Every finding on record at Dignity Home Health of Utah

Based on a recertification survey conducted 3/3/2025 through 3/5/2025, it was determined that Dignity Home Health of Utah was found in compliance with the Conditions of Participation for Emergency Preparedness; 42 CFR (Code of Federal Regulations) 484.22 and 484.102. No deficiencies were cited in the area of Emergency Preparedness.

Based on a recertification survey conducted from 3/3/2025 to 3/5/2025. It was determined that Dignity Home Health of Utah was not in compliance with all Conditions of Participation for home health 42 CFR (Code of Federal Regulations). Deficient practice was identified in the following area: 484.50 Patient Rights A deficiency was cited.

HHA administrator contact information CFR(s): 484.50(a)(1)(ii) (ii) Contact information for the HHA administrator, including the administrator's name, business address, and business phone number in order to receive complaints. This ELEMENT is not met as evidenced by: Based on interview and record review, it was determined the home health agency’s (HHA) admission packet did not include contact information for the HHA administrator, including the administrator’s name, business address, and business phone number in order to receive complaints. On 3/3/2025 at 9:30 am, surveyors requested the information given to patients in their admission packets and/or given to patients before care was provided by the HHA. Review of the information provided to surveyors revealed that the contact information for the HHA administrator, including the administrator’s name, business address, and business phone number in order to receive complaints, were not included in the information provided upon admission or before care was provided by the HHA. On 3/3/2025 at 12:25 PM during an interview with the owner, the owner stated that they used to put the actual administrator phone number in the packet but recently changed it to only include the agency phone number for contact information. During the exit conference, the owner presented the surveyors with the corrected admission packet that included the administrator’s contact information, including the administrator’s name, business address, and business phone number.

Contact info Federal/State-funded entities CFR(s): 484.50(c)(10)(i,ii,iii,iv,v) Be advised of the names, addresses, and telephone numbers of the following Federally-funded and state-funded entities that serve the area where the patient resides: (i) Agency on Aging (ii) Center for Independent Living (iii) Protection and Advocacy Agency, (iv) Aging and Disability Resource Center; and (v) Quality Improvement Organization. This ELEMENT is not met as evidenced by: Based on interview and record review, it was determined the home health agency ‘s (HHA) admission packet did not include the names, addresses and phone numbers of the required Federally funded and state-funded entities that serve the area. Finding Include: 1. On 3/3/2025 at 9:30 am, surveyors requested the information given to patients in their admission packets and/or given to patients before care was provided by the HHA. Review of the information provided to surveyors revealed the names, addresses and phone numbers of the required Federally funded and state-funded entities that serve the area were not included in the information provided to patients upon admission or before care was provided by the HHA. 2. On 3/3/2025 at 12:25 PM during an interview with the owner, the owner stated that the information once was in the packet, but somehow the page must have been removed. During the exit conference the owner presented surveyors with a corrected admission packet that included all required names, addresses and phone numbers of the required Federally funded and state-funded entities for the area.

Based on a recertification survey conducted 1/10/2022 through 1/12/2022, it was determined that Dignity Home Health of Utah was found in compliance with the Conditions of Participation for Emergency Preparedness; 42 CFR (Code of Federal Regulations) 484.22 and 484.102. No deficiencies were cited in the area of Emergency Preparedness.

Comprehensive Assessment of Patients CFR(s): 484.55 Condition of participation: Comprehensive assessment of patients. Each patient must receive, and an HHA must provide, a patient-specific, comprehensive assessment. For Medicare beneficiaries, the HHA must verify the patient's eligibility for the Medicare home health benefit including homebound status, both at the time of the initial assessment visit and at the time of the comprehensive assessment. This CONDITION is not met as evidenced by: Based on interview and record review it was determined that the home health agency (HHA) failed to ensure each patient received a patient specific comprehensive assessment. Findings include: 1. The HHA failed to complete a comprehensive assessment. (Refer to tag G-0518.) 2. The HHA failed to ensure the medication profile accurately reflected a list of medications the patient was 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. (Refer to tag G-0536.)

Completion of the comprehensive assessment CFR(s): 484.55(b) Standard: Completion of the comprehensive assessment. This STANDARD is not met as evidenced by: Based on interview and record review, it was determined the home health agency (HHA) did not complete a comprehensive assessment for 1 of 1 patient who was on a waiver service and received hands-on-care from a home health aide. (Patient identifier: 3) Findings include: Patient 3 was admitted to the HHA for home health aides to provide personal cares as directed by a waiver program. Patient 3 was admitted on 11/16/2020, the diagnosis for admission was not documented. There was no documented evidence of a comprehensive assessment in patient 3’s medical record. On 1/11/2022 around 2:31 PM, an interview was conducted with the agency’s home health coordinator (HHC), administrator, and chief operations officer (COO). They were asked about the missing comprehensive assessment in patient 3’s medical record. The COO responded they were told by the waiver program not to do an assessment of the patient that they would not get paid for that. They were unaware the waiver patient needed to follow the same conditions of participation as their other patients.

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 interview and record review, it was determined the medication profile did not accurately reflect a list of medications the patient was 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. Specifically, the clinical record did not identify all medications that the patient was taking (both prescription and non-prescription), dosages, times of medication administration and route for 3 of 10 sample patients. (Patient identifiers: 1, 4 and 9) 3. Patient 4 was admitted to the HHA on 2/3/2021, with a diagnosis of type 2 diabetes with diabetic peripheral angiopathy without gangrene. Patient 4's medical record review was completed on 1/12/2022. It was documented in an order dated 1/7/2022, with a start date of 12/29/2021, to administer Cubicin (daplomycin) 500 milligrams (mg) every 24 hours for 7 days. It was documented in an order dated 1/10/2022, with a start date of 12/29/2021, to administer Victoza (liraglutide) 0.6 mg every morning. Patient 4’s medication profile for the certification period 11/30/2021 through 1/28/2022 was reviewed. There was no documented evidence of the ordered Cubicin (daplomycin) or the Victoza (liraglutide) on the medication profile. On 1/11/2022 at 4:14 PM, an interview was conducted with case manager 3 (CM3). She was asked when medication profiles were updated. She responded medication profiles were usually updated during the patient’s recertification and if any medications had changed. CM3 was asked about the patient’s orders that were not on the medication profile. She stated “that is my error.” She further stated, “I am just really struggling putting in orders and updating med (medication) profiles.” On 1/11/2022 at 2:31 PM, an interview was conducted with the agency’s home health coordinator (HHC), administrator, and chief operations officer (COO) in regards to when medication profiles were updated. The HHC responded they go over medications on admission and any change of condition. She further stated she reviewed them regularly, at least once in a certification period to see if any changes had been made. The HHC stated medications were reviewed at their bimonthly meetings. She was asked if there was any way for us to see if the medication profiles had been reviewed. The HHC responded there was no way for us to know when the medication profiles were reviewed and understood the concern of medications not making it onto the medication profile. The HHC was asked when verbal orders should be updated onto the POC and if the medication profile should reflect discontinued orders as well. She replied if an antibiotic was ordered for just a week it should still show on the medication profile. She also stated new orders should be updated to the profile within 24 hours. The COO commented she noticed there was a problem with medication profiles and they were going to start a performance improvement project on it. Findings include: 1. Patient 1 was admitted to the home health agency (HHA) on 6/16/2021 with diagnoses which included history of stroke with right sided hemiplegia, bradycardia, and type 2 diabetes mellitus. Patient 1's medical record was reviewed on 1/11/2022. The medication profile completed by a registered nurse (RN), for certification periods 10/14/2021 through 12/12/2021 and 12/13/2021 through 2/10/2022, had the following insulin orders: (a) Insulin Glargine (Lantus) 100 units/ml (milliliters) 5 units subcutaneously twice a day (the start date was documented as 6/16/2021) and (b) Insulin Lispro (Humalog) 100 units/ml 4 units subcutaneously twice a day (the start date was documented as 6/6/2021). The Humalog was to be held for blood sugars that were less than 100. Additionally, the RNs were to administer and additional 1 unit for every 50 over 200. For example, if a blood sugar of 250 was obtained, the RN should have administered 5 units of Humalog. The blood sugars and insulin that was administered between 11/7/2021 and 1/8/2022 were reviewed. During that period of time, the RNs only obtained blood sugars and administered insulin once a day. Additionally, the Humalog was not administered during the nine week period reviewed. A telephone interview was conducted with case manager (CM) 1 on 1/12/2022 at 8:01 AM related to patient 1's insulin orders. CM 1 stated patient 1 was to receive Lantus 5 units subcutaneously once a day and that the Humalog was discontinued. The current orders documented on the medication profile were reviewed with CM 1. CM 1 stated that patient 1's insulin orders changed back in July, 2021. CM 1 stated that she would change the order and make sure that it was current going forward. Note: Patient 1's medical record was reviewed from 7/1/2021 to 1/12/2022. There was no documentation from a physician or nurse practitioner that changed patient 1's insulin orders for Lantus 5 units subcutaneously daily or discontinuing the Humalog order. A telephone interview was conducted with the director of nursing (DON) on 1/12/2022 at 9:30 AM related to patient 1's insulin orders. The DON stated that she had a discussion with CM 1 earlier in the day related to patient 1's insulin orders. The DON stated that the medication profile was changed to reflect that Lantus 5 units subcutaneously daily was to be administered. At the time of the interview, there was no documentation that patient 1's primary care physician had been contacted to verify what time and how much insulin was to be administered. 2. Patient 9 was admitted to the agency on 1/1/2021 with diagnoses which included type 2 diabetes mellitus and chronic obstructive pulmonary disease. Patient 9's medical record was reviewed on 1/12/2022. Patient 9 was seen by a physician on 8/17/2021. The physician documented on a clinic report that patient 9 was to take Soliqua 100/33 100 unit-33 mcg/ml 56 units subcutaneously every day. The Soliqua was to be increased by 2 units weekly "as needed for elevated" blood sugars. The order did not define what the parameter was for elevated blood sugars. The start date for the Soliqua order was 8/12/2021. It was further documented that patient 9 was to take Novolog insulin inject up to 16 units twice a day to correct elevated blood sugar levels (per ALF (assisted living facility) order). The order did not include parameters as to how much insulin to administer based on the blood sugars obtained. The order had a start date of 3/2/2021. The medication profile completed by a RN, for certification periods 10/28/2021 through 12/26/2021 and 12/27/2021 through 2/24/2022 had the following insulin orders: (a) Insulin Glargine-Lixisenatide (Soliqua) 100-33 unit-mcg (micrograms)/ml 56 units subcutaneously daily (the start date was documented as 8/25/2021) and (b) Novolog per sliding scale (SS) subcutaneously twice a day as needed (the start date was documented as 8/25/2021). The orders did not define what the SS was or how much insulin was to be administered based on the blood sugar obtained. There were no additional orders or documentation in patient 9's medical record to indicate what the insulin orders were that were input into the medication profile on 8/25/2021.

Discharge or Transfer Summary Content CFR(s): 484.58(b)(1) Standard: Discharge or transfer summary content. The HHA must send all necessary medical information pertaining to the patient's current course of illness and treatment, post-discharge goals of care, and treatment preferences, to the receiving facility or health care practitioner to ensure the safe and effective transition of care. This STANDARD is not met as evidenced by: Based on interview and record review, it was determined the home health agency (HHA) did not send all necessary medical information pertaining to the patient's current course of illness and treatment and treatment preferences to the receiving facility or health care practitioner to ensure the safe and effective transition of care for 1 of 1 patient that was transferred to a hospital. (Patient identifier: 8.) Findings include: Patient 8 was admitted to the HHA on 11/22/2021 with diagnoses which included dementia and low back pain. Patient 8's medical record was reviewed on 1/11/2022. A transfer OASIS (Outcome and Assessment Information Set) was completed by a registered nurse (RN) on 12/23/2021. It was documented that patient 8 was transferred to an inpatient facility and was admitted to the hospital. The RN further documented, "Patient taken to ER (emergency room) at the (local hospital) after suffering from a fall." There was no documentation in patient 8's medical record to indicate a discharge summary which included necessary medical information pertaining to the patient's current course of illness and treatment to the hospital. The HHA policies and procedures related to discharge requirements were reviewed. The policies and procedures did not address discharge summaries related to patients that were transferred to a health care facility that provided a higher level of care. On 1/11/2022 at 11:53 AM, an email correspondence was sent to the home health coordinator (HHC) related to the discharge summary. The HHC responded at 12:40 PM and wrote, "(Patient 8's) discharge summary was not sent to the receiving facility. We did not know which hospital he went to and have been unable to reach any caregivers." The discharge summary was not sent to the receiving facility despite the RN documentation of the hospital that patient 8 was admitted to. At 1:30 PM, the HHC further documented, "My understanding was that is where (the name of the hospital documented by the RN) we thought (patient 8) went, but had a hard time confirming that, and never received a for sure answer. We did not want to send patient information to the wrong hospital."

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 interview and record review, it was determined the home health agency (HHA) failed to provide care planning, coordination of services, and quality of care as required. Findings include: 1. The HHA failed to ensure each patient received the home health services that were written in an individualized plan of care (POC) that identified patient-specific measurable outcomes and goals, and which is established, periodically reviewed, and signed by a doctor of medicine, osteopathy, or podiatry.(Refer to tag G-072.) 2. The HHA failed to ensure all care orders, including verbal orders, were recorded in the plan of care. (Refer to tag G-0576.) 3. The HHA failed to ensure that drugs, services, and treatments were administered only as ordered by a physician. (Refer to tag G-0580.) 4. The HHA failed to promptly alert the physician to any changes in the patient's condition or needs that suggested that outcomes were not being achieved and/or that the plan of care should be altered. (Refer to tag G-0590.)

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 interview and record review it was determined that the home health agency (HHA) did not ensure each patient received the home health services that were written in an individualized plan of care (POC) that identified patient-specific measurable outcomes and goals, and which is established, periodically reviewed, and signed by a doctor of medicine, osteopathy, or podiatry for 1 of 1 patient. Specifically, a plan of care was not developed for one patient receiving care as directed by a waiver program. (Patient identifier: 3) Findings include: 1. Patient 3 was admitted to the HHA for home health aides to provide personal cares as directed by a waiver program. Patient 3 was admitted on 11/16/2020, the diagnosis for admission was not documented. There was no documented evidence of a signed POC in patient 3's medical record. On 1/11/2022 around 2:31 PM, an interview was conducted with the agency's home health coordinator (HHC), administrator, and chief operations officer (COO). They were asked about the missing documentation, such as the POC in patient 3’s medical record. They responded it was their understanding after they talked with the waiver program that the authorization they sign was considered the plan of care. They stated they were told because they were outsourcing cares all they needed was the authorization. They were unaware they needed to follow the same conditions of participation as their other patients.

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 interview and record review, it was determined the home health agency (HHA) did not ensure that all care orders, including verb al orders, were recorded in the plan of care for 3 of 10 sample patients. (Patient identifiers: 1, 4 and 9.) 3. Patient 4 was admitted to the HHA on 2/3/2021, with a diagnosis of type 2 diabetes with diabetic peripheral angiopathy without gangrene. Patient 4's medical record review was completed on 1/12/2022. Patient 4’s orders and the POC for the certification period 11/30/2021 through 1/28/2022 was reviewed and revealed the following: a. It was documented in an order dated 1/7/2022, with a start date of 12/29/2021, to administer Cubicin (daplomycin) 500 milligrams (mg) every 24 hours for 7 days and for the patient’s catheters to be flushed daily with 5 ml of heparin. There was no documented evidence of the new order on the POC. b. It was documented in an order dated 1/10/2022, with a start date of 12/29/2021, to administer Victoza (liraglutide) 0.6 mg every morning. There was no documented evidence of the new order on the POC. c. Patient 4’s blood sugar flow sheet/insulin log for the months of November and December were reviewed. Patient 4 had been receiving 85 units of Levemir (insulin detemir) for the months of November and December. There was no documented evidence of the 85 units on the POC. On 1/11/2022 at 2:31 PM, an interview was conducted with the agency’s home health coordinator (HHC), administrator, and chief operations officer (COO). The HHC was asked about patient 4’s orders and if they should have been on the POC. She responded “yes,” they should have. The HHC stated there was no way to update the POC until the next certification period because their electronic medical record (EMR) does not let them. She further stated they were aware they needed to update the POC as orders came in and they would try and find a solution with their EMR. On 1/11/2022 at 4:14 PM, an interview was conducted with case manager 3 (CM3) in regards to patient 4’s POC not being updated. CM3 stated she had never updated new orders to the POC; she had only updated intervention and goals. She stated she was not sure if people in the back office updated it or not. On 1/12/2022 at 9:26 AM, an interview was conducted with the HHC and administrator. The agency’s administrator stated their EMR did not let them update the POC. He stated they called their EMR and they said they had never heard of the regulation and requested the regulation we were referring to be sent to them. In an interview conducted with the director of nursing (DON) on 1/12/2022 at 9:30 AM, related to who checked the POC’s to ensure accuracy. The DON stated, “we don’t have a clear process in place.” Findings include: 1. Patient 1 was admitted to the agency on 6/16/2021 with diagnoses which included history of stroke with right sided hemiplegia, bradycardia, urinary incontinence and diabetes mellitus type2. Patient 1’s medical record was reviewed on 1/11/2022. a. The plan of care (POC) for the certification period of 10/14/2021 to 12/12/2021 was reviwed. The following changes were not documented on the POC: i. Patient 1 was to receive Lantus 100 units/ml (milliliters) 5 units twice a day and Humalog 100 units/ml 4 units daily. Additionally, orders for the Humalog included to hold the insulin if the blood sugar was less than 100 and to add 1 unit for every 50 over 200 twice a day. The skilled diabetic notes were reviewed from 11/8/2021 through 1/8/2022 and revealed the skilled nurses were administering 5 units of Lantus once a day and were not administering the Humalog. ii. An intervention for the treatment of the diabetes included that blood sugars were to be obtained twice a day. iii. A new order was received on 11/8/2021 for patient 1 to have a surgical consult related to a possible pilonidal cyst versus a lipoma. iv. A new order was received on 12/1/2021 to administer artificial tears twice a day as needed. An interview was conducted with case manager (CM) 1 on 1/12/2022 at 8:01 AM. CM 1 was asked to clarify the insulin orders for patient 1. CM 1 stated that patient 1 was receiving Lantus 5 units a day and that the Humalog had been discontinued in July 2021. She further stated that blood sugars were only obtained once a day. b. The POC for the certification period of 12/13/2021 through 2/10/2022 was reviewed. The following changes were not documented on the POC: i. Patient 1 was to receive Lantus 100 units/ml (milliliters) 5 units twice a day and Humalog 100 units/ml 4 units daily. Additionally, orders for the Humalog included to hold the insulin if the blood sugar was less than 100 and to add 1 unit for every 50 over 200 twice a day. The skilled diabetic notes were reviewed from 11/8/2021 through 1/8/2022 and revealed the skilled nurses were administering 5 units of Lantus once a day and were not administering the Humalog. ii. It was documented by a skilled nurse that patient 1 tested positive for COVID 19 on 1/3/2022. iii. A new order was received on 1/3/2022 to obtain a urinalysis (UA). The UA returned positive for two organisms. iv. It was documented in a diabetic visit note dated 1/4/2022, that patient 1 was started on a Z-Pack. 2. Patient 9 was admitted to the agency on 1/1/2021 with diagnoses which included diabetes mellitus type 2 and chronic obstructive pulmonary disease. Patient 9’s medical record was reviewed on 1/11/2022. The POC for the certification period of 12/27/2021 to 2/24/2022 was reviewed. The following changes were not documented on the POC: a. It was documented that patient 9 was to receive Soliqua 100-33 units mcg (micrograms)/ml. There was no documentation as to how much insulin was to be administered or how often. It was further documented that patient 9 was also to receive Novolog per a sliding scale twice a day as needed. The start date documented for both insulin orders was 8/25/2021. b. The SN endocrine interventions had that the SN was to reduce Soliqua by two units every three days until pre-prandial blood sugar was between 120-180 and that the Novolog was to be discontinued until the reference range was obtained. The SN was also to check patient 9’s blood sugar twice a day beginning 12/22/2021. In an interview conducted with CM 2, CM 2 stated that patient 9 received 42 units of Soliqua today and that the units were to be decreased by 2 units every 3 days until the blood sugars were 120-180.

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 record review, it was determined the home health agency (HHA) did not ensure that drugs, services, and treatments were administered only as ordered by a physician for 2 of 10 sampled patients. Specifically, 2 out of 10 patients did not have orders for all treatments and services they were receiving. (Patient identifier: 3 and 4) Findings include: 1. Patient 3 was admitted to the HHA for home health aides to provide personal cares as directed by a waiver program. Patient 3 was admitted on 11/16/2020, the diagnosis for admission was not documented. There was no documented evidence of physician orders for aide visits for 7 out of 8 certification periods. On 1/11/2022 around 2:31 PM, an interview was conducted with the home health coordinator (HHC), administrator, and chief operations officer (COO). They were asked about the missing documentation, such as the POC in patient 3’s medical record. They responded it was their understanding after they talked with the waiver program that the authorization they sign was considered the plan of care. They stated they were told because they were outsourcing cares all they needed was the authorization. They were unaware they needed to follow the same conditions of participation as their other patients. 2. Patient 4 was admitted to the HHA on 2/3/2021, with a diagnosis of type 2 diabetes with diabetic peripheral angiopathy without gangrene. Patient 4’s medical record review was completed on 1/12/2022. Patient 4’s blood sugar flow sheet/insulin log for the months of November and December and orders for the certification period 11/10/2021 through 1/28/2022 were reviewed and revealed the following: a. Patient 4 had been receiving 85 units of Levemir (insulin detemir) for the months of November and December. The only order for Levemir (insulin detemir) in patient 4’s medical record was located on the plan of care (POC). It was for 80 units of Levemir (insulin detemir). There was no documented evidence of an order for the 85 units of Levemir (insulin detemir). b. It was documented on patient 4’s POC for 1.2 milligrams (mg) of Victoza (liraglutide) to be given every day starting on 10/28/2020. On 11/20/2021 through 11/28/2021, the Victoza (liraglutide) was not documented as being given on the blood sugar sheet/insulin log. There was no documented evidence of the order being canceled. A new order was documented on 1/7/2022, with a start dated of 12/29/2021, for Victoza (liraglutide) 0.6 mg to be administered every morning. Patient 4 started receiving Victoza 0.6 mg on 11/29/2021. There was no documented evidence of a previous order of the Victoza (liraglutide) 0.6 mg for the doses that were given starting on 11/29/2021. On 1/11/2022 at 4:14 PM, an interview was conducted with case manager 3 (CM3) in regards to the missing orders for patient 4. She stated the paperwork was with her and the orders just never got put in. She further stated "it is huge error on my part.” CM3 stated she could see how a new nurse coming in would not know what was going on with the patient because the correct orders were not put in and the POC was not updated. CM3 stated “I am embarrassed. I promise I will never make that mistake again.”

Promptly alert relevant physician of changes CFR(s): 484.60(c)(1) The HHA must promptly alert the relevant physician(s) or allowed practitioner(s) to any changes in the patient's condition or needs that suggest that outcomes are not being achieved and/or that the plan of care should be altered. This ELEMENT is not met as evidenced by: Based on interview and record review, it was determined the home health agency (HHA) did not promptly alert the physician to any changes in the patient's condition or needs that suggested that outcomes were not being achieved and/or that the plan of care should be altered for 2 of 10 sampled patients. Specifically, the ordering physician was not immediately notified when abnormal laboratory tests were received. (Patient identifier: 1 and 5.) Findings include: 1. Patient 1 was admitted to the HHA on 6/16/2021 with diagnoses which included history of stroke with right sided hemiplegia, bradycardia, and type 2 diabetes mellitus. Patient 1's medical record was reviewed on 1/11/2022. A registered nurse (RN) documented in a daily diabetic note, dated 1/2/2022, "Patient is in his room, patient is not feeling well at all. Patient believes he has a UTI (urinary tract infection), he is coughing and is congested. Facility is testing patient for covid this morning while RN is present…" On 1/3/2022, a verbal order was received to obtain a urinalysis related to signs and symptoms of a urinary tract infection. The urinalysis was completed and a culture and sensitivity (C&S) ran. The C&S returned positive for Enterococcus faecalis and staphylococcus aureus methicillin resistant. There was no indication that the organisms were susceptible to the Z-Pack that was started on 1/4/2022. The laboratory company documented that the results of the UA with C&S was faxed to the agency on 1/7/2022. There was no documented evidence the agency followed up with patient 1's physician related to the UA with C&S results. On 1/12/2022 at 8:01 AM, a telephone interview was conducted with case manager (CM) 1 related to what follow up had been completed in relation to the abnormal laboratory values. CM 1 stated that she had been out of on a leave of absence for the prior week and had just returned to work on 1/10/2022. CM 1 stated that she did not know if someone from the office followed up or not. On 1/12/2022 at 9:00 AM, an telephone interview was conducted with the agency director of nursing (DON). The DON stated that the urinalysis "fell through the cracks" and that the physician had not been notified until today, after questioning by the surveyor. The DON stated that patient 1 was to be started on Macrobid 100 mg (milligrams) three times a day and that the order would be "expedited." Due to the lack of follow up, this placed patient 1 at a high risk for obtaining a more serious illness and possible hospitalization. 2. Patient 5 was admitted to the agency on 3/4/2021 with diagnoses which included immobility syndrome, chronic pain, diabetes mellitus type 2 and hypertension. Patient 5's medical record was reviewed on 1/11/2022. A RN documented in a skilled nursing (SN) visit note dated 11/4/2021, "...Patient had some sediment in his catheter last week when SN changed it, this is not usual for him and the doctor requested that SN collect a urine sample and flush his catheter..." There was no documentation of the laboratory result in patient 5's medical record. A request was sent to the agency administration requesting a copy of the laboratory result. According to the laboratory company the UA results were faxed to the agency on 1/11/2022 at 12:08 AM. The laboratory company faxed a copy of the UA results to the agency on 11/4/2021 at 7:25 PM. The UA was positive for nitrites, white blood cells, red blood cells and bacteria. There was no documentation found in patient 5's medical record to indicate the physician was notified of the results. An email correspondence was submitted to the agency administration on 1/11/2022 at 1:15 PM as to what documented evidence there was to indicate the physician was notified of the abnormal UA results. At 1:30 PM, a clinical staff member responded with, "As far as I can see there is no paper evidence of the follow up on (patient 5)."