home Health Agency conducted 09/09/24 through 09/12/24. A standard recertification survey was initiated on 09/09/24. Deficient practices were identified within Level 1 standards Conditions of 484.55 Comprehensive Assessment of Patients and 484.60 Care Planning, Coordination, Quality of Care resulting in a partial extended survey. The survey included a review of 7 clinical records, including 2 discharged patients, 3 home visits, 7 personnel records, pertinent policies and procedures, Quality Improvement Committee Meeting and Governing Body meeting minutes for the past 12 months, the agency’s Admission Packet, Complaint Log, and the Emergency Preparedness Plan. There were no contracts to review. The patient census at the time of survey was 66. Pre-survey activities consisted of a review on 08/21/24 of the agency's Health Commerce System account, Home Care Worker Registry, Criminal History Record Check, internet Quality Improvement and Evaluation System (iQIES) reports for the period 06/01/23 to 05/30/24, and the agency's compliance with report submissions for the most recent statistical report. The agency's Administrator/Director of Patient Services, Clinical Manager, and Director of Quality were interviewed. Findings were reviewed at the exit conference on 09/12/24. The following deficiencies are being cited as a result of the survey: Federal: G 528 Comprehensive Assessment of Patients; G 574 and G 590 Care Planning, Coordination, Quality of Care State: J 1156 and J 1276 Governing Authority; J 1401 and J 1424 Personnel

Health, psychosocial, functional, cognition CFR(s): 484.55(c)(1) Standard: Content of the comprehensive assessment. The comprehensive assessment must accurately reflect the patient's status, and must include, at a minimum, the following information: (1) The patient's current health, psychosocial, functional, and cognitive status; This ELEMENT is not met as evidenced by: Based on a review of clinical records, observational home visits, and interviews with the Administrator/Director of Patient Services (DPS) and Clinical Manager, it was determined in 3 of 7 records (patients #2, 4, and 7) comprehensive assessments were incomplete and/or not of sufficient scope to identify all patient needs. Evidence as follows: Home VisitPatient #2 was admitted to the agency on 06/12/24 with diagnoses of cellulitis to the left and right lower limbs, type 2 diabetes with foot ulcer of the left heel, lymphedema, hypertension, hypothyroidism, and morbid obesity. The skilled nurse failed to assess the patient's ability to manage diabetes. The 06/12/24-08/10/24 Plan of Care included: - Patient/caregiver to test blood glucose 3 times per day and as needed via Freestyle Libre continuous glucose monitor and to notify the MD if results were 300. The 06/12/24 initial visit note included: - Freestyle Libre sensor not intact to patient's skin upon RN arrival and patient states [patient] is not able to apply due to difficulty opening the packaging foil. The nurse applied and activated the new sensor with the scanner/reader. The patient was able to complete glucose check at the end of the visit and the result was 136. - Patient stated [friend] is willing to learn to apply the sensor and can be present for the next sensor change. The nurse failed to assess: - if the patient had a working glucometer and supplies - patient's ability to use the glucometer On 07/10/24, the nurse documented the patient was unable to obtain glucose due to: - the Freestyle Libre sensors hadn't come in yet - the patient could not get blood for the fingerstick today On 07/18, 07/24, 07/31, 08/07, 08/14, 08/21, 08/28, and 09/04/24 the nurse documented, "patient did not obtain BG (blood Glucose) today because Freestyle Libre (sensors) had not come in yet, and [patient] could not get blood from [patient] fingerstick today." For 8 weeks, the nurse failed assess the patient's ability to perform fingerstick blood glucose and notify the physician the patient was not testing the blood glucose 3 times per day. On 09/11/24 at 10:30 a.m., the surveyor performed an observational home visit with the nurse. During the visit the nurse discussed the ongoing insurance issues with the Freestyle libre sensors and documented, "patient did not obtain BG today because patient is unable to get blood from fingersticks." After the visit, the surveyor interviewed the patient who stated they had difficulty getting blood from their fingers. The nurse failed to: - educate the patient on ways to facilitate obtaining blood from fingerstick - offer to perform a fingerstick for the patient On 09/11/24 at 1:00 p.m., the findings were reviewed with the Administrator/Director of Patient Services and Clinical Manager who acknowledged the findings and provided no additional information. On 09/12/24, the Quality Manager provided a Quality review audit tool that indicated the provider was notified of the problems obtaining the Freestyle Libre equipment, however, there was no audit finding the blood sugar was not being tested via fingerstick 3 times per day or that the physician was notified that no glucose testing was completed. The information provided did not change the findings. Patient #7 was admitted to the agency on 07/31/23 with diagnoses that included fracture to right shoulder, Alzheimer’s, coronary artery disease, chronic obstructive pulmonary disease, chronic pain, and hypertension. This patient was selected from the potentially avoidable event report, generated by the Center for Medicare and Medicaid Services from 06/01/23-05/30/24. The patient was identified on the report as an increase in pressure ulcers and discharge to the community with a stage 2 pressure ulcer. On 07/31/23, the physical therapist visited the patient to complete the start of care comprehensive assessment and on 08/01/23 the registered nurse visited to complete a medication reconciliation. The agency failed to assess the patient and caregiver’s ability to manage the fracture, including the ordered sling, need for occupational therapy, respiratory status, and as needed medication needs. Fracture The 07/26/23 hospital discharge summary included an order to “continue to wear your sling only removing when therapy is present or for hygiene purposes.” On 07/31/23, the physical therapist visited the patient and completed the start of care comprehensive assessment. The visit documentation stated the patient’s right arm was “in a sling per MD request.” The physical therapist failed to assess patient’s use of the sling or adherence to physician ordered use of the sling. Occupational Therapy The 07/26/23 hospital discharge summary included an order for occupational therapy. The 07/31/23 physical therapist visit note documented the patient had decreased activity tolerance, including activities of daily living, making them less independent, and decreasing their quality of life. Based on this, the physical therapist identified patient would benefit from skilled home physical therapy services, however, the therapist failed to identify if patient would also benefit from occupational therapy. There is no documentation the ordered occupational therapy evaluation was discussed with or was refused by the patient or family. On 07/31/23 the Director of Patient Services documented that the physical therapist reported the patient refused any other services, and the therapist agreed with that plan (despite this documentation, the patient had skilled nursing evaluation on 08/01/23). On 07/31/24, the physical therapists documented that verbal authorization was obtained from the physician office but did not include documentation that the patient refused the ordered occupational therapy evaluation. The agency failed to implement a physician-ordered occupational therapy evaluation. Respiratory assessment The 07/26/23 hospital discharge summary included the diagnosis of asthma and an order for albuterol sulfate (a rescue inhaler) 2 puffs inhalation every 4 hours as needed for shortness of breath or wheezing. On 07/31/23, the physical therapist documented: - the patient had dyspnea when walking more than 20 feet or climbing stairs without documentation to support the severity of the dyspnea, how the dyspnea was treated, or how the asthma or chronic obstructive pulmonary disease was managed. - an oxygen saturation of 90% but without indication of whether it was obtained at rest or after ambulation - the medication section documented no issues found during review and did not address use of albuterol On 08/01/23, the registered nurse visited the patient and documented: - the patient did not have an albuterol inhaler in the home and had not needed it without identifying the timeframe the patient had not used the albuterol - had a history of asthma but did not address how the asthma was managed - had an oxygen saturation of 93 without stating if this was at rest or after exertion On 08/01/23, the registered nurse documented that the patient did not have an albuterol inhaler in the home, nor had they needed it, with verbal orders taken. The agency failed to perform a complete respiratory assessment. Gastrointestinal assessment The 07/26/23 hospital discharge summary included an order for hemorrhoidal ointment 1 application rectally every 8 hours as needed for irritation. The 07/31/23 physical therapist visit note did not include an assessment the use of the hemorrhoid cream or the presence of hemorrhoids. The 08/01/23 registered nurse visit documentation reported the patient had not used hemorrhoidal cream but did not identify the timeframe the patient had not used it. The nurse also documented the patient was taking 2 over-the-counter medications as needed for constipation but without assessment of how often the patient took the medications. The elimination section stated, “patient cannot recall when they last moved their bowels but denies any concerns.” The clinician failed to identify if the patient has hemorrhoids and how often the patient used medication to treat constipation. On 09/27/23, the registered nurse visited the patient to complete skilled nursing evaluation and documentation supported patient had external hemorrhoids and that caregiver had been applying over-the-counter hemorrhoid cream. Physician was notified and order was obtained. The agency failed to assess for hemorrhoids or history of hemorrhoid cream use at the start of care. Home Visit1. Patient #2 was admitted to the agency on 06/12/24 with diagnoses of cellulitis to the left and right lower limbs, type 2 diabetes with foot ulcer of the left heel, lymphedema, hypertension, hypothyroidism, and morbid obesity. The skilled nurse failed to assess the patient's ability to manage diabetes. The 06/12/24-08/10/24 Plan of Care included: - Patient/caregiver to test blood glucose 3 times per day and as needed via Freestyle Libre continuous glucose monitor and to notify the MD if results were 300. The 06/12/24 initial visit note included: - Freestyle Libre sensor not intact to patient's skin upon RN arrival and patient states they are not able to apply due to difficulty opening the packaging foil. The nurse applied and activated the new sensor with the scanner/reader. The patient was able to complete glucose check at the end of the visit and the result was 136. - Patient stated [friend] is willing to learn to apply the sensor and can be present for the next sensor change. The nurse failed to assess: - if the patient had a working glucometer and supplies - patient's ability to use the glucometer On 07/10/24, the nurse documented the patient was unable to obtain glucose due to: - the Freestyle Libre sensors hadn't come in yet - the patient could not get blood for the fingerstick today On 07/18, 07/24, 07/31, 08/07, 08/14, 08/21, 08/28, and 09/04/24 the nurse documented, "patient did not obtain BG (blood glucose) today because Freestyle Libre (sensors) had not come in yet, and [patient] could not get blood from [patient] fingerstick today." For 8 weeks, the nurse failed assess the patient's ability to perform fingerstick blood glucose and notify the physician the patient was not testing the blood glucose 3 times per day. On 09/11/24 at 10:30 a.m., the surveyor performed an observational home visit with the nurse. During the visit the nurse discussed the ongoing insurance issues with the Freestyle Libre sensors and documented, "patient did not obtain BG today because patient is unable to get blood from fingersticks." After the visit, the surveyor interviewed the patient who stated they had difficulty getting blood from their fingers. The nurse failed to: - educate the patient on ways to facilitate obtaining blood from fingerstick - offer to perform a fingerstick for the patient On 09/11/24 at 1:00 p.m., the findings were reviewed with the Administrator/Director of Patient Services and Clinical Manager who acknowledged the findings and provided no additional information. On 09/12/24, the Quality Manager provided a Quality review audit tool that indicated the provider was notified of the problems obtaining the Freestyle Libre equipment, however, there was no audit finding that the blood sugar was not being tested via fingerstick 3 times per day or that the physician was not notified that no glucose testing was completed. The information provided did not change the findings. 2. Patient #7 was admitted to the agency on 07/31/23 with diagnoses that included fracture to right shoulder, Alzheimer’s disease, coronary artery disease, chronic obstructive pulmonary disease, chronic pain, and hypertension. This patient was selected from the internet Quality Improvement and Evaluation System (iQIES) potentially avoidable events report for the period 06/01/23 to 05/30/24. The patient was identified on the report as an increase in pressure ulcers and discharge to the community with a stage 2 pressure ulcer. On 07/31/23, the physical therapist visited the patient to complete the start of care comprehensive assessment and on 08/01/23 the registered nurse visited to complete a medication reconciliation. The agency failed to assess the patient and caregiver’s ability to manage the fracture, including the ordered sling, need for occupational therapy, respiratory status, and as needed medication needs. Fracture The 07/26/23 hospital discharge summary included an order to “continue to wear your sling only removing when therapy is present or for hygiene purposes.” On 07/31/23, the physical therapist visited the patient and completed the start of care comprehensive assessment. The visit documentation stated the patient’s right arm was “in a sling per MD request.” There is no evidence the physical therapist assessed the patient’s use of the sling or adherence to physician ordered use of the sling. Occupational Therapy The 07/26/23 hospital discharge summary included the patient was referred to home health for physical and occupational therapy. The 07/31/23 physical therapist visit note documented the patient had decreased activity tolerance, including activities of daily living, making them less independent, and decreasing their quality of life. Based on this, the physical therapist identified patient would benefit from skilled home physical therapy services, however, the therapist failed to identify if patient would also benefit from occupational therapy. There was no evidence the ordered occupational therapy evaluation was discussed with or was refused by the patient or family. On 07/31/23 the Director of Patient Services documented that the physical therapist reported the patient refused any other services, and the therapist agreed with that plan (despite this documentation, the patient had skilled nursing evaluation on 08/01/23). On 07/31/24, the physical therapist documented that verbal authorization for physical therapy was obtained from the physician office but did not include documentation that the patient refused the ordered occupational therapy evaluation. There is no evidence the agency informed the physician the patient declined an occupational therapy evaluation. Respiratory assessment The 07/26/23 hospital discharge summary included the diagnosis of asthma and an order for albuterol sulfate (a rescue inhaler) 2 puffs inhalation every 4 hours as needed for shortness of breath or wheezing. On 07/31/23, the physical therapist documented: - the patient had dyspnea when walking more than 20 feet or climbing stairs without documentation of the severity of the dyspnea, how the dyspnea was treated, or how the asthma or chronic obstructive pulmonary disease was managed. - an oxygen saturation of 90% without indicating whether it was obtained at rest or after ambulation - no issues found during review and did not address use of albuterol On 08/01/23, the registered nurse visited the patient and documented: - the patient did not have an albuterol inhaler in the home and had not needed it without identifying the timeframe the patient had not used the albuterol - had a history of asthma but did not address how the asthma was managed - had an oxygen saturation of 93% without stating if this was at rest or after exertion The registered nurse documented that the patient did not have an albuterol inhaler in the home, nor had they needed it, and obtained verbal orders without specifying what orders were obtained. Gastrointestinal assessment The 07/26/23 hospital discharge summary included an order for hemorrhoidal ointment 1 application rectally every 8 hours as needed for irritation. The 07/31/23 physical therapist visit note did not include an assessment of the use of the hemorrhoid cream or the presence of hemorrhoids. The 08/01/23 registered nurse visit documentation reported the patient had not used hemorrhoidal cream but did not identify the timeframe the patient had not used it. The nurse also documented the patient was taking 2 over-the-counter medications as needed for constipation without assessment of how often the patient took the medications. The elimination section stated, “patient cannot recall when they last moved their bowels but denies any concerns.” The clinician failed to identify if the patient has hemorrhoids and how often the patient used medication to treat constipation. On 09/27/23, the registered nurse visited the patient to complete skilled nursing evaluation and documentation supported patient had external hemorrhoids and that caregiver had been applying over-the-counter hemorrhoid cream. Physician was notified and order was obtained. 3. Patient #4 was admitted to the agency on 02/15/24 with diagnoses of hypertensive heart disease, congestive heart failure, chronic kidney disease, and chronic obstructive pulmonary disease. The skilled nurse failed to perform a comprehensive assessment of the patient and their needs. On 05/16/24 the skilled nurse visited the patient to perform a resumption of care visit (patient was hospitalized 05/11/24-05/15/24) and updated the plan of care to include instructing the patient to wear Tubigrips (compression bandages) to bilateral lower legs. The skilled nurse documented in the 05/16/24 assessment the patient needed assistance with completing lower body activities, such as putting on undergarments, pants, socks, and shoes. The assessment did not include any documentation of instruction/education regarding the Tubigrips. There is no evidence the skilled nurse: - assessed the patient’s ability to apply and remove the ordered Tubigrips to their bilateral lower legs - instructed/educated the patient in the use of the Tubigrips to the bilateral lower extremities including frequency of use and length of time they should be worn On 09/11/24 at 1:00 p.m. the above findings were reviewed with the Administrator/Director of Patient Services and Clinical Manager who acknowledged the findings and provided no additional information. Failure to ensure comprehensive assessments are complete and/or accurately reflect the patient's status has the potential for negative outcomes for the agency patient population.

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 a review of clinical records and interviews with the Administrator/Director of Patient Services and Clinical Manager, it was determined in 2 of 7 records (patients #2, and 7), the agency failed to develop individualized plans of care that were complete, accurate, and/or addressed the total needs of the patients. Evidence as follows: Patient #4 was admitted to the agency on 02/15/24 with diagnoses of hypertensive heart disease, congestive heart failure, chronic kidney disease, and chronic obstructive pulmonary disease. The skilled nurse failed to update the plan of care with individualized and complete orders/instructions. The patient was hospitalized from 05/11/24-05/15/24 with a diagnosis of congestive heart failure exacerbation and had pitting edema to both lower extremities on examination. On 05/16/24 the skilled nurse visited the patient and performed a resumption of care visit. The plan of care was updated to include instructing the patient to wear Tubigrips (compression bandages) to their bilateral lower legs. The plan of care failed to include the frequency of use and length of time the Tubigrips should be worn. On 09/11/24 at 1:00 p.m. the findings were reviewed with the Administrator/Director of Patient Services and Clinical Manager who acknowledged the findings and provided no additional information. Failure to ensure the Plan of Care is complete, accurate, and updated has the potential for unmet patient needs and possible negative patient outcomes. Patient #7 was admitted to the agency on 07/31/23 with diagnoses that included fracture to right shoulder, Alzheimer’s, atherosclerotic heart disease, chronic obstructive pulmonary disease, chronic pain, and hypertension. This patient was selected from the potentially avoidable event report, generated by the Center for Medicare and Medicaid services from 06/01/23-05/30/24. The patient was identified on the report as an increase in pressure ulcers and discharge to the community with a stage 2 pressure ulcer. Sling The 07/26/23 hospital discharge summary included an order to “continue to wear your sling only removing when therapy is present or for hygiene purposes.” On 07/31/23, the physical therapist visited the patient and completed the start of care comprehensive assessment. The visit documentation stated the patient right arm “in a sling per MD request.” The 07/31/24 Plan of Care failed to include an order for sling use. Vital signs The 07/26/23 hospital discharge summary included a diagnosis of asthma. The 07/31/24 Plan of Care included diagnoses of hypertension, atherosclerotic heart disease, and chronic obstructive pulmonary disease. The 07/31/24 Plan of Care failed to include order to assess vital signs or parameters to contact the physician. Patient #2 was admitted to the agency on 06/12/24 with diagnoses of cellulitis to the left and right lower limbs, type 2 diabetes with foot ulcer of the left heel, lymphedema, hypertension, hypothyroidism, and morbid obesity. The skilled nurse failed to update the Plan of Care as follows: The 06/12/24-08/10/24 Plan of Care included the following wound care orders: - skilled nurse to do wound care to left plantar foot/heel. - cleanse wound with Vashe - prep surrounding skin with skin prep - apply nickel-thick layer of Santyl to wound bed - cover with cut to size Aquacel extra - secure with adherent foam dressing - apply Tubigrip size G to secure - change dressing daily and PRN (as needed) if loose or soiled - patient/caregiver to complete wound care on days of no skilled nurse visit On 07/15/24, the patient visited the wound care clinic and received new wound care orders that were scanned into the electronic health record as follows: - cleanse wound with normal saline prior to applying a clean dressing. Do not scrub or use excessive force - apply a thin layer of zinc oxide ointment on the intact skin surrounding the wound. Do not get ointment in the wound - Aquacel Ag 2x2, cut the dressing to fit the size of the wound and apply to the wound surface - apply a layer of Santyl ointment nickel-thick out to the edges of the wound - change dressing daily and apply new ointment with each dressing change - secured with soft cloth surgical tape and stretch bandage roll (4x4) - Juzo compression calf wrap w/ Tubigrip, compression amount 30-40 mmHg - put compression wraps on as soon as you wake up in the morning and remove as you are getting into bed The 07/24/24 visit note included, “Wound clinic sent out a new compression wrap and stockings. Pt. reports [patient] was told [patient] can begin to use them immediately, but pt does not feel [patient] can apply compression stockings independently. SN (skilled nurse) called wound clinic and left a message regarding compression devices and requesting an order if pt is to be wearing them.” It was identified in the initial visit note [friend] was performing wound care on the days of no nurse visit. It was unclear why [friend] was not educated to assist patient with compression wraps after daily wound care. It was unclear why the wound care clinic physician was called to clarify the order when the new 07/15/24 orders specifically indicated the wraps should applied in the morning and removed when getting into bed at night. The 07/24/24 wound care note included, “Cleansed wound with Vashe. Prepped surrounding skin with skin prep. Applied nickel-thick layer of Santyl to wound bed, covered with cut to size Aquacel Extra. Secured with adherent foam dressing. Pt. declined Tubigrip application.” On 09/11/24 at 10:30 a.m., the surveyor performed an observational home visit with the nurse who performed wound care on the left heel wound. The surveyor observed the nurse complete the following steps of wound care: - cleanse with Vashe - apply Santyl and Aquacel Extra - cover with Mepilex foam bordered dressing The nurse failed to update the Plan of Care and follow the wound clinic physician's new 07/15/24 orders: - by using Vashe and not saline - by using Aquacel Extra and not Aquacel Ag - by using skin prep to the peri wound and not zinc oxide - by securing with Mepilex and not cloth surgical tape and stretch rolled 4x4 gauze - not using Juzo compression calf wrap w/ Tubigrip The nurse asked the patient if Tubigrip could be applied, and the patient declined. After the visit, the surveyor interviewed the patient who told the surveyor the Tubigrip "falls down all the time." The 08/11/24-10/09/24 Plan of Care included the 07/03/24 updated wound care orders but failed to include the 07/15/24 wound clinic order changes. The nurse continued to perform the wound care per the 06/12/24 original orders and failed to notify the physician the patient was refusing the application of the Juzo compression calf wrap w/ Tubigrip. On 09/11/24 at 1:00 p.m., the findings were reviewed with the Administrator/Director of Patient Services and Clinical Manager who acknowledged the findings and provided no additional information.

Promptly alert relevant physician of changes CFR(s): 484.60(c)(1) The HHA must promptly alert the relevant physician(s) or allowed practitioner(s) to any changes in the patient's condition or needs that suggest that outcomes are not being achieved and/or that the plan of care should be altered. This ELEMENT is not met as evidenced by: Based on a review of clinical records and interviews with the Administrator/Director of Patient Services and Clinical Manager, it was determined in 2 of 7 records (patients #4 and 5), the skilled nurse failed to communicate with the physician when changes in the patient's condition occurred. Evidence as follows: Patient #5 was admitted to the agency on 04/04/24 with diagnoses including type 2 diabetes with foot ulcer, non-pressure chronic ulcer of right foot, and other chronic osteomyelitis. At the 09/06/24 nursing visit, the skilled nurse documented the patient had a pain level of 7 out of 10 in their right foot. Under “additional narrative – pain management”, the nurse documented the patient stated they had a burning pain in the right foot that “comes and goes”. They reported they last took Tylenol at 8:00 a.m. that morning and the pain remained “about the same after the Tylenol”. The 08/02/24 - 09/30/24 Plan of Care included an order to call the physician if the patient had pain 4 out of 10 that is unrelieved with interventions. There is no evidence the nurse called to inform the physician of the unrelieved pain above 4 out of 10. On 09/12/24 at 10:30 a.m. the surveyor reviewed the findings with the Administrator/Director of Patient Services and Clinical Manager, who acknowledged the findings. Patient #4 was admitted to the agency on 02/15/24 with diagnoses of hypertensive heart disease, congestive heart failure, chronic kidney disease, and chronic obstructive pulmonary disease. The skilled nurse failed to update the physician as ordered. The 06/14/24 - 08/12/24 and 08/13/24 - 10/11/24 Plan of Care included the following: Weights - call physician for weight gain of 2 pounds overnight or 5 pounds in a week Edema - bilateral lower extremity measurements every visit, call physician for 3 cm increase from previous visit The skilled nurse failed to notify the physician for: Weights - 8 pound increase between the 06/11/24 (325 pounds) and 06/18/24 (333 pounds) nursing visits - 11 pound increase between the 07/23/24 (341 pounds) and 07/30/24 (352 pounds) nursing visits - 9 pound increase between the 08/13/24 (338 pounds) and 08/20/24 (347 pounds) nursing visits Edema - 3.5 increase in the left calf between the 04/23/24 (42.5 cm) and 04/30/24 (46 cm) nursing visits - 5.5 increase in the right calf between the 05/16/24 (42 cm) and 05/21/24 (47.5 cm) nursing visits On 09/11/24 at 1:00 p.m. the findings were reviewed with the Administrator/Director of Patient Services and Clinical Manager who acknowledged the findings and provided no additional information. Failure to ensure the physician is notified regarding changes in the patient's condition has the potential for unmet patient needs and possible negative patient outcomes. Home Visit Patient #2 was admitted to the agency on 06/12/24 with diagnoses of cellulitis to the left and right lower limbs, type 2 diabetes with foot ulcer, hypertension, hypothyroidism, and morbid obesity. Wound Care The 06/12/24-08/10/24 Plan of Care included wound care orders which included: - apply Tubigrip size G to secure The 07/17/24 nurse visit note included, "Pt. declined Tubigrip application.” On 09/11/24 at 10:30 a.m., the surveyor performed an observational home visit with the nurse who performed wound care on the left heel wound. The nurse asked the patient if Tubigrip could be applied, and the patient declined. After the visit, the surveyor interviewed the patient who told the surveyor the Tubigrip "falls down all the time." The nurse failed to notify the physician the patient was refusing the Tubigrip. Diabetes The 06/12/24-08/10/24 Plan of Care included: - Patient/caregiver to test blood glucose 3 times per day and as needed via Freestyle Libre continuous glucose monitor and to notify the provider if the results were 300. On 07/10/24, the nurse documented they were unable to assess the patient's glucose due to: - Freestyle Libre sensors hadn't come in yet - patient could not get blood from the fingerstick today On 07/18, 07/24, 07/31, 08/07, 08/14, 08/21, 08/28, and 09/04/24 the nurse documented, "patient did not obtain BG (blood Glucose) today because Freestyle Libre has not come in yet, and [patient] could not get blood from [patient] fingerstick today. For 8 weeks, the nurse failed to notify the physician the patient was not testing the blood glucose 3 times per day. On 09/11/24 at 1:00 p.m., the findings were reviewed with the Administrator/Director of Patient Services and Clinical Manager who acknowledged the findings and provided no additional information. On 09/12/24, the Quality Manager provided an audit tool that indicated the provider was notified of the problems obtaining the Freestyle Libre equipment, however, there was no audit finding the blood sugar was not being tested via fingerstick 3 times per day or that the physician was notified of the lack of glucose testing. The information provided did not change the findings.