Every finding on record at Crest Home Health & Hospice

The Medicare recertification survey of your facility, conducted from 1/08/24 - 1/11/24 , included Emergency Preparedness. Crest Home Health was found to be in substantial compliance for the regulations found at 42 CFR 494.62.

The following deficiencies were cited during the Medicare recertification survey of your agency conducted on 1/08/2024 - 1/11/2024. Acronyms used in this report include: ADL - Activities of Daily Living DCS - Director of Clinical Services EMS - Emergency Medical Services HHA - Home Health Aide mmHg - Millimetres of Mercury MSW - Master Social Worker OT – Occupational Therapist PCP - Primary Care Provider POC – Plan of Care PT – Physical Therapist PTA - Physical Therapy Assistant RN – Registered Nurse RNCM - Registered Nurse Care Manager SN – Skilled Nursing SNF - Skilled Nursing Facility SOC - Start of Care SW - Social Work

Patient rights CFR(s): 484.50 Condition of participation: Patient rights. The patient and representative (if any), have the right to be informed of the patient's rights in a language and manner the individual understands. The HHA must protect and promote the exercise of these rights. This CONDITION is not met as evidenced by: Based on record review, observation, and staff interview, it was determined the agency failed to ensure patient's rights were protected from neglect and that patient was given contact information for other agencies or providers who may be able to provide care. This negatively impacted quality, coordination, and safety of patient care. Findings include: Refer to G430 as it related to a failure of the agency to ensure the patient is free from neglect. Refer to G468 as it related to a failure of the agency to ensure the patient was provided with contact information for other agencies or providers who may be able to provide care. The cumulative effects of these negative practices seriously impeded the ability of the agency to provide services of adequate quality and ensure the rights of patients.

Be free from abuse CFR(s): 484.50(c)(2) Be free from verbal, mental, sexual, and physical abuse, including injuries of unknown source, neglect and misappropriation of property; This ELEMENT is not met as evidenced by: Based on record review and staff interview, it was determined the agency failed to ensure the patient was free from neglect, as outlined in the POC and ordered by the physician were provided for 1 of 10 patients (Patient #10) whose records were reviewed. This failure resulted in insufficient goods and services necessary to avoid adverse clinical outcomes. Findings include: Patient #10 was a 71-year-old male who was admitted to the agency on 12/08/23, with a primary diagnosis of alcohol dependence with withdrawal delirium. Additional diagnoses included primary osteoarthritis, atrial fibrillation, and chronic obstructive pulmonary disease. He received MSW, PT, SN, and OT services. His record, including the POC, for the certification period 12/09/23 to 2/06/24, was reviewed. Patient #10’s medical record included a PTA visit note dated 12/20/23, signed by the PTA. She documented a 30-minute home visit which included a review of systems and fall assessment for Patient #10. Additionally, the PTA documented Patient #10 stated he had not had a fall. Further, the PTA documented, “PT [patient] sleeping and unable to be woken up.” The PTA did not document the disposition of Patient #10, nor if his physician was contacted regarding his presentation. She did not document follow-up or communication with Patient #10’s PT, RNMC, or physician. It was unclear if Patient #10 was safe to be left at home due to his clinical presentation. Patient #10’s PTA was interviewed on 1/10/24 at 1:10 PM. She confirmed Patient #10 was on the floor when she arrived at visit, she could not wake him, and she did not call EMS for additional assistance. The PTA stated Patient #10’s roommate, who was not his caregiver, was home at the time of the visit and was aware of Patient #10’s situation. When asked if Patient #10 was soiled and wet at time of visit, the PTA stated, “he was.” When asked if she provided any physical therapy during the home visit, the PTA confirmed the patient was not awake at any point and therefore did not provide ordered therapy. Additionally, the PTA confirmed Patient #10 was left on his floor at end of visit and she did not make arrangements for follow-up care with his PT, RNCM, or physician. The agency failed to protect Patient #10 from potential neglect.

Provide contact info other services CFR(s): 484.50(d)(5)(iii) (iii) Provide the patient and representative (if any), with contact information for other agencies or providers who may be able to provide care; and This ELEMENT is not met as evidenced by: Based on medical record review and staff interview, it was determined the agency failed to ensure patients were provided contact information for other agencies or providers able to provide care for 1 of 1 patient (Patient #3) who was discharged for cause and whose record was reviewed. This had the potential for unmet patient needs and breakdown in continuity of patient care. Patient #3 was a 77 year old female admitted to the agency on 5/06/23, with a primary diagnosis of Pain due to internal orthopedic prosthetic devices. Additional diagnoses included repeated falls, essential hypertension, and acute embolism and thrombosis of left lower extremity. She received SN, MSW and PT services. Her record, including the POC, for the certification period 5/06/23 – 5/17/23, was reviewed. She was discharged from the agency on 5/17/23. Patient #3’s medical record included a discharge oasis assessment note, dated 5/17/23, signed by the RNCM. The note included in the narrative section: “Patient will still not make a decision on if she will go to [ local SNF ] or not. I reminded the patient that there is not any more we can do for her in the current situation she is in…. I explained that either way she is being discharged from the home health…” Patient #3's record did not include documentation that she was provided with contact information for other agencies or providers who may be able to provide care after her home health discharge. The Director of Clinical Services was interviewed on 1/10/24 beginning at 9:30 AM and Patient #3’s medical record was reviewed in her presence. She confirmed there was no documentation Patient #3 was given contact information for other agencies or providers who may be able to provide care after his home health discharge. The agency failed to ensure Patient #3 was given contact information for providers or home health agencies who could provide care, prior to his discharge for cause.

Care planning, coordination, quality of care CFR(s): 484.60 Condition of participation: Care planning, coordination of services, and quality of care. Patients are accepted for treatment on the reasonable expectation that an HHA can meet the patient's medical, nursing, rehabilitative, and social needs in his or her place of residence. Each patient must receive an individualized written plan of care, including any revisions or additions. The individualized plan of care must specify the care and services necessary to meet the patient-specific needs as identified in the comprehensive assessment, including identification of the responsible discipline(s), and the measurable outcomes that the HHA anticipates will occur as a result of implementing and coordinating the plan of care. The individualized plan of care must also specify the patient and caregiver education and training. Services must be furnished in accordance with accepted standards of practice. This CONDITION is not met as evidenced by: Based on record review, observation, and staff and patient interviews, it was determined the agency failed to ensure services were furnished in accordance with the POC and consistent with patients' needs. This negatively impacted quality, coordination, and safety of patient care. Findings include: Refer to G572 as it related to a failure of the agency to ensure the patients received all services outlined in the POCs. Refer to G574 as it related to a failure of the agency to ensure the POCs included all interventions, measurable outcomes, medications, and goals needed to meet the needs of the patient. Refer to G586 as it related to a failure of the agency to ensure services ordered by the physician were provided. The cumulative effects of these negative practices seriously impeded the ability of the agency to provide services of adequate quality had the potential to lead to harm to the patient(s).

Plan of care CFR(s): 484.60(a)(1) Each patient must receive the home health services that are written in an individualized plan of care that identifies patient-specific measurable outcomes and goals, and which is established, periodically reviewed, and signed by a doctor of medicine, osteopathy, or podiatry acting within the scope of his or her state license, certification, or registration. If a physician or allowed practitioner refers a patient under a plan of care that cannot be completed until after an evaluation visit, the physician or allowed practitioner is consulted to approve additions or modifications to the original plan. This STANDARD is not met as evidenced by: Based on observation, medical record review and staff and patient interviews, it was determined the agency failed to ensure the the interventions, measurable outcomes, medications, and goals outlined in the POC were provided for 2 of 10 patients (Patients #2 and #10) whose records were reviewed. This failure resulted in the patients not receiving the care and services outlined in their POCs and had the potential to result in unmet needs and harm to the patient. Findings include: 1. Patient #10 was a 71-year-old male admitted to the agency on 12/08/23, with a primary diagnosis of alcohol dependence with withdrawal delirium. Additional diagnoses included primary osteoarthritis, atrial fibrillation, and chronic obstructive pulmonary disease. He received MSW, PT, SN, and OT services. His medical record, including the POC, for the certification period 12/09/23 to 2/06/24, was reviewed. Patient #10’s medical record included a POC dated 12/20/23 with Medication Management as a written goal. The POC interventions included “1. Assess current medications including – new/changed medications, side effects and interaction. 2. Assess patient/caregiver’s current knowledge of medications and medication management." Additionally, Patient #10’s POC documented a goal of impaired safety awareness/home environment with interventions listed as “1, Assess.re-assess home environment. 2. Assess/re-assess patient’s safety awareness 3. Instruct patient/caregiver in safety awareness strategies and how to safely mange/maintain home environment.” Patient #10 did not receive all interventions ordered in his POC. Examples include: A visit was conducted in Patient #10’s home on 1/09/24, beginning at 12:25 PM, in the presence of his PTA, RN, and MSW. a. During the visit, Patient #10 was not asked if he had taken his medications, what medications he was currently taking, and if there were medication changes or any issues with medication access. Patient #10 was interviewed after his RN and PTA left. Patient #10 stated he had not taken any of his medications for the last 2 days. G0572 b. During the visit, Patient #10’s gas oven was observed being used as a heat source. Agency staff had not noticed Patient #10’s open oven, speak to him about the issue, or discussed the safety of ongoing gas use in enclosed area. Patient #10’s RN, who was observed during his home visit, was interviewed on 1/10/24 at 11:30 AM. She confirmed Patient #10 was not asked about his medication, if he had taken any medication, or if he had medications in his home. Patient #10’s RN confirmed she did not know he was out of morning medications. When asked if she knew Patient #10 was using his gas oven as heat source, she stated she did not notice the oven was on or open. Patient #10’s PTA, who was present during his home visit, was interviewed on 1/10/24 at 1:10 PM. She confirmed Patient #10’s medications were not assessed during his home visit. Patient #10’s PTA stated she had not assessed the safety of his home and did not note or address his gas oven being used as heat source. Patient #10 did not receive all interventions outlined in his POC. 2. Patient #2 was a 63-year-old male who was admitted to the agency on 8/28/23, with a primary diagnosis of a unspecified cirrhosis of liver. Additional diagnoses included acute and chronic respiratory failure with hypoxia, chronic right heart failure and end stage renal failure. He received PT and OT services, but declined SN services. Patient #2's medical record, including his POC, for the certification period 8/28/23 to 10/26/23, was reviewed. Patient #2 passed away on 9/10/23. Patient #2 did not receive all interventions outlined in his POC. Examples include: a. Patient #2's POC, dated 9/01/23, included physician orders for blood pressure parameters of “systolic 160; diastolic 100” as well as oxygen saturation parameters of “SPO2 >88%.” Patient #2’s medical record included an occupational therapy note, dated 8/30/23, signed by the OT. The note documented Patient #2’s blood pressure was 86/42 mmHg. Additionally, the OT documented, “Followed/documented appropriate Care Plan Interventions”. The Mayo Clinic website, accessed on 1/22/23, stated, “Low blood pressure is generally considered a blood pressure reading lower than 90 millimeters of mercury (mm Hg) for the top number (systolic) or 60 mm Hg for the bottom number (diastolic).” “For some people, low blood pressure may be a sign of an underlying health condition, especially when it drops suddenly or occurs with symptoms. A sudden fall in blood pressure can be dangerous. A change of just 20 mm Hg — a drop from 110 mm Hg systolic to 90 mm Hg systolic, for example — can cause dizziness and fainting. And big drops, such as those caused by uncontrolled bleeding, severe infections or allergic reactions, can be life-threatening. Extreme low blood pressure can lead to a condition known as shock.” It was unclear from Patient #2’s medical record what interventions were implemented for his low blood pressure. Further, Patient #2’s OT documented, “did doze off a few times during interview.” It could not be determined if Patient #2’s OT provided education, interventions, or planned a follow-up for the low blood pressure. b. Patient #2’s medical record included an occupational therapy note, dated 9/06/23, signed by his OT, stated Patient #2’s blood pressure was 65/50 mmHg and, “RN case manager notified.” However, Patient #2 had declined SN services during his SOC. Additionally, the OT documented, “BP remains low today, and patient did just take Midorine just before my arrival … Patient has follow-up with PCP tomorrow morning to discuss all concerns, including blood pressure.” The OT did not document Patient #2’s oxygen saturation or follow-up for his low blood pressure. c. Patient #2's POC, dated 9/01/23, included a goal of being, “pain free or verbalize acceptable pain level with current pain management regimen” with “teach pain management and comfort measures and teach patient/caregiver regarding medications and medication management” noted as interventions. Patient #2’s medical record included an occupational therapy note, dated 8/21/23, signed by his OT, which stated Patient #2’s pain was assessed as, “9- excruciating”. No additional information on interventions, including medication, or education on comfort measures were documented, nor was Patient #2’s physician. Patient #2’s OT was interviewed on 1/10/24 at 4:00 PM. He confirmed Patient #2 had low blood pressure on several visits. The OT stated Patient #2 had been very sick with varying blood pressures. She confirmed she did call an RN regarding Patient #2’s blood pressure documented on 9/06/23, but confirmed his physician was not called. Additionally, the OT confirmed Patient #2 declined and was not receiving SN services. When asked if oxygen saturation level was taken, the OT stated she remembered Patient #2’s oxygen level often was not able to be read due to his fingers being cold. When asked if the inability to read oxygen saturation and dozing off during conversation could be a sign of low oxygen saturation, the OT agreed. She further confirmed no additional calls, follow-up, or assessments were provided to Patient #2 after his 65/50 mmHg reading was documented. Patient #2’s OT confirmed no additional services, including comfort measures or discussion of already prescribed medications, were provided to Patient #2 after assessment of his pain.

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 observation, medical record review and staff interview, it was determined the agency failed to ensure the the interventions, measurable outcomes, medications, and goals needed by the patient were included in the POC for 1 of 10 patients (Patients #3) whose records were reviewed. This failure resulted in the patient's not receiving the care and services outlined in their POCs and had the potential to result in unmet patient needs and harm to the patient. Findings include. Patient #3 was a 77 year old female admitted to the agency on 5/06/23, with a primary diagnosis of pain due to internal orthopedic prosthetic devices. Additional diagnoses included repeated falls, essential hypertension, and acute embolism and thrombosis of left lower extremity. She received RN, MSW, and PT services. Her medical record, including the POC, for the certification period 5/06/23 – 5/17/23, was reviewed. She was discharged by the agency on 5/17/23. Patient #3’s medical record included a SOC assessment dated 5/06/23 signed by the RNCM. Under the section titled “Functional Assessment” The SOC assessment included: - “Someone must assist the patient to groom self.” - “Someone must help the patient put on upper-body clothing.” - “Someone must help the patient put on undergarments, slacks, socks or nylons, and shoes.” - “Unable to use the shower or tub, but able to participate in bathing self in the bed, at the sink in bedside chair, or on commode, with the assistance or supervision of another person. “ - “Someone must help the patient to maintain toileting hygiene and. Or adjust clothing.” Patient #3’s POC was reviewed. It included a narrative note that included, “She [Patient #3] lives alone in a single level home. She has little outside support.” Patient #3’s POC did not include interventions to related to Patient #3’s inability to perform her activities of daily living. Additionally, there was no documentation a home health aide or bath aide was offered to Patient #3 conflicting documentation on the status of Patient #2 The DCS was interviewed on 1/10/24 beginning at 9:30 AM and Patient #3’s medical record was reviewed in her presence. She confirmed there were no documented interventions for Patient #3’s ADL’s. Additionally, she confirmed there was no documentation Patient #3 was offered a Home Health Aide. Patient #3’s POC did not include necessary interventions related to her inability to perform her ADL’s

Conformance with physician orders CFR(s): 484.60(b) Standard: Conformance with physician or allowed practitioner orders. This STANDARD is not met as evidenced by: Based on record review and staff interview, it was determined the facility failed to ensure services ordered by the physician were provided for 2 of 10 patients (Patient #7 and Patient #3) whose records were reviewed. This failure caused patients not to receive therapy services and social work services as ordered. Findings include: 1. Patient #7 was a 75 year old female admitted to the agency on 10/13/23 with a primary diagnosis of neurocognitive disorder. Additional diagnoses included anxiety, hypertension, and chronic pain. She received SN, PT, and aide services. Her record for the certification period 10/13/23 to 12/11/23 was reviewed. Patient #7's record included a POC which was verbally approved by the physician on 10/13/23 and signed by the physician on 10/18/23. The POC stated, "Orders/Treatments: ... Medical Social Worker to Assess and Evaluate." Patient #7's visit notes were reviewed. There were no MSW visits provided to Patient #7. It was unclear why MSW visits were ordered by the physician but not provided. The administrator and DCS were interviewed together on 1/10/23 at 3:14 PM and Patient #7's record was reviewed in their presence. The DCS confirmed MSW visits were ordered. When asked why MSW visits were not provided for Patient #7 she stated the order for MSW visits was deleted because of a clerical error. She confirmed MSW visits should have been provided to Patient #7. 2. Patient #3 was a 77 year old female admitted to the agency on 5/06/23, with a primary diagnosis of Pain due to internal orthopedic prosthetic devices. Additional diagnoses included repeated falls, essential hypertension, and acute embolism and thrombosis of left lower extremity. She received SN, MSW and PT services. Her record, including the POC, for the certification period 5/06/23 – 5/17/23, was reviewed. A physician order dated 5/08/23, signed by a physician, ordered "Occupational therapy to Assess and Evaluate.” Patient #3's record did not include a assessment by occupational therapy. Additionally, there was no documentation of a reason Occupational Therapy was unable to see Patient #3. The Director of Clinical Services was interviewed on 1/10/24 beginning at 9:30 AM and Patient #3’s medical record was reviewed in her presence. She confirmed there were no documented Occupationally Therapy assessment. She stated she did not know why OT did not evaluate Patient #3. The agency failed to ensure Patient #3 received services as ordered.

A Medicare recertification survey of your agency, including Emergency Preparedness, was conducted from 2/23/21 to 2/25/21, and was found in compliance for the regulations found in Appendix Z of the State Operations Manual. Surveyors conducting the survey were: Kimberly Mehlhaff, RN, HFS, Team Lead Weslianne Lewis, RN, HFS

The following deficiencies were cited during your agency's Medicare recertification and focused COVID-19 infection control surveys conducted from 2/23/21 to 2/25/21. Surveyors conducting the surveys were: Kimberly Mehlhaff, RN, HFS, Team Lead Weslianne Lewis, RN, HFS Acronyms used in this report include: CHF - Congestive Heart Failure ER - Emergency Room HFS - Health Facility Surveyor LBS - Pounds LPN - Licensed Practical Nurse mL - milliliters mg - milligram NSAID - Nonsteroidal Anti-Inflammatory Drug OT - Occupational Therapy PMH - Past Medical History POC - Plan of Care PT - Physical Therapy PTA - Physical Therapy Assistant RN - Registered Nurse RNCM - Registered Nurse Case Manager ROC - Resumption of Care SN - Skilled Nursing SOC - Start of Care ST - Speech Therapy VA - Veteran's Administration

Update of the comprehensive assessment CFR(s): 484.55(d) Standard: Update of the comprehensive assessment. The comprehensive assessment must be updated and revised (including the administration of the OASIS) as frequently as the patient's condition warrants due to a major decline or improvement in the patient's health status, but not less frequently than- This STANDARD is not met as evidenced by: Based on medical record review and staff interview, it was determined the agency failed to ensure patients' comprehensive assessments were updated to include necessary information for 1 of 8 patients (Patient #4) whose records were reviewed. This resulted in incomplete assessment information to staff providing care and had to potential to affect patient outcome. Findings include: Patient #4 was a 90 year old male admitted to the agency on 1/15/21, with a primary diagnosis of acute on chronic diastolic (congestive) heart failure (CHF). Additional diagnoses included atrial fibrillation, a pressure ulcer on the left buttock, and a history of falling. He received SN, PT, and OT services. His record, including the POC for the certification period of 1/15/21 to current, was reviewed. Patient #4's record included a PTA Missed Visit Note, dated 2/02/21, signed by a PTA. The Narrative Notes stated, "Patient exhausted from outings this week and disturbing news of bone marrow cancer." During an interview on 2/25/21 at 8:30 AM, the PTA reviewed Patient #4's medical record. She confirmed her 2/02/21 discussion of bone marrow cancer with the patient and stated that he was "depressed" about his change in health status. During an interview on 2/25/21 at 12:50 PM, the RNCM reviewed Patient #4's medical record. She confirmed the POC had not been updated and it did not include interventions, education, or goals for bone marrow cancer. She stated she understood the bone marrow cancer was related to Patient #4's PMH of thrombocytopenia, but the POC should have been updated. Patient #4's POC was not updated to address interventions, education, goals for bone marrow cancer or any new psychosocial needs.

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 medical record review, observation, and patient and staff interview, it was determined the agency failed to ensure the POCs included all medications, interventions, education, measurable outcomes, and goals for 3 of 8 patients (#1, #2 and #4) whose records were reviewed. This failure resulted in an incomplete plan of care and had the potential to result in unmet patient needs. Findings include: 1. Patient #1 was an 87 year old male admitted to the agency on 1/07/21 with a primary diagnosis of myasthenia gravis with acute exacerbation. Additional diagnoses included CHF and paroxysmal atrial fibrillation. He received SN, PT, and ST services. His record, including the POC, for certification period 1/07/21 to 3/07/21, was reviewed. Patient #1's SN visit was observed on 2/23/21, beginning at 3:00 PM. a. During the visit, the LPN asked Patient #1 if he had any new medications or changes in his medication. He provided her with a prescription bottle of Myrbetriq (overactive bladder medication) he had received from the VA the same day. The LPN documented the medication and notified Patient #1's RNCM. Patient #1's updated medication list was requested and provided on 2/25/21. Myrbetriq 25 milligrams, one tablet orally once per day, was documented twice with the start dates of 1/07/21 and 2/23/21. No end dates were documented. The Administrator and the Clinical Director were interviewed together on 2/25/21, beginning at 11:40 AM, and Patient #1's medical record was reviewed in their presence. They confirmed Patient #1's Myrbetriq was listed twice on his medication list in error. b. At the end of the SN visit on 2/23/21, Patient #1 provided the surveyor with his medications. They did not include Zofran, which was documented as a current medication on his POC. When asked if he was currently taking Zofran, Patient #1 stated no, he had only taken Zofran while he was in the hospital before resuming care with the agency on 2/16/21. Patient #1's medical record included an RN visit for his ROC, dated 2/16/21, signed by the RN. The RN documented, "Medication Profile reviewed ... New/changed medication identified, medication profile updated." The Administrator and the Clinical Director were interviewed together on 2/25/21, beginning at 8:15 AM, and Patient #1's medical record was reviewed in their presence. They confirmed Patient #1's Zofran was added to his POC from a list of his hospital medications and could not determine if the hospital medication list had been reconciled with the medications Patient #1 had in his home. Patient #1's POC was incomplete. 2. Patient #4 was a 90 year old male admitted to the agency on 1/15/2021, with a primary diagnosis of acute on chronic diastolic (congestive) heart failure (CHF). Additional diagnoses included atrial fibrillation, a pressure ulcer on the left buttock and a history of falling. He received SN, PT, and OT services. His record, including the POC for the certification period of 1/15/21 to current, was reviewed. Patient #4's POC did not include all relevant information, interventions, and goals. Examples include: The American College of Cardiology website, accessed on 3/03/21, included patient education entitled, "Living with Heart Failure," and included a checklist of steps to best manage heart failure that included: "Weigh myself on the same scale every morning before breakfast and write it down ..." and "use caution when symptoms include increased swelling of feet, legs and ankles." The website also stated, "When you have heart failure, you need to watch for changes in your weight. A sudden weight gain can mean more fluid is building up in your body and your heart failure is getting worse." Additionally, it stated, "Call your doctor if you notice a sudden weight gain. In general, call if you gain 3 pounds or more in 2 to 3 days." a. Patient #4's record included an SOC comprehensive assessment dated 1/15/21, signed by the RNCM. It included the following: i. The assessment included his CHF diagnoses with a severity level of 2, meaning his CHF symptoms were controlled with difficulty, affected his daily functioning, and needed ongoing monitoring. ii. The narrative section stated, "Patient ...was hospitalized for CHF ...." iii. Under section M1033, "Risk for hospitalization", CHF was listed as a risk for ER visits and hospitalization. b. Eight SN visits were made but only 4 SN visits recorded weights as follows: 1/15/21 - "Weight 173 lbs." 1/21/21 - No weight documented 1/27/21 - No weight documented 2/04/21 - "Weight 175 lbs." 2/11/21 - No weight documented 2/17/21 - "Weight 179 lbs." 2/20/21 - No weight documented 2/22/21 - "Weight 178 lbs." Patient #4's SOC did not include an order to monitor his weight. It did not include an order to educate him regarding the importance of monitoring his weight. Patient #4's SOC did not include a problem, interventions or goals to address his CHF needs. c. Patient #4's record included an SN visit note, dated 2/04/21, which stated in the narrative notes, "Patient has slight decrease in edema. Blister open on anterior left shin." The prior SOC comprehensive assessment dated 1/15/21 and SN visits on 1/21/21 and 1/27/21 did not document any edema. It was unclear whether Patient #4 had edema during the visits prior to the 2/4/21 SN visit or if edema had been assessed. d. Patient #4's record included a PTA visit note, dated 2/16/21, signed by the PTA, which stated in the narrative notes, "Patient and wife frustrated with worsening condition of CHF." e. Patient #4's POC was not updated to include CHF as a problem with corresponding interventions and goals until 2/17/21, more than one month after his start of care with the agency. During an interview on 2/25/21 at 12:50 PM, the RNCM reviewed Patient #4's medical record. She confirmed the SOC comprehensive assessment and subsequent POC did not reflect the agency's expections for care related to patients with CHF. Patient #4's POC was incomplete. 3. Patient #2 was a 37 year old female admitted to the agency on 12/11/20, with a primary diagnosis of type 2 DM with foot ulcer. Additional diagnoses included lymphedema, type 2 DM with diabetic polyneuropathy and repeated falls. She received SN, PT, and bath aide services. Her record, including the POC, for certification period 2/09/21 to current, was reviewed. An observation of an SN was conducted in Patient #2's home on 2/23/21 beginning at 12:35 PM. After the visit ended, Patient #4 was interviewed and a medication review was conducted. Patient's #4's copy of her POC and medication profile included: - "Robaxin 500 mg oral tablet, Take 1 tab(s) orally every 8 hours as needed for muscle spasms - Lantus Solostar Pen 100units/mL Subcutaneous solution; Inject 20 units subcutaneously one a day" Patient #2 stated that she no longer took Robaxin and had not since January 2020 as she only had a 7-day supply. Patient #2 stated she had not taken Lantus for "about a month," because she had been prescribed a new long acting insulin, Basaglar, 22 units/mL subcutaneously in the morning. During an interview on 2/25/21 at 3:05 PM, the RNCM reviewed Patient #2's medical record. She confirmed the medication discrepancies and stated, "I usually ask at every visit." Patient #2's POC was incomplete.

Communication with all physicians CFR(s): 484.60(d)(1) Assure communication with all physicians or allowed practitioners involved in the plan of care. This ELEMENT is not met as evidenced by: Based on medical record review and staff interview, it was determined the agency failed to ensure communication with the physician involved in patient care of 1 of 8 patients (Patient #4) whose records were reviewed. This failure had the potential to increase an adverse cardiac event. Findings include: Patient #4 was a 90 year old male admitted to the agency on 1/15/2021, with a primary diagnosis of acute on chronic diastolic (congestive) heart failure (CHF). Additional diagnoses included atrial fibrillation, a pressure ulcer on the left buttock, and a history of falling. He received SN, PT, and OT services. His record, including the POC for the certification period of 1/15/21 to current, was reviewed. Patient #4's record included a PTA visit note, dated 2/04/21, signed by the PTA. The PTA had recorded a current pain level of an "8." Under "Care Plan Documentation," was a note, "Deep tissue massage over right outer lower leg to reduce pain prior to gait activity. Education to follow up with ice and IB Profin [sic]." Patient's #4's medication list did not include a physician order for Ibuprofen, a nonsteroidal anti-inflammatory drug (NSAID) used for pain and inflammation. According to the U.S. Food and Drug Administration website, accessed on 3/03/21, NSAIDs can increase the risk of a heart attack or stroke in patients with or without heart disease and there is an increased risk of heart failure with NSAID use. During an interview on 2/25/21 at 8:30 AM, the PTA reviewed Patient #4's medical record. She confirmed her documentation directing the patient to use Ibuprofen and confirmed Ibuprofen was not on the physician approved medication list nor had she contacted the physician regarding the use of Ibuprofen for Patient #4. The agency failed to ensure communication with the physician involved in Patient #4's care.

Patient medication schedule/instructions CFR(s): 484.60(e)(2) Patient medication schedule/instructions, including: medication name, dosage and frequency and which medications will be administered by HHA personnel and personnel acting on behalf of the HHA. This ELEMENT is not met as evidenced by: Based on observation, record review, patient and staff interview, it was determined the agency failed to ensure a written medication schedule/instructions was provided to patients for 1 of 3 patients (Patient #1) whose home visits were observed and whose records were reviewed. This resulted in patients not having access to their medication lists. Findings include: Patient #1 was an 87 year old male admitted to the agency on 1/07/21 with a primary diagnosis of myasthenia gravis with acute exacerbation. Additional diagnoses included CHF and paroxysmal atrial fibrillation. He received SN, PT, and ST services. His record, including the POC, for certification period 1/07/21 to 3/07/21, was reviewed. Patient #1's SN visit was observed on 2/23/21, beginning at 3:00 PM. At the end of the SN visit, the surveyor asked Patient #1 if the agency had provided him with a list of his medications including medication administration instructions. He stated he could not recall receiving the list from the agency. The Administrator and the Clinical Director were interviewed together on 2/25/21, beginning at 11:40 AM. They stated it is the agency's expectation that a medication list including administration instructions be provided to every patient. The agency failed to ensure Patient #1 received a list of his current medications.

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 observation, policy review, and staff interview, it was determined the agency failed to ensure infection prevention for COVID-19 was followed. This had the potential to result in unintended spread of the virus. Findings include: The agency's policy, "Coronavirus Surveillance #6073," dated 9/01/20, stated, "This facility will implement heightened surveillance activities for coronavirus illness during periods of transmission in the community and/or during a declared public health emergency for the illness." Additionally, it included guidelines for screening visitors for COVID-19 signs, symptoms, and recent exposure. Upon arrival at the agency on 2/23/21, 2/24/21, and 2/25/21, 2 surveyors were allowed entrance to the agency without screening by agency staff for COVID-19 symptoms and exposure. Additionally, 1 surveyor was not screened prior to 2 home visits to observe patient care on 2/23/21 and 2/24/21. The Administrator was interviewed on 2/24/21 beginning at 8:30 AM. She confirmed the agency did not follow its policy for visitor screening when surveyors entered the facility or patient homes since agency staff assumed surveyors were tested and screened regularly according to the surveyors' own department policies. The agency failed to ensure visitors were screened for infectious and communicable diseases.