Every finding on record at Eraj Holdings, LLC

An unannounced, onsite recertification survey was conducted 9/8/25-9/9/25. No deficiencies to the Emergency Preparedness Plan were identified.

An unannounced, onsite recertification survey was conducted 9/8/25-9/9/25. Standard level deficiencies were identified to the Medicare CoPs.

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, interviews with staff and patients, the Plan of Care [POC] failed to include all current/correct medications the patient was taking for 2 of 3 home visits [#3 and 4]; and the POC failed to include all wound care orders for 1 of 1 patient receiving wound care during a home visit [#3]. The findings included: The policy, Care Planning: Initial Care Plan and Updates to the Plan of Care [03/24], was provided by the agency director on 9/9/25 at 8 am. The policy stated, “...The Plan of Care also included documentation of the following...All current prescriptions and over the counter medications...All patient care orders, including verbal orders must be recorded in the plan of care..." 1A. Patient # 3 had a Start of Care date of 1/8/25 with an admitting diagnosis of pressure ulcer, sacral area [lower back, just above the buttocks] stage 4 [skin damage involving full-thickness tissue loss, exposing muscle, tendon or bone]. Review of the Plan of Care [POC] for the certification period 9/5/25-11/3/25 included orders for SN [skilled nursing] 1 time a week for 1 week, 2 times a week for 7 weeks and “SN to perform medication review each skilled nursing visit and reconcile medications as indicated...” On 9/8/25 at approximately 12 noon a joint visit was made with RN # 1. During the visit a medication review was conducted using a medication profile provided by the agency. The following discrepancies were noted: The medication profile listed cranberry [supplement] 1000 mg. Take 2 tablets daily. During an interview with the patient he stated, “I don’t take that anymore.” The medication profile listed gabapentin [used for nerve pain] 800 mg. Take 1 capsule 3 times a day. During an interview with the patient he stated, “The doctor changed that to 900 mg 3 times a day several months ago.” During an interview with the agency director on 9/9/25 at 10 am, the director confirmed the POC did not include all current/correct medications. 1B. Patient # 3 had a Start of Care date of 1/8/25 with an admitting diagnosis of pressure ulcer, sacral area [lower back, just above the buttocks] stage 4 [skin damage involving full-thickness tissue loss, exposing muscle, tendon or bone]. Review of the Plan of Care [POC] for the certification period 9/5/25-11/3/25 included orders for SN [skilled nursing] 1 time a week for 1 week, 2 times a week for 7 weeks and “Wound care to sacral/upper buttock wound-clean wound with soap and water, rinse and pat dry...apply to wound bed fibercol plus then cover with abdominal pads...Change dressing 3 times per week and as needed if soiled and drainage. Caregiver to perform wound care when RN not present.” A joint visit was made with RN # 1 on 9/8/25 to observe wound care. After the wound care was completed, an interview was conducted with the patient. The patient reported the wound care is done 2 times a week by the RN. The patient went on to explain that his wife recently had surgery and couldn’t do the dressing change. During an interview with the agency director on 9/9/25 at 10 am, the director reported the frequency for the wound care was changed in April 2025 from 3 times a week to 2 times a week, and the RN had failed to write the order to change the frequency. A late order was noted on the chart dated 9/8/25 for 4/2025 to change the frequency of the wound care. The director confirmed the order was not included in the POC. 2. Patient # 4 had a Start of Care of 7/17/25 with an admitting diagnosis of hemiplegia [paralysis of half of body] following cerebral infarction [stroke] affecting left non-dominant side. Review of the Plan of Care [POC] for the certification period 7/17/25-9/14/25 revealed orders for PT [physical therapy] 1 time a week for 9 weeks. On 9/8/25 at approximately 2 pm a joint visit was made with PT # 2. During the visit a medication review was conducted using a medication profile provided by the agency. The following discrepancies were noted: The medication profile listed vitamin B 12 [supplement] 1000 mcg. Take 2 every day. During an interview with the patient he reported, “I don’t take those anymore.” The medication profile listed melatonin [sleep aid] 3 mg. Take 2 tablets each night. During the interview with the patient he stated, “I don’t take those anymore either.” During an interview with the agency director on 9/9/25 at 10 am, the director confirmed the POC did not include all current/correct medications.

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 agency policy, direct observation, and clinical interviews, the RN failed to follow correct bag technique for 1 of 1 patient who received wound care during a home visit [3]. The findings included: The policy, Bag Technique, home care [revised 5/19/25], was provided by the agency director on 9/9/25 at 8 am. The policy stated, “...Remove all needed equipment from the bag and place them on a clean, dry surface. Use a fluid-impermeable pad as a barrier...” Patient # 3 had a Start of Care date of 1/8/25 with an admitting diagnosis of pressure ulcer, sacral area [lower back, just above the buttocks] stage 4 [skin damage involving full-thickness tissue loss, exposing muscle, tendon or bone]. Review of the Plan of Care for the certification period 9/5/25-11/3/25 included orders for SN [skilled nursing] 1 time a week for 1 week, 2 times a week for 7 weeks and “Wound care to sacral/upper buttock wound-clean wound with soap and water, rinse and pat dry...apply to wound bed fibercol plus then cover with abdominal pads...” On 9/8/25 at approximately 12 noon a joint visit was made with RN # 1 to observe wound care. RN # 1 removed disposable gloves from the nursing bag along with other supplies for the dressing change and placed the items at the foot of the bed on the bed covers. The RN failed to use a barrier between the bed and the clean wound care supplies. During an interview with the agency director on 9/9/25 at approximately 10 am, the director confirmed the RN should have placed a barrier on the bed before placing the clean supplies/gloves on the bed.

A recertification survey was conducted 9/12/22-9/14/22. No deficiencies to the Emergency Preparedness Plan was identified.

An onsite recertification survey was conducted 9/12/22-9/14/22. Standard level deficiencies were identified.

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, clinical record review and staff interviews the agency failed to include correct medication doses/strength on the Plan of Care for 2 of 14 patients [#3 and 6]; failed to include all pertinent diagnoses for 1 of 14 patients [#6]; and failed to include the bulb size for a urinary catheter for 1 of 2 patients with a catheter [#9]. The findings included: The policy, Care Planning: Initial Care Plan and Updates to the Plan of Care [3/22], was provided by RN # 2 on 9/14/22 at 9:00 am. The policy stated, “…The plan of care also includes documentation of the following…all pertinent primary, secondary and surgical diagnoses with dates of onset or exacerbation…All current prescription and over-the-counter medications…Specific patient care orders, including verbal orders, interventions and treatments…” 1A. Patient # 3 had a Start of Care date of 8/11/22 and admitting diagnoses of Bloodstream Infection due to Central Venous Catheter [catheter placed in a large vein-used in patients requiring prolonged intravenous therapies] and Methicillin Resistant Staphylococcus [type of bacteria] causing diseases. Review of the Plan of Care [POC] for the certification period 8/11/22 to 10/9/22 [medication section] included orders for “Oxygen 2-2.5 liters/minute, continuous, inhaled”. Further review of the POC included the following order, “SN to instruct patient/caregiver regarding self-management of oxygen therapy…administer O2 [oxygen] at 2-3 liters per minute…” During an interview with RN # 1 on 9/14/22 at 10:00 am, RN # 1 confirmed the POC included discrepancies related to the order for Oxygen. 1B. B. Patient # 3 had a Start of Care date of 8/11/22 and admitting diagnoses of Bloodstream Infection due to Central Venous Catheter [catheter placed in a large vein-used in patients requiring prolonged intravenous therapies] and Methicillin Resistant Staphylococcus [type of bacteria] causing diseases. Review of the Plan of Care [POC] for the certification period 8/11/22 to 10/9/22 [medication section] included an order for “Nystatin [antifungal] 100,000 units/gram topical powder. 1 application. Twice a day as needed topical”. There was no indication for the use of the Nystatin. During an interview with RN # 1 on 9/14/22 at 10:00 am, RN # 1 confirmed the order did not include the indications for the use. 2A. Patient # 6 had a Start of Care date of 8/10/22 and admitting diagnoses of Pneumonia and Chronic Obstructive Pulmonary Disease [COPD-lung disease]. Review of the Plan of Care [POC] for the certification period 8/10/22 to 10/8/22 [medication section] included an order for Fentanyl [pain patch] 1 film every 72 hours. There was no strength listed for the Fentanyl. During an interview with RN # 2 on 9/14/22 at 2:00 pm. During the interview, RN # 2 confirmed no strength/dose was on the POC. 2B. Patient # 6 had a Start of Care date of 8/10/22 and admitting diagnoses of Pneumonia and Chronic Obstructive Pulmonary Disease [COPD-lung disease]. Review of the Plan of Care [POC] for the certification period 8/10/22 to 10/8/22 included orders for SN [skilled nursing] 2 times a week for 1 week, 1 time a week for 2 week, 0 times a week for 1 week, 1 time every other week for 5 weeks, 2 PRN [as needed] elevated blood pressure, signs of CHF [congestive heart failure] exacerbation…SN to assess other co-morbidities including CHF…” The POC did not include CHF as a diagnosis. During an interview with RN # 2 on 9/14/22 at 2:00 pm, CHF should have been included on the POC. 3. Patient # 9 had a Start of Care [SOC] date of 8/12/22 and admitting diagnoses of Cutaneous Abscess [a swollen area within body tissue, containing an accumulation of pus] of Back, Cellulitis [bacterial skin infection] of Back, Retention of Urine, and Encounter for fitting and adjustment of Urinary Catheter. The Plan of Care for the certification period 8/12/22 to 10/10/22 included orders for SN [skilled nursing] 1 time a week for 1 week, 3 times a week for 2 weeks, 2 times a week for 1 week, 1 time a week for 5 weeks, 2 PRN [as needed] for changes in clinical condition and “SN to instruct patient/caregiver regarding self-management and prevention of urinary tract infection. __________ [name of facility] currently managing foley [type of an indwelling urinary catheter] catheter changes…” A supplemental order was written on 8/16/22 for “SN to insert 14 fr [French] catheter to gravity drainage system q [every] month…]. The order did not include the size of bulb. An interview was conducted with RN # 1 on 9/14/22 at approximately 3 pm. During the interview RN # 1 confirmed the order was incomplete.

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 the physician’s order related to Heparin [blood thinner] flushes for 1 of 1 patient with a PICC line [peripherally inserted central catheter] [#11]; and failed to follow the physician’s order related to new wound care orders for 1 of 5 patients with a wound[#6]. The findings included: 1. Patient # 11 had a Start of Care date of 8/23/22 with the admitting diagnoses of Disruption of External Operation Wound [cut made during a surgical procedure reopens], Encounter for Adjustment and Management of VAD [vascular access device-allow repeated and long-term access to the blood steam for frequent or regular administration of drugs such as antibiotics]. Review of the Plan of Care [POC] for the certification period 8/23/22 to 8/23/22 to 10/21/22 included orders for SN [skilled nursing] 2 times a week for 9 weeks, 3 PRN [as needed] for labs, PICC [peripherally inserted central catheter] line complications and dressing changes and “…SN to infuse/administer, instruct patient/caregiver to infuse/administer vancomycin [antibiotic] 1250 mg [milligrams] /250 mg NACL [Sodium Chloride 0.9%- used with intravenous therapy]…Flush IV [intravenous therapy] access with 10 ml [milliliters] of NACL…Follow this with heparin [used to prevent clotting of the PICC] 5 ml/10 units…”Review of the SN visit notes revealed during a routine visit on 8/25/22 the patient complained of itching. RN # 3 contacted the physician and documented the following, “…I reported that the patient is having a reaction to something which includes a light rash and itching… ______ [name of physician’s nurse] called back and said the MD said to hold the heparin due to itching…” A supplemental order was noted in the clinical record dated 8/25/22 to “discontinue Heparin”. Review of the SN visit note dated 9/1/22 by RN # 3 revealed the following documentation, “…Flushed line with…followed by Heparin 5 ml/10 units/ml…” During an interview with RN # 1 on 9/14/22 at 1 pm, the RN confirmed the Heparin had been discontinued and the PICC line should not have been flushed with the Heparin. 2. Patient # 6 had a Start of Care date of 6/10/22. Review of the Plan of Care [POC] for the certification period 8/9/22 to 10/7/22 included diagnoses of Pressure Ulcer of Left Buttock Stage 4 [deep wound that reaches the muscles, ligaments, or bone], Unspecified Wound of Left Elbow and Quadriplegia [paralysis of all four limbs]. The POC included orders for SN [skilled nursing] 0 times a week for 1 week, 1 time a week for 8 weeks, 2 PRN[as needed] complications with wounds and “…left elbow-cleanse affected area gently with soap and water, apply skin protection ointment such as Manuka Honey [type of topical medication] and cover with island [type of wound dressing], change daily and as needed…Stage 4-left buttock, irrigate with normal saline, apply skin protectant to skin surrounding wound, lightly pack with silver alginate [type of wound dressing], cover with hydrocolloid [type of wound dressing] or island dressing. Change every 3 days and as needed…” A supplemental order was written on 8/23/22 by ______ [name of wound clinic]. The supplemental ordered stated, “…buttock- clean with normal saline, apply Hydrofiber AG [type of wound dressing]…pack with dry 4x4 gauze, cover with Allevyn [type of wound dressing] foam…apply polymem pink [type of wound dressing] and gentle foam border…Do not omit or substitute wound care products…home health nurse to do dressing changes 1 time per week…” Review of the SN visit notes dated 8/23/22, 8/30/22 and 9/6/22 revealed the SN did not follow the new orders related to wound care. During an interview with RN # 2 on 9/14/22 at 2:30 pm, RN # 2 confirmed the new orders for wound care were not followed, “I don’t see where the new order was transcribed as an order for our clinicians to know there was a new order.”

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 communicate with the physician when vital signs were outside the given parameters for 1 of 14 patients [#2]. The findings included: The policy, Coordination and Communication Activities [12/2021], was provided by RN # 1 on 9/14/22 at 9:00 am. The policy stated, “…Home health staff will maintain on-going communication with all physicians involved in the plan of care…significant changes in the patient’s condition, including findings that are outside of established reporting parameters…” Patient # 2 had a Start of Care date of 7/7/22. Review of the Plan of Care for the certification period 9/5/22 to 11/3/22 included diagnoses of Pressure Ulcer of Right Hip, Unstageable [full thickness tissue loss but is either covered by extensive necrotic tissue or an eschar]and Chronic Obstructive Pulmonary Disease [COPD-lung disease] and orders for SN [skilled nursing] 1 time a week for 9 weeks, 2 PRN [as needed] change in clinical status and “Notify physician of vital sign parameters out of range… systolic blood pressure[measures the pressure in the arteries when the heart beats] greater than 160 or less than 90, diastolic blood pressure [measures the pressure in the arteries when the heart is at rest -between heart beats] greater than 90 or less than 60…” A review of the skilled nursing visit note dated 9/5/22 and completed by RN # 3 revealed blood pressure readings of 80/66 and 82/77. There was no evidence the physician was notified of the blood pressure reading being outside the given parameters. An interview was conducted with RN # 2 on 9/14/22 at 2:30 pm. During the interview, RN # 2 confirmed the physician was not notified of the blood pressure reading.

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 an overdose of medications for 1 of 1 patient who overdosed on prescription medication [#8]. The findings included: The policy, Coordination and Communication Activities [12/2021], was provided by RN # 1 on 9/14/22 at 9:00 am. The policy stated, “…Home health staff will maintain on-going communication with all physicians involved in the plan of care…significant changes in the patient’s condition…” Patient # 8 had a Start of Care of 8/22/22 and admitting diagnoses of Chronic Obstructive Pulmonary Disease [COPD-lung disease] and Bipolar [disorder associated with episodes of mood swings ranging from depressive lows and manic highs]. Review of the Plan of Care for the certification period 8/22/22 to 10/20/22 and “SN [Skilled nursing] 2 times a week for 1 week, 1 time a week for 2 weeks, 10 [sic] week 6, 2 PRN [as needed] for change in medical condition…” Review of the clinical record revealed a hospitalization summary dated 9/9/22 from ______ [name of physician] at ______ [name of hospital]. The summary stated, “As clarification, the patient was not under involuntary commitment, but a 24-hour hold…Stated Complaint: ‘Overdose? [sic]’ …History of Present Illness [HPI] MD complaint: Present intentional overdose…HPI: 60-year-old female presents with an overdose. She states she took 20 of her Singular [anti-inflammatory used to treat allergies and prevent asthma attacks] tablets (10 milligrams) at noon to ‘wake my brain up’ …” Patient # 8 returned home on 9/10/22. The clinical record revealed the last SN visit was made on 9/7/22 by RN # 4. There had not been a follow up visit since the patient had returned home on 9/10/22. The clinical record revealed no evidence the agency had notified the physician of the patient’s attempted overdose. During an interview with RN # 1 on 9/14/22 at 2:00 pm, the RN stated, “the hospital summary indicates the physician was forwarded a copy of the ER [emergency room] physician.”

Home health aide assignments and duties CFR(s): 484.80(g)(1) Standard: Home health aide assignments and duties. Home health aides are assigned to a specific patient by a registered nurse or other appropriate skilled professional, with written patient care instructions for a home health aide prepared by that registered nurse or other appropriate skilled professional (that is, physical therapist, speech-language pathologist, or occupational therapist). This STANDARD is not met as evidenced by: Based on agency policy, clinical record review and staff interviews the agency failed to include vital sign parameters on the aide care plan for 1 of 3 patients who received aide services [#6]. The findings included: The policy, Home Health Aide Care Plan and Documentation [4/2021], was provided by RN # 1 on 9/14/22 at 2:30 pm. The policy stated, “…The registered nurse or other appropriate skilled professional develops the home health aide care plan in consultation with the patient and/or family, completing all parts and providing the aide with all necessary information to carry out his/her duties safely…notes any special information or instructions specific to the patient, including parameters for reporting to the supervising clinician…” Patient # 6 had a Start of Care date of 6/10/22. Review of the Plan of Care [POC] for the certification period 8/9/22 to 10/7/22 included diagnoses of Pressure Ulcer of Left Buttock Stage 4 [deep wound that reaches the muscles, ligaments, or bone], Unspecified Wound of Left Elbow and Quadriplegia [paralysis of all four limbs]. The POC included orders for SN [skilled nursing] 0 times a week for 1 week, 1 time a week for 8 weeks, 2 PRN [as needed] complications with wounds and HHA [aide] 2 times a week for 9 weeks. Review of the Aide Visit notes dated 8/9/22, 8/12/22, 8/18/22, 8/23/22, 8/30/22, 9/2/22, 9/6/22 and 9/9/22 revealed the section “Report vital signs outside given parameters” was checked but the parameters were not listed. During an interview with RN # 1 on 9/14/22 at 1:00 pm, the RN stated, “Yes, the vital sign parameters should have been included on the aide visit notes, but the new system did not carry the parameters over.”

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 clinical record review and staff interviews the clinical record failed to include the bulb size for an indwelling catheter for 1 of 2 patients with an indwelling catheter [#9]; and failed to include PICC [peripherally inserted central catheter] line assessments for 1 of 1 patient with a PICC line [#11];and failed to include orders related to wound care for 1 of 5 patients with a wound [#11]; and failed to include a wound assessment for 1 of 5 patients with a wound [#11]; and failed to include an order for insulin [diabetic medication] for 1 of 5 patients with Diabetes [#13]. The findings included: 1. Patient # 9 had a Start of Care [SOC] date of 8/12/22 and admitting diagnoses of Cutaneous Abscess [a swollen area within body tissue, containing an accumulation of pus] of Back, Cellulitis [bacterial skin infection] of Back, Retention of Urine, and Encounter for fitting and adjustment of Urinary Catheter. The Plan of Care for the certification period 8/12/22 to 10/10/22 included orders for SN [skilled nursing] 1 time a week for 1 week, 3 times a week for 2 weeks, 2 times a week for 1 week, 1 time a week for 5 weeks, 2 PRN [as needed] for changes in clinical condition and “SN to instruct patient/caregiver regarding self-management and prevention of urinary tract infection. __________ [name of facility] currently managing foley [a type of indwelling urinary catheter] catheter changes…” A supplemental order was written on 8/16/22 for “SN to insert 14 fr [French] catheter to gravity drainage system q [every] month…]. Review of the Skilled Nurse Visit Note dated 8/19/22 included the following documentation, “…Aseptic technique used to deflate balloon on current catheter and remove foley …Sterile technique used…insert sterile lubricated 14 fr foley…balloon inflated…” The bulb size/amount of fluid inserted into the bulb of the catheter is not included in the documentation. During an interview with RN # 1 on 9/14/22 at 3 pm, the RN confirmed the bulb size was not included. 2A. Patient # 11 had a Start of Care date of 8/23/22 with the admitting diagnoses of Disruption of External Operation Wound [cut made during a surgical procedure reopens], Encounter for Adjustment and Management of VAD [vascular access device-allow repeated and long-term access to the blood steam for frequent or regular administration of drugs such as antibiotics]. Review of the Plan of Care [POC] for the certification period 8/23/22 to 8/23/22 to 10/21/22 included orders for SN [skilled nursing] 2 times a week for 9 weeks, 3 PRN [as needed] for labs, PICC [peripherally inserted central catheter] line complications and dressing changes and “…SN to perform sterile dressing changes to picc line on right arm weekly…” Review of the Goal section of the POC included the following goal “..Patient’s IV [intravenous therapy] access will remain patent during this episode of care and patient will be free from signs of symptoms of infection…” Review of the SN visit notes from 8/23/22-9/12/22 [7 visits] revealed no PICC line assessments. The PICC line was removed on 9/12/22. During an interview with RN # 2 on 9/14/22 at 3:30 pm the RN confirmed no documented PICC line assessments were noted in the clinical record. 2B. Patient # 11 had a Start of Care date of 8/23/22 with the admitting diagnoses of Disruption of External Operation Wound [cut made during a surgical procedure reopens], Encounter for Adjustment and Management of VAD [vascular access device-allow repeated and long-term access to the blood steam for frequent or regular administration of drugs such as antibiotics]. Review of the Plan of Care [POC] for the certification period 8/23/22 to 8/23/22 to 10/21/22 included orders for SN [skilled nursing] 2 times a week for 9 weeks, 3 PRN [as needed] for labs, PICC [peripherally inserted central catheter] line complications and dressing changes and “SN to perform wound care to right ankle; Cleanse wound with normal saline, apply iodoform [type of topical ointment] gel to wound bed, cover with aquacel ag [type of wound dressing], secure with unna boot and coban twice weekly…”Review of the SN visit note dated 9/1/22, by RN # 3 revealed the following documentation, “Diabetic foot assessment completed with a new open area below the wound. I reported to the MD. _____ [name of physician] called me back…MD said to perform the same wound care for it.” Review of the clinical record revealed no written order dated 9/1/22 related to wound care to the “new wound”. During an interview with RN # 1 on 9/14/22 at approximately 12:30 pm, she confirmed no order was found in the clinical record. 2C. Patient # 11 had a Start of Care date of 8/23/22 with the admitting diagnoses of Disruption of External Operation Wound [cut made during a surgical procedure reopens], Encounter for Adjustment and Management of VAD [vascular access device-allow repeated and long-term access to the blood steam for frequent or regular administration of drugs such as antibiotics]. Review of the Plan of Care [POC] for the certification period 8/23/22 to 8/23/22 to 10/21/22 included orders for SN [skilled nursing] 2 times a week for 9 weeks, 3 PRN [as needed] for labs, PICC [peripherally inserted central catheter] line complications and dressing changes and “SN to perform wound care to right ankle; Cleanse wound with normal saline, apply iodoform [type of topical ointment] gel to wound bed, cover with aquacel ag [type of wound dressing], secure with unna boot and coban twice weekly…”Review of the SN visit note dated 9/1/22, by RN # 3 revealed the following documentation, “Diabetic foot assessment completed with a new open area below the wound..” Review of the clinical record revealed no wound assessment was documented for the “new wound” noted on 9/1/22 for 4 of 4 visits [9/1/22-9/12/22]. During an interview with RN # 1 on 9/14/22 at 12:30 pm, she confirmed there was no wound assessment documented in the clinical record for the “new wound”. 3. Patient # 13 had a Start of Care date of 1/25/22. Review of the Plan of Care for the certification period 3/26/22 to 5/24/22 included diagnoses of Chronic Obstructive Pulmonary Disease [COPD-lung disease] and Type 2 Diabetes Mellitus with Diabetic Chronic Kidney Disease and SN [Skilled nursing] 1 time a week for 2 weeks then once every 2 weeks for 4 weeks. Patient # 13 resided at _________ [name of assisted living facility -ALF]. RN # 3 made a routine visit on 4/26/22. During the visit on 4/22/22, ALF staff reported blood sugars of “500 at 7 am and 438 at 11:10 am” RN # 3 contacted the physician and documented, “I notified MD of high blood sugar, and he ordered 10 units of fast acting insulin…” Review of the clinical record revealed no order for “high acting insulin”. An interview with RN # 2 on 9/14/22 at 1:30 pm confirmed there was no order written for insulin on 4/44/22 in the clinical record.

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 review, clinical record review and staff interviews the clinical record failed to include a discharge summary for 1 of 4 discharged patients [#1]. The findings included: The policy, Discharge and Transfer of Patients [9/2021] was provided by the agency administrator on 9/14/22 at approximately 11 am. The policy stated, “…The clinician will complete a discharge summary and will discharge the patient from the system withing 1 calendar day…” Patient # 1 had a Start of Care date of 7/28/22 and admitting diagnoses of Displaced Trimalleolar Fracture [break of the lower leg section that forms the ankle joint and helps move the ankle and foot] of Right Lower Leg, Unspecified Injury of the Head, and Unspecified Fall. The Plan of Care for the certification period 7/28/22 to 9/25/22 included orders for PT [physical therapy] 1 time a week for 5 weeks. The clinical record revealed the patient was transferred to _______ [name of the hospital] on 8/3/22 and was admitted with a diagnosis of UTI [urinary tract infection]. The discharge plan from ______ [name of hospital was dated 8/15/22. The discharge plan included the following documentation,” …Family is in agreement with hospice, and they have been consulted…I suspect pt [patient] has less than 48 hours…” Further review revealed the patient died on 8/16/22 at _______ [name of hospice house]. There was no evidence a discharge summary was completed. An interview with RN # 1 on 9/14/22 at approximately 12:30 pm confirmed no discharge summary was completed.