Every finding on record at Evergreen Medical Center, LLC

A recertification survey was conducted on 8/12/25 to 8/13/25 at Evergreen Home Care. Standard level deficiencies for Emergency Preparedness were cited and will require an acceptable Plan of Correction.

Develop EP Plan, Review and Update Annually CFR(s): 484.102(a) §403.748(a), §416.54(a), §418.113(a), §441.184(a), §460.84(a), §482.15(a), §483.73(a), §483.475(a), §484.102(a), §485.68(a), §485.542(a), §485.625(a), §485.727(a), §485.920(a), §486.360(a), §491.12(a), §494.62(a). The [facility] must comply with all applicable Federal, State and local emergency preparedness requirements. The [facility] must develop establish and maintain a comprehensive emergency preparedness program that meets the requirements of this section. The emergency preparedness program must include, but not be limited to, the following elements: (a) Emergency Plan. The [facility] must develop and maintain an emergency preparedness plan that must be [reviewed], and updated at least every 2 years. The plan must do all of the following: * [For hospitals at §482.15 and CAHs at §485.625(a):] Emergency Plan. The [hospital or CAH] must comply with all applicable Federal, State, and local emergency preparedness requirements. The [hospital or CAH] must develop and maintain a comprehensive emergency preparedness program that meets the requirements of this section, utilizing an all-hazards approach. * [For LTC Facilities at §483.73(a):] Emergency Plan. The LTC facility must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least annually. * [For ESRD Facilities at §494.62(a):] Emergency Plan. The ESRD facility must develop and maintain an emergency preparedness plan that must be [evaluated], and updated at least every 2 years. . This STANDARD is not met as evidenced by: Based on review of the agency's Emergency Preparedness (EP) documentation and staff interview, it was determined the agency failed to develop and maintain a comprehensive EP plan that was reviewed and updated at least every two years. This had the potential to negatively affect all 25 patients serviced by the agency and agency employees. Findings include: A review of the agency's EP plan revealed there was no documentation the agency had reviewed and updated their EP plan since 2020. An interview was conducted on 8/13/25 at 2:00 PM with Employee Identifier # 1, Director, who confirmed the agency failed to review and update the EP plan at least every two years.

Plan Based on All Hazards Risk Assessment CFR(s): 484.102(a)(1)-(2) §403.748(a)(1)-(2), §416.54(a)(1)-(2), §418.113(a)(1)-(2), §441.184(a)(1)-(2), §460.84(a)(1)-(2), §482.15(a)(1)-(2), §483.73(a)(1)-(2), §483.475(a)(1)-(2), §484.102(a)(1)-(2), §485.68(a)(1)-(2), §485.542(a)(1)-(2), §485.625(a)(1)-(2), §485.727(a)(1)-(2), §485.920(a)(1)-(2), §486.360(a)(1)-(2), §491.12(a)(1)-(2), §494.62(a)(1)-(2) [(a) Emergency Plan. The [facility] must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least every 2 years. The plan must do the following:] (1) Be based on and include a documented, facility-based and community-based risk assessment, utilizing an all-hazards approach.* (2) Include strategies for addressing emergency events identified by the risk assessment. * [For Hospices at §418.113(a):] Emergency Plan. The Hospice must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least every 2 years. The plan must do the following: (1) Be based on and include a documented, facility-based and community-based risk assessment, utilizing an all-hazards approach. (2) Include strategies for addressing emergency events identified by the risk assessment, including the management of the consequences of power failures, natural disasters, and other emergencies that would affect the hospice's ability to provide care. *[For LTC facilities at §483.73(a):] Emergency Plan. The LTC facility must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least annually. The plan must do the following: (1) Be based on and include a documented, facility-based and community-based risk assessment, utilizing an all-hazards approach, including missing residents. (2) Include strategies for addressing emergency events identified by the risk assessment. *[For ICF/IIDs at §483.475(a):] Emergency Plan. The ICF/IID must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least every 2 years. The plan must do the following: (1) Be based on and include a documented, facility-based and community-based risk assessment, utilizing an all-hazards approach, including missing clients. (2) Include strategies for addressing emergency events identified by the risk assessment. This STANDARD is not met as evidenced by: Based on review of the agency's Emergency Preparedness (EP) documentation and staff interview, it was determined the agency failed to develop and maintain an EP plan specific to the location of the agency, considering particular hazards most likely to occur in the surrounding area (Hazard Risk Assessment) at least every two years. This had the potential to negatively affect all 25 patients served by the agency and agency employees. Findings include: A review of the agency's EP plan revealed there was no documentation the agency had completed a Hazard Risk Assessment, specific to the location of the agency, since 2022. An interview was conducted on 8/13/25 at 2:00 PM with Employee Identifier # 1, Director, who confirmed the agency failed to complete the Hazard Risk Assessment every two years.

A recertification survey was conducted on 8/12/25 to 8/13/25 at Evergreen Home Care. Standard level deficiencies were cited and will require an acceptable Plan of Correction.

A review of all current medications CFR(s): 484.55(c)(5) A review of all medications the patient is currently using in order to identify any potential adverse effects and drug reactions, including ineffective drug therapy, significant side effects, significant drug interactions, duplicate drug therapy, and noncompliance with drug therapy. This ELEMENT is not met as evidenced by: Based on observations, agency policy and procedure, medical record (MR) review, and interviews, it was determined the agency failed to ensure medications in the home were reconciled with the current physician's medication orders. This deficient practice affected one of three home visit (HV) patients, including HV # 3, and had the potential to affect all patients admitted to this agency. Findings include: Agency Policy: Medication Management Policy Number: Not Listed Revised: 9/2019 Purpose: It is the policy of Evergreen Home Care to ensure that every patient has an accurate and complete list of patient medications they are taking at home recorded in their medical record... A medication list is completed at the time of the patient's start of care and updated as medications are added, changed, or discontinued. ...It is the policy of ... that the Skilled Nurse (SN) assess home medications on each visit... 1. HV # 3 was admitted on 8/1/25 with diagnoses including Type 2 Diabetes Mellitus with Foot Ulcer, Non-Pressure Chronic Ulcer of Right Foot, and Pressure Ulcer of Other Site, Stage 2. Review of the Home Health Certification and Plan of Care dated 8/1/25 revealed physician's orders for SN one visit per week for one week, two visits per week for eight weeks, then one visit per week for one week. SN to perform medication review each skilled nursing visit and reconcile medications as indicated. A HV was conducted on 8/12/25 at 2:30 PM with Employee Identifier (EI) # 3, Physical Therapist Assistant (PTA). A review of the home medications was conducted with HV # 3 at the completion of the PTA visit. The following is a list of the medication discrepancies: 1. Aspirin 81 milligrams (mg) take one daily was listed on the Medication Profile (MP). HV # 3 stated he/she had not been taking the Aspirin for three to four years. 2. Metformin 500 mg take one half tablet twice daily was listed on the MP. HV # 3 stated he/she has not taken the Metformin for over a year. 3. Gabapentin 300 mg take two tablets three times a day was in the home but not on the MP. HV # 3 stated he/she had been taking the Gabapentin for leg pain for a few years. 4. Clopidogrel 75 mg take one daily, prescription bottle dated 8/4/25, was in the home and not on the MP. HV # 3 stated he/she had been taking the medication since the prescription was filled on 8/4/25. Review of the SN Visit Notes revealed SN visits on 8/7/25 and 8/11/25. 5. Allopurinol 300 mg take one daily, prescription bottle dated 7/31/25, was in the home but not on the MP. HV # 3 stated he/she had been taking the medication since the prescription was filled on 7/31/25. Review of the SN Visit Notes revealed SN visits on 8/4/25, 8/7/25, and 8/11/25. 6. Empagliflozin 25 mg take one half tablet every morning was in the home but not on the MP. HV # 3 stated he/she had been taking the medication for over a year. An interview was conducted on 8/13/25 at 1:40 PM with EI # 1, Director, who confirmed the medications were not reconciled during each SN visit per agency policy.

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 observations, agency policy and procedure, and interviews with staff, it was determined the agency failed to ensure staff followed agency policy to prevent the spread of infection. This deficient practice did affect Home Visit (HV) # 2 and had the potential to negatively affect all patients admitted to this agency. Findings include: Agency Policy: Home Care Bag Policy Number: Not Listed Revised: 6/2022 Policy: ...The home Care Bag will provide the basic equipment and supplies ... The Home Care Bag shall be used to prevent the potential spread of infection between and among staff and patients. Procedure: ... 4. Handwashing supplies shall be kept in the outermost pocket of the Home Care Bag for easy accessibility... 1. HV # 2 was admitted on 7/16/25 with diagnoses including Laceration Without Foreign Body, Right Lower Leg, Cellulitis of Right Lower Leg, and Chronic Kidney Disease. A HV was conducted on 8/12/25 at 9:50 AM to observe wound care provided by Employee Identifier (EI) # 2, Licensed Practical Nurse. The following is a summary of the visit: EI # 2 obtained Vital Signs, removed hand sanitizer from the uniform pocket, performed hand hygiene, then placed the sanitizer bottle back in the uniform pocket. EI # 2 then applied gloves, placed a plastic bag over the trash receptacle, removed gloves, removed sanitizer bottle from the pocket, performed hand hygiene, then returned the sanitizer bottle to the pocket. EI # 2 applied gloves, cleaned the re-useable vital sign equipment with disinfecting wipes, removed gloves, removed hand sanitizer from the pocket, performed hand hygiene, then returned the sanitizer bottle to the pocket. EI # 2 applied gloves, removed the soiled dressing from the right lower leg, removed gloves, removed sanitizer bottle from the pocket, performed hand hygiene, then returned the sanitizer bottle to the pocket. EI # 2 applied gloves, performed wound cleansing, removed gloves, removed hand sanitizer bottle from the pocket, performed hand hygiene, then returned the sanitizer bottle to the pocket. EI # 2 applied gloves, applied Xeroform gauze to wound bed, removed gloves, then performed hand hygiene with hand sanitizer from the uniform pocket. EI # 2 applied gloves, applied bordered dressing to the wound, removed gloves, then performed hand hygiene with the hand sanitizer from the uniform pocket. An interview was conducted on 8/13/25 at 8:15 AM with EI # 2 who confirmed he/she used the hand sanitizer from the uniform pocket each time hand hygiene was required. An interview was conducted on 8/13/25 at 1:30 PM with EI # 1, Director, who confirmed the agency failed to ensure staff followed the agency policy for hand hygiene and storing of hand sanitizer.

EP Testing Requirements CFR(s): 484.102(d)(2) §416.54(d)(2), §418.113(d)(2), §441.184(d)(2), §460.84(d)(2), §482.15(d)(2), §483.73(d)(2), §483.475(d)(2), §484.102(d)(2), §485.68(d)(2), §485.625(d)(2), §485.727(d)(2), §485.920(d)(2), §491.12(d)(2), §494.62(d)(2). *[For ASCs at §416.54, CORFs at §485.68, OPO, "Organizations" under §485.727, CMHCs at §485.920, RHCs/FQHCs at §491.12, and ESRD Facilities at §494.62]: (2) Testing. The [facility] must conduct exercises to test the emergency plan annually. The [facility] must do all of the following: (i) Participate in a full-scale exercise that is community-based every 2 years; or (A) When a community-based exercise is not accessible, conduct a facility-based functional exercise every 2 years; or (B) If the [facility] experiences an actual natural or man-made emergency that requires activation of the emergency plan, the [facility] is exempt from engaging in its next required community-based or individual, facility-based functional exercise following the onset of the actual event. (ii) Conduct an additional exercise at least every 2 years, opposite the year the full-scale or functional exercise under paragraph (d)(2)(i) of this section is conducted, that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or individual, facility-based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the [facility's] response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the [facility's] emergency plan, as needed. *[For Hospices at 418.113(d):] (2) Testing for hospices that provide care in the patient's home. The hospice must conduct exercises to test the emergency plan at least annually. The hospice must do the following: (i) Participate in a full-scale exercise that is community based every 2 years; or (A) When a community based exercise is not accessible, conduct an individual facility based functional exercise every 2 years; or (B) If the hospice experiences a natural or man-made emergency that requires activation of the emergency plan, the hospital is exempt from engaging in its next required full scale community-based exercise or individual facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional exercise every 2 years, opposite the year the full-scale or functional exercise under paragraph (d)(2)(i) of this section is conducted, that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or a facility based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (3) Testing for hospices that provide inpatient care directly. The hospice must conduct exercises to test the emergency plan twice per year. The hospice must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual facility-based functional exercise; or (B) If the hospice experiences a natural or man-made emergency that requires activation of the emergency plan, the hospice is exempt from engaging in its next required full-scale community based or facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional annual exercise that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or a facility based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop led by a facilitator that includes a group discussion using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the hospice's response to and maintain documentation of all drills, tabletop exercises, and emergency events and revise the hospice's emergency plan, as needed. *[For PRFTs at §441.184(d), Hospitals at §482.15(d), CAHs at §485.625(d):] (2) Testing. The [PRTF, Hospital, CAH] must conduct exercises to test the emergency plan twice per year. The [PRTF, Hospital, CAH] must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise; or (B) If the [PRTF, Hospital, CAH] experiences an actual natural or man-made emergency that requires activation of the emergency plan, the [facility] is exempt from engaging in its next required full-scale community based or individual, facility-based functional exercise following the onset of the emergency event. (ii) Conduct an [additional] annual exercise or and that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or individual, a facility-based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the [facility's] response to and maintain documentation of all drills, tabletop exercises, and emergency events and revise the [facility's] emergency plan, as needed. *[For PACE at §460.84(d):] (2) Testing. The PACE organization must conduct exercises to test the emergency plan at least annually. The PACE organization must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise; or (B) If the PACE experiences an actual natural or man-made emergency that requires activation of the emergency plan, the PACE is exempt from engaging in its next required full-scale community based or individual, facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional exercise every 2 years opposite the year the full-scale or functional exercise under paragraph (d)(2)(i) of this section is conducted that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or individual, a facility based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the PACE's response to and maintain documentation of all drills, tabletop exercises, and emergency events and revise the PACE's emergency plan, as needed. *[For LTC Facilities at §483.73(d):] (2) The [LTC facility] must conduct exercises to test the emergency plan at least twice per year, including unannounced staff drills using the emergency procedures. The [LTC facility, ICF/IID] must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise. (B) If the [LTC facility] facility experiences an actual natural or man-made emergency that requires activation of the emergency plan, the LTC facility is exempt from engaging its next required a full-scale community-based or individual, facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional annual exercise that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or an individual, facility based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the [LTC facility] facility's response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the [LTC facility] facility's emergency plan, as needed. *[For ICF/IIDs at §483.475(d)]: (2) Testing. The ICF/IID must conduct exercises to test the emergency plan at least twice per year. The ICF/IID must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise; or. (B) If the ICF/IID experiences an actual natural or man-made emergency that requires activation of the emergency plan, the ICF/IID is exempt from engaging in its next required full-scale community-based or individual, facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional annual exercise that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or an individual, facility-based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the ICF/IID's response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the ICF/IID's emergency plan, as needed. *[For HHAs at §484.102] (d)(2) Testing. The HHA must conduct exercises to test the emergency plan at least annually. The HHA must do the following: (i) Participate in a full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise every 2 years; or. (B) If the HHA experiences an actual natural or man-made emergency that requires activation of the emergency plan, the HHA is exempt from engaging in its next required full-scale community-based or individual, facility based functional exercise following the onset of the emergency event. (ii) Conduct an additional exercise every 2 years, opposite the year the full-scale or functional exercise under paragraph (d)(2)(i) of this section is conducted, that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or an individual, facility-based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the HHA's response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the HHA's emergency plan, as needed. *[For OPOs at §486.360] (d)(2) Testing. The OPO must conduct exercises to test the emergency plan. The OPO must do the following: (i) Conduct a paper-based, tabletop exercise or workshop at least annually. A tabletop exercise is led by a facilitator and includes a group discussion, using a narrated, clinically relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. If the OPO experiences an actual natural or man-made emergency that requires activation of the emergency plan, the OPO is exempt from engaging in its next required testing exercise following the onset of the emergency event. (ii) Analyze the OPO's response to and maintain documentation of all tabletop exercises, and emergency events, and revise the [RNHCI's and OPO's] emergency plan, as needed. *[ RNCHIs at §403.748]: (d)(2) Testing. The RNHCI must conduct exercises to test the emergency plan. The RNHCI must do the following: (i) Conduct a paper-based, tabletop exercise at least annually. A tabletop exercise is a group discussion led by a facilitator, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (ii) Analyze the RNHCI's response to and maintain documentation of all tabletop exercises, and emergency events, and revise the RNHCI's emergency plan, as needed. This STANDARD is not met as evidenced by: Based on review of the agency Emergency Operations Plan (EOP) notebook, and interview with Employee Identifier (EI) # 1 Director, it was determined the agency failed to participate in a full scale community wide or facility based exercise or tabletop discussion annually. Findings include: Agency Policy: Evergreen Home Health Emergency Operation Plan Date: November 15, 2016 Purpose: To describe the actions to be taken in an emergency or exercise to make sure that the clients, staff and visitors of this facility are kept safe from harm. The safety and wellbeing of clients and staff take first priority over all other considerations.... ...VI. Testing A. The facility will participate in a full-scale exercise that is community- based or when a community-based exercise is not accessible, an individual, facility based full scale exercise will be done annually. B. In the event that the facility experiences an actual or man-made emergency that requires activation of the EOP, the facility is exempt from engaging in an individual full scale exercise for one year following the onset of the actual event. C. The facility must conduct a second exercise every year. The second exercise can be another individual full scale exercise or a tabletop exercise. D. After full scale exercises, tabletops or actual events, the facility should analyze the response, identify areas of improvement and update the EOP, if required. Review of the EOP notebook provided to the surveyor 10/04/22, revealed there is no documentation the agency conducted or participated in a community wide or facility based exercise annually or in a tabletop discussion annually. An interview conducted on10/6/22 at 1:07 PM with EI # 1 confirmed that the agency does not have any documentation of participation in a community wide or facility based event or a tabletop discussions in the past two to four years.

A recertification survey was conducted on 10/6/22 at Evergreen Home Care and standard level deficiencies were cited.

A review of all current medications CFR(s): 484.55(c)(5) A review of all medications the patient is currently using in order to identify any potential adverse effects and drug reactions, including ineffective drug therapy, significant side effects, significant drug interactions, duplicate drug therapy, and noncompliance with drug therapy. This ELEMENT is not met as evidenced by: Based on review of medical records (MR), observations and agency policy and procedure it was determined the agency failed to follow the policy for ensuring every patient has a complete and accurate medication profile. This deficient practice affected one of three home visits (HV) and did affect HV # 3 and had the potential to negatively affect all patients served by the agency. Findings include: Agency Policy: Medication Management Revised Date: 9/19 Purpose: It is the policy of Evergreen Home Care to ensure that every patient has an accurate and compete list of patient medications they are taking at home recorded in their medication record. A medication list is completed at the time of the patient's start of care ad updated as medications are added, changed or discontinued. It is the policy of Evergreen Home Care that the Skilled Nurse (SN) assess home medications on each visit... 1. Home visit # 3 was admitted to the agency on 8/23/22 with certification dates of 8/23/22 to 10/21/22 and admitting diagnoses of Peripheral Vascular Disease and Diabetes Mellitus with Diabetic Chronic Kidney Disease. Review of the Home Health Certification (HHC) and Plan of Care (POC) dated 8/23/22 revealed the SN was to visit two times a week for two weeks and then one time a week for eight weeks. A HV was conducted on 10/4/22 at 12:30 PM with Employee Identifier # 6, Physical Therapy Assistant, (PTA) to observe care provided to the patient. During the HV the patient's Medication Profile (MP) was compared to the medication bottles in the home with the caregiver. The following medications were on the MP and the patient was not currently taking: Potassium Chloride 20 mEq (milliequivalent) one tablet three times a day. Caregiver stated was discontinued 2 weeks ago. Lipitor 80 mg (milligrams) one tablet daily at bedtime. Caregiver stated was discontinued 8/23/22. Cinacalcet 30 mg one tablet three times daily with meals. Caregiver stated was discontinued at least a month ago 9/22. Doxycycline 100 mg one tablet two times a day. Discontinued 10 days after start date. Caregiver stated on 8/13/22 and discontinued on 8/23/22. The following medication were in the home, confirmed current by the caregiver and not on the MP: Metoclopramide 5 mg one QID (four times a day). Started 8/3/22. ASA (Aspirin) 325 mg one tablet every day since 8/3/22. Rena Vite one tablet daily. Started 6/29/22. Carvedilol 3.125 mg one every AM and one every PM with meals since 8/30/22. An interview was conducted on 10/6/22 with EI # 1, Director, who confirmed the medication profile was complete and accurate per policy.

Promptly alert relevant physician of changes CFR(s): 484.60(c)(1) The HHA must promptly alert the relevant physician(s) or allowed practitioner(s) to any changes in the patient's condition or needs that suggest that outcomes are not being achieved and/or that the plan of care should be altered. This ELEMENT is not met as evidenced by: Based on medical record (MR) review, home visits (HV), agency policy and staff interviews, it was determined the agency failed to notify the physician for the following: 1. Blood glucose results outside of ordered parameters. 2. Pain levels outside of ordered parameters. 3. Heart rate outside of ordered parameters. 4. Blood pressure outside of ordered parameters. . This affected four of seven MRs reviewed, including HV # 1, MR # 3, HV # 3, and MR # 2, and had the potential to affect all patients served by the agency. Findings include: Agency Policy: Abnormal Findings/MD Notification Policy Number: 200.3 Date Revised: 3/15 Policy: All abnormal findings assessed by the skilled nurse (SN) will be reported to the patient's physician and documented on the clinical note... This is to include: vital signs, blood sugars and weight gains outside of the physician's orders, edema, wound changes or new wounds, patient safety issues, abnormal lab findings, and pain. Agency Policy: Abnormal Findings/MD Notification Policy Number: None Date Revised: 9/19 Policy: ... The physician may order specific clinical parameters relevant to the patient's condition. The parameters may be ranges and may include: temperature, pulse, respirations, blood pressure, weight, wound measurements, pain intensity ratings,... blood sugar levels, other relevant clinical assessments findings... ... It is our policy to notify the patient's physician of any abnormal findings during the HV's, which may include any of the above referenced items, as well as any deemed as abnormal for the patient by the assessing clinician. 3. HV # 3 was admitted to the agency on 8/23/22 with certification dates of 8/23/22 to 10/21/22 and admitting diagnoses of Peripheral Vascular Disease and Diabetes Mellitus with Diabetic Chronic Kidney Disease. Review of the HHC and POC dated 8/23/22 revealed the SN was to visit two times a week for one week, then one time a week for eight weeks and the PT (Physical Therapist) was to visit one time a week for one week and then two times a week for three weeks. Review of the HHC and POC dated 8/23/22 revealed orders to notify the physician of vital signs falling out side the following ranges: Pain level greater then 5/10, Systolic Blood Pressure greater than 190 and less than 90 and Diastolic Blood Pressure greater then 90 and less than 60... Review of the SN VN date 8/23/22 revealed the patient's blood pressure (BP) was 130/58. Further review of the SN VN dated 8/23/22 revealed no documentation the physician was notified of the diastolic blood pressure of 58 which was reportable to the physician per the parameters. Review of the SN VN note dated 9/1/22 revealed the patient's BP was 98/48. Further review of the SN VN dated 9/1/22 revealed no documentation the physician was notified of the BP outside the established parameters. Review of the SNV note dated 9/29/22 revealed the patient rated his/her pain a 6/10 on the pain scale and it interferes with activity. Further review of the SNV note dated 9/29/22 revealed no documentation the physician was notified of the patient's pain level outside the ordered parameters. Review of the PTA (Physical Therapy Assistant) note dated 10/4/22 revealed the patient rated his/her pain an 8/10 on the pain scale. Further review of the PTA note dated 10/4/22 revealed no documentation the physician was notified of pain rating outside the parameters of 5/10. An interview was conducted on 10/6/22 at 1:40 PM with EI # 1, who confirmed the staff failed to notify the physician of vital signs outside the established parameters as ordered. 4. MR # 2 was admitted to the agency on 6/24/22 and certified from 6/24/22 to 8/22/22 with admitting diagnoses of After Care Following Joint Replacement and Chronic Kidney Disease. Review of the HHC and POC dated 6/24/22 revealed orders to notify the physician when vital signs fall outside the following parameters: Pain level greater then 5. Review of the Physical Therapy Assessment/Evaluation note dated 6/24/22 revealed the patient rated his/her pain 6/10 on the pain scale. Further review revealed no documentation by the PT the physician was notified of the patient's pain level of 6 per the physician orders. Review of the SN VN dated 6/24/22 revealed the patient rated his/her pain a 6/10 on the pain scale. Further review of the SN VN dated 6/24/22 revealed no documentation the physician was notified of the pain level falling outside of the established parameters. Review of the PTA visit note dated 6/28/22 revealed the patient rated his/her pain 6/10 on the pain scale. Further review of the PTA visit note dated 6/28/22 revealed no documentation the physician was notified of the pain level outside the ordered parameters. An interview was conducted on 10/6/22 at 2:00 PM with EI # 1 who confirmed the staff failed to notify the physician of the pain level outside the ordered parameters. 1.HV # 1 was admitted to the agency on 6/4/21 and recertified for care 9/27/22 to 11/25/22 with diagnoses including Type Two Diabetes Mellitus with Diabetic Polyneuropathy and Alzheimer's Disease with Late Onset. Review of the Home Health Certification (HHC) and Plan of Care (POC) dated 9/27/22 revealed SN visits one time a week for nine weeks and to notify the physician of vital sign parameters out of range: Heart rate: > (greater than) 110; 7/10... ...Blood sugar, Fasting: >200; 200; 100 beats per minute (BPM)... Review of the SN VN dated 8/30/22 revealed a HR of 110 BPM. Review of the SN VN dated 9/16/22 revealed a HR of 110 BPM. Review of the SN VN dated 9/23/22 revealed a HR of 102 BPM. There was no documentation the physician was notified of the HR of 110 BPM on 8/30/22, 110 BPM on 9/16/22 and 102 BPM on 9/23/22. An interview was conducted on 10/6/22 at 1:36 PM with EI # 1 who confirmed there was no documentation the physician was notified of the heart rates falling outside of the established parameters on 8/30/22, 9/16/22 and 9/23/22.

Visit schedule CFR(s): 484.60(e)(1) Visit schedule, including frequency of visits by HHA personnel and personnel acting on behalf of the HHA. This ELEMENT is not met as evidenced by: Based on review of medical records (MR), agency policy and procedure and interviews with the staff it was determined the agency failed to ensure the staff followed physician orders for the frequency of visits. This affected one of three records with Physical Therapy (PT) and did affect Home Visit (HV) # 3, and had the potential to negatively affect all patients served by the agency. Findings include: Agency Policy: Physical Therapy Revised Date: 9/19 Policy: Senior management provides organization direction and staffing for patient care services according to the scope of care or services offered. Procedure: 1. Patients care services are provided according to the scope and level of care planned by the organization. 2. Services are provided in a timely manner to meet patient's needs... 6. Physical therapy must document all missed visits as to reason why visit was missed. Therapy must communicate with physician by phone call , order, or communication note that is faxed to the physician office of the missed therapy visit. 1. Home visit # 3 was admitted to the agency on 8/23/22 with certification dates of 8/23/22 to 10/21/22 and admitting diagnoses of Peripheral Vascular Disease and Diabetes Mellitus with Diabetic Chronic Kidney Disease. Review of the Home Health Certification (HHC) and Plan of Care (POC) dated 8/23/22 revealed the Physical Therapist was to visit one time a week for one week then two times a week for three weeks. Review of the Missed Visit note by the PTA (Physical Therapy Assistant) on 8/30/22 revealed in the note the spouse was not home at this time. Further review of the PTA missed visit note dated 8/30/22 revealed no documentation the physician was notified of the missed visit on 8/30/33 and only one PTA visit was made for the week of 8/28/22 to 9/3/22. Review of the PTA missed visit notes for 9/27/22 and 9/29/22 revealed no documentation of 2 visits as ordered. Further review of the PTA missed visit notes dated 9/27/22 and 9/29/22 revealed no documentation the physician was notified of the missed visits on 9/27/22 and 9/29/22 and no PTA visits were completed as ordered An interview was conducted on 10/6/22 at 1:40 PM with Employee Identifier (EI) # 1, Director, who confirmed there was no documentation the staff followed the physician's orders for PT visit frequency.

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 observation, agency policy and procedure, and staff interview, it was determined the agency failed to ensure staff followed agency policy for hand hygiene and infection control. This deficient practice affected one of three home visits (HV) including HV # 1, and had the potential to negatively affect all patients admitted to the agency. Findings include: Agency Policy: Hand Washing Technique Date Revised: 9/30/19 Purpose: To prevent or minimize the spread of infection. Guidelines: 1. Hand washing before and after physical contact... ...9. Hands should be washed after close patient contact even when gloves worn. 10. Faucets are considered contaminated; when turning off the faucets, use a dry paper towel to prevent infecting hands and fixtures again. 11....personnel should always wash their hands: ...d. After handling a source that is likely to be contaminated, such as equipment. e. Between patient care sites,... Agency Policy: Handwashing Technique Date revised: 1/22 Policy Statement: To cleanse the hands of germs and prevent contamination between patients and homecare personnel. All personnel providing direct or indirect care/service will wash their hands in the home prior to contact with the patient. Procedure: Personnel also will wash their hands: a. after gloves are removed... ... d. after assisting the patient in using the toilet or changing diapers/protective undergarments... Washing with water: ...Turn off faucet with clean paper towel or cloth towel 1.HV # 1 was admitted to the agency on 6/4/21 and recertified for care 9/27/22 to 11/25/22 with diagnoses including Type Two Diabetes Mellitus with Diabetic Polyneuropathy and Alzheimer's Disease with Late Onset. Review of the Home Health Certification (HHC) and Plan of Care (POC) dated 9/27/22 revealed Skilled Nurse (SN) frequency one time a week for nine weeks and Home Health Aide (HHA) frequency two times a week for nine weeks. Review of the HHA Care Plan dated revealed a shower with chair was assigned each visit. A HV was conducted on 10/4/22 to observe a shower with chair and care provided by Employee Identifier (EI) # 3, HHA. During the visit the HHA washed his/her hands, donned gloves and assisted the patient to ambulate with his/her walker to the shower. The HHA assisted the patient in removal of his/her clothes and diaper/undergarment. The HHA removed his/her gloves, and without washing his/her hands, donned a new pair of gloves, and washed the patient's face, torso, arms, hair and rinsed the patient with water. The HHA removed his/her gloves, performed hand hygiene but failed to utilize a towel to turn off the faucet. Then, without performing HH, donned clean gloves to wash the patients back, down to buttocks, legs, then perineal area. Using the same dirty gloves and without performing hand hygiene, the HHA towel dried patient. The patient had to urinate. The HHA assisted the patient with the toilet, handed the patient toilet paper to dry his/her self. The HHA flushed the toilet and assisted the patient with new diaper/undergarment, a new change of clothes, combed the patient's hair retrieved the patients walker and walked with the patient back to the den and covered the patient with a blanket. The HHA removed the dirty gloves, washed his/her hands at the sink and turned off the faucet failing to use a towel to turn off the faucet per policy. An interview conducted on 10/6/22 at 1:28 PM with EI # 1 Director, confirmed hand hygiene was not performed per agency policy/.

Interdisciplinary assessment of the patient CFR(s): 484.75(b)(1) Ongoing interdisciplinary assessment of the patient; This ELEMENT is not met as evidenced by: Based on review of medical records (MR), agency policy and procedure and interviews with the staff it was determined the staff failed to instruct the caregiver on wound care and obtain a return demonstration of competency. This deficient practice affected two of three MR's with wounds and did affect Home Visit (HV) # 3 and MR # 2 and had the potential to negatively affect all patients served by the agency with wounds. Findings include: Agency Policy: Patient Education Revised Date: 9/19 Policy: The home health agency plans, and coordinates patient and caregiver education designed to promote optimal patient health and safety... Procedure: Educational resources are made available to the patient and caregiver based on assessed and or potential learning needs of the patient and caregiver... 9. The patient and caregiver receive education on an ongoing basis regarding the patient responsibility to the agency providing information regarding changes in the patient's condition and to provide a safe environment for staff to render care in the patient's home. 10. Patient/caregiver is given the opportunity with each nursing visit to review the education provided...Nurse will ask patient/caregiver to give feedback regarding education to establish return demonstration and determine how well patient/caregiver understands education. 1. Home visit # 3 was admitted to the agency on 8/23/22 with certification dates of 8/23/22 to 10/21/22 and admitting diagnoses of Peripheral Vascular Disease and Diabetes Mellitus with Diabetic Chronic Kidney Disease. Review of the Home Health Certification (HHC) and Plan of Care (POC) dated 8/23/22 revealed the following orders: SN (Skilled Nurse) to provide skilled assessment...provide instructions and reinforcement to teaching to prevent pressure ulcer development...Instruct in materials used in wound care...Check the wound daily for signs of infection... Review of the physician order dated 8/25/22 revealed the SN to perform wound care to fourth digit to right hand related to open area from gangrene. Clean area with wound cleanser, pat dry, apply medihoney, cover with gauze and secure with tape daily. SN to apply wound care with SN visit and caregiver to change on non-skilled nurse days. Review of the SNV (skilled nurse visit) note dated 8/25/22 revealed SN performed wound care. Further review of the SNV note dated 8/25/22 revealed no documentation the caregiver was taught wound care and no documentation of a return demonstration by the caregiver. Review of the physician order dated 9/1/22 revealed the following order for wound care: SN to perform wound care to 4th digit to right hand related to open area from gangrene. Cleanse area with wound cleanser, pat dry, apply Iodine, cover with gauze and secure with tape using aseptic technique. SN to teach caregiver to perform daily. SN to perform on SNV days. Review of the SNV note dated 9/1/22 revealed the SN documented wound care applied to right hand per MD (Medical Doctor) order... Further review of the SNV note dated 9/1/22 revealed no documentation the SN taught the caregiver the new wound care per the physician order nor is there documentation the caregiver performed a return demonstration of the wound care. An interview was conducted on 10/6/22 with Employee Identifier (EI) # 1, Director, who confirmed the SN failed to document the teaching of wound care and the new wound care ordered and failed to document a return demonstration of wound care by the caregiver. 2. MR # 2 was admitted to the agency on 3/25/22 and certified from 3/25/22 to 5/23/22 with admitting diagnoses of Pressure Ulcer of Left Buttock Stage 2 and Unspecified Atrial Fibrillation. Review of the HHC and POC dated 3/25/22 revealed the SN was one time a week for one week, two times a week for one week, one time a week for three weeks and one time every other week for four weeks. Review of the physician order dated 4/25/22 revealed the following physician order: SN to perform pressure ulcer care to left inner buttock one time weekly. Cleanse/irrigate wound with wound cleanser. apply duoderm, pt (patient) cg (caregiver) to apply duoderm as needed between visits using aseptic technique. SN may teach patient/caregiver to perform wound care. Review of the SN visit note dated 4/25/22 revealed no documentation the caregiver was taught the new wound care and no documentation a return demonstration was performed per the caregiver. An interview was conducted on 10/6/22 at 1:37 PM with EI # 1 who confirmed the SN failed to document the teaching and the return demonstration by the caregiver for the new wound care.