Every finding on record at Excelsior Springs City Hospital

The Emergency Preparedness regulations were reviewed as part of the Medicare recertification survey completed on 10/24/2024. During the survey it was determined the home health provider is in compliance with the requirements of 42 CFR 484.102 Condition of Participation: Emergency Preparedness for Home Health Providers.

A partial extended survey for Medicare recertification for the home health provider was completed on 10/24/2024. The provider had 99 current patients.

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, record review, and interview, the home health provider failed to ensure an individualized plan of care (POC) that included functional limitations, activities permitted, equipment required, and all relevant physicians that were providing home health orders, in four of five full records reviewed (Records/Patients #1, #2, #3, and #4). This deficient practice has the potential to affect the coordination of care and services for all patients on service with the provider. RECORD/PATIENT #2: Review the clinical record showed the patient was admitted to the home health provider on 09/06/2024 with a primary diagnosis of lymphedema (swelling, most often in an arm or leg, caused by a lymphatic system blockage) and surgical aftercare following surgery on the skin and subcutaneous tissue (tissue that is located beneath the skin and contains fat). The patient was admitted with orders for skilled nursing (SN) to provide wound care. The patient lived at home with his/her child. Review of the referral information with a print date of 09/05/2024 showed in part: - The patient was status post (condition after a surgery) excision of excessive skin/subcutaneous tissue of the abdomen with infraumbilical panniculectomy (surgical procedure that removes excessive skin and fat from the lower abdomen); and - The procedure was done by, and the referral orders were received from “named” plastic surgeon. Review of the POC dated 09/06/2024 to 11/04/2024 showed: - A FNP (family nurse practitioner- a registered nurse who specializes in family medicine and provides primary and preventative care to patients of all ages) listed as the responsible physician; and - It failed to list the plastic surgeon. Review of physician orders dated 09/12/2024, 10/01/2024, and 10/16/2024 showed they were obtained from “named” plastic surgeon that failed to be listed on the POC. During an interview with the clinical manager on 10/24/2024 at 10:45 AM he/she stated that the provider did not have an order to accept wound care orders from the plastic surgeon. RECORD/PATIENT #4: Review of the clinical record showed in part: - The patient was admitted to the home health provider on 09/18/2024 with a primary diagnosis of a fracture of the right forearm. The patient had undergone a closed reduction internal fixation with debridement (CRIF-a surgical procedure that realigns a broken bone without cutting the skin and then uses pins, wires, or plates to hold the bone in place. Debridement is a procedure that involves extending and closing a wound after it has been debrided (removal of damaged, infected, or dead tissue)) on 08/29/2024, followed by and ORIF (Open Reduction with Internal Fixation- a surgical procedure that treats broken bones and dislocations by realigning the bones and stabilizing them with internal hardware) on 09/05/2024. The patient also had a diagnosis of presence of artificial right leg; - The patient was admitted with orders for skilled nursing, occupational therapy (OT), physical therapy (PT) and medical social services (MSS); and - The patient lived in their own home alone with assistance from friends and family as needed. Review of the POC dated 09/18/2024 to 11/16/2024 showed in part: - It failed to contain the patient’s NWB (non-weight bearing) status of the RUE (right upper extremity); - It failed to show the presence of a soft cast/brace to the RUE; - Functional limitations- ambulation (failed to include anything about weight restrictions to RUE); - Activities permitted: wheelchair, walker, other (specify)- prosthetic (artificial body part that replaces a part that is missing) (failed to include limitations to RUE); - The DME and supplies included a wheelchair, walker, foley catheter and bag (soft cast/splint to RUE failed to be listed); - It failed to show any orders and/or interventions for a soft cast and/or brace on the RUE or a NWB status of the RUE; - It listed a DO (doctor of osteopathy) as the responsible physician; and - It failed to list the orthopedic MD. Review of the SN SOC visit note, dated, 09/18/2024, showed, in part: - A surgical incision on the front of right wrist with surgical dressing/splint in place (non-removable dressing in place); and - The patient is hopeful that once he/she is in a smaller splint he/she will be able to return to self-catheterization (independently intermittently place a tube in the bladder to drain urine) and will not need an indwelling Foley catheter (a sterile tube placed in the bladder and left there to drain urine). Review of the OT evaluation visit note, dated, 09/18/2024, showed, in part: - The patient was NWB to RUE; and - RUE elbow/wrist/digit ROM significantly impaired secondary to cast; and - A follow-up with ortho anticipated 09/19/2024. Review of a physician order dated 09/18/2024 showed it was from a urologist that failed to be listed on the POC. Review of an OT visit note dated 09/24/2024 showed under the visit narrative summary: patient went to ortho MD (orthopedic medical doctor) 09/19 2024, reporting release to complete range of motion (ROM) but unsure of specific precautions except to wear brace most of the time. Call into ortho MD (not listed on the POC) placed to determine specific ROM orders. During an interview on 10/24/2024 at 11:45 AM the clinical manager stated that orders were written yesterday (10/23/2024) to clarify the current and on admit weight bearing status of the RUE, the presence of a soft cast on admission and may accept orders form “named” orthopedic physician. Findings included: Review of the provider’s undated policy titled, “Medical Policies and Plan of Care (Reference # HHHO416)” showed in part: - The individualized plan of care will include the following: * The types of services, supplies, and equipment required * Functional limitations * Activities permitted * Patient specific interventions and education * Any additional items the HHA (home health agency) or physician or allowed practitioner may choose to include - The only medical treatments carried out by the agency staff will be those ordered by the physician; and - When providing care to a patient according to the orders of one physician, additional orders from another physician shall be approved by the patient’s attending physician before the agency staff can accept them. RECORD/PATIENT #1: Review of the clinical record, showed, in part: - The patient was admitted to home health services on 09/11/2024 with a primary diagnosis of a fracture to the lateral condyle of left femur (a break in the outside of the left knee) residing in an apartment with the assistance of his/her niece; and - The home health referral orders showed, PT (physical therapy), OT (occupational therapy), and nursing to evaluate and treat. Review of the POC (plan of care), showed, in part: - The patient was NWB (no weight bearing) to LLE (left lower extremity); - The patient had to transfer to and from the bed and the wheelchair using a sliding board; - The patient was to perform mobility around his/her apartment using a wheelchair; and - The DME (durable medical equipment) and supplies included a wheelchair, platform walker, sliding board, and a bedside commode. Review of the SN (skilled nurse) SOC visit note, dated, 09/11/2024, showed, in part: - The patient was NWB with an immobilizer in place (brace to prevent mobility of the LLE); and - The follow-up visit with the orthopedic doctor was scheduled for 09/16/2024 (5 days after the SOC). Review of the PT evaluation visit note, dated, 09/11/2024, showed, in part: - The patient was NWB to LLE; and - “Pt with left knee immobilizer possibly transitioning to hinged knee brace in 3 weeks.” Review of the SN visit note, dated, 09/17/2024, showed, in part: - The patient had a follow-up appointment with the orthopedic doctor yesterday (09/16/2024); and - The patient “can have 25% WB on left leg.” Review of the SN visit note, dated, 10/01/2024, showed, in part: - The patient was educated on how to adjust the left knee immobilizer; and - The importance of wearing the knee immobilizer at all times. Review of the POC (plan of care), failed to show: - Any orders and/or interventions for an immobilizer and/or brace on the LLE; and - The name of the orthopedic doctor providing home health orders related to the LLE. During an interview on 10/24/2024 at 11:25 AM, the Clinical Manager stated that the orthopedic doctor and the knee immobilizer orders had just been added to the patient’s record (The surveyor was provided these updated orders). RECORD/PATIENT #3: Review of the clinical record, showed, in part: - The patient was resumed to home health services on 10/17/2024 after being hospitalized with osteomyelitis (an infection in the bone); - The patient resided in the home with his/her spouse; and - The patient’s spouse was the primary caregiver with the assistance of an adult daughter. Review of the resumption of care (ROC) visit on 10/17/2024, showed, in part: - The patient was discharged home with a PICC (peripherally inserted central catheter- a long. Flexible tube that’s inserted into a vein in the arm and threated into a larger vein near the heart) line and IV (intravenous- in the vein) antibiotics; - An infectious disease physician was following the patient and giving orders related to the PICC line, IV antibiotics and weekly lab (blood tests that provide information about a person’s health including the effectiveness of a treatment) orders (The plan of care failed to show the name and contact number for the infectious disease physician with instructions to contact the physician for issues and/or orders related to the PICC line, IV antibiotics, and labs); - The (named) infectious disease doctor would be the one to determine when the IV antibiotics and PICC line would be discontinued (The plan of care failed to include this); - The patient had multiple wounds that required wound care treatment; and - “Pt (patient) to have wound care 3x (three times) week, 2x (two times) week by by home health, et (and) weekly by (named) burn clinic then graft per (named employee) at (named) plastic surgery” (The plan of care failed to include that the home health provider would be completing wound care twice a week and the clinic would be completely wound care once a week. The plan of care failed to include name and contact information for the clinic and/or physician providing wound care treatment/orders, and/or who to contact with issues/orders related to the patient’s wounds). During an interview on 10/24/2024 at 10:45 AM, the Administrator and Clinical Manager stated that: - Prior to using the new EMR (electronic medical record), the plan of cares used to include all of the physicians that provided orders; and - “May accept orders” were added to include all physician providing orders (The surveyor was provided these updated orders for patient #1 and #3).

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 policy review, record review, and interview, the home health provider failed to ensure that all verbal orders were recorded in the plan of care (POC) in one of five full records reviewed (Record/Patient #4). This deficient practice has the potential to adversely affect the care provided to all the provider’s patients. Findings included: Review of the provider’s undated policy titled, “Medical Policies and Plan of Care (Reference # HHHO416),” showed in part: - The plan of care specifies the care and services necessary to meet the patient- specific needs identified by the physician, interdisciplinary group and patient; - All patient care orders are included in the individualized plan of care that identifies patient specific measurable goals and which is established and periodically reviewed and signed by a Doctor of Medicine, osteopathy, or Podiatry or allowed practitioner acting within the scope of his or her state license; - All services provided to the patient follow the written plan of care established and periodically updated by the physician; and - The plan of care is updated and revised as frequently as the condition of the patient requires but not less frequently than every 60 (sixty) days beginning with the start of care date for home health patients. Review of the provider’s undated policy titled, “Medical Policies and Physician’s Orders (Reference # HHHO416),” showed in part: - All patients who receive skilled home care services will have orders for all services from a physician; - The plan of care specifies the care and services necessary to meet the patient-specific needs identified by the physician, interdisciplinary group, and patient; - All patient care orders are included in the plan of care; - All services provided to the patient follow the written plan of care established and periodically updated by the physician; - Changes to the plan of care are usually made through verbal or written communication with the physician; and - The only medical treatments carried out by agency (provider) staff will be those ordered by the physician. RECORD/PATIENT #4: Review of the referral information with a print date of 09/12/2024, showed in part, the patient was NWB (non-weight bearing) of the RUE (right upper extremity). Review of the clinical record showed the patient was admitted to the home health provider on 09/18/2024 with a primary diagnosis of a fracture of the right forearm. The patient had also undergone a closed reduction internal fixation with debridement (CRIF-a surgical procedure that realigns a broken bone without cutting the skin and then uses pins, wires, or plates to hold the bone in place. Debridement is a procedure that involves extending and closing a wound after it has been debrided (removal of damaged, infected, or dead tissue)) on 08/29/2024, followed by and ORIF (Open Reduction with Internal Fixation- a surgical procedure that treats broken bones and dislocations by realigning the bones and stabilizing them with internal hardware) on 09/05/2024. The patient was admitted with orders for skilled nursing (SN), occupational therapy (OT), physical therapy (PT) and medical social services (MSS). The patient lived in their own home alone with assistance from friends and family as needed. Review of the POC, dated 09/18/2024 to 11/16/2024 failed to show an order for NWB of the RUE. Review of an initial OT evaluation visit note dated 09/18/2024, showed under the visit narrative summary: RUE NWB- follow-up with ortho anticipated on 09/19/2024. Review of an OT visit note dated 09/24/2024, showed under the visit narrative summary: The patient went to ortho MD (orthopedic Doctor of Medicine) on 09/19/2024, reporting release to complete range of motion (ROM), but unsure of specific precautions except to wear brace most of the time. Call into ortho MD placed to determine specific ROM orders. Review of the clinical record failed to show any physician orders with regards to the weight bearing status change, the brace, or specific ROM orders. During an interview on 10/24/2024 at 11:45 AM (when discussing physician orders that were provided to the state agent (SA) on 10/24/2024 regarding the weight bearing status and soft cast presence on admission (dated 09/18/2024), and weight bearing status after the OT visit on 09/24/2024 with clearance for right wrist AROM (active range of motion-independently moving a body part without assistance) and adding external pressure during PROM (passive range of motion-movement of a joint caused by an outside force, such as a therapist or a machine) dated 09/26/2024), the clinical manager stated that the orders were written on 10/23/2024 to clarify the current and the admission weight bearing status of the RUE after questioned by SA regarding the omissions from the clinical record.

Patient medication schedule/instructions CFR(s): 484.60(e)(2) Patient medication schedule/instructions, including: medication name, dosage and frequency and which medications will be administered by HHA personnel and personnel acting on behalf of the HHA. This ELEMENT is not met as evidenced by: Based on policy review, record review, home visit observation, and interview, the home health provider failed to ensure each patient received accurate, updated/current written instructions related to the patient’s medication schedule, in two of three home visit observations (Records/Patients #2 and #3). This deficient practice has the potential to affect all the provider’s patients. RECORD/PATIENT #3: Review of the clinical record, showed, in part: - The patient was resumed to home health services on 10/17/2024 after being hospitalized with osteomyelitis (infection in the bone); - The patient resided in the home with his/her spouse; - The patient’s spouse was the primary caregiver; and - The patient was discharged home with IV (intravenous- through the vein) medication orders for Vancomycin (antibiotic) 750mg (milligrams) every 24 hours and Cefepime (antibiotic) 2gm (grams) every 12 hours. During home visit observation, on 10/23/2024, beginning at 10:45 AM, showed, in part: - The patient had a PICC (peripherally inserted central catheter- a long. Flexible tube that’s inserted into a vein in the arm and threated into a larger vein near the heart) line in the right upper arm for IV antibiotic infusions; - The patient reported that his/her spouse manages all of his/her medications including the IV antibiotics; - The patients medication list was reviewed and showed Vancomycin 750mg/250ml (milliliters) intravenous infusion, give one medi dispense ball, 250 ml to be administered by the caregiver; and - The frequency was missing from the medication instructions on the medication list. During an interview on 10/24/2024 at 10:45 AM, the Administrator and Clinical Manager stated that the Vancomycin frequency was missing from the medication list but it will be added to show the complete order. Findings included: Review of the provider’s undated policy titled, “Medication administration (Reference # HHHO418)” showed in part: - All known medications, both prescription and over the counter, are listed on the medication profile at the time of the patient’s admission to the agency (provider); - Medication orders shall include the medication name, dose, frequency and route of administration; - A copy of the current drug profile is kept in the medical record and the patient’s home folder; - The medication is reviewed on an ongoing basis, but at least every 60 (sixty) days for effectiveness of medications; and - Medication use shall be reviewed with the patient, family or both, and instructions will be provided on appropriate medication use, purpose, side effects, dosing, frequency, administration techniques, contraindications, storage, and modifications in the diet. RECORD/PATIENT #2: Review the clinical record showed in part: - The patient was admitted to the home health provider on 09/06/2024 with a primary diagnosis of lymphedema (swelling, most often in an arm or leg, caused by a lymphatic system blockage) and surgical aftercare following surgery on the skin and subcutaneous tissue; - The patient was admitted with orders for skilled nursing to provide wound care; and - The patient lived at home with his/her child. Review of the referral discharge medication list from “named” hospital with a print date of 09/05/2024 showed in part: - Duloxetine DR 60mg take one capsule by mouth twice daily; and - Furosemide 40mg tablet, take two tablets by mouth every morning. Review of the POC dated 09/06/2024 to 11/04/2024 showed in part: - Duloxetine DR 60mg take one capsule by mouth daily; and - Furosemide 40mg tablet, take one tablet by mouth every morning. Observation on 10/22/2024, starting at 10:30AM, during the patient’s medication reconciliation, the following discrepancies were noted when comparing what the patient was taking with the current medication profile supplied by the provider: - The patient was taking Duloxetine DR 60mg one capsule by mouth twice daily; - Furosemide 40mg tablet, two tablets by mouth every morning; - Docusate Sodium 100 mg capsule take one capsule daily; and - Senna Plus 8.6 mg-50 mg capsule take one tablet daily. Per interview conducted during the observation the patient stated that he/she (the patient) was taking: - Duloxetine DR 60mg one capsule by mouth twice daily since a few years ago; - Furosemide 40mg tablet, two tablets by mouth every morning since he/she had surgery; and - Docusate Sodium 100 mg capsule take one capsule daily as needed for a while now; and - Senna Plus 8.6 mg-50 mg capsule take one tablet daily as needed for a while now. Per interview conducted during the observation, the clinical manager stated that: - The patient did take the bowel medications daily on admission; and - That’s my fault for not changing that. During an interview on October 24th, 2024, at 10:30 AM the clinical manager stated that the patient had previously been a patient and the medications automatically pull over, but you have to adjust the order to match how they are taking them currently.

The Emergency Preparedness regulations were reviewed as part of the Medicare certification survey completed on 12/16/2021. During the survey it was determined Excelsior Springs Hospital Home Health/Hospice is in compliance with the requirements of 42 CFR 484.102 Conditions of Participation: Emergency Preparedness for Home Health Agencies.

A partial extended survey for Medicare certification for Excelsior Springs Hospital Home Health/Hospice was completed on 12/16/2021. The agency had 131 current patients. A COVID-19 Focused Infection Control Survey was completed in conjunction with the survey and one deficiency was identified related to the Focused Infection Control Survey.

Payment from federally funded programs CFR(s): 484.50(c)(7)(i, ii, iii, iv) Be advised, orally and in writing, of- (i) The extent to which payment for HHA services may be expected from Medicare, Medicaid, or any other federally-funded or federal aid program known to the HHA, (ii) The charges for services that may not be covered by Medicare, Medicaid, or any other federally-funded or federal aid program known to the HHA, (iii) The charges the individual may have to pay before care is initiated; and (iv) Any changes in the information provided in accordance with paragraph (c)(7) of this section when they occur. The HHA must advise the patient and representative (if any), of these changes as soon as possible, in advance of the next home health visit. The HHA must comply with the patient notice requirements at 42 CFR 411.408(d)(2) and 42 CFR 411.408(f). This ELEMENT is not met as evidenced by: Based on agency policy review, home visit observation, and interview, the agency failed to ensure the patient was advised orally and in writing of the extent to which payment for services may be expected from Medicare, Medicaid, or any other federally-funded aid program, the charges of services that may not be covered in two (Record/Patient #1 and #2) of three home visit observations. This deficient practice has the potential to adversely affect the patient's ability to pay for services for all agency's patients. Findings included: Review of the agency's policy titled, "Patient Rights and Responsibilities," dated February 22, 2019 showed: - The patient has the right to be advised of the extent to which payment for agency services may be expected from Medicare, Medicaid, or any other federally funded or federal aid program known to the agency; and - Receive proper written notice, in advance of a specific service being furnished, if the agency believes that the service may be non-covered care, or in advance of the agency reducing or terminating on-going care. RECORD/PATIENT #1: During a home visit observation on 12/15/2021 at 9:10 AM, review of the patient's home admission folder showed: - Staff did not complete the financial liability/authorization form for the patient; and - Staff and patient signed a blank financial liability/authorization form on 11/26/2021. RECORD/PATIENT #2: During a home visit observation on 12/14/2021 at 11:10 AM, review of the patient's home admission folder showed: - Staff did not complete the financial liability/authorization form for the patient; and - Staff and patient signed a blank financial liability/authorization form on 11/23/2021. On 12/15/2021 at 9:45 AM, Registered Nurse (RN) B was interviewed about the financial liability/authorization form. RN B reported that the form should have been filled out with the patient having zero financial responsibility as the patient’s insurance covers services 100%.

State toll free HH telephone hotline CFR(s): 484.50(c)(9) Be advised of the state toll free home health telephone hot line, its contact information, its hours of operation, and that its purpose is to receive complaints or questions about local HHAs. This ELEMENT is not met as evidenced by: Based on review of the agency's current patient rights information, agency policy, and interview, the agency failed to ensure staff provided the written notice of the updated state toll free home health telephone hotline hours of operation (7:00 AM to 8:00 PM, seven days a week). This deficient practice has the potential to adversely affect the patient's knowledge and comprehension of the rights and responsibilities of all the agency's patients. Findings included: The agency administrator provided an admission packet for review on 12/13/2021. The agency notice of patient rights and other information given to a patient during the initial visit contained the wrong information regarding the patient’s right to be advised of the state hotline days and hours. The information provided to patients was 7:00 AM to 12:00 midnight, seven days a week. The correct information should have been 7:00 AM to 8:00 PM, seven days a week. Review of the agency policy titled, “Patient Rights and Responsibilities Form, Policy & Procedure # 400.2,” dated February 19, 2019 showed, in part: - Patients have the right to be informed of your rights or to have your family or legal representative exercise your rights if you are unable to do so; and - Patients have the right to access the Missouri Home Health and Hospice 24 hour hotline number; and - Questions or concerns may be reported to the State Home Health/Hospice Hotline 1-800-392-0210 7AM – 12AM, 7 days a week. During an interview on 12/14/2021 at 11:47 AM, the administrator stated that he/she was unaware of the time change of the hotline hours.

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 policy review, record review, home visit observation, and interviews, the agency failed to ensure the patient's medications were reconciled during the start of care comprehensive assessment and that the medication profile was updated with medication changes in, but not limited to, two (Records/Patients #2 and #3) of six full records reviewed. This deficient practice has the potential to adversely affect the accuracy and safety of medication administration for all the agency's patients. Findings included: Review of the agency’s policy titled, “Medication Administration, Policy & Procedure #419,” dated February 27, 2019 showed, in part: - On admission the RN/PT will obtain a list of all medications the patient is currently taking; - An RN will review the medication profile within 5 days of start of care or resumption of care or whenever a drug is prescribed and assess for non-compliance with drug therapy. RECORD/PATIENT #2: Review of the plan of care dated 11/23/2021 through 01/21/2022 showed in part: - The patient was admitted to home health services on 11/23/2021 for aftercare following joint replacement surgery to left knee; - Buprenorphine 15mcg/hr (micrograms per hour) 1 patch weekly for pain; - Buspirone 10mg (milligrams) 1 tablet by mouth two times daily for anxiety; - Risperidone 0.5mg 1 tablet by mouth at bedtime for bipolar disorder; - Insulin Sliding Scale subcutaneous (under the skin) injection as needed of 4U (units) for blood sugar range of 181-220, 6U for 221-260, 8U for 301-350, 10U for 301-350; and - Insulin sliding scale subcutaneous injection as needed 12U for blood sugar of 351-400 and 14U for 401. Review of the referral medication list dated 11/20/2021 showed in part: - Buprenorphine 15mcg/hr (micrograms per hour) transdermal film, extended release apply 1 patch transdermal weekly for pain; - Buspirone 10mg (milligrams) 1 tablet by mouth two times daily for anxiety; - Risperidone 0.5mg 1 tablet by mouth at bedtime for bipolar disorder; and - Insulin Aspart 100 units/ml (milliliter) injectable solution subcutaneous 3 times a day with meals: 2 units if blood sugar 120-180, 4U (units) for 181-220, 6U for 221-260, 8U for 261-300, 10U for 301-350, 12U for 351-400, and 14U for 401. During a home visit on 12/14/2021 at 9:10 AM, the following medication discrepancies were identified: - Buprenorphine patch for pain not in the home due to the pharmacy having difficulty getting medication; - Buspirone bottle with dose of 15mg 1 tablet by mouth two times daily for anxiety is the correct dose; - Risperidone not in the home due to medication needing refilled; - Patient taking insulin sliding scale of Aspart 100 units/ml injectable solution subcutaneous 3 times a day with meals: 1 unit if blood sugar is 150-200, 2U for blood sugar of 201-250, 3U for 251-300, 4U for 301-350, 5U for 351-400; and - No medication list in the home. RECORD/PATIENT #3: Review of the plan of care dated 11/28/2021 through 01/26/2022 showed, in part, the patient was admitted with hemiplegia and hemiparesis following cerebral infarction affecting right side (stroke with resulting right sided partial or total paralysis). Review of the current medication profile supplied by the agency as well as the plan of care dated 11/28/2021 through 01/26/2022 showed topiramate 50mg (milligram) capsule ER (extended release) 24hour one capsule twice daily for b/p (blood pressure.) Review of the physician progress note dated 11/22/2021 sent as part of the referral on 11/26/2021 showed topiramate ER 50mg 24hour capsule orally (by mouth) twice daily. During a home visit on 12/14/2021 at 9:15 AM the patient was found to be taking topiramate 50mg capsule ER 24hour one capsule once daily. During an interview while on the home visit observation 12/14/2021 the patient and spouse stated that: - The patient takes the topiramate 50mg only once daily; - They never told the nurse because the nurse never asks about how the medications are being taken; - The doctor knows; - It was making the patient sick to his/her stomach; and - The agency left no medication profile in the home. During an interview with the administrator on 12/14/2021 at 11:47 AM he/she stated that: - All medications the patient is currently taking should be reviewed at least on admission, every certification period or if there is a change in medications; and - The nurse would have to ask the patient to know if there was a change in medications.

Only as ordered by a physician CFR(s): 484.60(b)(1) Drugs, services, and treatments are administered only as ordered by a physician or allowed practitioner. This ELEMENT is not met as evidenced by: Based on policy review, clinical record review, and interview, the agency failed to ensure services and treatments were administered only as ordered by a physician in, but not limited to, two (Record/Patient #2 and #3) of five full records reviewed. This deficient practice has the potential to adversely affect the care provided to all patients served by the agency. Findings included: Review of the agency's policy titled, "Medical Policies and Physician’s Orders,” dated February 26, 2019 showed in part: - All patient care orders are included in the plan of care; - All services provided to the patient follow the written plan of care established and periodically updated by the physician; and - The only medical treatments carried out by agency staff will be those ordered by the physician. RECORD/PATIENT #2: Review of the clinical record showed, in part: - The patient was admitted to home health services on 11/23/2021 for aftercare following joint replacement surgery to left knee; - Skilled nurse visit note on 11/29/2021 stated that patient had “heating pad on leg” and patient “has been using ice.” No documentation of orders for ice or heat. No documentation of education being provided for ice or heat; - Skilled nurse visit note on 12/06/2021 noted that ice used to alleviate pain to left knee. No documentation of education being provided for use of ice; and - On 12/15/2021 Registered Nurse (RN) A received a verbal order from physician that stated patient may alternate ice and heat to knee. During chart reviews with the administrator on 12/16/2021 at 10:00 AM, the administrator acknowledged the findings. No other documentation provided. RECORD/PATIENT #3: Review of the plan of care dated 11/28/2021 through 01/26/2022 showed, in part: - The patient was admitted with hemiplegia and hemiparesis following cerebral infarction affecting right side (stroke with resulting right sided partial or total paralysis); - SN (skilled nursing) 1 time a week for 9 weeks and 2 prn (as needed) visits for medical concerns and for skilled follow-up assessment and re-cert (recertification) documentation per Medicare guidelines; - SN visit notes showed that 2 visits were made the week of 11/28/2021 and again the week of 12/05/2021; - The skilled visit notes 11/28/2021, 12/02/2021, 12/06/2021 and 12/09/2021 were each marked at the top of the visit note as a scheduled visit; - 12/09/2021 SN visit note showed changes planned for frequency/additional services with SN decrease to 1 time a week written in by the nurse; and - The record failed to show an order for a 2 time a week frequency for the skilled nurse or any communication with the physician requesting an increase in SN visits to two times a week.

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 policy review, record review, and interview, the agency failed to promptly alert the physician to changes in the patient's condition that may suggest a need to alter the plan of care (POC) in, but not limited to, one (Record/Patient #2) of five full records reviewed. This deficient practice has the potential to affect all patients served by the agency. Findings included: Review of the agency policy titled, "Skilled Nursing Services," dated on February 24, 2019 showed in part: - The skilled nurse informs the physician and other personnel of changes in the patient’s condition and needs; and - All communication to coordinate client care shall be recorded in the client record by the professional on a daily visit note or other forms. RECORD/PATIENT #2: Review of the plan of care (POC) dated 11/23/2021 through 01/21/2022, showed in part: - The patient was admitted to home health services on 11/23/2021 for aftercare following joint replacement surgery to left knee; - Patient has a diagnosis of chronic pain syndrome; and - Licensed staff to report when pain is greater than 5 on a pain scale of 0-10 (0 being no pain and 10 being the worst pain). Review of skilled nursing visit notes showed in part: - On 11/29/2021 the patient reported pain to left knee at a 7; - On 12/01/2021 the patient reported pain to left knee at an 8 with pain described as dull; - On 12/06/2021 pain was reported to left knee at a 7 to 8; - On 12/08/2021 pain to left knee was at a 7; and - No documentation of physician being notified of patient reporting pain greater than a 5 on any of the skilled nurse visits. During an interview on 12/14/2021 at 11:45 AM, RN A reported the physician was not notified of pain greater than a 5.

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 policy review, home visit observation, and interview, the agency failed to provide the patient/caregiver with a copy of written instruction outlining the visit schedule, including frequency of visits in two (Records/Patients #2 and #3) of three home visit observations. This deficient practice has the potential to affect the patient's knowledge of self-care and agency expectations in all patients served by the agency. Findings included: Review of the agency's policy titled, "Assignment of Personnel and Visit Scheduling, Policy and Procedure # 500," dated February 28, 2019, showed in part, the following: -Purpose is to assure that competent agency staff is aware of his/her responsibilities and duties regarding visits and scheduling; -Policy is that a visit schedule of proposed visits from all disciplines will be left in the home; - All agency visit staff will submit a weekly schedule of visits that will be updated on an ongoing basis as schedules change; and -Patients will be notified in advance of changes to an agreed upon visit schedule. RECORD/PATIENT #2: During a home observation visit on 12/14/2021 at 11:10 AM with RN A, the surveyor observed the patient's home chart. The agency failed to provide a written visit schedule for the patient in the home. RECORD/PATIENT #3: During a home observation visit on 12/14/2021 at 9:15 AM with PT-A, the surveyor observed the patient's home chart. The agency failed to provide a written visit schedule for the patient in the home. There was a calendar noted that was blank. During an interview on 12/14/2021 at 11:47 AM, the administrator stated that he/she would expect the visit calendar to be filled out that was left in the patient’s home.

Patient medication schedule/instructions CFR(s): 484.60(e)(2) Patient medication schedule/instructions, including: medication name, dosage and frequency and which medications will be administered by HHA personnel and personnel acting on behalf of the HHA. This ELEMENT is not met as evidenced by: Based on home visit observation, and interview, the agency failed to provide the patient/caregiver with an updated/current copy of written instructions outlining the patient’s medication schedule, including medication name, dosage, and frequency in two (Records/Patients #2 and #3) of three home visit observations performed. This deficient practice has the potential to adversely affect all the patients served by the agency. Findings included: RECORD/PATIENT #2: During home visit observation on 12/14/2021 at 9:10 AM with the Registered Nurse (RN) A, the home folder/book was reviewed and failed to contain a medication list. During an interview on 12/14/2021 at 9:30 AM, the patient reported that he/she was not provided with a medication list. RECORD/PATIENT #3: During a home visit observation on 12/14/2021 at 9:15 AM with PT-A, the home folder/book was reviewed and failed to contain a medication list. During an interview on 12/14/2021 during the home visit observation starting at 9:10 AM the patient and spouse stated that no written medication list was left in the home, that the agency wrote it down but they didn’t leave anything. During an interview on 12/14/2021 at 11:47 AM the administrator stated that he/she would expect a written list be left in the patient’s home and that it should be in the plastic folder.

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, observation, and interview, the agency failed to use standard precautions to prevent the transmission of infections and communicable diseases by failing to screen visitors/non-employees for COVID-19 (pandemic infection) who entered the home health agency office. This deficient practice has the potential to adversely affect infection control needs for all visitors/non-employees, employees and patients served by the agency. Findings included: Review of the agency's policy titled, “Corona Virus Protocol: Home Health and Hospice,” updated 4/17/2020, showed in part: - Starting Monday, April 20 we will be checking temperatures on all individuals that report to ESH (Excelsior Springs Hospital) HH (Home Health) and Hospice. This will include employees, vendors/contractors, patients, etc….. The surveyor entered the agency for a recertification survey on 12/13/2021 at 9:50 AM. The surveyor was greeted by staff, introductions were made and staff directed the surveyor to enter a conference room via direct access through a basement door. Staff failed to screen the surveyor for temperature or ask COVID-19 screening questions upon entrance to the agency lobby or the conference room. 12/14/2021 at 8:40 AM, 12/15/2021 at 8:30 AM and 12/16/2021 at 8:30 AM with appropriate facemasks in place, the surveyors entered the conference room of the agency. Each of these times staff failed to screen the surveyors for temperature or ask COVID-19 screening questions upon entrance. During an interview on 12/15/2021 at 9:00 AM, the administrator acknowledged the agency failed to provide temperature checks or COVID-19 screening to visitors upon entry.

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 interview, the agency failed to ensure a transfer summary was sent to the receiving facility in three (Record/Patient #4, #5, and #6) of six records reviewed. This deficient practice has the potential to adversely affect all transferred patients served by the agency. Findings included: Review of the agency's policy titled, "Discharge/Transfer,” dated July 1993, showed in part: - The staff member completes a discharge summary, assessment (Oasis), patient discharge instructions, a reconciled list of the patient’s medications and a physician’s order at the time of discharge; - A copy of the discharge summary and the reconciled medication list is sent to the Physician; - Discharge instructions and medication list is given to the patient and or family members responsible for on-going care; - The staff member may complete a transfer summary if the client is transferred to another agency or institution; and - When the patient is transferred to another agency or institution the professional communicates pertinent information which may include the following: *The reason for transfer; *The client’s physical and psychosocial status at the time of transfer, including specific problems requiring follow-up; * A summary of the care provided and progress towards foals including both positive and adverse patient responses to treatment or services; * A copy of the patient’s medication profile, including discontinued medications; * Continuing symptom management needs (i.e. pain, nausea, and dyspnea); * Follow-up to be provided by the transferring agency staff; * Pertinent laboratory data; * Instructions provided to the client and their comprehension of that information; * The existence of any advance directives; and * If the patient is referred to another organization, service or individual for ongoing services and treatment, the staff member informs the client of any financial benefit to ESH Home Health/Hospice resulting from that referral. RECORD/PATIENT #4: Review of the clinical record showed: - The patient was hospitalized from 12/03/2021 to 12/08/2021; and - The transfer summary signed and dated 12/03/2021 at 10:00 AM failed to show documentation of transfer summary being submitted to receiving facility. RECORD/PATIENT #5: Review of the clinical record showed: - The patient was hospitalized from 07/16/2021 to 07/23/2021; and - Transfer summary dated 07/19/2021 failed to show documentation of the transfer summary being submitted to receiving facility. RECORD/PATIENT #6: Review of the clinical record showed: - The patient was hospitalized on 08/31/2021; and - The transfer summary dated 08/31/2021 failed to show documentation of the transfer summary being submitted to receiving facility. During an interview on 12/15/2021 at 2:52 PM the administrator stated that the agency only sends the transfer summaries to the physician. The agency does not send the transfer summary to the receiving institution.