Every finding on record at Egan Healthcare Northshore Inc

The entity is in compliance with the federal emergency preparedness requirements.

Recertification Survey Abbreviations: dl- deciliter DR- delayed release ER- extended release IU- international unit mcg- microgram meq- milliequivalent mg- milligram PoC-Plan of Care SR-slow release QIDP- Qualified Intellectual Disability Professional SOC-Start of Care

Encoding and transmitting OASIS CFR(s): 484.45(a) Standard: An HHA must encode and electronically transmit each completed OASIS assessment to the CMS system, regarding each beneficiary with respect to which information is required to be transmitted (as determined by the Secretary), within 30 days of completing the assessment of the beneficiary. This STANDARD is not met as evidenced by: Based on record review and interviews, the agency failed to ensure each OASIS (Outcome and Assessment Information Set) was successfully transmitted to the Centers for Medicare and Medicaid Services (CMS) system within 30 days of completion. This deficient practice had the potential to affect all 243 patients according to the agency’s active census on 04/07/2025. Findings: Review of the agency's OASIS Agency Final Validation Report with a submission date of 03/11/2025 revealed 135 records were processed with 3 records receiving a message the record was submitted late due to a submission date of more than 30 days after date on the record. Review of the agency's OASIS Agency Final Validation Report with a submission date of 03/19/2025 revealed 58 records were processed with 1 record receiving a message the record was submitted late due to a submission date of more than 30 days after date on the record. Review of the agency's OASIS Agency Final Validation Report with a submission date of 03/25/2025 revealed 89 records were processed with 3 records receiving a message the record was submitted late due to a submission date of more than 30 days after date on the record. An interview was conducted with S2BM on 04/08/2025 at 11:10 a.m. She stated she was responsible for reviewing all Oasis Validation Reports to ensure they were submitted timely. She confirmed the above late submissions should have been submitted within 30 days of completion and were not. An interview was conducted with S1ED on 04/10/2025 at 2:00 p.m. S1ED confirmed the above records were submitted late. S1ED stated all OASIS Assessments should be submitted within 30 days of completion and were not.

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 record reviews, observations, and interviews, the agency failed to maintain an accurate medication profile for 7 of 7 (#1, #2, #3, #4, #5, #6, and #7) sampled patients reviewed who received home visits. This deficient practice had the potential to affect all 243 patients, according to the agency’s current active census reported on 04/07/2025. Findings: Review of the agency’s policy titled “Monitoring Medications,” with revision date of 07/01/2024, revealed, in part: Policy: A drug regimen review will be performed on all patients in conjunction with all comprehensive assessment. Additionally, all clinicians will participate in medication review and reconciliation throughout the episode. The physician is contacted immediately if any discrepancies between agency information and patient medications are found. Procedure: 2. All clinicians participating in the patient’s care are responsible to assist with the maintenance of accurate patient medication information throughout the episode of care. b. The Physician will be notified of discrepancies and documentation of notification must be evident in the medical record. Patient #1 Review of Patient #1’s clinical record revealed a Start of Care (SOC) date of 02/20/2025. The patient's primary diagnosis was Venous Insufficiency (Chronic) (Peripheral). A review of the Home Health Certification and Plan of Care (PoC) for the Certification Period of 02/20/2025 through 04/20/2025 revealed orders, which included: Skilled Nurse 1 time a week for 1 week then 3 times a week for 8 weeks. Physical Therapy 1 time a week for 4 weeks. Occupational Therapy 1 time a week for 1 week then 2 times a week for 2 weeks. Review of the agency’s current medication profile for Patient #1 dated 04/07/2025 revealed the following, in part: Docusate Sodium 100 milligram (mg) 1 tablet by mouth daily. Insulin Glargine 100units/milliliter (ml) 10 units subcutaneous at bedtime. Metoprolol Succinate ER (extended release) 25mg 1 tablet by mouth daily. On 04/07/2025 at 10:45 a.m., a home visit was conducted in the home of Patient #1 with S5LPN. Patient #1's current medication profile list provided by the agency was reviewed with S5LPN, Patient #1 and his daughter. Patient #1 stated his daughter managed his medications and verified the following: 1. Docusate Sodium 100mg daily. Patient #1 stated he was taking daily as needed for constipation. 2. Insulin Glargine 100units/ml 10 units subcutaneous at bedtime. This medication was on the medication profile and Patient #1 stated he was not taking this medication. 3. Metoprolol Succinate ER 25mg 1 tablet by mouth daily. This medication was on the medication profile and Patient #1 stated he was not taking this medication. 4. Oxycodone 5mg/325mg 1 tablet by mouth every 4 hours as needed for pain. A prefilled blister pack of this medication was observed in the home with a fill date of 12/31/2024. This medication was not on the medication profile and Patient #1 stated he was taking this medication as needed. 5. Vitamin D3 50,000 units by mouth weekly. A package of Vitamin D3 50,000 unit capsules with a fill date of 02/24/2025 was observed in the home. This medication was not on the medication profile and Patient #1 stated he was taking this medication. 6. Vitamin D2 1000 international units (IU) by mouth daily as needed for cold symptoms. This medication was not on the medication profile and Patient #1’s daughter stated he was taking this medication as needed. 7. Furosemide 40mg 1 tablet by mouth daily. A bottle of the medication with a fill date of 02/16/2025 was observed in the home, instructions stated one tablet by mouth once daily. This medication was not on the medication profile and Patient #1 stated he was taking this medication. An interview was conducted with S5LPN on 04/07/2025 at 11:30 a.m. S5LPN verified the above medication discrepancies. S5LPN confirmed Patient #1’s agency and home medication profile list had not been updated to reflect his current medications. Patient #2 Review of Patient #2’s clinical record revealed a Start of Care (SOC) date of 03/01/2025. The patient's primary diagnosis was Hypertensive Heart and Chronic Kidney Disease with Heart Failure and Stage 1-4 Unspecified Chronic Kidney Disease. A review of the Home Health Certification and Plan of Care (PoC) for the Certification Period of 03/01/2025 through 04/29/2025 revealed orders, which included: Skilled Nurse 1 time a week for 10 weeks and 2 as needed visits for cardiac complications. Review of the agency’s current medication profile for Patient #2 dated 04/07/2025 revealed the following, in part: Berberine ES-5-200 mg 2 capsules by mouth daily. Dandelion Root 1 tablet by mouth daily. Fish Oil 1000mg 1 capsule by mouth daily. Ketoconazole 2% shampoo topical weekly. Liver-Kidney Cleanser capsule 1 capsule by mouth daily. Vitamin B-Complex-Vitamin C-Folic Acid-400mcg tablet 1 tablet by mouth daily. On 04/08/2025 at 8:30 a.m., a home visit was conducted in the home of Patient #2 with S3RN. Patient #2's current medication profile list provided by the agency was reviewed with S3RN and Patient #2. Patient #2 stated she managed her own medications and verified the following: 1. Prednisolone 1% eye drops 1 drop into right eye three times daily. This medication was not on the medication profile and Patient #2 stated she was taking this medication. 2. Ilevro eye drops, 1 drop into right eye daily. This medication was not on the medication profile and Patient #2 stated she was taking this medication. 3. Metoprolol Succinate ER 25mg 1 tablet by mouth daily. A bottle of this medication, with fill date of 03/19/2025, was observed in the home. This medication was not on the medication profile and Patient #2 stated she was taking this medication. 4. Blood Builder 1 tablet by mouth daily. A bottle of this over-the-counter (OTC) medication was observed in the home. This medication was not on the medication profile and Patient #2 stated she was taking this medication. 5. Berberine ES-5-200 capsule by mouth daily. This medication was on the medication profile and Patient #2 stated she was not taking this medication. 6. Dandelion Root 1 tablet by mouth daily. This medication was on the medication profile and Patient #2 stated she was not taking this medication. 7. Fish Oil 1000mg 1 capsule by mouth daily. This medication was on the medication profile and Patient #2 stated she was not taking this medication. 8. Ketonazole 2% shampoo topical weekly. This medication was on the medication profile and Patient #2 stated she was not taking this medication. 9. Liver-Kidney Cleanser Capsule 1 capsule by mouth daily. This medication was on the medication profile and Patient #2 stated she was not taking this medication. 10. Vitamin B-Complex-Vitamin C-Folic Acid-400mcg tablet 1 tablet by mouth daily. This medication was on the medication profile and Patient #2 stated she was not taking this medication. 11. Entresto 49mg-51mg 1 tablet by mouth every 12 hours. This medication was not on the medication profile and Patient #2 stated she was taking this medication. 12. Zyrtec 10mg 1 tablet by mouth daily. This medication was not on the medication profile and Patient #2 stated she was taking this medication. On 04/08/2025 at 9:45 a.m. an interview was conducted with S3RN. S3RN verified the above discrepancies and confirmed Patient #2’s agency and home medication profile list had not been updated to reflect his current medications. Patient #3 Review of Patient #3’s clinical record revealed a Start of Care (SOC) date of 04/01/2025. The patient's primary diagnosis was Aftercare Following Joint Replacement Surgery. A review of the Home Health Certification and Plan of Care (PoC) for the Certification Period of 04/01/2025 through 05/30/2025 revealed orders which included: Skilled Nurse 3 times a week for 1 week, then 1 time a week for 2 weeks. Physical Therapy 3 times a week for 2 weeks. Review of the agency’s current medication profile for Patient #3 dated 04/07/2025 revealed the following, in part: Allegra Allergy 180mg 1 tablet by mouth daily. Oxycodone 10mg 1 tablet by mouth as needed. On 04/08/2025 at 2:00 p.m., a home visit was conducted in the home of Patient #3 with S4RN and Patient #3’s spouse. Patient #3's current medication profile list provided by the agency was reviewed with S4RN and Patient #3. Patient #3 stated he and his spouse managed his medications and verified the following: 1. Allegra Allergy 180mg 1 tablet by mouth daily. Patient #3 stated he was taking this medication as needed for allergies. 2. Oxycodone 10mg 1 tablet by mouth as needed. This medication was on the medication profile and Patient #3 stated he was not taking this medication. 3. Miralax 17gram (gm) 1 capful in 8 ounces of liquid by mouth daily. This medication was not on the medication profile and Patient #3 and spouse stated he was taking this medication. An interview was conducted with S4RN on 04/08/2025 at 2:15 p.m. S4RN verified the above discrepancies and confirmed Patient #3’s agency and home medication profile list had not been updated to reflect his current medications. Patient #4 Review of Patient #4’s clinical record revealed a Start of Care (SOC) date of 01/02/2025. The patient's primary diagnosis was Acute Embolism and Thrombosis Unspecified Deep Veins of Right Distal Lower Extremity. A review of the Home Health Certification and Plan of Care (PoC) for the Certification Period of 03/03/2025 through 05/01/2025 revealed orders which included: Skilled Nurse 2 times a week for 1 week, then 1 time a week for 8 weeks, and 2 as needed. Physical Therapy 2 times a week for 5 weeks. Occupational Therapy 2 times a week for 3 weeks. Review of the agency’s current medication profile for Patient #4 dated 04/07/2025 revealed the following, in part: Bupropion HCL SR (slow release) 150mg 3 tablets by mouth daily. Cozaar 50mg 1 tablet by mouth daily. Warfarin 5mg tablet by mouth as instructed daily by Coumadin Clinic. On 04/09/2025 at 8:30 a.m., a home visit was conducted in the home of Patient #4 with S6PT and Patient #4’s spouse. Patient #4's current medication profile list provided by the agency was reviewed with S6PT and Patient #4. Patient #4 stated she and her spouse managed her medications and verified the following: 1. Bupropion HCL SR 150mg 1 tablet by mouth daily. This medication was on the medication profile and Patient #4 stated she was not taking this medication. 2. Cozaar 50mg tablet by mouth daily. This medication was on the medication profile and Patient #4 stated she was not taking this medication. 3. Magnesium Oxide 400mg 1 tablet by mouth daily. This medication was on the medication profile and Patient #4 stated she was not taking this medication. 4. Warfarin 5mg 1 tablet by mouth as instructed daily by Coumadin Clinic. The medication profile had Warfarin 5mg listed twice. Patient #4 stated she was taking Warfarin 5mg daily. 5. Pregabalin 75mg 1 capsule by mouth twice daily. A bottle of this medication, with fill date of 04/03/2025, was observed in the home. This medication was not on the medication profile and Patient #4 stated she was taking this medication. 6. Methocarbamol 750mg 1 tablet by mouth four times a day as needed for spasms. A bottle of this medication, with fill date of 05/23/2024, was observed in the home. This medication was not on the medication profile and Patient #4 stated she was taking this medication. 7. Potassium Chloride 20 milliequivalent (meq) 1 tablet by mouth daily. A bottle of this medication, with fill date of 09/24/2024, was observed in the home. This medication was not on the medication profile and Patient #4 stated she was taking this medication. 8. Novolog 100units/ml 3 ml Flex pen 26 units with 2 additional units for every 50 mg/deciliter (dl) blood glucose level above 200. This medication was not on the medication profile and Patient #4 stated she was taking this medication. 9. Verapamil ER 240mg 1 tablet by mouth at bedtime. A bottle of this medication, with fill date of 09/24/2024, was observed in the home. This medication was not on the medication profile and Patient #4 stated she was taking this medication. An interview was conducted with S6PT on 04/09/2025 at 8:55 a.m. S6PT verified the above discrepancies and confirmed Patient #4’s agency and home medication profile list had not been updated to reflect her current medications. Patient #5 Review of Patient #4’s clinical record revealed a Start of Care (SOC) date of 02/25/2025. The patient's primary diagnosis was Hemiplegia Following Cerebral Infarction Affecting Right Dominant Side. A review of the Home Health Certification and Plan of Care (PoC) for the Certification Period of 02/25/2025 through 04/25/2025 revealed orders, which included: Physical Therapy 2 times a week for 1 week, 1 time a week for 1 week, 2 times a week for 1 week, and 1 time a week for 1 week. On 04/09/2025 at 9:30 a.m., a home visit was conducted in the home of Patient #5 with S8PTA and the QIDP (Qualified Intellectual Disability Professional) from the group home. Patient #5's current medication profile list provided by the agency was reviewed with S8PTA and Patient #5’s QIDP. Patient #5’s QIDP stated the group home managed her medications and verified the following: 1. Clotrimazole Cream 1% topical twice daily as needed. This medication was not on the medication profile and Patient #5’s QIDP stated she was taking this medication. 2. Mupirocin Ointment 2% topical 3 times a day as needed. This medication was not on the medication profile and Patient #5’s QIDP stated she was taking this medication. 3. Nystatin 10,000 units topical to affected area after each meal and at bedtime as needed. This medication was not on the medication profile and Patient #5’s QIDP stated she was taking this medication. 4. Triamcinolone 1% topical to affected area after each meal and at bedtime as needed. This medication was not on the medication profile and Patient #5’s QIDP stated she was taking this medication. 5. ACT Mouthwash 15milliliters (ml) by mouth swish and spit every morning and evening. This medication was not on the medication profile and Patient #5’s QIDP stated she was taking this medication. 6. Lasix 20mg one-half tablet by mouth daily as needed for weight gain >3 pounds or more. This medication was not on the medication profile and Patient #5’s QIDP stated she was taking this medication. 7. Loratadine 10mg 1 tablet by mouth daily as needed for allergies. This medication was not on the medication profile and Patient #5’s QIDP stated she was taking this medication. An interview was conducted with S8PTA on 04/09/2025 at 9:50 a.m. S8PTA verified the above discrepancies and confirmed Patient #5’s agency and home medication profile list had not been updated to reflect her current medications. Patient #6 Review of Patient #6’s clinical record revealed a Start of Care (SOC) date of 03/10/2025. The patient's primary diagnosis was Unspecified Displaced Fracture of Surgical Neck of Left Humerus, Subsequent Encounter for Fracture with Routine Healing. A review of the Home Health Certification and Plan of Care (PoC) for the Certification Period of 03/10/2025 through 05/08/2025 revealed orders which included: Skilled Nurse 1 time a week for 9 weeks, and 2 visits as needed. Physical Therapy 3 times a week for 1 week, and 2 times a week for 2 weeks. Occupational Therapy 2 times a week for 1 week, and 1 time a week for 4 weeks. Speech Therapy 1 time a week for 4 weeks. Review of the agency’s current medication profile for Patient #4 dated 04/07/2025 revealed the following, in part: Glipizide 2.5mg 1 tablet by mouth daily. Wellbutrin SR 100mg 1 tablet by mouth daily. On 04/09/2025 at 11:15 a.m., a home visit was conducted in the home of Patient #6 with S9ST. Patient #6's current medication profile list provided by the agency was reviewed with S9ST and Patient #6. Patient #6 stated her daughter managed her medications and verified the following: 1. Glipizide 10mg 1 tablet by mouth daily. A bottle of this medication, with fill date of 03/24/2025, was observed in the home. This medication was not on the medication profile and Patient #6 stated she was taking this medication. 2. Wellbutrin SR 75mg 1 tablet by mouth every morning. A bottle of this medication, with fill date of 12/13/2024, was observed in the home. This medication was not on the medication profile and Patient #6 reported she was taking this medication. 3. Iron 65mg 1 tablet by mouth daily. An OTC bottle of this medication was in the home. This medication was not on the medication profile and Patient #6 stated she was taking this medication. 4. Oxycodone 7.5mg/325mg 1 tablet by mouth every 6 hours as needed for pain. A bottle of this medication was in the home. This medication was not on the medication profile and Patient #6 stated she was taking this medication. 5. Aspirin EC 81mg 1 tablet by mouth daily. A bottle of this medication, with fill date of 03/12/2025, was observed in the home. This medication was not on the medication profile and Patient #6 stated she was taking this medication, which was on hold for surgery currently. An interview was conducted with S9ST on 04/09/2025 at 11:45 a.m. S9ST verified the above discrepancies and confirmed Patient #6’s agency and home medication profile list had not been updated to reflect her current medications. Patient #7 Review of Patient #7’s clinical record revealed a Start of Care (SOC) date of 03/25/2025. The patient's primary diagnosis was Unspecified Fracture Upper End of Left Humerus, Subsequent Encounter for Fracture with Routine Healing. A review of the Home Health Certification and Plan of Care (PoC) for the Certification Period of 03/25/2025 through 05/23/2025 revealed orders which included: Skilled Nursing 1 time a week for 9 weeks and 2 visits as needed for complications related to fracture. Physical Therapy 2 times a week for 3 weeks, 1 time a week for 1 week. Occupational Therapy 1 time a week for 5 weeks. Review of the agency’s current medication profile for Patient #7 dated 04/08/2025 revealed the following in part: Vitamin D2 1,250 mcg (50,000 unit) 1 capsule by mouth weekly. On 04/09/2025 at 1:00 p.m., a home visit was conducted in the home of Patient #7 with S7OT. Patient #7's current medication profile list provided by the agency was reviewed with S7OT. Patient #7 stated she managed her own medications and verified the following: 1. Vitamin D3 13,000 IU 1 capsule by mouth weekly on Wednesdays. A sample package of this medication was observed in the home. This medication was not on the medication profile and Patient #7 stated she was taking this medication. 2. Meloxicam 15mg 1 tablet by mouth every day. A bottle of this medication, with fill date of 02/05/2025, with instructions to take 1 tablet by mouth once daily, was observed in the home. This medication was not on the medication profile and Patient #7 stated she was taking this medication daily as needed. An interview was conducted with S7OT on 04/09/2025 at 1:15 p.m. S7OT verified the above discrepancies and confirmed Patient #7’s agency and home medication profile list had not been updated to reflect her current medications. An interview was conducted with S1ED on 04/10/2025 at 2:00 p.m. S1ED was made aware of the medication discrepancies found during the home visits above. S1ED confirmed Patients #1-#7’s agency and home medication profile lists should have accurately reflected the medications currently prescribed and did not.

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 record reviews and interviews, the agency failed to provide skilled professional services according to the patient’s Plan of Care (PoC) for 1 (#6) of 17 (#1-#17) sampled patients reviewed. This deficient practice had the potential to affect all 243 patients according to the agency’s active census reported on 04/07/2025. Findings: Review of the agency’s policy titled, “Coordination of Care, From Admit Through Discharge,” with revision date of 09/02/2024, revealed in part: Procedure: 5. Coordination of Care among disciplines and between in-person and virtual clinicians. Patient care is coordinated among various disciplines through care planning processes to ensure continuity of care from admission to discharge. This includes: i. All clinicians will report within 1 business day to the Patient Care Manager or Clinical Director by fax, telephone, in person at the agency, or through coordination notes. Report will include: Missed visits and changes to scheduled visits. a. Reason for missed visit b. Changes to patient schedule Review of Patient #6’s Plan of Care (PoC) for the Certification period dated 03/10/2025 through 05/08/2025 revealed a primary diagnosis of Unspecified Displaced Fracture of Surgical Neck of Left Humerus. Further review of the plan of care revealed the following orders, in part: Physical Therapy 3 times a week for 1 week. Occupational Therapy 2 times a week for 1 week. Review of the agency’s visit summary report for Patient #6 revealed the following: Physical Therapy (PT) visits were completed on 03/10/2025 and 03/12/2025. An Occupational Therapy (OT) visit was completed on 03/11/2025. Further review revealed there was no missed visit documentation available for review for Patient #6’s missed PT and OT visit the week of 03/10/2025. A phone interview was conducted with S11PT on 04/10/2025 at 3:20 p.m. S11PT verified a PT visit was not completed on 03/15/2025. She stated a PT missed visit on 03/15/2025 should have been documented. She verified Patient #6’s ordered PT frequency was 3 times a week, and only 2 visits had been completed the week of 03/10/2025. S11PT confirmed all patients should receive services per their ordered PoC, and Patient #6 did not. A phone interview was conducted with S7OT on 04/10/2025 at 3:30 p.m. S7OT verified an OT visit was not completed on 03/15/2025. She stated an OT missed visit on 03/15/2025 should have been documented. She verified Patient #6’s ordered OT frequency was 2 times a week, and only 1 visit had been completed the week of 03/10/2025. S7OT confirmed all patients should receive services per their ordered PoC, and Patient #6 did not. An interview was conducted with S1ED on 04/10/2025 at 3:10 p.m. S1ED verified Patient #6’s visit summary for PT and OT. S1ED confirmed Patient #6 did not receive all ordered PT and OT visits the week of 03/10/2025 per the PoC and should have. S1ED stated the clinicians should have documented a missed visit coordination note when services were not provided per Patient #6’s PoC and did not.

The entity is in compliance with the federal emergency preparedness requirements.

Recertification Survey.

Verbal orders CFR(s): 484.60(b)(3)(4) (3) Verbal orders must be accepted only by personnel authorized to do so by applicable state laws and regulations and by the HHA's internal policies. (4) When services are provided on the basis of a physician or allowed practitioner's verbal orders, a nurse acting in accordance with state licensure requirements, or other qualified practitioner responsible for furnishing or supervising the ordered services, in accordance with state law and the HHA's policies, must document the orders in the patient's clinical record, and sign, date, and time the orders. Verbal orders must be authenticated and dated by the physician or allowed pracitioner in accordance with applicable state laws and regulations, as well as the HHA's internal policies. This ELEMENT is not met as evidenced by: Based on record review and interview, the agency failed to ensure the plan of care (POC) was signed by the physician within 30 days for 3 (#6, #12, #16) of 18 sampled patients (#1-18). Cross-referenced with State Regulations 9123. Patient Care Standards: C. Plan of Care. The plan of care for each patient must be individualized to address the patient's problems, goals, and required services. 1. The Plan of Care, telephone and/or verbal orders must be signed by the physician within a timely manner, not to exceed 30 days. Findings: Patient #6 Review of the clinical record for Patient #6 revealed the patient began receiving services with the agency on 05/05/2022. The patient had diagnoses that included Hypertensive Heart Disease, Chronic Kidney Disease with Heart Failure, Chronic Diastolic Heart Failure, Chronic Kidney Disease Stage 3, Atrial Fibrillation, Gastro-Esophageal Reflux Disease, and History of Falling. Review of the Plan of Care on 06/03/2022 at 10:00 a.m. revealed Patient #6 was certified to receive services from 05/05/2022-07/03/2022. Further review of the plan of care revealed no physician signature. A request was made for a signed Plan of Care to S1ED on 06/03/2022 at 10:30 a.m. She stated she did not have a signed copy of the plan of care for Patient #6. Patient #12 Review of the clinical record for Patient #12 revealed the patient began receiving services with the agency on 04/10/2022. The patient had diagnoses that included Stage 2 Pressure Ulcer of Other Site, Non-pressure Chronic Ulcer of Right Foot with Unspecified Severity, and Hemiplegia following Cerebral Infarction Affecting Right Dominant Side. Review of the Plan of Care revealed the patient was certified to receive services from 04/10/2022-06/08/2022. Further review of the plan of care revealed the physician did not sign it until 05/12/2022, which was not within the 30 day requirement. Patient #16 Review of the clinical record for Patient #16 revealed the patient began receiving services with the agency on 02/13/2021. The patient had diagnoses that included Atherosclerosis Heart Disease of Native Coronary Artery without Angina Pectoris, Hypertension, Vascular Dementia without Behavioral Disturbance, Personal History of Malignant Neoplasm of Other Uterus, Transient Ischemic Attack, Cerebral Infarction without Residual Side Effects and History of Falling. Review of the Plan of care revealed the patient was certified to receive services from 02/13/2021-03/29/2021. Further review of the plan of care revealed it was not signed by the physician until 10/19/2021, which was not within the 30 day requirement. On 06/03/2022 at 12:15 p.m., S1ED (Executive Director) provided the signed Plan of Care for Patient #12 and #16 and verified the plan of care was not signed within the 30 day window as required. S1ED further verified there was no physician signature on the plan of care for Patient #6.

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 interviews and record review, the agency failed to ensure the skilled nurse notified the physician when there was a change noted to the patient’s skin for 1 (#3) of 8 (#3, #4, #7, #9, #12, #13, #14, #15) patients reviewed for wound care. The agency failed to ensure the Skilled Nurse notified the physician when there was weeping noted to his lower extremity on 05/30/2022. Findings: Review of the clinical record for Patient #3 revealed he began receiving services with the agency on 02/22/2022 with diagnoses that included Congestive Heart Failure, Diabetes Mellitus II and Atrial Fibrillation. The patient was certified to receive services from 04/23/2022-06/21/2022 and received Skilled Nursing Services 1w9 (once a week for 9 weeks). Review of the skilled nursing notes for Patient #3 revealed the following, in part: 04/30/2022- PRN (As Needed) Skilled Nurse Visit- Erythema documented to left lower extremity, instructed patient to make appointment with physician as soon as possible. Review of the clinical record for Patient #3 revealed the patient was assessed by their physician on 05/02/2022 and was diagnosed with Cellulitis to bilateral lower extremities. Review of Patient #3’s skilled nursing notes revealed the following, in part: 05/03/2022- Erythema to left dorsum, +1 Edema, Patient to have Mupirocin applied to affected red areas. 05/06/2022- +2 Edema- no documentation of Erythema noted to the patient’s lower extremities. 05/10/2022- Edema identified, no documentation of Erythema noted to the patient’s lower extremities. 05/13/2022- No problems identified. 05/17/2022- No problems identified. 05/20/2022- No problems identified, no Edema Present. 05/24/2022- No problems identified. 05/30/2022- After examining patient, noticed that weeping was from the patient’s left lower extremities and had two reddened dime size areas - Documented by S2LPN (Licensed Practical Nurse) On 06/01/2022 at 9:30 a.m., a home visit was conducted with Patient #3 to observe S2LPN provide services which included wound care. Patient #3 was observed sitting in a chair with legs elevated, both of the lower legs were noted to be red and swollen. S2LPN confirmed the patient was to have Mupirocin applied to the affected areas on his lower legs twice a day. Upon further observation of Patient #3’s lower legs, there was a small area on the patient’s right lower leg noted to show some weeping of clear serous fluid. Patient #3 also stated at that time he noticed a small area on the back of his left leg behind his knee that was also weeping. S2LPN was present during this observation and also verified the weeping from both lower extremities. An interview was held with the Patient #3’s family member #1 on 06/01/2022 at 3:00 p.m. She stated the patient’s leg was not weeping over the weekend. She stated when the patient first received treatment for his legs, they had improved but she noticed the redness to both of his lower legs was slowly returning. She confirmed his legs were also very swollen. An interview was held with the Patient #3’s family member #2 on 06/02/2022 at 9:05 a.m. She stated the patient’s legs were really swollen back in January and he was sent to the hospital. She stated they never really changed after that hospitalization. She stated she would visit her father once a week. She stated she last saw the patient last week. She stated she still had some concerns with the swelling in his legs. She stated the physician ordered some antibiotics for the patient in the beginning of May because his legs began to weep but he completed those antibiotics some time ago. Review of the physician communication portion of Patient #3’s record revealed there was no documentation S2LPN notified the physician on or after 05/30/2022 when it was discovered the resident’s left lower extremity began weeping again. An interview was conducted with S1ED (Executive Director) on 06/02/2022 at 10:30 a.m. She confirmed S2LPN should have notified the physician when she documented the patient’s left leg was weeping on 05/30/2022.

Coordinate care delivery CFR(s): 484.60(d)(4) Coordinate care delivery to meet the patient's needs, and involve the patient, representative (if any), and caregiver(s), as appropriate, in the coordination of care activities. This ELEMENT is not met as evidenced by: Based on interviews and record review, the agency failed to ensure the skilled nurse coordinated with the patient’s caregiver for 1 (#3) of 6 (#1, #2, #3, #4, #5, #6) patients reviewed that had home visits. The agency failed to ensure the skilled nurse coordinated with the caregivers to ensure the patient was receiving Lasix as ordered. Findings: Review of the clinical record for Patient #3 revealed he began receiving services with the agency on 02/22/2022 with diagnoses that included Congestive Heart Failure, Diabetes Mellitus II and Atrial Fibrillation. The patient was certified to receive services from 04/23/2022-06/21/2022 and received Skilled Nursing Services 1w9 (once a week for 9 weeks). Review of the skilled nursing notes for Patient #3 revealed the following, in part: 04/30/2022- PRN (As Needed) Skilled Nurse Visit- Erythema documented to left lower extremity, instructed patient to make appointment with physician as soon as possible. Review of the clinical record for Patient #3 revealed the patient was seen by their physician on 05/02/2022 and was diagnosed with Cellulitis to his bilateral lower extremities. Further review revealed the physician increased the patient’s Lasix from 40 mg once a day to twice daily. Review of Patient #3’s current medication profile revealed the patient was to receive Lasix 40 mg twice a day. This medication was last reconciled on 05/03/2022. An interview was held with S2LPN (Licensed Practical Nurse) on 06/01/2022 at 9:30 a.m. She stated Patient #3 and his wife were very forgetful and their daughters both monitored their care. She stated she spoke with the daughter frequently, usually the night before her visit to the patient’s home to discuss the patient’s medications. She stated the patient’s daughter had “bags of medications” and they would reconcile the medications together. She stated the patient’s daughter also would leave the Mupirocin for her to apply to the patient’s lower legs. An observation was made of Patent #3’s medications on 06/01/2022 at 9:45 a.m. The patient had a weekly pill container with several pills in each day of the week. There were no medication bottles for Patient #3 available for review. S2LPN stated the patient’s daughter did not leave the medication bottles in the home and she took them with her. She stated again that she would frequently communicate with the daughter regarding Patient #3’s drug regimen. An interview was held with Patient #3’s family member #1 on 06/01/2022 at 3:00 p.m. She stated she had never spoke to S2LPN over the phone regarding the patient’s medications. She confirmed she filled the patient’s pill box on a regular basis. She stated she was only giving the patient one Lasix 40 mg tablet a day and was not told she should be giving it twice a day. She stated last time she saw or spoke to a nurse in the home was when they initially discovered the cellulitis with the patient on 05/02/2022. She stated she had not spoken to anyone from the home health agency since then. An interview was held with the patient’s family member #2 on 06/02/2022 at 9:05 a.m. She stated she would visit her father once a week. She stated she never spoke to the home health agency nurse. She stated when she received any kind of updates regarding Patient #3’s care, it was obtained from her parents. An interview was held with S1ED (Executive Director) on 06/02/2022 at 10:30 a.m. She verified the skilled nurse should reconcile the patient’s medication regimen every visit. She confirmed the nurse should have been ensuring the patient’s family member was administering the correct dose of Lasix. She stated she spoke to Patient #3’s daughter and confirmed she was also told the family member had not spoken to the skilled nurse for several weeks.

Services by skilled professionals CFR(s): 484.75(a) Standard: Provision of services by skilled professionals. Skilled professional services are authorized, delivered, and supervised only by health care professionals who meet the appropriate qualifications specified under §484.115 and who practice according to the HHA's policies and procedures. This STANDARD is not met as evidenced by: Based on record reviews and interviews, the agency failed to ensure that Nursing Services were provided to meet the needs of 3 (#3, #9, #12) of 8 (#3, #4, #7, #9, #12, #13, #14, #15) sampled patients reviewed for wound care. The agency failed to ensure staff followed acceptable standards of practice by failing to ensure: 1. the skilled nurse documented complete and accurate weekly assessments of a wound for Patient #3; 2. the RN (Registered Nurse) conducted wound assessments for Patients’ #9 and #12 per agency policy and procedure; 3. the skilled nurse documented wound measurements for Patients’ #3 and #9. Findings: Review of the Policy titled “Wound Assessment, Documentation, and Photography” revealed, in part: Purpose: To ensure the accurate and consistent assessment and documentation of wounds. Policy: Upon initial visit and subsequently as indicated below, all wounds will be assessed with appropriate documentation within the medical record. Unless otherwise ordered by the physician, the Registered Nurse or Physical Therapist will assess wounds at least: Every other week for patients receiving wound care by the agency at a frequency less than daily. Reassessments will be documented on the Wound Assessment Tool. The assessment includes measurements of the length, width, and depth, undermining and tunneling, wound bed description, wound edges, exposed tissue types, drainage and the condition of the periwound. At each dressing change, the clinician should record the wound bed description, wound edges, exposed tissue types, drainage and the condition of the periwound. Procedure: 3. Document the following in the medical record: a. Wound type (pressure injury, stasis ulcer, abscess, surgical wound, burn, trauma wound) b. Location and laterality c. Stage or Thickness: i. Stage pressure injuries according to the National Pressure Ulcer Advisory Panel (NPUAP) Pressure Injury Stages. ii. For all other ulcers, document underlying etiology of the ulcer and skin involvement to include limited to breakdown of skin; fat layer exposed; necrosis of muscle; or necrosis of bone. iii. All other wounds will be described as either Partial or Full Thickness c. Wound size: Length, Width, and Depth are measured in centimeters with length measured from 12:00-6:00 and width measured from 3:00-9:00, unless otherwise noted. Depth is measured at the deepest area using cotton tipped applicator (CTA) or foam tipped applicator (FTA). d. Undermining and/or tunneling: measure location and depth using CTA or FTA and document according to the clock e. Wound bed: percentage of eschar, slough, and granulation f. Wound Edges: whether open or closed g. Drainage: odor, type (color) and amount h. Periwound condition i. Exact wound care performed, following physician orders. Patient #3 Review of the clinical record for Patient #3 revealed the patient began receiving services with the agency on 02/22/2022 with diagnoses that included Congestive Heart Failure, Diabetes Mellitus II and Atrial Fibrillation. The patient was certified to receive services from 04/23/2022-06/21/2022 and received Skilled Nursing Services 1w9 (once a week for 9 weeks). Review of the skilled nursing notes for Patient #3 revealed the following, in part: 04/30/2022- PRN (As Needed) Skilled Nurse Visit- Erythema documented to left lower extremity, instructed patient to make appointment with physician as soon as possible. Review of the clinical record for Patient #3 revealed the patient was assessed by their physician on 05/02/2022 and was diagnosed with Cellulitis to bilateral lower extremities. Apply Mupirocin to affected areas. Review of the Skilled Nurse notes for Patient #3 revealed the following, in part: 05/03/2022- Patient placed on antibiotic and Mupirocin to apply to affected red areas of lower extremities. 05/06/2022- +2 Edema - no documentation of Erythema noted on SN (Skilled Nurse) note 05/10/2022- Edema identified, no documentation of Erythema noted- Wound not assessed due to caregiver completed care. 05/13/2022- No problems identified, Wound care not provided, caregiver completed care, wound not assessed, caregiver completed care. 05/17/2022- No problems identified, Wound care not provided, caregiver completed care, wound not assessed, caregiver completed care. 05/20/2022- No problems identified, no Edema Present, wound assessment done. 05/24/2022- No problems identified for Cardio or Skin. Wound not assessed due to client completing care, wound care not provided due to client providing care. 05/30/2022- Pitting Edema +1- Right lower extremity, Wound Documented in ICC (Integumentary Command Center) 06/01/2022- Pitting Edema +1- Right lower extremity, Wound Documented in ICC- Wound Care not provided, healed. Review of the wound report for Patient #3 revealed the following, in part: 05/06/2022- Wound Assessed- No, Awaiting orders 05/10/2022- Wound Assessed- No, caregiver completed care 05/13/2022- Wound Assessed- No, caregiver completed care 05/17/2022- Wound Assessed- No, awaiting orders 05/24/2022- Wound Assessed- No, client completed care 05/30/2022- No documentation of a wound assessment. An observation was made of Patient #3’s legs on 06/01/2022 at 9:30 a.m. The patient’s bilateral lower legs were red and swollen. Patient stated that his legs were starting to “leak.” Further observation of the patient’s legs revealed there were some small areas that were weeping with clear serous fluid. There were some red bumps noted on the back of the patient’s right leg. Patient also verbalized there was a small “leaking” area to the back of the left leg. An interview was held with S2LPN (Licensed Practical Nurse) on 06/01/2022 at 9:45 a.m. She stated the patient had been diagnosed with Cellulitis to the bilateral lower extremities about 4 weeks ago. She stated the patient’s caregiver was applying Mupirocin to his legs twice a day and she would apply it when she conducted her visits. She confirmed the doctor never ordered for the patient’s legs to be wrapped and they were always left open to air. She stated the patient’s legs were not weeping last week and verified there was weeping noted again during this visit. An interview was held with the Patient #3’s family member #1 on 06/01/2022 at 3:00 p.m. She stated the patient’s leg was not weeping over the weekend. She stated when the patient first received treatment for his legs, the redness had improved but she noticed the redness to both of his lower legs was returning. She confirmed his legs were also very swollen. An interview was held with the Patient #3’s family member #2 on 06/02/2022 at 9:05 a.m. She stated she visited her father once a week. She stated since his original hospitalization in January 2022, the redness and swelling to his lower legs never went away. She stated she still had some concerns regarding the swelling in his legs. An interview was held with S1ED (Executive Director) on 06/02/2022 at 10:30 a.m. She reviewed the record for Patient #3 and verified there were no weekly skin assessments of Patient #3’s legs. She confirmed due to the lack of the patient’s skin assessments in the record, they could not determine if there was a decline in status. She confirmed there were some concerns with the lack of documentation for Patient #3’s skin assessments. Patient #9 Review of the clinical record for Patient #9 revealed a Start of Care date of 01/07/2022. The patient had diagnoses that included Cellulitis of Left Lower Limb, Right Lower Extremity Infection of Amputation Stump, Non-pressure Chronic Ulcer of Left Foot, Hypertension, Raynaud’s Syndrome with Gangrene, and Acquired Absence of Right Leg Below Knee. The patient was certified to receive services from 05/07/2022-07/05/2022 and received Skilled Nursing Services 2w8 (twice a week for 8 weeks). A review of the Wound Record Report dated 05/11/2022-05/30/2022 revealed no RN wound assessments and no wound measurements since 05/11/2022 for Patient #9’s Left Foot wound. Patient #12 Review of the clinical record for Patient #12 revealed a Start of Care date of 04/10/2022. The patient had diagnoses that included Stage 2 Pressure Ulcer of Other Site, Non-pressure Chronic Ulcer of Right Foot with Unspecified Severity, and Hemiplegia following Cerebral Infarction Affecting Right Dominant Side. The patient was certified to receive services from 04/10/2022-06/08/2022 and received Skilled Nursing Services 2w1, 1w8 (twice a week for 1 week and once a week for 8 weeks). A review of the wound record report from 04/14/2022-05/25/2022 revealed an RN did not assess Patient #12’s pressure ulcers to the Right Foot since 04/10/2022. On 06/03/2022 at 12:15 p.m., an interview was conducted with S1ED. She reviewed Patient #9’s Wound Record Report dated 05/11/2022-05/30/2022. She verified Patient #9’s wound to the Left Foot was not assessed by an RN from 05/11/2022-05/30/2022. She verified Patient #9’s wound to the Left Foot was not measured weekly from 05/18/2022-05/30/2022. She then reviewed Patient #12’s Wound Record Report dated 04/14/2022-05/25/2022. She verified Patient #12’s pressure ulcers to the Right Foot were not assessed by an RN from 04/14/2022-05/25/2022. She verified wound measurements should be performed weekly. She reviewed the policy titled “Wound Assessment, Documentation, and Photography.” She verified the policy stated an RN will assess wounds at least every other week for patient’s receiving wound care by the agency at a frequency less than daily.