Every finding on record at Emerald Care LLC

An unannounced, onsite recertification survey was conducted 2/19/24-2/21/24. No deficiencies to the Emergency Preparedness Plan were identified.

An unannounced, onsite recertification survey was conducted 2/19/24-2/21/24. Standard level deficiencies were identified to the Medicare CoP.

Plan of care must include the following CFR(s): 484.60(a)(2)(i-xvi) The individualized plan of care must include the following: (i) All pertinent diagnoses; (ii) The patient's mental, psychosocial, and cognitive status; (iii) The types of services, supplies, and equipment required; (iv) The frequency and duration of visits to be made; (v) Prognosis; (vi) Rehabilitation potential; (vii) Functional limitations; (viii) Activities permitted; (ix) Nutritional requirements; (x) All medications and treatments; (xi) Safety measures to protect against injury; (xii) A description of the patient's risk for emergency department visits and hospital re-admission, and all necessary interventions to address the underlying risk factors. (xiii) Patient and caregiver education and training to facilitate timely discharge; (xiv) Patient-specific interventions and education; measurable outcomes and goals identified by the HHA and the patient; (xv) Information related to any advanced directives; and (xvi) Any additional items the HHA or physician or allowed practitioner may choose to include. This ELEMENT is not met as evidenced by: Based on agency policy, direct observation, clinical record review, and interviews with patient/caregivers and staff, the Plan of Care [POC] failed to include all medications the patient was taking for 2 of 4 home visits [# 3 and 14]. The findings included: The policy, Plan of Care [POC] [10/31/23], was provided by the agency director on 2/21/24 at 3 pm. The policy stated, “…The individualized plan of must [sic] include the following…all medications and treatments…” 1. Patient # 3 had a Start of Care [SOC] of 11/27/23 and an admitting diagnosis of chronic obstructive pulmonary disease [COPD-lung condition]. Review of the Plan of Care [POC] for the certification period 11/27/23-1/25/24 included orders for PT [physical therapy] 1 time a week for 1 week, 2 times a week for 3 weeks, 1 time a week for 3 weeks, 1 time every 2 weeks for 2 weeks. A joint visit was made with PT # 9 on 2/19/24 at approximately 2 pm. During the visit, a medication review was conducted using a medication profile provided by the agency. The following discrepancy was noted: The medication profile listed Hydrocodone [pain medication] 7.5 mg – Acetaminophen 325 mg. Take 1 tablet twice a day as needed. The caregiver presented a bottle of Hydrocodone 10 mg – Acetaminophen 325 mg and advised this was the correct strength of the medication. During an interview with the agency director on 2/21/24 at approximately 9:15 am, the director confirmed the POC did not include the correct strength of the medication. 2. Patient # 14 had a Start of Care [SOC] date of 1/4/24 and an admission diagnosis of sever persistent asthma with acute exacerbation. Review of the Plan of Care [POC] for the certification period 1/4/24-3/3/24 included orders for PT [physical therapy] 1 time a week for 1 week, 2 times a week for 2 weeks, 1 time a week for 6 weeks. On 2/20/24 at approximately 1 pm a joint visit was conducted with PT # 8. During the visit, a medication review was conducted using a medication profile provided by the agency. The following discrepancies were noted: The patient provided a bottle of Amlodipine [blood pressure] 5 mg. Take 1 every day with a start date of 1/2/24. The Amlodipine was not included on the medication profile. During an interview with the patient, the patient confirmed she was taking this medication before admission to home health. The patient provided a bottle of Vitamin D 3 [supplement]. Take 50 mcg each day. The medication profile did not list Vitamin D. During the interview the patient confirmed she had been using Vitamin D since before admission to the agency. During an interview with the agency director on 2/21/24 at approximately 9:30 am, the director confirmed the POC did not include all the correct/current medications.

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 agency policy, clinical record review and staff interviews the agency failed to include orders related to a VAD [vascular access device- thin flexible tube that provides access to blood vessels without the need for repeated needle sticks] on the Plan of Care for 1 of 2 patients with a VAD [# 7]. The findings included: The policy, Plan of Care [10/31/23], was provided by the agency director on 2/21/24 at approximately 3 pm. The policy stated, "...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 disciplines(s), and 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..." Patient # 7 had a Start of Care [SOC] date of 12/20/23 and an admitting diagnosis of type 2 diabetes mellitus with foot ulcer, other streptococcal [type of bacteria] arthritis, left shoulder, bacteremia [bacteria in the blood], type 2 diabetes with hyperglycemia [high blood glucose], unspecified systolic [congestive] heart failure and encounter for adjustment and management of VAD [vascular access device- thin flexible tube that provides access to blood vessels without the need for repeated needle sticks]. Review of the Plan of Care [POC] for the certification period 12/20/23-2/17/24 included orders for SN [skilled nursing] 2 times a week for 9 weeks. Review of the hospital discharge orders from _____ [name of hospital] dated 12/18/23 revealed the following orders “IV catheter care instructions: Inspect and clean site and apply a clear dressing …weekly…Flush with 10 ml normal saline before and after administration of medication. Flush with 5 ml heparin [prevent clotting of line] following last normal saline flush …administer Ceftriaxone [antibiotic] 2 gram every 24 hours. Review of the POC did not include the information related to the PICC line flushes or the antibiotic. RN # 5 was not available for interview. During an interview with the agency director on 2/21/24 at approximately 10 am, the director confirmed the POC did not include orders related to the PICC line.

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 agency policy, clinical record review and staff interviews the agency failed to follow physician's orders on the Plan of care for 4 of 7 patients with diabetes [#1, 7, 16 and 20]; and failed to follow physician's orders on the Plan of Care related to wound care for 1 of 6 patients with a wound [#7]; and failed to follow physician's orders on the Plan of Care to monitor weights for 2 of 4 patients [#1 and 16]. The findings included: The policy, Plan of Care [10/31/23], was provided by the agency director on 2/21/24 at approximately 3 pm. The policy stated, "Plan of Care will be developed through a care planning process, which is designed to provide care, treatment, and services that are appropriate to the patient's individual needs...To provide physician ordered care, treatment and services..." 1A. Patient # 1 had a Start of Care [SOC] date of 1/9/23 and an admitting diagnosis of type 1 diabetes mellitus with ketoacidosis [body can’t make enough insulin and acid builds up in the body]. Review of the Plan of Care [POC] for the certification period 1/9/23-3/9/23 included orders for PT [physical therapy] 1 time a week for 5 weeks, 1 time every 2 weeks for 4 weeks and “Diabetes management [PT] blood sugar parameters 70-300…stick frequency of patient/caregiver daily…” The POC included a goal of “Patient’s blood sugar will remain well controlled throughout the episode of care…” Review of the clinical record revealed PT # 1 completed the SOC visit on 1/9/23 and no blood glucose readings were documented. PTA [physical therapy assistant] # 2 conducted routine visits on 1/18/23 and 1/23/23 and no blood glucose readings were documented. The clinical record revealed the patient was transferred to the hospital on 1/27/23 for elevated blood sugar readings. Review of the hospital ED [emergency department] report revealed the patient had a blood glucose reading of 1197 at the time he was admitted to the hospital. Resumption of Care [ROC-assessment completed after in-patient stay] orders were written on 2/2/23 by PT # 3. The ROC orders included a PT frequency of 1 time a week for 6 weeks and “Diabetes Management”. The patient received 5 PT visits from 2/2/23-3/2/23. Review of the PT visit documentation revealed no blood glucose readings were documented. During an interview with the agency director on 2/21/24 at approximately 9:30 am, the director confirmed physician’s orders were not followed. 1B. Patient # 1 had a Start of Care [SOC] date of 1/9/23 and an admitting diagnosis of type 1 diabetes mellitus with ketoacidosis [body can’t make enough insulin and acid builds up in the body]. Review of the Plan of Care [POC] for the certification period 1/9/23-3/9/23 included orders for PT [physical therapy] 1 time a week for 5 weeks, 1 time every 2 weeks for 4 weeks. A supplemental order was written on 2/2/23 for SN [skilled nursing] to evaluate diabetes management. Review of the clinical record revealed an order dated 2/9/23 for SN visits 1 time a week for 5 weeks and “Report increased edema or weight gain of greater than 2 pounds in 1 day or 5 pounds in 1 week. May measure abdominal girth if unable to weight…SN for instructions on diabetic care to include…signs and symptoms of hypo/hyperglycemia…blood glucose testing 3 x frequency [sic]…Skilled nurse may perform blood glucose test as needed…Skilled nurse to report to physician blood glucose readings greater than 300 or less than 70…” There were 4 SN visits made from 2/9/23-2/27/23. Review of the documentation revealed there were no blood glucose readings obtained for 3 of those SN visits and no weights or abdominal girths obtained for 3 of those visits. During an interview with the agency director on 2/21/24 at approximately 9:30 am, the director confirmed the SN failed to follow physician’s orders. 2. Patient # 7 had a Start of Care [SOC] date of 12/20/23 and an admitting diagnosis of type 2 diabetes mellitus with foot ulcer, other streptococcal [type of bacteria] arthritis, left shoulder, bacteremia [bacteria in the blood], type 2 diabetes with hyperglycemia [high blood glucose], unspecified systolic [congestive] heart failure and encounter for adjustment and management of VAD [vascular access device- thin flexible tube that provides access to blood vessels without the need for repeated needle sticks]. Review of the Plan of Care [POC] for the certification period 12/20/23-2/17/24 included orders for PT [physical therapy] 2 times a week for 1 week, 1 time a week for 3 weeks, 1 time every 2 weeks for 4 weeks and “Physical therapy to observe wound/incisions and/or intact dressing on right foot and left shoulder…” Review of the clinical record revealed 3 PT visits were made from 12/24/23-12/31/23 [patient transferred to hospital]. There is no evidence the wounds were observed for 3 of the 3 PT visits. During an interview with the agency director on 2/21/24 at approximately 10 am, the director confirmed the PT failed to follow the physician’s order related to observing the wounds. 3A. Patient # 16 had a Start of Care [SOC] date of 1/11/24 with admitting diagnoses of acute and chronic respiratory failure with hypoxia [low oxygen level in the blood] and hypertensive heart and chronic kidney disease with heart failure and type 2 diabetes with hyperglycemia [high blood sugars]. Review of the Plan of Care [POC] for the certification period 1/11/24-3/10/24 included orders for SN [skilled nursing] 2 times a week for 1 week, 2 times a week for 8 weeks and “report blood glucose readings greater than 350 and less than 70…Report increased edema or weight gain greater than 2 pounds in 1 day or 5 pounds in 1 week or more than target weight…Target weight 370 pounds with maximum weight of 375 pounds…” Review of the clinical record revealed 10 SN visits were made from 1/11/24-2/12/24. There was a weight of 356 pounds documented at the SOC. The record revealed no blood glucose readings for any of the SN visits. During an interview with the administrator on 2/21/24, the administrator confirmed the SN did not follow the physician’s orders on the POC. 3B. Patient # 16 had a Start of Care [SOC] date of 1/11/24 with admitting diagnoses of acute and chronic respiratory failure with hypoxia [low oxygen level in the blood] and hypertensive heart and chronic kidney disease with heart failure and type 2 diabetes with hyperglycemia [high blood sugar]. Review of the Plan of Care [POC] for the certification period 1/11/24-3/10/24 included orders for PT [physical therapy] 1 time a week for 1 week, 2 times a week for 3 weeks, 1 time a week for 4 weeks and “…PT for diabetes management…blood sugar parameters 70-300…Physical therapy to assess and record patient reported weight and notify CM [case manager/RN case manager for MD notification for signs and symptoms of exacerbation (2 pounds weight gain in 1 day or 5 pounds in 1 week over the baseline…” Review of the clinical record revealed 3 PT visits were made from 1/16/24-2/12/24 and there were no blood sugar readings or weights documented for 3 of 3 visits. During an interview with the administrator on 2/21/24 at approximately 9:15 am, the director confirmed PT did not follow the physician’s orders on the POC. 3C. Patient # 16 had a Start of Care [SOC] date of 1/11/24 with admitting diagnoses of acute and chronic respiratory failure with hypoxia [low oxygen level in the blood] and hypertensive heart and chronic kidney disease with heart failure and type 2 diabetes with hyperglycemia [high blood sugars]. Review of the Plan of Care [POC] for the certification period 1/11/24-3/10/24 included orders for OT [occupational therapy] 2 times a week for 2 weeks, 1 time a week for 6 weeks and “…OT to assess and record patient reported weight…OT for diabetes management-Blood sugar parameters 70-300 finger stick frequency of patient/caregiver 1 x a day…”Review of the clinical record revealed OT visits were made on 1/15/24, 1/19/24, 1/23/24 and 2/9/24. Further review of the clinical record revealed no evidence of blood sugar readings or weights in accordance with the physician’s order on the POC. During an interview with the agency director on 2/21/24 at approximately 9:15 am, the director confirmed OT failed to follow the physician’s orders on the POC. 4. Patient # 20 had a Start of Care [SOC] date of 11/8/23 with admitting diagnoses of type 2 diabetes with foot ulcer, type 2 diabetes mellitus with diabetic neuropathic arthropathy [serious complication of diabetes, causing destruction of bones and joints of the foot], and type 2 diabetes with diabetic peripheral angiopathy without gangrene [narrowing of the arteries]. Review of the Plan of Care [POC] for the certification period 1/7/24-3/6/24 included orders for SN [skilled nursing] 3 times a week for 8 weeks then 2 times a week for 1 week and “Diabetes management: RN to assess and teach LPN to observe and teach…blood glucose testing daily…observe and teach to perform and record blood glucose testing as ordered and to report abnormal findings to physician…Nurse to report to physician blood glucose readings greater than 350 and less than 70…” Review of the clinical record revealed the SN made 14 routine visits from 1/8/24-2/16/24. There were 5 visits which had no blood glucose readings documented. During an interview with the agency director on 2/21/24 at approximately 9:30 am, the director confirmed the SN failed to follow the POC.

Communication with all physicians CFR(s): 484.60(d)(1) Assure communication with all physicians or allowed practitioners involved in the plan of care. This ELEMENT is not met as evidenced by: Based on agency policy, clinical record review and staff interviews the agency failed to coordinate care with the physician for 1 of 2 patients with VAD [vascular access device] [#7]; and failed to coordinate care for 1 of 1 patients receiving MSW [social work] services which required an APS [adult protective services] report [#9]. The findings included: The policy, Coordination of Care [5/4/23], was provided by the agency director on 2/21/24 at approximately 3 pm. The policy stated, "...Relevant physicians are notified promptly of any changes in the patient's condition or needs that suggest that outcomes are not being achieved..." 1. Patient # 7 had a Start of Care [SOC] date of 12/20/23 and an admitting diagnosis of type 2 diabetes mellitus with foot ulcer, other streptococcal [type of bacteria] arthritis, left shoulder, bacteremia [bacteria in the blood], type 2 diabetes with hyperglycemia [high blood glucose], unspecified systolic [congestive] heart failure and encounter for adjustment and management of VAD [vascular access device- thin flexible tube that provides access to blood vessels without the need for repeated needle sticks]. Review of the Plan of Care [POC] for the certification period 12/20/23-2/17/24 included orders for SN [skilled nursing] 2 times a week for 9 weeks [the POC did not include any orders related the VAD]. Review of the clinical record revealed RN # 5 completed the SOC visit on 12/20/23 and documented the following PICC [peripheral inserted central catheter-type of VAD device] line assessment: “Power PICC, RUE [right upper extremity], 17 cm exposed PICC catheter length, 29 cm arm circumference”. LPN # 6 conducted a routine visit on 12/26/23 and documented the following assessment “12 cm exposed catheter length and an arm circumference of 30.5 cm.” There was no evidence the LPN notified the physician of the measurements she had obtained. LPN # 6 was not available for interview. During an interview with the agency director on 2/21/24 at approximately 10 am, the director confirmed the physician should have been notified of the possible migration of the PICC line. 2. Patient # 9 had a Start of Care [SOC] date of 1/9/24 and admitting diagnoses of unspecified open wound to left lower leg, diffuse large B-cell lymphoma [cancer] and malignant pleural effusion [cancer extending into the pleural space]. Review of the Plan of Care [POC] for the certification period 1/9/24-3/8/24 included orders for MSW [social work] 1 time a week for 1 week, 1 time every 3 weeks for 3 weeks and 1 time every 2 weeks for 2 weeks. Review of the clinical record revealed MSW # 7 made a routine visit on 1/15/24 and documented the following information, “MSW met with patient and caregiver, MSW observed marks on the patient from his spouse. MSW discussed concerns and made APS [adult protective services] report to _________ [name of county] …” The MSW conducted a visit on 2/7/24 and documented, “MSW met with patient to complete discharge…MSW followed up with APS to report holes in the wall. Patient reports holes are from his wife throwing a water glass at him. MSW noted DSS [department of social services/APS worker response. Case is under review at this time…” Further review of the clinical record revealed no evidence the MSW notified the physician of the allegations related to abuse. During an interview with the agency director on 2/21/24 at approximately 9:30 am, the director confirmed there was no evidence the physician was notified.

Responsibilities of skilled professionals CFR(s): 484.75(b) Standard: Responsibilities of skilled professionals. Skilled professionals must assume responsibility for, but not be restricted to, the following: This STANDARD is not met as evidenced by: Based on agency policy, clinical record review and staff interviews the registered nurse failed to conduct an evaluation visit for 7 days after the completion of the resumption of care visit for 1 of 1 patients [#1]; and failed to identify a wound for 1 of 6 patients with a wound [#7]. The findings included: The policy, The provision of Wound and Skin Care [3/8/23], was provided by the agency director on 2/21/24 at approximately 3 pm. The policy stated, “…Assessment of the integumentary system is part of the comprehensive total body assessment…Documentation of the skin and any wounds will take place in the EMR [electronic medical record] 4in the areas provided each time wound or skin care is provided…”. 1. Patient # 1 had a Start of Care [SOC] date of 1/9/23 and an admitting diagnosis of type 1 diabetes mellitus with ketoacidosis [body can’t make enough insulin and acid builds up in the body]. Review of the Plan of Care [POC] for the certification period 1/9/23-3/9/23 included orders for PT [physical therapy] 1 time a week for 5 weeks, 1 time every 2 weeks for 4 weeks. Review of the clinical record revealed supplemental orders [ROC-resumption of care orders] were obtained on 2/2/23 for “SN [skilled nursing] to evaluate for diabetes management” after the patient was admitted to the hospital with a blood glucose level of 1197. Further review of the clinical record revealed RN # 4 did not complete the evaluation visit until 2/9/23. There was no evidence in the clinical record that RN # 4 notified the physician to obtain an order to complete the evaluation visit. RN # 4 was not available for interview. During an interview with the agency director on 2/21/24 at approximately 9:30 am, the director confirmed the evaluation visit was delayed. 2. Patient # 7 had a Start of Care [SOC] date of 12/20/23 and an admitting diagnosis of type 2 diabetes mellitus with foot ulcer, other streptococcal [type of bacteria] arthritis, left shoulder, bacteremia [bacteria in the blood], type 2 diabetes with hyperglycemia [high blood glucose], unspecified systolic [congestive] heart failure and encounter for adjustment and management of VAD [vascular access device- thin flexible tube that provides access to blood vessels without the need for repeated needle sticks]. Review of the Plan of Care [POC] for the certification period 12/20/23-2/17/24 included orders for SN [skilled nursing] 2 times a week for 9 weeks. Review of the hospital discharge orders from _____ [name of hospital] dated 12/18/23 revealed the following orders “Patient with diabetic ulcer on his right, lateral, plantar foot…Patient also has a left shoulder incision. Cover with large gauze and tape to secure it. Ensure incision is clean and dry. Daily dressing changes…” Review of the clinical record revealed RN # 5 completed the SOC admission visit on 12/20/23. The RN identified the wound to the right foot [completed wound assessment at the SOC] and the POC included orders for wound care. The RN did not identify the wound [incision noted on the left shoulder] and the POC did not include any orders. The wound to the shoulder was not identified until 12/24/23 when the PT identified the wound. RN # 5 was not available for interview. During an interview with the agency director on 2/21/24 at approximately 10 am, the director confirmed the RN should have identified the wound.

An unannounced on-site complaint investigation was conducted 11/14/22-11/15/22. The allegations related to infection control and Patient Rights were substantiated. Standard level deficiencies to the Medicare CoP were identified.

Advise the patient of discharge for cause CFR(s): 484.50(d)(5)(i) (i) Advise the patient, representative (if any), the physician(s) or allowed practitioner(s), issuing orders for the home health plan of care, and the patient's primary care practitioner or other health care professional who will be responsible for providing care and services to the patient after discharge from the HHA (if any) that a discharge for cause is being considered; This ELEMENT is not met as evidenced by: Based on agency policy, clinical record review and staff interviews the agency failed to advise 1 of 1 patient [#3] who was discharged for cause [patient’s or other person in the patient’s home behavior is disruptive, abusive or uncooperative to the extent that delivery of care to the patient or the ability of the HHA [home health agency] to operate effectively is seriously impaired] the agency was considering the discharge before the actual discharge. The findings included: The policy, Discharge of Patients [8/26/22], was provided by the agency director on 11/14/22 at approximately 3:20 pm. The policy stated, “…Discharge for Cause…The HHA [home health agency] must do the following before it discharges a patient for cause: Advise the following that a discharge for cause is being considered…the patient, representative [if any], the physician issuing orders for the home health plan of care…” Patient # 3 had a Start of Care date of 8/13/22 and admitting diagnoses of Encounter for change or removal of nonsurgical wound dressing, Venous Insufficiency [Chronic] [Peripheral] [walls or valves in the veins are not working effectively, making it difficult for blood to return to the heart], Type 2 Diabetes Mellitus with other Skin Ulcer, Non-pressure Chronic Ulcer of Right Lower Leg and Non-Pressure Chronic Ulcer of Left Lower Leg. Review of the Plan of Care for the certification period 8/13/22 to 10/11/22 included orders for SN [skilled nursing] 1 time a week for 2 weeks, 2 times a week for 5 weeks, 1 time a week for 2 weeks. Review of the clinical record revealed on 10/12/22 the patient was discharged by RN # 2. The patient was discharged for cause [patient’s or other person in the patient’s home behavior is disruptive, abusive or uncooperative to the extent that delivery of care to the patient or the ability of the HHA [home health agency] to operate effectively is seriously impaired]. Review of RN # 2’s documentation dated 10/11/22 revealed the following information, “ Patient seen in home for discharge visit…Patient non-compliant with daily weights stating ‘I just don’t feel like doing that when I wake up and have already been up all night’…Patient refuses to check BG [blood glucose] [sic] despite education for monitoring BG and effects of diabetes on wound…Patient continually unable for visits unless they [visits] are late in the business day…” Further review of the clinical record revealed no evidence the patient nor the physician was notified the agency was planning to discharge the patient for cause. During an interview with RN # 2 on 11/15/22, the RN stated, “It should be in the chart. I am not sure when I told him, but I am pretty sure it’s in the chart.”

Make efforts to resolve the problem(s) CFR(s): 484.50(d)(5)(ii) (ii) Make efforts to resolve the problem(s) presented by the patient's behavior, the behavior of other persons in the patient's home, or situation; This ELEMENT is not met as evidenced by: Based on agency policy review, clinical record review and staff interviews the agency failed to resolve the issues prior to discharging 1 of 1 patient for discharge for cause [patient’s or other person in the patient’s home behavior is disruptive, abusive or uncooperative to the extent that delivery of care to the patient or the ability of the HHA [home health agency] to operate effectively is seriously impaired]. The findings included: The policy, Discharge of Patients [8/26/21], was provided by the agency director on 11/14/22 at approximately 3:20 pm. The policy stated, “…The HHA [home health agency] must do the following before it discharges a patient for cause…Make efforts to resolve the problem presented by the patient’s behavior…” Patient # 3 had a Start of Care date of 8/13/22 and admitting diagnoses of Encounter for change or removal of nonsurgical wound dressing, Venous Insufficiency [Chronic] [Peripheral] [walls or valves in the veins are not working effectively, making it difficult for blood to return to the heart], Type 2 Diabetes Mellitus with other Skin Ulcer, Non-pressure Chronic Ulcer of Right Lower Leg and Non-Pressure Chronic Ulcer of Left Lower Leg. Review of the Plan of Care for the certification period 8/13/22 to 10/11/22 included orders for SN [skilled nursing] 1 time a week for 2 weeks, 2 times a week for 5 weeks, 1 time a week for 2 weeks. Review of the clinical record revealed on 10/12/22 the patient was discharged by RN # 2. The patient was discharged for cause [patient’s or other person in the patient’s home behavior is disruptive, abusive or uncooperative to the extent that delivery of care to the patient or the ability of the HHA [home health agency] to operate effectively is seriously impaired]. Review of RN # 2’s documentation dated 10/11/22 revealed the following information, "Patient seen in home for discharge visit…Patient non-compliant with daily weights stating ‘I just don’t feel like doing that when I wake up and have already been up all night’…Patient refuses to check BG [blood glucose] [sic] despite education for monitoring BG and effects of diabetes on wound…Patient continually unable for visits unless they [visits] are late in the business day…” Further review of the clinical record revealed no evidence the agency attempted to resolve issues related to the discharge for cause. During an interview with RN # 2 on 11/15/22 at 10 am, the RN stated, “I guess if it’s not in the chart, I didn’t document it.”

Provide contact info other services CFR(s): 484.50(d)(5)(iii) (iii) Provide the patient and representative (if any), with contact information for other agencies or providers who may be able to provide care; and This ELEMENT is not met as evidenced by: Based on agency policy review, clinical record review and staff interviews the agency failed to provide contact information for other agencies which might provide care for 1 of 1 patient discharged for cause [#1] [patient’s or other person in the patient’s home behavior is disruptive, abusive or uncooperative to the extent that delivery of care to the patient or the ability of the HHA [home health agency] to operate effectively is seriously impaired]. The findings included: The policy, Discharge of Patients [8/26/21], was provided by the agency director on 11/14/22 at approximately 3:20 pm. The policy stated, “…The HHA [home health agency] must do the following before it discharges a patient for cause…Provide the patient and representative [if any], with contact information for other agencies or providers who may be able to provide care…” Patient # 3 had a Start of Care date of 8/13/22 and admitting diagnoses of Encounter for change or removal of nonsurgical wound dressing, Venous Insufficiency [Chronic] [Peripheral] [walls or valves in the veins are not working effectively, making it difficult for blood to return to the heart], Type 2 Diabetes Mellitus with other Skin Ulcer, Non-pressure Chronic Ulcer of Right Lower Leg and Non-Pressure Chronic Ulcer of Left Lower Leg. Review of the Plan of Care [POC] for the certification period 8/13/22 to 10/11/22 included orders for SN [skilled nursing] 1 time a week for 2 weeks, 2 times a week for 5 weeks, 1 time a week for 2 weeks. Further review of the POC revealed the patient was receiving SN visits related to skin breakdown to lower extremities. Review of the clinical record revealed on 10/12/22 the patient was discharged by RN # 2. The patient was discharged for cause [patient’s or other person in the patient’s home behavior is disruptive, abusive, or uncooperative to the extent that delivery of care to the patient or the ability of the HHA [home health agency] to operate effectively is seriously impaired]. Review of RN # 2’s documentation dated 10/11/22 revealed the following information, “ Patient seen in home for discharge visit…Patient non-compliant with daily weights stating ‘I just don’t feel like doing that when I wake up and have already been up all night’…Patient refuses to check BG [blood glucose] [sic] despite education for monitoring BG and effects of diabetes on wound…Patient continually unable for visits unless they [visits] are late in the business day…”Further review of the clinical record revealed no evidence the agency provided the patient with a list of other agencies who may be available to provide care. During an interview with RN # 2 on 11/15/22 at 10 am, the RN confirmed the patient was not provided information on other agencies which might be able to provide care.

Document complaint and resolution CFR(s): 484.50(e)(1)(ii) (ii) Document both the existence of the complaint and the resolution of the complaint; and This ELEMENT is not met as evidenced by: Based on agency policy, clinical record review, interviews with patient and staff, the agency failed to document the existence of a complaint for 1 of 1 patient who requested discharge [#1]. The findings included: The policy, Patient/Caregiver Grievance/Complaint [6/24/21], was provided by the agency director on 11/14/22 at approximately 11 am. The policy stated, “…Documentation of the complaint is completed by the employee to whom the complaint is received and forwarded to the agency…Complaints are documented, and a Complaint Log is maintained…” Patient # 1 had a Start of Care [SOC] date of 10/16/22 and admitting diagnoses of Chronic Obstructive Pulmonary Disease [CODP-lung disease], Heart Failure and Chronic Obstructive Pulmonary Disease with acute exacerbation [an acute increase in the severity of an illness]. Review of the Plan of Care for the certification period 10/16/22 to 12/14/22 included orders for SN [skilled nursing] 1 time a week for 1; PT [physical therapy] 2 times a week for 2 weeks, 1 time a week for 1 week, 1 time every 2 weeks for 6 weeks. Review of the clinical record revealed PT # 1 completed the SOC OASIS [Outcome and Assessment Information Set] on 10/16/22. RN # 2 completed the nursing evaluation visit on 10/19/22. Patient # 1 requested discharge from the agency on 10/20/22. During an interview with patient # 1 on 11/14/22 at approximately 11:30 am, the patient stated, “When the nurse came to see me that day, she didn’t have a mask on. I had already been in the hospital and “rehab” for a month. When I was at rehab, everyone wore masks. The patients wore masks, and the employees wore masks. The nurse didn’t do anything but take my vital signs. She sat down on my bed, and I was lying on the bed. I know that when someone takes your blood pressure you are supposed to have your feet on the floor. She didn’t do it right. I called the office, the one on __________ [name of street] in _________ [name of city]. I told whoever I talked to what had happened and I told them not to come back. I said I don’t need your services. Then the next day someone called from the therapy department and asked if they could come out to see me. I didn’t even call them back.” A review of the communication section of the clinical record revealed an entry for 10/20/22. The entry stated, “Patient no longer wants services.” Review of the agency complaint log revealed no entry related to patient # 1. During an interview with the agency director on 11/15/22 at approximately 8:30 am, the director confirmed the entry should have been recorded in the complaint log.

Within 48 hours of the patient's return CFR(s): 484.55(d)(2) Within 48 hours of the patient's return to the home from a hospital admission of 24 hours or more for any reason other than diagnostic tests, or on physician or allowed practitioner - ordered resumption date; This ELEMENT is not met as evidenced by: Based on clinical record review and staff interviews the agency failed to conduct a Resumption of Care [ROC-visit conducted after inpatient stay] within 48 hours after the patient was discharged home for 1 of 1 patient [#3]. The findings included: Patient # 3 had a Start of Care date of 8/13/22 and admitting diagnoses of Encounter for change or removal of nonsurgical wound dressing, Venous Insufficiency [Chronic] [Peripheral] [walls or valves in the veins are not working effectively, making it difficult for blood to return to the heart], Type 2 Diabetes Mellitus with other Skin Ulcer, Non-pressure Chronic Ulcer of Right Lower Leg and Non-Pressure Chronic Ulcer of Left Lower Leg. Review of the Plan of Care for the certification period 8/13/22 to 10/11/22 included orders for SN [skilled nursing] 1 time a week for 2 weeks, 2 times a week for 5 weeks, 1 time a week for 2 weeks. Review of the clinical record revealed the patient was transferred and admitted to _______ [name of the hospital] on 8/25/22. Further review of the clinical record revealed Patient # 3 contacted the agency on 9/5/22 and inquired about when the nurse would be out to see him. The patient stated, “I have been home since Friday [9/2/22].” Review of the clinical record revealed the patient was discharged home on 9/2/22. The RN did not see the patient for the ROC [resumption of care – visit done after inpatient hospital stay] until 9/8/22. During an interview with the agency director on 11/15/22, the director confirmed the ROC visit was not made until 9/8/22.

Plan of care must include the following CFR(s): 484.60(a)(2)(i-xvi) The individualized plan of care must include the following: (i) All pertinent diagnoses; (ii) The patient's mental, psychosocial, and cognitive status; (iii) The types of services, supplies, and equipment required; (iv) The frequency and duration of visits to be made; (v) Prognosis; (vi) Rehabilitation potential; (vii) Functional limitations; (viii) Activities permitted; (ix) Nutritional requirements; (x) All medications and treatments; (xi) Safety measures to protect against injury; (xii) A description of the patient's risk for emergency department visits and hospital re-admission, and all necessary interventions to address the underlying risk factors. (xiii) Patient and caregiver education and training to facilitate timely discharge; (xiv) Patient-specific interventions and education; measurable outcomes and goals identified by the HHA and the patient; (xv) Information related to any advanced directives; and (xvi) Any additional items the HHA or physician or allowed practitioner may choose to include. This ELEMENT is not met as evidenced by: Based on agency policy review, clinical record review and staff interviews the agency failed to provide a target weight on the Plan of Care [POC] for 2 of 3 records [#3 and 2]. The findings included: 2- Patient #2 had a Start of Care 7/13/22 which included diagnoses of Chronic obstructive pulmonary disease [a group of lung diseases] with lower lobe infection; Urinary tract infection; Dementia [impairment of brain function]; Pneumonitis [inflammation of lung tissue]; Systolic (congestive) heart failure [improper function of the heart]. The Plan of Care [POC] for the certification period 7/13/22 to 9/10/22 included orders for Skilled nursing [SN] 1 time per week for 4 weeks; 1 every 2 weeks for 4 weeks; 1 time per week for 1 week. Further orders included, “SN to assess… patients [sic] ability to monitor and record daily weights…record patient reported weight, or weigh patient as needed. Report increased edema or weight gain of >2 lbs [pounds] in 1 day or > 5lbs in 1 week or 5 lbs or more over target weight.” There is no target weight documented on the POC. The following weights were documented: 7/13/22 initial visit- 190 lbs; 7/18/22- 187 lbs; 7/22/22- 178 lbs; 8/2/22 and 8/17/22- 193 lbs. An interview with SN #2 on 11/15/22 at approximately 9:50 am revealed the POC did not have a target weight. LPN #4 stated in an interview on 11/15/22 at approximately 10:00 am, did not know the target weight. Also stated the caregiver weighed the patient and reported to the LPN. The policy, Plan of Care [12/4/20] was provided by the agency director on 11/14/22 at approximately 3:20 pm. The policy stated, “…The plan of care must include the following: …All medications and treatments…Patient specific interventions and education…” 1. Patient # 3 had a Start of Care date of 8/13/22 and admitting diagnoses of Encounter for change or removal of nonsurgical wound dressing, Venous Insufficiency [Chronic] [Peripheral] [walls or valves in the veins are not working effectively, making it difficult for blood to return to the heart], Type 2 Diabetes Mellitus with other Skin Ulcer, Non-pressure Chronic Ulcer of Right Lower Leg and Non-Pressure Chronic Ulcer of Left Lower Leg. Review of the Plan of Care [POC] for the certification period 8/13/22 to 10/11/22 included orders for SN [skilled nursing] 1 time a week for 2 weeks, 2 times a week for 5 weeks, 1 time a week for 2 weeks and “…Record patient reported weight, or weigh patient as needed. Report increased edema or weight gain of more than 2 pounds in 1 day or 5 pounds or move over target weight…” Further review of the POC revealed no target weight. During an interview with the agency director on 11/15/22, the director confirmed the POC did not include a target weight for the patient.

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 clinical record review and staff interviews the agency failed to monitor weights for of 1 patient [#3] who was discharged for cause. The findings included: Patient # 3 had a Start of Care date of 8/13/22 and admitting diagnoses of Encounter for change or removal of nonsurgical wound dressing, Venous Insufficiency [Chronic] [Peripheral] [walls or valves in the veins are not working effectively, making it difficult for blood to return to the heart], Type 2 Diabetes Mellitus with other Skin Ulcer, Non-pressure Chronic Ulcer of Right Lower Leg and Non-Pressure Chronic Ulcer of Left Lower Leg. Review of the Plan of Care [POC] for the certification period 8/13/22 to 10/11/22 included orders for SN [skilled nursing] 1 time a week for 2 weeks, 2 times a week for 5 weeks, 1 time a week for 2 weeks and “…Record patient reported weight, or weigh patient as needed. Report increased edema or weight gain of more than 2 pounds in 1 day or 5 pounds or move over target weight…” Review of the clinical record revealed no baseline weight was recorded during the admission visit. During the visit on 8/19/22, LPN # 4 documented a weight of 355.6 pounds. On 9/12/22, 9/15/22 LPN # 4 documented a weight of 344 pounds. No weight or reason why weight was not obtained was documented on 9/19/22. RN # 2 made routine visits on 9/22/22, 9/26/22, 9/29/22 and 10/3/22. No weight or a reason why no weight was obtained during those visits were documented. On 10/6/22, RN # 2 made a routine visit and documented a weight of 352. RN # 2 visited the patient on 10/11/22 for a discharge for cause visit. No weight was obtained during that visit. During an interview with the agency director on 11/15/22, the director confirmed the POC was not followed related to monitoring/recording the patient’s weight.

Infection Prevention CFR(s): 484.70(a) Standard: Infection Prevention. The HHA must follow accepted standards of practice, including the use of standard precautions, to prevent the transmission of infections and communicable diseases. This STANDARD is not met as evidenced by: Based on clinical record review and patient and staff interviews the agency failed to ensure infection control practices were followed when the RN sat on the patient’s bed during the visit for 1 of 1 patient requesting to be discharged from agency [#1]. The findings included: Patient # 1 had a Start of Care [SOC] date of 10/16/22 and admitting diagnoses of Chronic Obstructive Pulmonary Disease [CODP-lung disease], Heart Failure and Chronic Obstructive Pulmonary Disease with acute exacerbation [an acute increase in the severity of an illness]. Review of the Plan of Care for the certification period 10/16/22 to 12/14/22 included orders for SN [skilled nursing] 1 time a week for 1; PT [physical therapy] 2 times a week for 2 weeks, 1 time a week for 1 week, 1 time every 2 weeks for 6 weeks. Review of the clinical record revealed PT # 1 completed the SOC OASIS [Outcome and Assessment Information Set] on 10/16/22. RN # 2 completed the nursing evaluation visit on 10/19/22. During an interview with patient # 1 on 11/14/22 at approximately 11:30 am, the patient stated, “When the nurse came to see me that day, she didn’t have a mask on. I had already been in the hospital and “rehab” for a month. When I was at rehab, everyone wore masks. The patients wore masks, and the employees wore masks. The nurse didn’t do anything but take my vital signs. She sat down on my bed, and I was lying on the bed…” During an interview with RN # 2 on 11/14/22 at approximately 3 pm, the RN stated, “I think I had a mask on when I saw the patient. Yes, I did sit on her bed. I can’t remember if I asked for permission to sit on the bed, but I sat at the foot of the bed…” During an interview with the agency director on 11/14/22 at approximately 2 pm. The director stated, “I do not think we have a policy related to sitting on the patient’s beds, however, it would be a given that clinicians never sit on the bed due to infection control concerns. We require staff to always wear surgical masks when in the patient’s home.”

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 agency policy review, clinical record review and staff interviews the RN failed to provide wound care in accordance with the Plan of Care for 1 of 1 patient with a wound [#3]. The findings included: The policy, Plan of Care [12/4/20], was provided by the agency director on 11/14/22 at 3:20 pm. The policy stated, “A plan of care will be developed through a care planning process, which is designed to provide care, treatment, and services that are appropriate to the patient’s individual needs… 1A. Patient # 3 had a Start of Care date of 8/13/22 and admitting diagnoses of Encounter for change or removal of nonsurgical wound dressing, Venous Insufficiency [Chronic] [Peripheral] [walls or valves in the veins are not working effectively, making it difficult for blood to return to the heart], Type 2 Diabetes Mellitus with other Skin Ulcer, Non-pressure Chronic Ulcer of Right Lower Leg and Non-Pressure Chronic Ulcer of Left Lower Leg. Review of the Plan of Care [POC] for the certification period 8/13/22 to 10/11/22 included orders for SN [skilled nursing] 1 time a week for 2 weeks, 2 times a week for 5 weeks, 1 time a week for 2 weeks and “SN to perform/teach venous stasis ulcer care to bilateral extremities. Cleanse with wound cleanser, apply Bl [bilateral] Unna boot [special gauze bandage which can be used for treatment of venous stasis ulcers and other venous insufficiencies of the leg]. May apply skin barrier to periwound [tissue surrounding a wound] area PRN [as needed] to prevent skin maceration and protect periwound. Secure with coflex [sic] wrap. Change dressing every 3 days and PRN [as needed] dislodgement…” Review of the clinical record revealed the patient had the Unna boots changed weekly from 8/13/22 until 8/25/22 when he was admitted to the hospital. During an interview with RN # 2 on 11/15/22, the RN confirmed the wound care was not completed in accordance with the POC. RN # 2 stated, “We were just seeing him 1 time a week, so we just changed the Unna boots 1 time per week.” There was no evidence the physician was notified to report the patient was not getting the wound care as ordered. 1B. Patient # 3 had a Start of Care date of 8/13/22 and admitting diagnoses of Encounter for change or removal of nonsurgical wound dressing, Venous Insufficiency [Chronic] [Peripheral] [walls or valves in the veins are not working effectively, making it difficult for blood to return to the heart], Type 2 Diabetes Mellitus with other Skin Ulcer, Non-pressure Chronic Ulcer of Right Lower Leg and Non-Pressure Chronic Ulcer of Left Lower Leg. Review of the clinical record revealed a ROC [resumption of care-visit completed after the patient had had an inpatient stay and is discharged home] visit was made on 9/8/22. The ROC orders stated, “SN [skilled nursing] visits 1 time a week for 1 week, 2 times a week for 2 weeks, 1 time every 3 weeks for 3 weeks…SN to perform/teach venous stasis ulcer care to lower left extremity area-cleanse with saline or wound cleanser, apply alginate dressing. May apply skin barrier to periwound [tissue surrounding the wound] area PRN [as needed] to prevent skin maceration and protect periwound. Cover with Unna boot [special gauze bandage which can be used for treatment of venous stasis ulcers and other venous insufficiencies of the leg] from base of toes to bottom of knee. Secure with 2-layer compression of kerlix and coban. Change dressing every 2-3 days and PRN for contamination or dislodgement. SN [skilled nursing] to perform/teach venous stasis ulcer care to right [sic] left extremity area-cleanse with saline or wound cleanser, apply alginate dressing. May apply skin barrier to periwound area PRN [as needed] to prevent skin maceration and protect periwound. Cover with Unna boot from base of toes to bottom of knee. Secure with 2-layer compression of kerlix and coban. Change dressing every 2-3 days and PRN for contamination or dislodgement. SN to perform/teach wound care to abdomen area- irrigate/cleanse with saline or wound cleanser, apply alginate dressing…cover with bordered foam. Change dressing every 2-3 days and PRN [as needed] for contamination or dislodgement…” A supplement order for SN visit frequencies was written on 9/25/22 for SN visits 2 times a week for 2 weeks, 1 time a week for 1 week. Further review of the clinical record revealed SN visits were made on 9/8/22 for wound care, 9/12/22 for wound care [dressing change was 4 days apart], 9/15/22 for wound care, 9/19/22 for wound care [4 days from last dressing change], 9/22/22 for wound care, 9/26/22 for wound care [4 days], 9/29/22 for wound care, 10/3/22 for wound care [4 days], 10/6/22 for wound care, 10/11/22 for wound care and discharge for cause [5 days]. During an interview with RN # 2 on 11/15/22, RN # 2 stated, “We changed the dressings when we saw the patient. He didn’t have anyone in the home to educate on dressing changes and he wasn’t able to do his own Unna boots.

Communication with physicians CFR(s): 484.75(b)(7) Communication with all physicians involved in the plan of care and other health care practitioners (as appropriate) related to the current plan of care; This ELEMENT is not met as evidenced by: Based on agency policy, clinical record review and staff interviews the agency failed to notify the physician of 1 of 1 patient requesting discharge [#1]; failed to notify the physician when wound care was not being completed as ordered for 1 of 1 patient [#3] patient with a wound; failed to notify the physician of RN assessment findings for 1 of 1 patient [#3] discharged for cause. The findings included: The policy, Coordination of Care [5/9/22], was provided by the agency director on 11/14/22 at approximately 3:20 pm. The policy stated, “…Coordination of Care- Assure communication with all physicians involved in the Plan of Care…Relevant physicians are notified promptly of any changes in the patient’s condition or needs…” 1. Patient # 1 had a Start of Care [SOC] date of 10/16/22 and admitting diagnoses of Chronic Obstructive Pulmonary Disease [CODP-lung disease], Heart Failure and Chronic Obstructive Pulmonary Disease with acute exacerbation [an acute increase in the severity of an illness]. Review of the Plan of Care for the certification period 10/16/22 to 12/14/22 included orders for SN [skilled nursing] 1 time a week for 1; PT [physical therapy] 2 times a week for 2 weeks, 1 time a week for 1 week, 1 time every 2 weeks for 6 weeks. Review of the clinical record revealed PT # 1 completed the SOC OASIS [Outcome and Assessment Information Set] on 10/16/22. RN # 2 completed the nursing evaluation visit on 10/19/22. Patient # 1 requested discharge from the agency on 10/20/22. Review of the clinical record revealed a communication note dated 10/20/22. The communication note stated, “…. Patient called. No longer wants services.” There was no evidence the physician was notified of the patient’s desire to be discharged from the agency. On 11/15/22 at approximately 9 am, the director provided an email from the branch manager of the ________ [city] office dated 10/24/22. The email contained information related to the patient’s desire to be discharged from the agency. During an interview with the agency director on 11/15/22 at approximately 9 am, the director confirmed the physician was not notified of the patient’s discharge. “It happened because the discharge was entered as “a non-admit”. 2A. Patient # 3 had a Start of Care date of 8/13/22 and admitting diagnoses of Encounter for change or removal of nonsurgical wound dressing, Venous Insufficiency [Chronic] [Peripheral] [walls or valves in the veins are not working effectively, making it difficult for blood to return to the heart], Type 2 Diabetes Mellitus with other Skin Ulcer, Non-pressure Chronic Ulcer of Right Lower Leg and Non-Pressure Chronic Ulcer of Left Lower Leg. Review of the Plan of Care [POC] for the certification period 8/13/22 to 10/11/22 included orders for SN [skilled nursing] 1 time a week for 2 weeks, 2 times a week for 5 weeks, 1 time a week for 2 weeks and “SN to perform/teach venous stasis ulcer care to bilateral extremities. Cleanse with wound cleanser, apply Bl [bilateral] Unna boot [special gauze bandage which can be used for treatment of venous stasis ulcers and other venous insufficiencies of the leg]. May apply skin barrier to periwound [tissue surrounding a wound] area PRN [as needed] to prevent skin maceration and protect periwound. Secure with coflex [sic] wrap. Change dressing every 3 days and PRN [as needed] dislodgement…” Review of the clinical record revealed the patient had the Unna boots changed weekly from 8/13/22 until 8/25/22 when he was admitted to the hospital. During an interview with RN # 2 on 11/15/22 at 10 am. During the interview, RN # 2 stated, “We were just seeing him 1 time a week, so we just changed the Unna boots 1 time per week.” There was no evidence the physician was notified the wound care was only being done 1 time per week. 2B. Patient # 3 had a Start of Care date of 8/13/22 and admitting diagnoses of Encounter for change or removal of nonsurgical wound dressing, Venous Insufficiency [Chronic] [Peripheral] [walls or valves in the veins are not working effectively, making it difficult for blood to return to the heart], Type 2 Diabetes Mellitus with other Skin Ulcer, Non-pressure Chronic Ulcer of Right Lower Leg and Non-Pressure Chronic Ulcer of Left Lower Leg. Review of the Plan of Care [POC] for the certification period 8/13/22 to 10/11/22 included orders for SN [skilled nursing] 1 time a week for 2 weeks, 2 times a week for 5 weeks, 1 time a week for 2 weeks. Supplemental orders were written on 9/8/22 for SN to see patients 1 time a week for 1 week, 2 times a week for 2 weeks, 1 time every 3 weeks for 3 weeks. RN # 2 visited the patient on 9/22/22 and documented the following information, “…Patient has numerous venous stasis ulcer [sic]to BLE [bilateral lower extremities]. Wound care performed…Patient short of breath at rest. Lungs diminished at the bases; slight hypotension noted. Adamantly refuses RN recommendations for hospitalization…” Further review of the clinical record revealed no evidence the RN contacted the physician to report her findings prior to advising the patient to seek “hospitalization”. During an interview with the agency director on 11/15/22 at approximately 10 am, the director confirmed the physician was not notified.

Discharge and transfer summaries CFR(s): 484.110(a)(6)(i-iii) (i) A completed discharge summary that is sent to the primary care practitioner or other health care professional who will be responsible for providing care and services to the patient after discharge from the HHA (if any) within 5 business days of the patient's discharge; or (ii) A completed transfer summary that is sent within 2 business days of a planned transfer, if the patient's care will be immediately continued in a health care facility; or (iii) A completed transfer summary that is sent within 2 business days of becoming aware of an unplanned transfer, if the patient is still receiving care in a health care facility at the time when the HHA becomes aware of the transfer. This ELEMENT is not met as evidenced by: Based on agency policy, clinical record review and staff interviews the agency failed to complete an agency discharge summary for 1 of 1 patient who requested agency discharge [#1]; and failed to complete discharge summary for 1 of 1 patient discharged for cause [patient’s or other person in the patient’s home behavior is disruptive, abusive, or uncooperative to the extent that delivery of care to the patient or the ability of the HHA [home health agency] to operate effectively is seriously impaired] [# 3]. The findings included: The policy, Discharge of Patients [8/26/21], was provided by the agency director on 11/14/22 at approximately 3:20 pm. The policy stated, “…A completed discharge summary is sent to the primary care practitioner…after discharge from the HHA [home health agency] within 5 business days of the patient’s discharge…” 1 1. Patient # 1 had a Start of Care [SOC] date of 10/16/22 and admitting diagnoses of Chronic Obstructive Pulmonary Disease [CODP-lung disease], Heart Failure and Chronic Obstructive Pulmonary Disease with acute exacerbation [an acute increase in the severity of an illness]. Review of the Plan of Care for the certification period 10/16/22 to 12/14/22 included orders for SN [skilled nursing] 1 time a week for 1; PT [physical therapy] 2 times a week for 2 weeks, 1 time a week for 1 week, 1 time every 2 weeks for 6 weeks. Review of the clinical record revealed PT # 1 completed the SOC OASIS [Outcome and Assessment Information Set] on 10/16/22. RN # 2 completed the nursing evaluation visit on 10/19/22. Patient # 1 requested discharge from the agency on 10/20/22. Review of the clinical record revealed a communication note dated 10/20/22. The communication note stated, “…. Patient called. No longer wants services.” Review of the clinical record revealed no discharge summary. During an interview with the agency director on 11/14/22 at 2 pm, the director confirmed there was no discharge summary sent to the physician. The discharge was entered as “a non-admit discharge.” 2. Patient # 3 had a Start of Care date of 8/13/22 and admitting diagnoses of Encounter for change or removal of nonsurgical wound dressing, Venous Insufficiency [Chronic] [Peripheral] [walls or valves in the veins are not working effectively, making it difficult for blood to return to the heart], Type 2 Diabetes Mellitus with other Skin Ulcer, Non-pressure Chronic Ulcer of Right Lower Leg and Non-Pressure Chronic Ulcer of Left Lower Leg. Review of the Plan of Care [POC] for the certification period 8/13/22 to 10/11/22 included orders for SN [skilled nursing] 1 time a week for 2 weeks, 2 times a week for 5 weeks, 1 time a week for 2 weeks. Further review of the POC revealed the patient was receiving SN visits related to skin breakdown to lower extremities. Review of the clinical record revealed on 10/12/22 the patient was discharged by RN # 2. The patient was discharged for cause [patient’s or other person in the patient’s home behavior is disruptive, abusive, or uncooperative to the extent that delivery of care to the patient or the ability of the HHA [home health agency] to operate effectively is seriously impaired]. A review of the clinical chart revealed no discharge summary. During an interview with the agency director on 11/15/22 at approximately 11 am, the director confirmed the discharge summary was not completed.

An onsite recertification survey was conducted from 09/27/21 to 09/29/21. No deficiencies to the Emergency Preparedness Program were identified. ABH

An unannounced onsite complaint investigation was conducted 09/27/21 to 09/29/21. The complaint was unsubstantiated. No deficiencies were identified to the Medicare Conditions of Participation. ABH

Plan of care must include the following CFR(s): 484.60(a)(2)(i-xvi) The individualized plan of care must include the following: (i) All pertinent diagnoses; (ii) The patient's mental, psychosocial, and cognitive status; (iii) The types of services, supplies, and equipment required; (iv) The frequency and duration of visits to be made; (v) Prognosis; (vi) Rehabilitation potential; (vii) Functional limitations; (viii) Activities permitted; (ix) Nutritional requirements; (x) All medications and treatments; (xi) Safety measures to protect against injury; (xii) A description of the patient's risk for emergency department visits and hospital re-admission, and all necessary interventions to address the underlying risk factors. (xiii) Patient and caregiver education and training to facilitate timely discharge; (xiv) Patient-specific interventions and education; measurable outcomes and goals identified by the HHA and the patient; (xv) Information related to any advanced directives; and (xvi) Any additional items the HHA or physician or allowed practitioner may choose to include. This ELEMENT is not met as evidenced by: Based on policy review, client record review, and staff interview the agency failed to include all medications on the plan of care for 2 of 3 patients on oxygen (#9 and #12); failed to include Heparin and Normal Saline flushes for 1 of 2 patients with a PICC [peripherally inserted central catheter] line [#10]; failed to include J [jejunostomy] tube feedings and free water flushes for 1 [#16] of 1 patients with a J tube. The findings included: 2.Patient # 12 had a Start of Care [SOC] date of 8/2/21 and admitting diagnoses of Peripheral Vascular Disease, unspecified [PVD] and Chronic Obstructive Pulmonary Disease [COPD]. A review of the Plan of Care [POC] for the certification period 8/2/21 to 9/30/21 revealed orders for PT [physical therapy] 2 times a week for 3 weeks; 1 time a week for 4 weeks; 1 time every 2 weeks for 2 weeks. A review of the SOC documentation by PT # 14 revealed Patient # 12 was on oxygen precautions. A review of the POC did not include oxygen on the medication profile. An interview was conducted with RN # 2 on 9/29/21. During the interview the RN confirmed the patient was using supplemental oxygen and the oxygen should have been included on the POC. 3. Patient # 10 had a Start of Care date of 9/11/21 and admitting diagnoses of Encounter for Adjustment and Management of VAD [vascular access device], Infection and Inflammatory Reaction due to Nephrostomy Catheter and Infection and Inflammatory Reaction due to indwelling Urethral Catheter. A review of the Plan of Care [POC] for the certification period 9/11/21 to 11/9/21 revealed orders for SN [skilled nursing] 1 time a week for 5 weeks; 1 time every 2 weeks for 4 weeks and 3 PRN [as needed] and “…skilled nurse for observation/assessment of IV access site…skilled nurse to infuse and or teach patient/caregiver infusion of Zosyn [antibiotic] 3.37 gram via PICC [peripherally inserted central catheter] line every 8 hours…SN to perform/instruct patient/caregiver to flush PICC line with Saline and Heparin…” A review of the POC did not include the heparin or the saline. An interview was conducted with RN # 2 on 9/29/21. During the interview the RN confirmed the heparin and saline along with the dose should have been included on the POC. 4. Patient # 16 had a Start of Care [SOC] date of 9/4/21 and an admitting diagnosis of Malignant Neoplasm of Esophagus and Gastrostomy status. A review of the Plan of Care [POC] for the certification period 9/4/21 to 11/2/21 revealed orders for SN [skilled nursing] 1 time a week for 1 week; 2 times a week for 3 weeks; 1 time a week for 5 weeks. A review of the discharge summaries dated 9/3/21 revealed the following information “Tube feeds: Kate Farms 1.0 or equivalent by J Tube at 80 ml per hr for 18 hours per day, flush J tube with 50-100 ml of water before and after tube feeding.” A review of the POC does not include the name of the tube feeding nor the amount of free water to flush the J Tube with. An interview was conducted with RN # 2 on 9/29/21. During the interview the RN confirmed the information should be on the POC. Findings included: Review of a policy “Plan of Care, Care Planning Process”, revised 06/24/21 was received from the agency director on 09/29/21 at 9:27 a.m. The policy stated,” ….the plan of care includes… all medications and treatments…”. 1.Patient #9 was admitted on 08/19/21 with diagnoses of copd (chronic obstructive pulmonary disease), pneumonia, atrial fibrillation, anemia, and history of falling. Review of the start of care oasis visit on 08/19/21, revealed the patient was on oxygen therapy, but it was not included on the plan of care. Interview with agency director on 09/29/21 at 9:43 a.m. revealed “ it should be on his med list if it not on there”. Interview with Employee #5 on 03/17/21 at 10:09 a.m. revealed “ oxygen is not on the medication profile; it should be on the profile”.

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 clinical record review and staff interviews the agency failed to follow the Plan of Care related to obtaining O2 saturation levels for 1 of 1 patient complaining of shortness of breath [# 14]; failed to follow the POC related to blood sugar readings for 1 of 6 diabetics [#18]. The findings included: 1. Patient # 14 had a Start of Care [SOC] for 8/13/21 and an admitting diagnosis of Pressure Ulcer of Sacral Region, Stage 3. A review of the Plan of Care for the certification period 8/13/21 to 10/11/21 revealed orders for SN [skilled nursing] 1 time a week for 1 week; 2 times a week for 3 weeks; 1 time a week for 3 weeks; 1 time every 2 weeks for 2 weeks and, “SN may perform O2 saturation level on admission and PRN [as needed] to assess patient…” A review of the clinical record revealed during the SN visits on 9/8/21 and 9/14/21 by RN # 13 the nurse documented the patient was experiencing shortness of breath. Further review of the clinical record revealed no evidence the nurse obtained an O2 saturation reading. An interview was conducted with RN # 2 on 9/29/21. During the interview the RN stated it was “an oversight not to obtain the O2 saturation readings" in accordance with the POC. 2. Patient # 18 had a Start of Care [SOC] date of 7/23/21 and admitting diagnoses of Pressure Ulcer Left Heel, Stage 3 and Type 2 Diabetes Mellitus with Chronic Kidney Disease. A review of the Plan of Care [POC] for the certification period 7/23/21 to 9/20/21 revealed orders for SN [skilled nursing] 3 times a week for 1 week; 2 times a week for 8 weeks, “Skilled nursing to assess patient/caregiver ability to perform and record blood glucose testing as ordered and to report abnormal findings to physician…licensed professional to report vital signs falling outside the following parameters…FSBS [finger stick blood sugar] less than 70 or greater than 350…” A review of the clinical record revealed Patient # 18 received 17 SN visits from 7/23/21 to 9/17/21. Further review of the clinical record revealed no FSBS readings for 17 of 17 visits. An interview was conducted with RN # 2 on 9/29/21. During the interview the RN confirmed the blood sugar readings were not obtained in accordance with the POC.

Communication with all physicians CFR(s): 484.60(d)(1) Assure communication with all physicians or allowed practitioners involved in the plan of care. This ELEMENT is not met as evidenced by: Based on agency policy and procedure, clinical record review, and staff interviews the agency failed to coordinate care with the physician regarding pain for 4 of 24 records reviewed (#9,11, 13, 20); failed to coordinate care with the physician regarding an acute onset of chest pain for 1 of 1 pain with the diagnosis of Non-ST Elevation Myocardial Infarction [NSTEMI] [#1]; failed to coordinate care with the physician regarding missed IV antibiotic doses for 1 of 2 patients with a PICC line [#10]. Findings included: A policy, “Coordination of Care”, revised 04/2019 was received from the agency director on 09/29/21 at 9:27 a.m. The policy stated, “…the agency provides information in a timely manner to physicians and includes as appropriate: changes in condition, patient’s current condition”. A policy, “Pain Assessment and Management”, revised 12/04/20 was received from the agency director on 09/29/21 at 9:27 a.m. The policy stated, “…document in the clinical record: physician notification as appropriate”. 1.Patient #9 had a SOC (start of care) of 08/19/2021 and included diagnoses of copd (chronic obstructive pulmonary disease) with acute lower respiratory infection, pneumonia, atrial fibrillation, opioid dependence, anemia and history of falling. Review of skilled nurse start of care visit for 08/19/21 revealed Patient #9 had pain of 10 on a scale of 1 to 10. Review of physical therapist assistant note for 09/15/21 by Employee #4 revealed Patient #9 had pain of 10 on a scale of 1 to 10. Review of the physical therapist note for 9/21/21 by Employee #5 revealed Patient #9 had pain of 10 on a scale of 1 to 10. Further review of the record confirmed the physician was not notified of the pain. 2.Patient #11 had a SOC of 08/21/21 and included diagnoses of acute cystitis without hematuria, encounter for fitting and adjustment of urinary device, type 2 diabetes, atrial fibrillation, and bipolar disorder. Review of skilled nurse start of care visit for 08/21/21 revealed Patient #11 had pain of 9 on a scale of 1 to 10. Review of skilled nurse note for 09/14/21 by Employee #3 revealed Patient #11 had pain of 8 on a scale of 1 to 10. 3. Patient #13 had a SOC of 08/17/21 and included diagnoses of encounter for attention to other artificial openings of urinary tract, systemic lupus erythematosus, and essential hypertension. Review of the physical therapist assistant note for 9/9/21 by Employee #7 revealed Patient #13 had pain of 8 on a scale of 1 to 10. Interview with the agency director on 9/29/21 at 9:43 a.m. confirmed no documentation is in the record for reporting the pain to the physician. 4. Patient # 20 had a Start of Care [SOC] date of 8/17/20 and an admitting diagnosis of Aftercare Following Joint Replacement Surgery. A review of the Plan of Care [POC] for the certification period 8/17/20 to 10/15/20 included orders for SN [skilled nursing] 1 time a week for 4 weeks; PT [physical therapy] 2 times a week for 4 weeks; 1 time a week for 3 weeks; 1 time every 2 weeks for 2 weeks. A review of the clinical record revealed the patient had an inpatient stay from 9/4/20 until 9/8/20. The clinical record included resumption of care orders dated for 9/9/20 with SN visits for 1 time a week for 1 week; 1 time a week for 3 weeks; 1 time a week every 2 weeks for 2 weeks. A review of the clinical record revealed RN # 19 completed the resumption of care visit on 9/9/21 and documented the following information, “Pt [patient complaining of pain to her left knee. Leg immobilizer removed and RN assessed knee. Left knee is swollen and appears to be filled with fluid…Immobilizer placed back on pt and secured…” RN # 19 completed a routine visit on 9/10/21 and documented the patient reported a pain level of 10 on a scale of 1-10. The pain was noted in the left knee area. RN # 19 documented the following information, “Pt [patient] still complaining of pain to left knee. Knee remains swollen…” On 9/14/21 RN # 21 made a routine visit to assess Patient # 20. The patient continued to complain of a pain level of 8 on a scale of 1-10 with the pain not being relieved to a below an 8. The pain was continued to be noted in the left knee area. Further review of the clinical record revealed no evidence the physician was notified of the edema or the pain in the left knee. An interview was conducted with RN # 2 on 9/29/21. During the interview the RN confirmed the physician was not notified of the patient’s complaints. 5. Patient # 1 had a Start of Care [SOC] date of 8/27/21 and an admitting diagnosis of Non-ST Elevation Myocardial Infarction [NSTEMI]. A review of the Plan of Care [POC] for the certification period 8/27/251 to 10/25/21 revealed orders for SN [Skilled nursing] 1 time a week for 1 week; 2 times a week for 2 weeks; 1 time a week for 2 weeks; 1 time every 2 weeks for 4 weeks. A review of the SOC documentation revealed the following information by RN # 9, “…During nursing visit patient had acute onset of chest pain rated 8 out of 10. Nitroglycerin was administered. Blood pressure and heart rate remained stable. Within 5 minutes pain had decreased to 5 out of 10. Stable BP [blood pressure] and heart rate. Within 30 minutes pain was a 0 out of 10…” Further review of the documentation does not include any evidence the RN notified the MD of the acute onset of chest pain. An interview was conducted with RN # 2 on 9/29/21. The RN stated, “I feel certain the MD was notified but it is not documented.” 6. Patient # 10 had a Start of Care date of 9/11/21 and admitting diagnoses of Encounter for Adjustment and Management of VAD [vascular access device], Infection and Inflammatory Reaction due to Nephrostomy Catheter and Infection and Inflammatory Reaction due to indwelling Urethral Catheter. A review of the Plan of Care [POC] for the certification period 9/11/21 to 11/9/21 revealed orders for SN [skilled nursing] 1 time a week for 5 weeks; 1 time every 2 weeks for 4 weeks and 3 PRN [as needed] and “…skilled nurse for observation/assessment of IV access site…skilled nurse to infuse and or teach patient/caregiver infusion of Zosyn [antibiotic] 3.37 gram via PICC [peripherally inserted central catheter] line every 8 hours. A review of the SOC visit dated 9/11/21 and conducted by RN # 13 revealed the following documentation, “Patient did miss last night, and this am dose due to patient’s wife having a fall in the home…” There is no evidence the physician was notified the patient missed the 2 doses of antibiotic. An interview was conducted with RN # 2 on 9/29/21. During the interview the RN confirmed the MD should have been notified of the missed doses of antibiotic.

Required items in clinical record CFR(s): 484.110(a)(1) The patient's current comprehensive assessment, including all of the assessments from the most recent home health admission, clinical notes, plans of care, and physician or allowed practitioner orders; This ELEMENT is not met as evidenced by: Based on policy review, client record review, and staff interview the clinical record failed to include picc (peripherally inserted central catheter line measurements for 2 of 2 patients with a picc line (#17 and #10);copied and pasted from previous visit note for 1 of 2 patients with a picc line [#10]; failed to document wound measurements for 1 of 8 patients with wounds (# 18); failed to document correct information related to skin integrity/Braden scale in the Oasis for 2 of 8 patients with a wound [#18 and 24]. The findings included: 2A. Patient # 10 had a Start of Care date of 9/11/21 and admitting diagnoses of Encounter for Adjustment and Management of VAD [vascular access device], Infection and Inflammatory Reaction due to Nephrostomy Catheter and Infection and Inflammatory Reaction due to indwelling Urethral Catheter. A review of the Plan of Care [POC] for the certification period 9/11/21 to 11/9/21 revealed orders for SN [skilled nursing] 1 time a week for 5 weeks; 1 time every 2 weeks for 4 weeks and 3 PRN [as needed] and “…skilled nurse for observation/assessment of IV access site…skilled nurse to infuse and or teach patient/caregiver infusion of Zosyn [antibiotic] 3.37 gram via PICC [peripherally inserted central catheter] line every 8 hours. Change PRN for loose or soiled dressings…” A review of the SOC documentation by RN # 13 on 9/11/21 revealed no evidence the nurse obtained the arm circumference. An interview was conducted with RN # 2 on 9/29/21. During the interview the RN confirmed the measurements related to the PICC line should include the arm circumference and length of exposed catheter each week. A review of the clinical record for the routine visit on 9/13/21 by RN # 8 revealed no arm circumference. A review of the clinical record for the visit dated 9/21/21 revealed no arm circumference or exposed catheter measurement. An interview was conducted with RN # 2 on 9/29/21. During the interview the RN confirmed the measurements related to the PICC line should include the arm circumference and length of exposed catheter each week. 2B. Patient # 10 had a Start of Care date of 9/11/21 and admitting diagnoses of Encounter for Adjustment and Management of VAD [vascular access device], Infection and Inflammatory Reaction due to Nephrostomy Catheter and Infection and Inflammatory Reaction due to indwelling Urethral Catheter. A review of the Plan of Care [POC] for the certification period 9/11/21 to 11/9/21 revealed orders for SN [skilled nursing] 1 time a week for 5 weeks; 1 time every 2 weeks for 4 weeks and 3 PRN [as needed] and “…skilled nurse for observation/assessment of IV access site…skilled nurse to infuse and or teach patient/caregiver infusion of Zosyn [antibiotic] 3.37 gram via PICC [peripherally inserted central catheter] line every 8 hours…SN to perform/instruct patient/caregiver to flush PICC line with Saline and Heparin…” A review of the SOC visit dated 9/11/21 and conducted by RN # 13 revealed the following documentation, “Patient did miss last night, and this am dose due to patient’s wife having a fall in the home…” A review of the documentation for the SN visit on 9/13/21 by RN # 8 stated the following, “…Educated wife ____ [name] administration of IV. Patient did miss last night and this am…” RN # 8 was not available for interview. An interview was conducted with RN # 1 on 9/29/21. During the interview the RN stated, “we have had a problem with this nurse copying and pasting notes. It looks like that is what she has done this visit 3A. Patient # 18 had a Start of Care [SOC] date of 7/23/21 and an admitting diagnosis of Pressure Ulcer Left Heel, Stage 3. A review of the Plan of Care [POC] for the certification period 7/23/21 to 9/20/21 revealed orders for SN [skilled nursing] 3 times a week for 1 week; 2 times a week for 8 weeks and “skilled nurse to perform/teach patient/caregiver pressure ulcer care to left heel. Cleanse with wound cleanser or normal saline, apply silver alginate. May apply skin barrier to periwound PRN [as needed] to prevent maceration and protect periwound. Cover with foam and secure with kerlix and tape... " A review of the clinical record revealed no wound measurements from 7/28/21 to 8/17/21. An interview was conducted with RN # 2 on 9/29/21. During the interview the RN confirmed the wound measurements were not documented in accordance with the agency policy. 3B. Patient # 18 had a Start of Care [SOC] date of 7/23/21 and an admitting diagnosis of Pressure Ulcer Left Heel, Stage 3. A review of the Plan of Care [POC] for the certification period 7/23/21 to 9/20/21 revealed orders for SN [skilled nursing] 3 times a week for 1 week; 2 times a week for 8 weeks and “skilled nurse to perform/teach patient/caregiver pressure ulcer care to left heel. Cleanse with wound cleanser or normal saline, apply silver alginate…” A review of the SOC Oasis [Outcome and Assessment Information Set] completed by RN # 16 on 7/23/21 revealed the following documentation, “Initial Skin Assessment-Skin Intact/Within Normal Limits. An interview was conducted with RN # 2 on 9/29/21. During the interview the RN confirmed the initial skin assessment was documented incorrectly. 4. Patient # 24 had a Start of Care [SOC] date of 5/26/21 and an admitting diagnosis Pressure Ulcer of Right Buttock, Stage 2. A review of the Plan of Care [POC] for the certification period 5/26/21 to 7/24/21 revealed orders for SN [skilled nurse] 1 time a week for 9 weeks and , “…SN to perform/teach patient/caregiver pressure ulcer care to right buttock-irrigate/cleanse with wound cleanser, gauze and gloves. May apply skin barrier to periwound PRN [as needed] to prevent maceration and protect periwound. Cover with bordered foam, change dressing every 3 days and PRN for soiled or dislodgement…” A review of the SOC Oasis [[Outcome and Assessment Information Set] completed by RN # 6. A review of the clinical record revealed the RN documented the skin was intact/within normal limits for the initial skin assessment. The RN also documented the patient was not at risk for skin breakdown in the Braden Scale section of the Oasis. An interview was conducted with RN # 2 on 9/29/21. During the interview the confirmed the documentation was incorrect. Findings included: Review of a policy “Central venous Access Device Dressing Change”, revised 01/2020 was received from the agency director on 09/29/21 at 9:27 a.m. The policy stated” … document in the clinical record: length of external segment measured, appearance of catheter and insertion/exit site”. Review of policy “Removal of PICC, Midline, Non-Tunneled CVAD and Short Peripheral Cath”, revised 02/2017 was received from the agency directory on 09/29/21 at 9:27 a.m. The policy stated”…document in the clinical record: condition and length of catheter and appearance of the tip”. 1.Patient #17 was admitted on 08/17/21 with diagnoses of encounter for adjustment and management of vascular device, infection right tibia, essential hypertension, anemia, and type 2 diabetes. The plan of care for 08/17/21 to 10/15/21 had orders for skilled nursing 2 times a week for 1 week, and 1 time a week for 6 weeks. Orders for skilled nursing were to observe and assess of IV (intravenous) site picc, response to medication. SN for skilled teaching regarding infusion procedure, care of access device, signs and symptoms of access device complications, and care and use of infusion equipment. Review of skilled nursing notes for dates of 08/17/21, 08/24/21, 08/26/21, 08/30/21, and 09/08/21 revealed measurements were not obtained for the weeks of 08/24/21 and 08/30/21. Review of the skilled nurse visit note on 09/08/21 revealed the picc line was removed but did not include documentation on the condition and length of catheter tip. Interview with the agency director on 9/29/21 at 9:54 a.m. revealed, “the visits are missing picc measurements, and didn’t follow policy regarding pulling the picc line”.