Every finding on record at Cuyuna Reg Medical Ctr Homehealth, Palliative & Hospice Care

A survey for compliance with CMS Appendix Z Emergency Preparedness Requirements, was conducted June 7, 2021 through June 11, 2021, during a recertification survey. The facility is found o be out of compliance with the Condition of Participation 484.22: Establishment of the Emergency Program.

Policies/Procedures for Medical Documentation CFR(s): 484.102(b)(4) [(b) Policies and procedures. The [facilities] must develop and implement emergency preparedness policies and procedures, based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, and the communication plan at paragraph (c) of this section. The policies and procedures must be reviewed and updated at least every 2 years (annually for LTC).] At a minimum, the policies and procedures must address the following:] [(5) or (3),(4),(6)] A system of medical documentation that preserves patient information, protects confidentiality of patient information, and secures and maintains availability of records. *[For RNHCIs at §403.748(b):] Policies and procedures. (5) A system of care documentation that does the following: (i) Preserves patient information. (ii) Protects confidentiality of patient information. (iii) Secures and maintains the availability of records. *[For OPOs at §486.360(b):] Policies and procedures. (2) A system of medical documentation that preserves potential and actual donor information, protects confidentiality of potential and actual donor information, and secures and maintains the availability of records. This STANDARD is not met as evidenced by: Based on interview and policy review, the agency failed to develop and implement emergency preparedness policies and procedures which addressed a system of medical documentation that preserves patient information, protects confidentiality of patient information, and secures and maintains availability of records. This had the potential to affect all 259 patients currently being served by the agency. Findings include: During review of the Emergency Management Policy, the policies did not include a system of medical documentation that preserved medical information, protects confidentiality of patient information, and secures and maintains availability of records. During interview on 6/10/21, at 3:15 p.m. the director of nursing (DON) stated this specific policy is not currently in the emergency plan policy.

Policies/Procedures-Volunteers and Staffing CFR(s): 484.102(b)(5) [(b) Policies and procedures. The [facilities] must develop and implement emergency preparedness policies and procedures, based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, and the communication plan at paragraph (c) of this section. The policies and procedures must be reviewed and updated at least every 2 years (annually for LTC).] At a minimum, the policies and procedures must address the following:] (6) [or (4), (5), or (7) as noted above] The use of volunteers in an emergency or other emergency staffing strategies, including the process and role for integration of State and Federally designated health care professionals to address surge needs during an emergency. *[For RNHCIs at §403.748(b):] Policies and procedures. (6) The use of volunteers in an emergency and other emergency staffing strategies to address surge needs during an emergency. *[For Hospice at §418.113(b):] Policies and procedures. (4) The use of hospice employees in an emergency and other emergency staffing strategies, including the process and role for integration of State and Federally designated health care professionals to address surge needs during an emergency. This STANDARD is not met as evidenced by: Based on interview and policy review, the agency failed to ensure their emergency preparedness policies and procedures addressed the use of volunteers in an emergency, or other emergency staffing strategies, including the process and role for integration of State and Federally designated health care professionals to address surge needs during an emergency. This had the potential to affect all 259 patients currently being served by the agency. Findings include: During review of the Emergency Management Policy, the policies did not include the use of volunteers in an emergency, or other emergency staffing strategies that addressed surge needs in an emergency. During interview on 6/10/2 at 3:15 p.m., the director of nursing (DON) stated there was nothing in the emergency policy that addressed use of volunteers or other emergency staffing strategies.

A partial extended survey was conducted at Cuyuna Regional Medical Center Homehealth, Palliative and Hospice Care on 6/7/21 through 6/11/21. The agency was found to have not met the requirements at 42 CFR. Part 484 for Home Health Agencies. Unduplicated census: 259 (3 home visits completed). No branch offices. Hours of Operation: 8:00 a.m.- 4:30 p.m. Total number of records reviewed: 7

Participate in care CFR(s): 484.50(c)(4)(i,ii,iii,iv,v,vi,vii,viii) Participate in, be informed about, and consent or refuse care in advance of and during treatment, where appropriate, with respect to-- (i) Completion of all assessments; (ii) The care to be furnished, based on the comprehensive assessment; (iii) Establishing and revising the plan of care; (iv) The disciplines that will furnish the care; (v) The frequency of visits; (vi) Expected outcomes of care, including patient-identified goals, and anticipated risks and benefits; (vii) Any factors that could impact treatment effectiveness; and (viii) Any changes in the care to be furnished. This ELEMENT is not met as evidenced by: Based on interview and document review, the agency failed to ensure 7 of 7 patients (P1, P2, P3, P4, P5, P6, P7) were informed and consented to services or care being provided, including any ongoing changes in services. Findings Include: P1's start of care (SOC) was 4/29/21. P1's plan of care (POC) for the certification period 4/21/21 to 6/27/21, included diagnoses of pressure ulcer to right buttock, stage 2., type 2 diabetes, peripheral angiopathy, venous insufficiency and non-pressure chronic ulcer. The POC further indicated P1 received skilled nurse visits (SNV) two times weekly for one week, three times weekly for one week and two times weekly for seven weeks for various assessments, treatment and education. On 6/4/21 a physician order increased the SNV to every other day. Record review revealed P1's Patient Service Agreement was dated and signed by P1 on 4/29/21, however, the discipline of services, the frequency, and the charge per hour/visit were not indicated on the form. P1's record lacked a second service agreement indicating the change of services that occurred on 6/4/21. P1's record lacked evidence that P1 was informed of and agreed to the initial start of services or the change in the planned services and care that occurred 6/4/21. P2's SOC was 7/15/20. P2's POC for the certification period 7/15/20 to 9/12/20, included diagnoses of infection and inflammatory reaction due to other internal prosthetic devices, implants and grafts, chronic atrial fibrillation, hypertensive heart and chronic kidney disease with heart failure. The POC further indicated P2 received SNV two times a week for one week, three times a week for four weeks and two times per week for one week for various assessments, treatment and education, and aide visits one time per week for one week and two times per week for five weeks, however did not list aide services to be performed. On 8/3/20, a physician order was received for SNV one time per week for one week then three times per week for three weeks starting 8/21/20, and aide visits two times per week for three weeks to start 8/24/20. P2's POC for the certification period 9/13/20 to 11/11/20, indicated SNV three times a week for eight weeks then two times per week for one week for assessments, treatment and education and aide visits two times per week for 9 weeks without description of aide services to be provided. P2's POC 11/12/20 to 1/10/21, indicated SNV one time per week for nine weeks for assessments and education and aide visits one time a week for one week and two times per week for eight weeks without description of aide services to be provided. P2's POC for the certification period 1/11/21 to 3/11/21 indicated SNV one time a week for nine weeks for various assessments and education and aide visits two times per week for nine weeks without description of aide services to be provided. P2's POC for the certification period 3/12/21 to 5/10/21, indicated SNV one time per week for eight weeks for various assessments and education and aide visits two times a week for eight weeks then one time per week for one week without description of aide services to be provided. P2's POC for the certification period 5/11/21 to 7/9/21, indicated SNV one time per week for nine weeks for various assessments and education and aide visits one time per week for one week and then two times per week for eight weeks without description of aide services to be provided. Record review revealed P2's Patient Service Agreement was dated and signed by P2 on 4/23/20, however, the discipline of services, the frequency, and the charge per hour/visit were not indicated on the form. P2's Patient Service Agreement was dated and signed by P2 on 6/21/20, however, the discipline of services, the frequency, and the charge per hour/visit were not indicated on the form. P2's record lacked service agreements indicating changes in services that occurred since his SOC. P2's record lacked evidence that P2 was informed of and agreed to the initial start of services or the changes in the planned services and care that occurred since his SOC. P3's SOC was 1/25/21. P3's POC for the certification period 1/25/21 to 3/25/21, included diagnoses of critical illness myopathy, lumbosacral lexus disorders, hemoperitoneum, other amnesia and dysphagia. The POC further indicated P3 received SNV three time per week for one week, two times per week for three weeks and one time per week for one week for various assessments and education and physical therapy (PT) two times per week for nine weeks for assessments, treatment, exercises, develop home exercise program and education, and occupational therapy (OT) one time per week for one week, two times per week for five weeks and one time per week for three weeks for activities of daily living (ADL) training, fall and safety precautions and an aide two times per week for nine weeks without description of services to be provided. P3's POC for the certification period 3/26/21 to 5/24/21, indicated P3 received PT two times per week for four weeks for assessments, treatments, exercises, develop home exercise program and education, and OT two times per week for four weeks, for ADL training, and fall and safety precautions and an aide one time per week for four weeks without description of services to be provided. P3's POC for the certification period 5/25/21 to 7/23/21, indicated P3 received PT five times a month for one month for various assessments, treatments, exercises, and education, OT one time per week for four weeks for ADL training, and fall and safety precautions and an aide one time per week for five weeks without description of services to be provided. Record review revealed P3's Patient Service Agreement was dated and signed by P3 on 1/25/21, however, the discipline of services, the frequency, and the charge per hour/visit, were not indicated on the form. No other service agreements were documented in P3's medical record to reflect changes made with P3's services after her SOC on 1/25/21. P3's record lacked evidence that P3 was informed of and agreed to the initial start of services or the changes in the planned services and care that occurred since her SOC. P4's SOC was 10/12/20. P4's POC for the certification period 10/12/20 to 12/10/20, included diagnoses of heart disease, atrial fibrillation, osteoarthritis, Barrett's esophagus and gastro-esophageal reflux disease. The POC further indicated P4 received SNV one time a week for nine weeks for various assessments and education. P4's POC for the certification period 12/11/20 to 2/08/21, indicated P4 received SNV one time a week for nine weeks for various assessments and education. P4's POC for the certification period 2/9/21 to 4/9/21 indicated P4 received SNV four as needed for one week and one time a week for eight weeks for various assessments and education. P4's POC for the certification period 4/10/21 to 6/8/21, indicated P4 received SNV one time a week for nine weeks for various assessments and education. P4's POC for the certification period 6/9/21 to 8/7/21, indicated P4 received SNV three as needed for one week and one time a week for eight weeks for various assessments and education. Record review revealed P4's Patient Service Agreement was dated and signed by P4 on 9/13/20, a second Patient Service Agreement was dated and signed by P4 on 10/15/20 however, the discipline of services, the frequency, and the charge per hour/visit, were not indicated on either of the forms. No other service agreements were documented in P4's medical record to reflect changes made with P4's services after his SOC on 10/12/20. P4's record lacked evidence that P4 was informed of and agreed to the initial start of services or the changes in the planned services and care that occurred since his SOC. P5's SOC was 12/3/20. P5's POC for the certification period 12/3/20 to 1/31/21, included disruption of internal operation wound, type one diabetes, infection following a procedure, and chronic osteomyelitis, left tibia and fibula. The POC further indicated P5 received skilled nursing two times per week for one week, and three times per week for eight weeks to manage wound vac dressing changes, draw labs, and perform various assessments and education and PT two times per week for three weeks for assessment, exercise, transfer and gait training and education, OT one time a week for one week for evaluation, which was refused when attempted to schedule. P5's POC for the certification period 2/1/21 to 4/1/21 indicated P5 received SNV two times per week for one week, three times per week for six weeks and two times per week for two weeks for dressing changes, venipunctures as ordered and perform various assessments and education, PT one time per week for one week and OT one time per week for one week, which was again refused when attempted to schedule. P5's POC for the certification period 4/2/21 to 5/31/21 indicated P5 received SNV one time a week for one week, three times a week for eight weeks and one time a week for one week for dressing changes, perform various assessments and education. P5's POC for the certification period 6/1/21 to 7/30/21, indicated P5 received skilled nursing two times per week for one week, and three times per week for eight weeks to manage wound vac dressing changes and perform various assessments and education. Record review revealed P5's Patient Service Agreement was dated and signed by P5 on 12/3/20, however, the discipline of services, the frequency, and the charge per hour/visit were not indicated on the form. No other service agreements were documented in P5's medical record to reflect changes made with P5's services after his SOC on 12/3/20. P5's record lacked evidence that P5 was informed of and agreed to the initial start of services or the changes in the planned services and care that occurred since his SOC. P6's SOC was 10/16/20. P6's POC for the certification period 10/16/20 to 12/14/20 included diagnoses of chronic peripheral venous insufficiency, chronic ulcers of bilateral lower extremities, chronic kidney disease, Parkinson's disease, dementia, and repeated falls. P6's POC further indicated skilled nursing visits one time per week for one week, two times per week for eight weeks, one time per week for one week, and four visits as needed for wound infections, falls, or change in condition. The POC also indicated aide visits one time per week for eight weeks without a description of the services to be provided. P6's POC for the certification period 12/15/20 to 2/12/21 indicated SNV one time per week for nine weeks with four visits as needed for wound infections, falls, or change in condition. P6's POC for the certification period 2/13/20 to 4/13/21 indicated SNV one time per week for eight weeks with four visits as needed for wound infections, falls, or change in condition Record review revealed P6's Patient Service Agreement was dated and signed by P6 on 10/16/20, however, the discipline of services, the frequency, and the charge per hour/visit, were not indicated on the form. No other service agreements were documented in P6's medical record to reflect changes made with P6's services after her SOC on 10/16/20. P6's record lacked evidence that P6 was informed of and agreed to the initial start of services or the changes in the planned services and care that occurred since her SOC. P7's SOC was 3/23/21. P7's POC for the certification period 3/23/21 to 5/21/21 included diagnoses of aftercare following surgery for neoplasm, encounter for attention to ileostomy, malignant neoplasm of the rectum, and elevated blood pressure readings. P7's POC indicated SNV three times per week for one week, two times per week for two weeks and four as needed for any concerns. Record review revealed P7's Patient Service Agreement was dated and signed by P7 on 3/23/21, however, the discipline of services, the frequency, and the charge per hour/visit, were not indicated on the form. P7's record lacked evidence that P7 was informed of and agreed to the initial start of services. During interview on 6/10/21, at 3:15 p.m. the director of nursing (DON) stated the agency did not utilize a form for the client to sign to indicate what services and fees the client was agreeing to. The DON stated initiation and changes to client services were always discussed with the client, however, the agency did not give the client anything in writing to sign. The service agreement the agency used did not list services, frequency of services or cost of services. The agency's policy, Patients' Rights Implementation, with review date 12/16/16, indicated an admission agreement would contain specific printed information on services provided by the agency. This information would be discussed with the patient before the agreement is signed by the patient and a copy of the signed agreement would be given to the patient.

A review of all current medications CFR(s): 484.55(c)(5) A review of all medications the patient is currently using in order to identify any potential adverse effects and drug reactions, including ineffective drug therapy, significant side effects, significant drug interactions, duplicate drug therapy, and noncompliance with drug therapy. This ELEMENT is not met as evidenced by: Based on observation, interview and document review, the agency failed to complete a comprehensive drug regimen review to ensure the accuracy of all medications/dosage for 1 of 7 patients, (P5) whose medications were reviewed during home visit and record review. When interviewed on 6/9/21, at 2:00 p.m. clinical manager (CM)-B stated she was responsible for inputting initial medication orders on start of care (SOC). The nurses were to compare the medication lists with what the patient indicated they were taking and what medication bottles and labels were in their home. The nurses were suppose to ask patients if they had any new or changed medications at every visit. When they did recertification visits, they were suppose to have the patient take out all their medication bottles and do a complete medication reconciliation. During interview on 6/10/21, at 2:30 p.m. the director of nursing (DON) indicated when medication changes were implemented in the middle of a certification period, the nurse were to take the information off of the medication label as the patient's order. The medication list would be updated and the medication change would be entered onto the next POC on the next recertification period. Review of the agency's Medication Reconciliation, Loss/spillage of Meds policy, with review date of 6/25/20, indicated the purpose was to follow a process to obtain, document,and maintain a complete, accurate list of a client's current medications. Reconciliation required the nurse to compare what the client was actually taking to what was ordered by the physician for the client to take. If a client was taking a medication not on the medication list, the nurse would add it to the medication. list. Discrepancies were to be documented in the clinical note using the use code of order. Ongoing medication evaluation and reconciliation would be done at each home visit. Client medications lists were to be kept up to date Based on observation, interview and document review, the agency failed to complete a comprehensive drug regimen review to ensure the accuracy of all medications/dosage for 1 of 7 patients, (P5) whose medications were reviewed during home visit and record review. Findings include P5's plan of care (POC) indicated start of care (SOC) date of 12/3/20. The POC for the certification period 6/1/21 to 7/30/21, included diagnoses of chronic osteomyelitis of left tibia and fibula, MRSA, diabetes mellitus with diabetic polyneuropathy, hypertension, obesity, and history of falling. The POC further indicated P5 received skilled nursing two times per week for one week, and three times per week for eight weeks to manage wound vac dressing changes and perform various assessments and education. P5's POC included the following medications: Norvasc (lower blood pressure) 10 mg tablet one by mouth daily, aspirin 81mg one by mouth two tabs daily, Prozac (antidepressant) two 20 mg capsules by mouth daily, Crestor (cholesterol lowering) 20 mg tablet at bedtime daily, Flexeril (muscle relaxant) 10 mg tablet as needed daily, ferrous sulfate (iron supplement) 325 mg by mouth one tablet twice daily, gabapentin (pain relief) 300 mg capsules, take two by mouth two times per day, glucagon injection kit 1 mg intramuscularly as needed for blood sugar less than 60, normal saline flush intravenous solution 0.9% 10 milliliter as needed IV before and after line use for patency, ibuprofen 200mg tablet, take three tablets by mouth as needed every eight hours for pain, omeprazole (acid reducer) 20 mg capsule delayed release, take one by mouth daily, triamcinolone acetonide external ointment 0.1% twice a day topical to affected areas for irritation/infection prevention, vitamin D by mouth capsule 1.25 mcg every other day, insulin aspart subcutaneous solution 100 unit/ml as instructed, and insulin glargine subcutaneous solution pen-injector 100 unit/ml, 38 units as needed at bedtime as back up dose for insulin pump failure. During a home visit and interview conducted on 6/9/21, at 11:30 a.m. P5 confirmed his medications with the surveyor and stated everything on the POC was correct except for the following: P5 stated he no longer had his intravenous line as it had been discontinued in March, therefore no longer required the saline flush. P5 indicated he was also taking Lisinopril 20 mg by mouth daily, Melatonin 10 mg by mouth every evening as needed for sleep and one over the counter probiotic capsule by mouth daily. These medications were not included on the medication profile. P5 also stated he was taking vitamin D on Monday's and Thursday's, which was not consistent with the POC.

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 interview and document review, the agency failed to ensure the plan of care (POC) included a description of safety measures to protect against injury for 4 of 7 patients (P1, P4, P5, P7) reviewed in the sample. In addition, the facility failed to include the type of aide provided, treatments and patient specific care interventions to be provided for 3 of 7 patients (P2, P3, P6) reviewed who had orders for home health or therapy aide services. Based on interview and document review, the agency failed to ensure the plan of care (POC) included a description of safety measures to protect against injury for 4 of 7 patients (P1, P4, P5, P7) reviewed in the sample. In addition, the facility failed to include the type of aide provided, treatments and patient specific care interventions to be provided for 3 of 7 patients (P2, P3, P6) reviewed who had orders for home health or therapy aide services. Findings include: P1's start of care (SOC) was 4/29/21. P1's plan of care (POC) for the certification period 4/21/21 to 6/27/21, included diagnoses of pressure ulcer to right buttock, stage 2., type 2 diabetes, peripheral angiopathy, venous insufficiency and non-pressure chronic ulcer. The POC further indicated P1 received skilled nurse visits (SNV) two times weekly for one week, three times weekly for one week and two times weekly for seven weeks for various assessments, treatment and education. On 6/4/21 a physician order increased the SNV to every other day. P1 had unsteady gait, poor endurance, was insulin dependent with potential for hypo or hyper glycemic events and received a blood thinner medication to prevent blood clots. The POC listed basic home safety under safety measures and failed to identify a description of safety measures to protect P1 against injury. P2's SOC was 7/15/20. P2's POC for the certification period 7/15/20 to 9/12/20, included diagnoses of infection and inflammatory reaction due to other internal prosthetic devices, implants and grafts, chronic atrial fibrillation, hypertensive heart and chronic kidney disease with heart failure. The POC further indicated P2 received SNV two times a week for one week, three times a week for four weeks and two times per week for one week for various assessments, treatment and education, and aide visits one time per week for one week and two times per week for five weeks, however, the order did not include the type of aide required or patient specific interventions to be provided. P2's POC for the certification period 9/13/20 to 11/11/20, indicated SNV three times a week for eight weeks and two times per week for one week for assessments, treatment and education and aide visits two times per week for 9 weeks, however, the order did not include the type of aide required or patient specific interventions to be provided. P2's POC 11/12/20 to 1/10/21, indicated SNV one time per week for nine weeks for assessments and education and aide visits one time a week for one week and two times per week for eight weeks, however, the order did not include the type of aide required or patient specific interventions to be provided. P2's POC for the certification period 1/11/21 to 3/11/21 indicated SNV one time a week for nine weeks for various assessments and education and aide visits two times per week for nine weeks, however, the order did not include the type of aide required or patient specific interventions to be provided. P2's POC for the certification period 3/12/21 to 5/10/21, indicated SNV one time per week for eight weeks for various assessments and education and aide visits two times a week for eight weeks then one time per week for one week, however, the order did not include the type of aide required or patient specific interventions to be provided. P2's POC for the certification period 5/11/21 to 7/9/21, indicated SNV one time per week for nine weeks for various assessments and education and aide visits one time per week for one week and then two times per week for eight weeks, however, the order did not include the type of aide required or patient specific interventions to be provided. P3's SOC was 1/25/21. P3's POC for the certification period 1/25/21 to 3/25/21, included diagnoses of critical illness myopathy, lumbosacral lexus disorders, hemoperitoneum, other amnesia and dysphagia. The POC further indicated P3 received SNV three time per week for one week, two times per week for three weeks and one time per week for one week for various assessments and education and physical therapy (PT) two times per week for nine weeks for assessments, treatment, exercises, develop home exercise program and education, and occupational therapy (OT) one time per week for one week, two times per week for five weeks and one time per week for three weeks for activities of daily living (ADL) training, fall and safety precautions and an aide two times per week for nine weeks, however, the order did not include the type of aide required or patient specific interventions to be provided P3's POC for the certification period 3/26/21 to 5/24/21, indicated P3 received PT two times per week for four weeks for assessments, treatments, exercises, develop home exercise program and education, and OT two times per week for four weeks, for ADL training, and fall and safety precautions and an aide one time per week for four weeks, however, the order did not include the type of aide required or patient specific interventions to be provided. P3's POC for the certification period 5/25/21 to 7/23/21, indicated P3 received PT five times a month for one month for various assessments, treatments, exercises, and education, OT one time per week for four weeks for ADL training, and fall and safety precautions and an aide one time per week for five weeks, however, the order did not include the type of aide required or patient specific interventions to be provided. P4's SOC was 10/12/20. P4's POC for the certification period 10/12/20 to 12/10/20, included diagnoses of heart disease, atrial fibrillation, osteoarthritis, Barrett's esophagus and gastro-esophageal reflux disease. The POC further indicated P4 received SNV one time a week for nine weeks for various assessments and education. P4's POC for the certification period 12/11/20 to 2/08/21, indicated P4 received SNV one time a week for nine weeks for various assessments and education. P4's POC for the certification period 2/9/21 to 4/9/21 indicated P4 received SNV four as needed for one week and one time a week for eight weeks for various assessments and education. P4's POC for the certification period 4/10/21 to 6/8/21, indicated P4 received SNV one time a week for nine weeks for various assessments and education. P4's POC for the certification period 6/9/21 to 8/7/21, indicated P4 received SNV three as needed for one week and one time a week for eight weeks for various assessments and education. P4 had unsteady gait, used a walker when ambulating and received a blood thinning medication to prevent blood clots. The POC listed basic home safety under safety measures and failed to identify a description of safety measures to protect P4 against injury. P6's SOC was 10/16/20. P6's POC for the certification period 10/16/20 to 12/14/20 included diagnoses of chronic peripheral venous insufficiency, chronic ulcers of bilateral lower extremities, chronic kidney disease, Parkinson's disease, dementia, and repeated falls. P6's POC further indicated skilled nursing visits one time per week for one week, two times per week for eight weeks, one time per week for one week, and four visits as needed for wound infections, falls, or change in condition. The POC also indicated an aide one time per week for eight weeks, however, the order did not include the type of aide or patient specific interventions to be provided. P7's SOC was 3/23/21. P7's POC for the certification period 3/23/21 to 5/21/21 included diagnoses of aftercare following surgery for neoplasm, encounter for attention to ileostomy, malignant neoplasm of the rectum, and elevated blood pressure readings. P7's POC indicated SNV three times per week for one week, two times per week for two weeks and four as needed for any concerns. P7 had unsteady ambulation, weakness, poor endurance and received a blood thinning medication to prevent blood clots. The POC listed fall precautions under safety measure and failed to identify a description of safety measures to protect P7 against injury. During interview on 6/10/21, at 2:30 p.m. the director of nursing (DON) indicated safety measures on the POC should list what is applicable to the client, if the client had anticoagulant medications, cluttered environment, use of equipment to ambulate, it should be listed under safety measure in the POC. A description of services should be included on the POC and was not sure why the aide duties were not showing up. The DON indicated the aide duties were entered into a different area in their software and were not being pulled over to the POC. The POC should list all patient specific interventions to be provided to the client and this was an oversight that would need to be corrected. Surveyor: Christensen, Shannon P5's plan of care (POC) indicated start of care (SOC) date of 12/3/20. The POC for the certification period 6/1/21 to 7/30/21, included diagnoses of chronic osteomyelitis of left tibia and fibula, diabetes mellitus with diabetic polyneuropathy, hypertension, obesity, and history of falling. P5 had two dogs in the home, wore a leg immobilizer, was toe touch weight bearing, and did not live in a handicap accessible home. The POC further indicated P5 received skilled nursing two times per week for one week, and three times per week for eight weeks to manage wound vac dressing changes and perform various assessments. Safety measures listed on P5's POC indicated "fall precautions." The POC lacked sufficient safety measures to protect P5 against injury. The agency's policy Home Health Coordination of Care, with review date 11/15/18, indicated integration of services will include identification of patient needs and factors that could affect patient safety, treatment effectiveness and coordination of care provided by all disciplines. Staff would recommend and work with the patient on safety modifications in the home. Written information was to be provided to the patient and caregiver for any treatments to be done by home health staff. The agency's policy Home Health Plan of Care, with review date 4/13/21, indicated the individualized POC would include safety measures to protect against injury, types of services, supplies and equipment required and patient specific interventions and education. The agency's policy Acceptance, and Continuation of Services for the Home Health Program, with review date 2/1/19, indicated each client would receive an individualized written plan of care established to meet the client specific needs, including identification of the responsible discipline. The written information would include any treatments to be administered by home health staff and any other pertinent instructions related to clients care and treatment that home health would provide specific to client care needs.

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 interview and document review, the agency failed to obtain physician orders for physical therapy visits, for 1 of 7 patients (P6), reviewed for home care services. During interview on 6/9/21, at 2:00 p.m. clinical manager (CM)-B stated the agency had interdisciplinary meetings every two weeks in which all the disciplines meet and discuss patients. Nurse case managers were responsible to follow up that orders were being followed. The CM indicated she reviewed all the physical therapy certification and recertification visits. The CM also was responsible to review all the therapy driven cases, when they generate changes or orders and at start of care. Visit frequency is checked and she makes sure there is a discharge plan and reviews the goals. The agency's policy Acceptance, and Continuation of Services for the Home Health Program, with review date 2/1/19, indicated a physician orders would be obtained to add a new discipline, increase visits, decrease visits or make a change in the treatment plan. Based on interview and document review, the agency failed to obtain physician orders for physical therapy visits, for 1 of 7 patients (P6), reviewed for home care services. Findings include: P6's plan of care (POC) indicated start of care (SOC) date of 10/16/20. The POC for certification period 2/13/21 to 4/13/21, included diagnoses of chronic peripheral venous insufficiency, chronic ulcers of bilateral lower extremities, chronic kidney disease, Parkinson's disease, dementia, and repeated falls. The POC further indicated P6 received skilled nursing one time per week for four weeks and four visits as needed. Review of P6's physician's orders revealed a supplemental order dated 2/19/21 that indicated physical therapy to begin the week of 2/22/21, two times per week for two weeks. Upon further review, two additional physical therapy visits were provided beyond the two week order. The medical record lacked additional orders for the visits.