Every finding on record at Cozad Hospital District #2

Central Plains Home Health is in compliance with the requirements of 42 CFR 484.102 Condition of Participation for Home Health Agencies.

All orders recorded in plan of care CFR(s): 484.60(a)(3) All patient care orders, including verbal orders, must be recorded in the plan of care. This ELEMENT is not met as evidenced by: Based on record review, policy and procedure review, and staff interview, the agency failed to ensure the patient's medication orders on the plan of care and the medication profile (a real-time document used by the agency as part of the plan of care, that lists the patient’s medications, including new and updated orders received between certification periods), were accurate, for 2 of 7 patient records reviewed (Patient 1 and 3). The census was 42. Findings are: A. Review of the agency’s policy and procedure titled Patient Plan of Care for Home Health, revised 9/20/23, revealed: 1. The comprehensive plan of care was to be created by a Registered Nurse (RN) and reviewed by the Clinical Care Coordinator for completeness. 2. The plan of care includes a medication list. 3. The plan of care was to be updated as frequently as necessary. B. Review of the agency’s policy and procedure titled Medication Policy, effective 11/2022, revealed: 1. Medications were to be administered safely and correctly as ordered by a physician. 2. Medication orders were to be reviewed at a minimum with every recertification and updated on the care plan. 3. The primary nurse was to be responsible for continuous monitoring of all medications the patient may be taking. If problems or concerns occur, the nurse was to report them to the physician. C. Review of Patient 1’s clinical record revealed: 1. The referral orders from Lexington Regional Health Center to the agency, dated 3/16/26, included orders for Quetiapine Fumarate (used to treat mental health disorders) 100 mg (milligrams) 3 times daily. 2. The Home Health Certification and Plan of Care (POC) for the certification period 3/17/26 through 5/15/26 and the medication profile revealed Quetiapine Fumarate 100 mg daily. 3. There was no documentation in the clinical record of medication reconciliation of the medication discrepancy with the patient's physician. D. Review of Patient 3’s clinical record revealed: 1. The referral orders from Cozad Community Hospital to the agency, dated 3/2/26, included orders for Furosemide (used to treat fluid retention) 60 mg 2 times daily and Lexapro (used to treat depression) 20 mg daily. 2. The POC for the certification period 3/3/26 through 5/1/26 and the medication profile revealed: a. Furosemide 40 mg daily. b. Lexapro 10 mg daily. 3. There was no documentation in the clinical record of medication reconciliation of the medication discrepancies with the patient's physician. E. During interview on 4/9/26 at 2:00 PM, the Director of Home Health confirmed the POC and the medication profiles for Patients 1 and 3 were not accurate, and the agency failed to follow their policy and procedure to notify the patient's physician of the discrepancies.

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 record review, policy and procedure review, and staff interview, the agency failed to ensure staff followed the agency's policy and procedure for physician orders when a verbal order was received for 1 of 7 patient records reviewed (Patient 3). The census was 42. Findings are: A. Review of the agency’s policy and procedure titled Physician Orders – Verbal and Written, revised 4/23/23, revealed: 1. All care provided to patients is under the direction of a physician/provider order. 2. The agency was to have written, signed, and dated physician orders when any change to the patient’s plan of care occurs. 3. Any changes to medications, treatments, or services that arise after the care plan is developed were to be documented as a physician order and serve as an update to the plan of care. B. Review of Patient 3’s clinical record revealed: 1. The Home Health Certification and Plan of Care (POC) for the certification period 3/3/26 through 5/1/26 included orders for Skilled Nursing (SN) 1-3 times a week. 2. Review of SN documentation, dated 3/5/26, revealed: a. The Registered Nurse (RN) notified the physician to report an increase in the patient’s weight. b. The physician ordered to increase Furosemide (medication used to treat fluid retention) 80 mg (milligrams) in the AM for 2 days if weight gets to 339 pounds. When weight goes back down to 337 pounds, the patient was to return to Furosemide 60 mg 2 X daily. c. The RN failed to write a verbal order to adjust the Furosemide dosage and send the order to the physician for signature, and failed to update the plan of care. 3. Review of SN documentation, dated 3/25/26, revealed: a. The agency was notified by the Cozad clinic to perform an INR (A blood test that measures how quickly blood forms a clot). b. The INR was performed during the SN visit. c. The agency RN failed to write a verbal order to perform an INR and send the order to the physician for signature. C. During an interview on 4/9/26 at 2:00 PM, the Director of Home Health confirmed the agency failed to follow their policy and procedure for physician orders when verbal orders were received for Patient 3.

Reviewed, revised by physician every 60 days CFR(s): 484.60(c)(1) The individualized plan of care must be reviewed and revised by the physician or allowed practitioner who is responsible for the home health plan of care and the HHA as frequently as the patient's condition or needs require, but no less frequently than once every 60 days, beginning with the start of care date. This ELEMENT is not met as evidenced by: Based on record review, policy and procedure review, and staff interview, the agency staff failed to notify the physician or allowed practitioner of the need to change treatment orders on the plan of care, when a change in wound status occurred for 1 of 4 patients (Patient 3) receiving wound care. The census was 42. Findings are: A. Review of the agency’s policy and procedure titled Patient Plan of Care for Home Health, revised 9/20/23, revealed: 1. The care plan was to be individualized and patient-specific and sent to the physician for review and signature. 2. The care plan was to include orders and treatments to be performed. 3. The plan of care was to be updated as frequently as necessary. B. Review of the agency’s policy and procedure titled Physician Orders – Verbal and Written, revised 4/24/23, revealed any changes to treatments that arise after the care plan is developed were to be documented as a physician order and serve as an update to the plan of care. C. Review of Patient 3’s clinical record revealed: 1. The Home Health Certification and Plan of Care (POC) for the certification period 3/3/26 through 5/1/26 included orders for Skilled Nursing (SN) 1-3 times a week to provide wound care, to the patient’s right lower extremity shin wound, by washing the wound with anasept ( antimicrobial wound cleanser), applying silver alginate dressing (an absorbent wound dressing containing silver), wrapping with kerlix (rolled gauze dressing), and applying edema wear (tubular compression sock to reduce swelling). 2. Review of SN documentation, dated 3/17/26, revealed the Registered Nurse (RN) notified the physician to report the wound on patient’s left shin was healed. 3. The RN failed to obtain revised wound care orders for the right shin and failed to update the plan of care. D. During an interview on 4/9/26 at 2 PM, the Director of Home Health confirmed Patient 3’s healed wound was on the right shin, not on the left shin as indicated on the SN documentation on 3/17/26, and also confirmed the healed wound on the right shin was a change in condition for which the agency failed to notify the patient's physician or allowed practitioner of the need to change the patient's treatment order and update the patient's plan of care.

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 record review, policy and procedure review, observation of the provision of care, and staff interview, the agency failed to ensure 1of 3 staff (Staff C), observed during the provision of care to 1 of 3 patients (Patient 1), performed proper hand hygiene according to the agency's policy and procedure. The total patient sample size was 7. The census was 42. Findings are: A. Review of the agency’s policy and procedure titled Hand Hygiene Policy, revised 9/11/23, revealed hand hygiene was to be performed before donning gloves and immediately after removing gloves. B. Review of Patient 1’s clinical record revealed the Home Health Certification and Plan of Care (POC), for the certification period 3/17/26 through 5/15/26, included orders for Skilled Nursing (SN) 1-3 x per week to provide wound care to the patient’s abdomen. C. The observation of the provision of care for Patient 1 on 4/8/26 at 12:00 PM, revealed Staff C failed to perform hand hygiene after removing gloves and prior to applying clean gloves on 2 separate occasions. D. During an interview on 4/9/26 at 2:00 PM, the Director of Home Health confirmed Staff C failed to follow the agency’s policy and procedure for hand hygiene during the provision of care for Patient 1.

Onsite supervisory visit every 14 days CFR(s): 484.80(h)(1)(i) (1)(i) If home health aide services are provided to a patient who is receiving skilled nursing, physical or occupational therapy, or speech language pathology services— (A) A registered nurse or other appropriate skilled professional who is familiar with the patient, the patient's plan of care, and the written patient care instructions described in paragraph (g) of this section, must complete a supervisory assessment of the aide services being provided no less frequently than every 14 days; and (B) The home health aide does not need to be present during the supervisory assessment described in paragraph (h)(1)(i)(A) of this section. This ELEMENT is not met as evidenced by: Based on record review, policy and procedure review, and staff interview, the agency failed to conduct Registered Nurse (RN) supervisory visits at least every 14 days to 1 of 2 patients (Patient 6) receiving Home Health Aide services. The total sample size was 7. The census was 42. Findings are: A. Review of the agency’s policy and procedure titled Home Health Aide Services, revised 2/2014, revealed Home Health Aide services provided by a Certified Nursing Assistant must be supervised by an RN every 2 weeks if the patient receives a skilled service. B. Review of Patient 6’s clinical record revealed: 1. The Home Health Certification and Plan of Care (POC) for the certification period 11/7/25 through 1/5/26, included orders for Skilled Nurse (SN) 1-2 x weekly. 2. An order for Home Health Aide services was received on 11/26/25 to assist with personal cares 1-2 x weekly for the duration of the certification period. 3. The agency failed to conduct RN onsite Home Health Aide supervisory visits at least every 14 days from 12/9/25 through 1/2/26. C. During an interview on 4/9/26 at 2:00 PM, the Director of Home Health confirmed the agency failed to follow their policy and procedure for conducting RN onsite Home Health Aide supervisory visits at least every 14 days for Patient 6.

Central Plains Home Health is in compliance with the requirements of 42 CFR 484.102 Condition of Participation for Home Health Agencies.

All orders recorded in plan of care CFR(s): 484.60(a)(3) All patient care orders, including verbal orders, must be recorded in the plan of care. This ELEMENT is not met as evidenced by: Based on record review, policy and procedure review, and staff interview, the agency failed to ensure staff follow the agency policy and procedure to complete a verbal order/physician order when there was a change in orders for 2 of 8 records reviewed (Patient 3 and Patient 6). The census was 62. Findings are: A. Review of the agency policy and procedure titled, Verbal Orders, revised 3/05, revealed after a patient sees their physician, all medication changes must be verified by the primary nurse. A verbal order is to be written to reflect the change. B. Review of the agency policy and procedure titled, Physician Orders, revised 8/2014, revealed: 1. All home health staff are to follow the plan of care. 2. The plan of care is considered a physician order. 3. A physician order must be completed any time there is a change in the original plan of care in treatment, medication, and/or services to be provided. C. Review of Patient 3's clinical record revealed: 1. The Home Health Certification and Plan of Care for the certification period of 1/6/23 through 3/6/23 included orders for skilled nurse (SN) to complete wound care to left lateral foot 2 times per week, clean with anasept (a type of wound cleanser) or wound wash, pat dry, apply betadine moistened gauze to wound bed, and wrap foot with rolled gauze and/or coban (a self-adherent elastic wrap) to secure. 2. A 2- page wound clinic note dated 1/24/23: on page one the clinic nurse noted the patient's wound had a horseshoe pad placed around the wound bed, and a betadine wet to dry dressing (a dressing in which the moistened dressing is placed on the wound and then covered by a dry dressing) was applied. Page 2 included an order from the patient's wound physician for Promogran 1DSD 2-3 times per week, offload with cam boot [sic]. There was no documentation in the clinical record the order was clarified with the ordering physician. 3. A SN visit note dated 2/10/23 revealed the patient informed the nurse of a wound clinic visit completed on 2/7/23. The patient reports being instructed to apply neosporin (a type of antibiotic ointment) and a bandaid to the wound. The SN note indicated the wound was washed and antibiotic ointment and bandaid were applied. There was no documentation the SN verified the change of treatment order before applying the treatment. D. Review of Patient 6's clinical record revealed: 1. A Resumption of Home Health Plan of Care for the certification period of 11/26/22 through 1/24/23 included orders for oxycodone-acetaminophen oral (an opiod and non-opiod combination medication used to treat pain), 5 milligrams/325 milligram (mg), take one tablet two times per day for pain, and norco oral (an opiod and non-opiod combination medication used to treat pain) 5/325 mg, may take 1 to 2 tablets every 4 hours as needed for pain. 2. A SN note dated 1/4/23, the SN documented the patient's provider increased the patient's pain medication last week and today. There was no documentation of a physician/verbal order in the clinical record of the increase in medication as indicated in the 1/4/23 SN note. 3. A SN note dated 1/6/23, the SN documented the physician increased pain medications this week, oxycontin (an opiod pain medication) to 40 mg twice a day. There was no documentation of a physician/verbal order in the clinical record of the increase in medication as indicated in the 1/6/23 SN note. 4. A SN note dated 1/9/23 and again on 1/11/23, the SN documented the patient continues to take oxycontin 20 mg twice a day with tylenol 1000 mg every 6 hours. There was no documentation of a physician/verbal order in the clinical record of the change in medication as indicated in the 1/9/23 and 1/11/23 SN notes. E. During an interview on 3/22/23 from 2:30 PM - 2:45 PM, Patient-3's Case Manager (CM) confirmed the wound clinic orders on 1/24/23 were not clarified when received. The CM confirmed this order (1/24/23) was unclear. The CM also confirmed the orders on 2/10/23 as stated by the patient were not verified with the patient's wound physician. F. During an interview on 3/22/23 from 2:30 PM - 3:00 PM, the Director of Home Health confirmed the agency staff did not follow the agency policy and procedure to complete a physician order/verbal order when changes in treatment and /or medications occurred for Patient 3 and Patient 6.

Only as ordered by a physician CFR(s): 484.60(b)(1) Drugs, services, and treatments are administered only as ordered by a physician or allowed practitioner. This ELEMENT is not met as evidenced by: Based on record review, policy and procedure review, and staff interview, the agency failed to ensure staff follow treatments as ordered by the physician for 1 of 8 patient records reviewed (Patient 3) and failed to have a process in place for the timely verification and/or clarification from the ordering physician of orders relayed to the agency staff by the patient. The census was 62 Findings are: A. Review of the agency policy and procedure titled, Verbal Orders, revised 3/05, revealed after a patient sees their physician, all medication changes must be verified by the primary nurse. A verbal order is to be written to reflect the change. B. Review of the agency policy and procedure titled, Physician Orders, revised 8/2014, revealed: 1. All home health staff are to follow the plan of care. 2. The plan of care is considered a physician order. 3. A physician order must be completed any time there is a change in the original plan of care in treatment, medication, and/or services to be provided. C. Review of Patient 3's clinical record revealed: 1. The Home Health Certification and Plan of Care for the certification period of 1/6/23 through 3/6/23 included orders for skilled nurse (SN) to complete wound care to left lateral foot 2 times per week, clean with anasept (a type of wound cleanser) or wound wash, pat dry, apply betadine moistened gauze to wound bed, and wrap foot with rolled gauze and/or coban (a self-adherent elastic wrap) to secure. 2. A 2- page wound clinic note dated 1/24/23: on page one the clinic nurse noted the patient's wound had a horseshoe pad placed around the wound bed, and a betadine wet to dry dressing (a dressing in which the moistened dressing is placed on the wound and then covered by a dry dressing) was applied. Page 2 included an order from the patient's wound physician for Promogran 1DSD 2-3 times per week, offload with cam boot [sic]. There was no documentation in the clinical record the order was clarified with the ordering physician. 3. A SN note dated 1/27/23, 1/31/23, and 2/3/23 revealed the nurse applied an iodine wet-to-dry dressing, and edemawear (a compression stocking used to reduce swelling of the legs). 4. A SN visit note dated 2/10/23 revealed the patient informed the nurse of a wound clinic visit completed on 2/7/23. The patient reports being instructed to apply neosporin (a type of antibiotic ointment) and a bandaid to the wound. The SN note indicated the wound was washed and antibiotic ointment and bandaid were applied. There was no documentation the SN verified the change of treatment order before applying the treatment. 5. A SN note dated 2/14/23 revealed the SN applied antibiotic ointment and a bandaid. There was no order from the physician for this treatment. 6. A SN note dated 2/17/23 revealed the SN applied medipore (a type of wound dressing). There was no order for this treatment. The SN also noted, waiting for orders from the physician. 7. A SN note dated 2/24/23 revealed antibiotic ointment and medipore dressing was applied to the patient's wound. The SN also noted, waiting for orders from the physician. There was no order from the physician for this treatment. D. During an interview on 3/22/23 from 2:30 PM - 2:45 PM, Patient-3's Case Manager (CM) confirmed: 1. The 1/24/23 order was unclear. This order was not clarified when received. 2. The orders on 2/10/23 as stated by the patient were not verified with the patient's wound physician. 3. The ordering physician was difficult to contact for orders. 4. The CM also confirmed [gender] was unaware of a way to obtain orders when an ordering physician is difficult to contact. E. During an interview on 3/22/23 from 2:30 PM - 2:45 PM, the Director of Home Health (DHH) confirmed the agency staff did not follow Patient 3's treatment when changes in treatment were ordered or unclear. The DHH also confirmed the agency did not have a procedure in place for obtaining orders from difficult to reach physicians.