Every finding on record at Diversified Health Care Systems Inc

A recertification survey entrance conference was conducted on 11/12/24 at 12:08 p.m. Census: L&CHHS: 56 LHHS: 66 PAS: 0 Abbreviations: Adm – Administrator Act - actuation ADON - Alternate Director of Nursing BID – Twice daily CR – Clinical Record COPD – Chronic Obstructive Pulmonary Disease DON – Director of Nursing/Supervising Nurse ER – Extended release L&C - Licensed and Certified Home Health Services LHHS - Licensed Home Health Services gm - Gram mg – milligram mcg – microgram mg - milligram ml – milliliter PAS – Personal Assistance Services PO – orally POC – Plan of Care Prn – as needed RN – Registered Nurse SBP – systolic blood pressure SC - subcutaneous SN – Skilled nursing SOC – Start of Care tab – Tablet TID – Three times a day

A recertification survey entrance conference was conducted on 11/12/24 at 12:08 p.m. Census: L&CHHS: 56 LHHS: 66 PAS: 0 Abbreviations: Adm – Administrator Act - actuation ADON - Alternate Director of Nursing BID – Twice daily CR – Clinical Record COPD – Chronic Obstructive Pulmonary Disease DON – Director of Nursing/Supervising Nurse ER – Extended release gm - Gram L&C - Licensed and Certified Home Health Services LHHS - Licensed Home Health Services mg – milligram mcg – microgram mg - milligram ml – milliliter PAS – Personal Assistance Services PO – orally POC – Plan of Care Prn – as needed RN – Registered Nurse SBP – systolic blood pressure SC - subcutaneous SN – Skilled nursing SOC – Start of Care tab – Tablet TID – Three times a day

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 record review, agency failed to make sure that comprehensive assessment included a review of all medications the patient is currently using for 4 of 5 patients whose care was observed (#4, #5, #9, #10) in that the patients’ medication profiles did not reflect all current medications the patients were using. This failed practice may potentially harm patients served due to staff not identifying 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. Patient #9: Review of CR showed SOC on 6/26/24 with the primary diagnosis of emphysema (a long-term lung condition that causes shortness of breath), unspecified. Review of the current medication profile completed by RN A for recertification assessment on 10/16/24 for the certification period 10/18/24 – 12/16/24 showed the following medications: 1. Advair Diskus 250-50 mcg/act inhalation aerosol powder breath activated one puff BID for chronic obstructive pulmonary disease (a common lung disease that makes it difficult to breathe). 2. Basaglar KwikPen 100 unit/ml SC solution pen-injector 7 units once a day for diabetes (a chronic disease that occurs when the body can't produce or use insulin properly, resulting in high blood sugar levels) 3. Coreg 3.125 mg 1 tab PO BID for high blood pressure 4. Cozaar 25 mg 1 tab every night at bedtime for high blood pressure 5. Flovent HFA 44 mcg/act inhalation 2 puffs PRN (Flovent HFA is a prescription inhaled corticosteroid medicine used to treat asthma in people aged 4 years and older) 6. Lipitor 10 mg 1 tab PO once a day for high cholesterol (a waxy, fat-like substance that's found in all the cells in your body) (Lipitor is used to lower blood cholesterol level and fats) 7. Procardia XL 60 mg ER 24-hour tab 1 tab once a day to lower blood pressure 8. Sevelamer Carbonate 800 mg tab 1 tab PO TID (Sevelamer is used to control high blood levels of phosphorus (an essential mineral in the body) in people with chronic kidney disease who are on dialysis) 9. Tirosint 100 mcg cap 1 cap PO once a day (Tirosint (Levothyroxine) is used to treat an underactive thyroid (a butterfly-shaped gland in the front of the neck that produces hormones that regulate many bodily functions)) 10. Trelegy Ellipta 100-62.5-25 mcg/act inhalation aerosol powder 1 breath activated daily for COPD. 11. Zithromax 500 mg tab 1 tab PO once a day (Zithromax (azithromycin) is used to treat infections caused by bacteria) During home visit to Patient #9 on 11/13/24 at 11:56 a.m. with RN A, discrepancies were found between the medications on the medication profile and the patient’s current home medications as follows: The following medications were on the medication profile but not in the home medications: Basaglar KwikPen, Procardia XL and Flovent HFA. The following medications were found in the home medications but not listed on the medication profile:[ 1. Ferrous Sulfate 325 mg PO daily (Ferrous sulfate is used to treat iron deficiency anemia (a lack of red blood cells caused by having too little iron in the body)) 2. Pantoprazole Sodium 40 mg 1 tab PO daily (Pantoprazole reduces the amount of acid your stomach makes) 3. Ondansetron 4 mg PO every 8 hours prn nausea/vomiting 4. Lantus 10 units SC daily (Lantus is a long acting form of insulin used to treat type 1 or type 2 diabetes) 5. Polythene glycol 17 gm PO prn for constipation Interview with Ppatient #9 during the home visit, she stated the following: She did not used Basalgar KwikPen because of how the medication made her feel, and the medication was replaced with Novolog FlexPen. The Novolog FlexPen was discontinued 2 weeks ago. She was placed on Ondansetron 3 months ago. She has been using Lantus, Ferrous Sulfate and Pantoprazole for a long time. When Ppatient #9 was asked how long was “a long time”, she stated “years”. During interview with RN B after the home visit on 11/13/24 at 1:03 p.m., she was asked why patient #9’s medication profile did not reflect all the medications the patient was using. RN B stated that she usually asked the patient if there were changes to her medications, but the patient told her there were no changes to her medications. RN B acknowledged that she did not visibly check the medication bottles. RN B was asked if she realized the importance of checking the patient medications. RN B stated that medication review was necessary to prevent possible negative drug interaction. Patient #10: Review of CR showed SOC on 3/13/24 with the primary diagnosis of cellulitis of left lower limb (Cellulitis is a bacterial infection that affects the skin and tissue below, usually caused by bacteria entering a wound or broken skin). Review of the current medication profile completed by RN B for recertification assessment on 11/04/24 for the certification period 11/08/24 – 01/06/25 showed the following medications: 1. Zolpidem Tartrate 10 mg PO at bedtime for insomnia (trouble sleeping) During interview with Adm/ADON on 11/12/24 at 2:11 p.m., she was asked why Ppatient #10 had only one medication on her medication profile. Adm/ADON stated that the patient only wanted Zolpidem Tartrate and no other medications. Adm/ADON added that patient #10’s husband was a physician and was probably taking care of the patient. During home visit to Patient #10 on 11/13/24 at 10:04 a.m. with RN B, discrepancies were found between the medications on the medication profile and the patient’s current home medications as follows: The following medications were found in the home medications but not listed on the medication profile: 1. Furosemide 20 mg 1 tab PO daily prn (Furosemide is used to treat fluid retention (edema) and swelling that is caused by congestive heart failure, liver disease, kidney disease) 2. Levsin 0.125 mg tab PO daily (Levsin is used to treat a variety of stomach/intestinal problems such as cramps and irritable bowel syndrome. It is also used to treat other conditions) 3. Rybelsus 7 mg tab 1 tab PO daily (Rybelsus tablets are used to improve blood sugar control in adults with type 2 diabetes) 4. Welchol 625 mg tab 2 tabs PO BID (Welchol is commonly used to lower bad cholesterol (LDL-C) in people with high cholesterol) 5. Clopidogrel 75 mg tab 1 tab PO daily (Clopidogrel prevents platelets (small, disc-shaped cells in the blood that help stop bleeding and form blood clots) in your blood from sticking together. This helps prevent the formation of blood clots) 6. Tylenol extra strength 650mg 2 tabs every 8 hours prn for pain 7. Hydrocodone-Acetaminophen 5-325 mg ½ tab PO BID prn for pain Interview with FM during the home visit, she stated the following: She was started on Furosemide and Clopidogel a month ago after a procedure was done to open a blocked vein in her leg. She has been using Levsin since 1999 when she was diagnosed with Grave’s disease (an autoimmune disease that causes the thyroid gland to produce too much thyroid hormone). She was started on Rybelsus for diabetes about a year ago. She had been using Hydrocodone-Acetaminophen since April 2024. She also used Tylenol interchangeably with Hydrocodone-Acetaminophen. During interview with RN A after the home visit on 11/13/24 at 11:12 am, she was asked why the medication profile did not include all the medications the patient was using. RN A stated that she updated the medication profile during the recertification. RN B was asked why there was only one medication on the profile. RN B stated that she did not know why the medication profile did not show the update. During interview with DON on 11/13/24 at 11:30 am, she was asked how the nurses were supposed to complete the medication profile. DON stated that medication profiles were completed from the referral documents for admission. DON explained that the referral documents from the physicians usually had the list of the patient’s medications, and the medication profiles were developed from the lists. DON was asked if the nurses were supposed to copy the medications in the referral documents to the medication profiles or visible check the patient home medications as part of the comprehensive assessment. DON stated that the nurses were supposed to check the patient’s medications during the assessments. DON was asked why the medication profiles for the above patients were not updated. DON stated that she did not know why the medication profiles were not updated. During interview with Adm and DON on 11/13/24 at 11:48 am, Adm was asked how often the nurses were required to review patient medications. Adm stated that medication review should be done at least on admission and recertification. Adm added that the nurses were supposed to ask the patients on each visit if there were changes in their medications. Adm was asked why the medication profiles for the above patients were not updated. Adm stated that she did not know why the medication profiles were not updated. Review of agency undated policy titled “Medication Profile”, read in part: “Upon admission to the agency, the admitting RN or therapist is provided in the admission packet a sheet on which to record the medication(s) that the patient is taking on a routine or prn basis.” “The medication profile will be updated at least every 60 days or more often as needed. All new medications will be added to the medication profile and checked for interaction risks by the case manager". Findings include: Patient #4 Record review of Patient #4's POC for certification period 11/01/2024 to 12/30/2024 showed start of care date was 11/01/2024. The POC also revealed patient’s principal diagnosis as Dementia (Is a general term for loss of memory, language, problem-solving, and other thinking abilities that are severe enough to interfere with daily life). Review of patient #4’s current medication profile created by RN B on 11/01/2024 revealed that patient was on the following Medications: 1) Amlodipine Besylate 5mg tablet. Take 1 tab by mouth daily for blood pressure. 2) Ascorbic Acid 500mg oral tablet. Take 1 tab by mouth daily – Vitamin supplement. 3) Aspirin 81mg oral tablet. Take 1 tab by mouth daily for blood thinner. 4) Atorvastatin Calcium 20mg oral tablet. Take 1 tablet for High cholesterol. 5) Methimazole 5mg oral tablet. Take 1 tab by mouth daily for high thyroid hormone. 6) Trazodone HCL 50mg oral Tablet. Take 1 tab by mouth at bedtime for sleep. 7) Tylenol Extra Strength 500mg oral tablet. Take 1 tab by mouth 3 times a day as needed for pain or fever. During a home visit to patient #4 on 11/13/2024 at 11:30 a.m. upon review of patient’s home medications it was discovered that Patient #4 was on all the medications listed in the agency’s medication profile except the following: 1) Donepezil HCl 10mg oral tablet. Take 1 tab by mouth at bedtime for Dementia. 2) Nystatin 100000Unit/gram powder. Apply to affected part topically twice a day for fungal or yeast infection. During interview with the medication Aide at the personal care home where patient #4 resides on 11/13/2024 at 11:57a.m. the medication Aide was asked how long patient had been on Donepezil 10mg tablets. The medication Aide stated, “Patient #4 has been taking this medication for a long time.” When the medication Aide was asked if the Home health Nurses checked the patient’s medication during their visits. The Medication Aide replied, “No.” Patient #5 Record review of Patient #5's Plan of care (PoC) for certification period 10/02/2024 to 11/30/2024 showed start of care date was 02/05/2024. The POC also revealed patient’s principal diagnosis as Dementia (Is a general term for loss of memory, language, problem-solving, and other thinking abilities that are severe enough to interfere with daily life) along with other health issues. Review of patient #5’s medication profile revealed patient was on the following medications: 1) Cozaar 100mg oral tablet. Take 1 tab by mouth daily for blood pressure. 2) Flomax 0.4mg oral tablet. Take 1 tab by mouth daily for treatment of symptoms of enlarged prostate. 3) Gentle laxative 5mg oral tablet. Take 1 tab for constipation. 4) GoodSense All day Allergy 10mg oral tablet. Take 1 tab by mouth daily for allergies. 5) K-Tab 20mg MEQ oral tablet Extended Release. Take 1 tab by mouth daily for potassium replacement therapy. 6) Memantine HCl 10mg oral tablet. Take 1 tab by mouth for dementia. 7) Norvasc 10mg oral tablet. Take 1 tab by mouth for blood pressure. 8) Omeprazole 20mg oral tablet. Take 1 tab by mouth for acid reflux. 9) Proscar 5mg oral tablet. Take 2 tab by mouth daily for treatment of symptoms of enlarged prostate. 10) Senexon-s 8.6-50mg oral tablet. Take 2 tabs by mouth for constipation. 11) Vitamin B12 250Mg oral tablet. Take 2 tabs by mouth for oral Vitamin B supplement. 12) Multivitamins oral tablets. Take 1 tab by mouth daily for multivitamin supplements. During a home visit on 11/13/2024 at 10:30a.m. the surveyor noticed some discrepancies with medications patient was using at home with those on the patient’s medication profile from the agency. The following are the medications patient is using at home: 1) Amlodipine 10mg oral tablets Take 1 tab by mouth daily for high blood pressure. 2) Atorvastatin Calcium 80mg. Take 1 tab by mouth daily for Cholesterol. 3) Bisacodyl 5mg enteric coated oral tablet. Take 1 tab by mouth daily for constipation. 4) Carbamide Peroxide 6.5% Otic solution. Instill 2 drops in both ears daily to remove ear wax. 5) Carboxymethylcellulose Na 0.5% optic Solution. Instill 2 drops in eye as directed for dry eyes. 6) Cetirizine HCl 10mg oral tablet. Take 1 tab by mouth daily for allergies. 7) Clobetasol propionate 0.05% topical solution. Apply a small amount to the skin twice daily for itching. 8) Cyanocobalamin 500mcg oral tablet. Take 1 tab by mouth daily for Vitamin B12 deficiency. 9) Diclofenac Na 1% topical gel. Apply 2.25inches to upper extremities skin every 6 hours for pain and inflammation for shoulder pain. 10) Docusate sodium 100mg oral capsule. Take 1 cap by mouth every 12 hours for constipation. 11) Erythromycin 0.5% ophthalmic ointment. Apply a small amount to incision at bedtime for eye infection. 12) Eyelid cleanser, Eye scrub pad. Use eye lid cleanser externally as directed for eye care. 13) Finasteride 5mg oral tablet. Take 2 tab by mouth daily for prostate enlargement. 14) Hydrophilic topical cream. Apply moderate amount to the skin as needed to moisturize both dry feet. 15) Ketoconazole 2% cream. Apply small amount to the skin twice daily for fungal infection. 16) Losartan 100mg oral tablet. Take 1 tab by mouth daily for high blood pressure. 17) Lubricating ophthalmic ointment. Apply a small amount to both eyes at bedtime for dry eyes. 18) Memantine HCl 10mg oral tablet. Take 1 tab by mouth twice daily for memory loss. 19) Multivitamin oral Capsule. Take 1 cap by mouth daily for nutritional supplement. 20) Omeprazole 20mg EC oral tablet. Take 1 cap by mouth daily for Acid reflux. 21) Potassium Chloride 20meq oral capsule. Take 1 cap by mouth daily for potassium replacement therapy. 22) Sennosides 8.6mg oral tablet. Take 2 tab by mouth twice daily for constipation. 23) Tamsulosin HCl oral capsule. Take 1 cap by mouth daily at bedtime treatment of symptoms of enlarged prostate. Medications that patient was using at home that were not the patient’s medication profile from the agency include: 1) Atorvastatin Calcium 80mg tablet. Take 1 tab by mouth daily for Cholesterol. 2) Bisacodyl 5mg enteric coated oral tablet. Take 1 tab by mouth daily for constipation. 3) Carbamide Peroxide 6.5% Otic solution. Instill 2 drops in both ears daily to remove ear wax. 4) Carboxymethylcellulose Na 0.5% optic Solution. Instill 2 drops in eye as directed for dry eyes. 5) Cetirizine HCl 10mg oral tablet. Take 1 tab by mouth daily for allergies 6) Clobetasol propionate 0.05% topical solution. Apply a small amount to the skin twice daily for itching. 7) Cyanocobalamin 500mcg oral tablet. Take 1 tab by mouth daily for Vitamin B12 deficiency. 8) Diclofenac Na 1% topical gel. Apply 2.25inches to upper extremities skin every 6 hours for pain and inflammation for shoulder pain. 9) Docusate sodium 100mg oral capsule. Take 1 cap by mouth every 12 hours for constipation. 10) Erythromycin 0.5% ophthalmic ointment. Apply a small amount to incision at bedtime for eye infection. 11) Eyelid cleanser, Eye scrub pad. Use eye lid cleanser externally as directed for eye care. 12) Hydrophilic topical cream. Apply moderate amount to the skin as needed to moisturize both dry feet. 13) Ketoconazole 2% cream. Apply small amount to the skin twice daily for fungal infection. 14) Losartan 100mg oral tablet. Take 1 tab by mouth daily for high blood pressure. 15) Lubricating ophthalmic ointment. Apply a small amount to both eyes at bedtime for dry eyes. 16) Tamsulosin HCl oral capsule. Take 1 cap by mouth daily at bedtime treatment of symptoms of enlarged prostate. The patient’s physician change Cozaar 100mg to Losartan 100mg tablet for high blood pressure. During interview with Patient #5’s family on 11/13/2024 at 10:47 a.m., The patient’s family informed surveyor that patient’s physician reviewed all of patient’s medication during patient’s last hospitalization for a surgical procedure and subsequent follow up appointment in October 2024 and changed some medications and added some new medications. When patient’s family was asked if the Nurse checked patient’s medication during home visits. The patient’s family said, “No.”

Provide services in the plan of care CFR(s): 484.75(b)(3) Providing services that are ordered by the physician or allowed practitioner as indicated in the plan of care; This ELEMENT is not met as evidenced by: Based on records reviewed and interviews the agency’s Nurse failed to provide services as ordered in the plan of care for 1 of 2 (#14) discharged patients whose clinical records were reviewed. In that, the agency’s Nurse failed to assess and teach patient how to self-administer prescribed intravenous (IV) antibiotic therapy as ordered in plan of care. This failure led to Patient #14 missing multiple doses of prescribed intravenous antibiotics and was eventually readmitted back to the hospital 3 days after admission to Agency. Findings Include: Review of Patient #14’s Home Healthcare referral orders dated 09/25/2024 revealed that Patient was to receive Ampicillin 2gm every 6 hours via her peripherally inserted central catheter (PICC -This is a thin, flexible tube that is inserted into a vein in the upper arm and guided/threaded into a large vein above the right side of the heart called the superior vena cava). Review of Patient #14’s plan of care (PoC) for certification period from 09/26/24 to 11/24/24 showed that Patient was admitted to agency on 09/26/24 with the principal diagnosis of Sepsis (This refers to a life-threatening condition that occurs when the body's immune system has an extreme response to an infection). The PoC also revealed orders that the Nurse was to use aseptic techniques (methods to prevent contamination and spread of germs) to instruct Patient/caregiver on how to infuse/administer IV antibiotics via the Patient’s PICC line. The Nurse was also to assess, teach and train Patient/caregiver about IV management among other orders. Review of Patient #14’s Initial Comprehensive assessment record dated 09/26/24 conducted by RN D did not show any documentation that RN D assessed Patient #4’s ability to self-administer the prescribed antibiotic and the initial assessment document did not contain any information that RN D administered the medication during that visit. Review of a communication note dated 09/29/2024 revealed Director of Nursing (DON) lengthy discussion with Patient about Patient’s inability to self-administer IV antibiotics and subsequently the DON instructed Patient to go back to the hospital where she could get a referral to a skilled Nursing facility where skilled Nurses would administer the prescribed antibiotics for her. During interview with Administrator and DON on 11/15/24 at 12:17p.m., the agency’s representatives stated it was agency’s policy to teach Patients how to self-administer their prescribed intravenous medications, but they were unable to show that the admission’s Nurse RN D assessed Patient’s ability to self-administer the prescribed IV antibiotics or teach Patient #14 how to administer the intravenous antibiotics during the Patient’s initial comprehensive assessment/admission visit as ordered in the Patient’s plan of care. Surveyor was unable to interview RN D as he was no longer an employee of the agency at the time of the survey. Review of agency’ administrative policy titled, “Care Planning” reads in part, “…Care planning is performed to ensure that care and services are appropriate to each patient’s specific needs and problems…” “The care planning process will include the following: Implementation of the planned care or services by appropriate clinicians and/or the patient/family.”