Every finding on record at Eh Home Health of the Midwest, LLC

The Emergency Preparedness requirements were evaluated, in conjunction with the recertification survey on 1/12/24. The Agency was in compliance with the Condition, 42 CFR 484.22, Establishment of the Emergency Program for this survey.

A recertification survey was conducted in conjunction with the evaluation of Emergency Preparedness requirements on 1/12/24. The Agency was not in compliance with Standards for Home Health Agencies, 42 CFR 484 as evidenced by: Abbreviations: E- employee ml/mls- milliliter/ milliliters PICC-peripherally inserted central catheter POC- Plan of Care Pt.- patient RN- Registered nurse SOC- Start of Care

Conformance with physician orders CFR(s): 484.60(b) Standard: Conformance with physician or allowed practitioner orders. This STANDARD is not met as evidenced by: Based on document review and interview, it was determined in 1 of 1 (Pt#12) patients records reviewed with a PICC (peripherally inserted central catheter- vascular access device) line, the Agency failed to ensure staff provided care as indicated on the physician orders. This has the potential to affect all patients with a PICC line. Pt. #12 SOC (start of care) 12/20/23 Diagnosis: Sepsis Due to E-coli. The clinical record was reviewed on 1/10/24 at approximately 1:30 PM. The POC (Plan of Care) dated 12/20/23 noted a physician order to measure external length of vascular access device on SOC (Start of Care). The SOC OASIS lacked a measurement for the external vascular device (PICC line). The same POC dated 12/20/23 noted a physician order to flush the vascular assess with Normal Saline 10 mls then with 5 mls of 10unit/ml of Heparin solution flush. On 12/27/23 the RN (registered nurse) noted patient flushed line with no problems. The record lacked the type of solution used to flush the vascular assess. 2. During an interview with E#1 (Branch Director) on 1/11/24 at approximately 10:00 AM. E#1 noted the PICC line should have been measured and the type of the flush should have been documented.

The Emergency Preparedness requirements were evaluated in conjunction with the recertification survey on 03/04/2021 The Agency was in compliance with the Condition, 42 CFR 484.102, Establishment of the Emergency Program for this survey.

A recertification survey was conducted in conjunction with a Focused Infection Control (FIC) survey on 3/4/2021. The facility was not in compliance with the standards for Home Health Agencies, 42 CFR 484, as evidenced by: Abbreviations: E Employee HHA Home Health Agency OASIS Outcome Assessment System Information Set POC Plan of Care Pt patient

Accuracy of encoded OASIS data CFR(s): 484.45(b) Standard: The encoded OASIS data must accurately reflect the patient's status at the time of assessment. This STANDARD is not met as evidenced by: Based on document review and staff interview, it was determined for 2 of 13 (Pt #8, Pt #11) patients records reviewed, the Agency failed to ensure the encoded Outcome and Assessment Information Set (OASIS) accurately reflected the patient's status at the time of assessment. This has the potential to affect all patients receiving services from an Agency with a current census of 138 patients. Findings include: 1. On 03/2/2021, at approximately 2:00 PM, the clinical record of Pt #8 was reviewed. Pt #8 was referred (the date the written or verbal referral for initial care, was received by the HHA) on 07/18/2020. The OASIS data transmitted to the Centers for Medicare/Medicaid (CMS) indicated the referral date (M0140) was 07/21/2020, and should have been listed as 07/18/2021. 2. On 03/03/2021, at approximately 10:00 AM, the clinical record of Pt #11 was reviewed. Pt #11 was referred (the date the written or verbal referral for initial care, was received by the HHA) on 06/19/2020. The OASIS data transmitted to the Centers for Medicare/Medicaid (CMS) indicated the referral date (M0140) was 06/22/2020, and should have been listed as 06/19/2020. 3. On 03/04/2021, at 10:00 AM, the HHA policy "Oasis data collection A22, revised 09/09/2020 was reviewed. Under "Policy 3.2" it reads "The Agency ensures the OASIS data entered accurately reflects the patient's status at the time the information was collected." 4. On 03/04/2021 at approximately 10:30 AM, an interview with the Administrator (E #2) was conducted. E #2 confirmed the dates put into OASIS for Pt #8 and Pt #11 was inaccurate, and stated "I will update OASIS with the correct dates today."

RN performs assessment CFR(s): 484.55(a)(1) A registered nurse must conduct an initial assessment visit to determine the immediate care and support needs of the patient; and, for Medicare patients, to determine eligibility for the Medicare home health benefit, including homebound status. The initial assessment visit must be held either within 48 hours of referral, or within 48 hours of the patient's return home, or on the physician or allowed practitioner - ordered start of care date. This ELEMENT is not met as evidenced by: Based on document review and staff interview, it was determined for 2 of 13 (Pt #8, Pt #11) patients records reviewed, the Agency failed to ensure the initial assessment was conducted within 48 hours of referral. This has the potential to affect all patients receiving services from an Agency with a current census of 138 patient. Findings include: 1. On 03/2/2021, at approximately 2:00 PM, the clinical record of Pt #8 was reviewed. Pt #8 was referred to the HHA on 07/18/2020. The Plan of Care for certification period 07/21/2020 to 09/18/2020 indicated the initial assessment was conducted on 07/21/2020, 72 hours after referral. There was no physician order changing the start of care date. 2. On 03/03/2021, at approximately 10:00 AM, the clinical record of Pt #11 was reviewed. Pt #11 was referred to the HHA on 06/19/2020. The Plan of Care for certification period 06/23/2020 to 08/21/2020 indicated the initial assessment was conducted on 06/23/2020, 96 hours after referral. There was no physician order changing the start of care date. 3. On 03/03/2021, at 11:05 AM, the HHA policy "Admission process & patient assessment, (revised by the facility, 03/01/2021) was reviewed. Under "3.3" it reads "The initial admission evaluation/assessment will be performed in the patient's home by the appropriate licensed professional within 48 hours of the referral or patient's return from an inpatient stay or on the physician's ordered start of care date." 4. On 03/03/2021 at approximately 10:30 AM, an interview with the Administrator (E #2) was conducted. E #2 confirmed the initial assessment for Pt #8 and Pt #11 was conducted more than 48 hours after the referral. E #2 stated "I will have to change the OASIS for both patients."

Conformance with physician orders CFR(s): 484.60(b) Standard: Conformance with physician or allowed practitioner orders. This STANDARD is not met as evidenced by: Based on document review and staff interview, it was determined in 1 of 1 (Pt #2) patient records reviewed, the Home Health Agency (HHA) failed to ensure physician orders were followed, potentially affecting all patients receiving HHA services (current census of 138). Findings include: 1. On 3/1/21 at 12:00 PM, the medical record of Pt #2 was reviewed. Pt #2 was admitted on 1/15/21 with a primary diagnosis of Wound Dressing, Pressure Ulcer. The Plan of Care (POC) for certification period dated 1/15/21 to 3/15/21 listed a physician order for "skilled nurse to access and evaluate and teach wound care for pressure ulcer on left, right buttock and coccyx... 2 times weekly..." Review of the clinical record on 3/1/21 at approximately 2:30 PM, lacked documentation of left and right buttock wound measurements weekly. (2 out of 8 weeks measurements were documented). 2. A review on 3/1/201 at 3:30 PM, of the Facility Policy "Clinical records - Service delivery (revised 3/18/19) indicated, At minimum, the wound ulcer shall be measured using the following criteria for Home Health patients once a week or when wound care was provided". 3. An interview with Clinical Manager (E #1) and Administrator (E #2) was completed on 3/2/21. Both agreed that wound measurements should be completed weekly. E #2 remarked this has already been identified and education and audits are in the works.

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 document review and interview, it was determined that in 2 of 13 (Pt #3, #5) patient's records reviewed, the Agency failed to ensure the Plan of Care (POC) was updated. This has the potential to affect all patients who receive care by the Agency with a current census of 138 patients, as evidenced by: . Findings include: 1. Pt #3 SOC: 12/18/2020 Diagnosis: Acute/Chronic COPD. The clinical record was reviewed on 3/2/21 at approximately 10:00 AM. The POC for the recertification period 2/16/21 to 4/16/21 stated OT (Occupational Therapy), SN (Skilled Nursing) and PT (Physical Therapy) were to evaluate and treat. A home visit with E #5 (OT) was made on 3/1/21 at 1:30 PM. The patients POC did not list the Hydrocodone (6 pills remaining per patient) or Xanax (0 pills in bottle) which were observed at the Pt# 3's kitchen table. E #5 reviewed the medications in the home. A chart review of Pt #3 was completed on 3/2/21 at approximately 3:15 PM. No documentation was found of Hydrocodone or Xanax added to the 2/16/21 to 4/16/21 POC. 2. Pt #5 SOC: Diabetes, Heart Failure, End Stage Renal Disease (ESRD), Atria Fibrillation. The POC for the recertification period 2/17/21 to 4/1/21 listed on POC with a start date 12/18/20 an order for "Furosemide 80 mg tablet (1) to given orally daily." Also order dated 12/18/20 Isosorbide Dinitrate 10 mg tablet (1) to be given orally twice a day." A home visit was with E #6 (nurse) was made on 3/2/21 at 2:00 PM. The medication list was reviewed by E #6. There was no Furosemide or Isosorbide medications available at the home. The clinical record was reviewed on 3/2/21 at 3:00 PM. The 2/16/21 POC did not have a discharge of Furosemide or Isosorbide. However, an order to discontinue Furosemide and Isosorbide was obtained by E #6 on 3/2/21 entered at 2:11 PM; the day of the observation. 3. A review 3/1/201 at 3:30 PM, of the Agency policy "Physician's role- Service delivery" (revised -3/1/19) indicated " 2.1. plan of care is a written plan developed with the participation of professional staff and patient, in consultation with the physician and authorized by the physician ... 2.1.1 The plan includes ...medications, treatments ..." 4. An interview with Clinical Manager (E #1) and Administrator (E # 2) were completed on 3/2/21 at approximately 3:30 PM. They were unaware of the discrepancy on the POC's for Pt #3 and Pt #5. E #2 said "Any change of medication should be updated on the care plan".