Every finding on record at First Option Home Health, Inc.

First Option Home Health is in compliance with the federal emergency preparedness requirements

Recertification Survey

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 record review and interview, the agency failed to ensure Patient #2's physician was promptly alerted of a 14.2 pound weight loss in 19 days, which was noted by the skilled nurse during the skilled nurse visit made on 9/30/2023 for 1 (#2) out of 18 sampled patients. Patient #2. Review of the agency’s policy and procedure, Care Planning and Coordination, revealed, “…11. The home health promptly alerts the relevant physician(s) to any change in the patient’s condition or needs that suggest that outcomes are not being achieved and/or that the plan should be altered.” Review of the patient's electronic clinical record revealed the start of care date was 9/11/2023. The patient's diagnoses included Aftercare Following Surgery for Neoplasm, Presence of Aortocoronary Bypass Graft, Old Myocardial Infarction, and Diabetes. The certification period reviewed was 9/11/2023 to 11/9/2023. Review of the patient's POC (Plan of Care) for certification period 9/11/2023 to 11/9/2023 revealed the following order, SN 5wk 1wk; 7wk 1wk; 2wk 1wk; 1wk 6wk (skilled nurse visit five times a week for one week; skilled nurse visit seven times a week for one week; skilled nurse visit two times a week for one week; skilled nurse visit one time a week for six weeks). Further review of the POC revealed, “… SN to assess patient every visit, monitor… weight…SN to notify MD of any abnormal findings or complications… Monitor/record weights at least weekly…” Review of the patient's SN Visit Note dated 9/11/2023 revealed the patient’s weight was 156 pounds. Review of the patient’s SN Visit Addendum Note dated 10/4/2023 for the SN visit made on 9/18/2023 revealed the patient’s weight was 153.7 pounds, which was a 2.3 pound weight loss in one week. Review of the patient’s SN Visit Note dated 9/30/2023 revealed the patient’s weight was 141.8 pounds, which was a 14.2 pound weight loss in 19 days. There was no evidence the SN notified the physician of the patient’s 14.2 pound weight loss in 19 days. On 10/4/2023 at 11:15 a.m., an interview was conducted with S1DON (Director of Nurses) and after a review of the patient's electronic clinical record, S1DON verified that there was no evidence the physician was notified of the patient’s 14.2 pound weight loss since admission to agency, which was 19 days. S1DON confirmed the 14.2 pound weight loss should have been reported to the physician.

Coordinate care delivery CFR(s): 484.60(d)(4) Coordinate care delivery to meet the patient's needs, and involve the patient, representative (if any), and caregiver(s), as appropriate, in the coordination of care activities. This ELEMENT is not met as evidenced by: Based on record review and interview, the agency failed to coordinate care delivery to meet the patient's needs as evidenced by the agency failing to ensure the outside entity communicated the patient’s INR (International Normalized Ratio-the number that is calculated to measure the time it takes for the blood to clot) results to the home health agency staff for 1 (#18) out of 18 sampled patients. Patient #18. Review of the patient's electronic clinical record revealed the start of care date was 8/17/2023. The patient's diagnoses included Aftercare Following Surgery on Circulatory System and Congestive Heart Failure. The certification period reviewed was 8/17/2023 to 10/15/2023. Review of the patient's POC (Plan of Care) for certification period 8/17/2023 to 10/15/2023 revealed an order for SN 2wk 2wk; 1wk 7wk (skilled nurse visits two times a week for two weeks; skilled nurse visit one time a week for seven weeks). Further review of the patient's POC revealed an order for the “skilled nurse to assess anticoagulant therapy lab values…” Review of the patient’s SN visit notes dated 8/22/2023, 8/28/2023, 8/31/2023, 9/6/2023, 9/13/2023, and 9/19/2023 revealed that there was no evidence the patient’s INR results were assessed and monitored. On 10/5/2023 at 1:05 p.m., an interview was conducted with S1DON (Director of Nurses). S1DON stated the patient performs her own INR on her machine that was linked to the clinic (outside entity). S1DON stated the clinic receives the INR results from the patient’s linked machine. S1DON stated the clinic monitors the patient’s INR results and the clinic contacts the patient with the results. S1DON stated the clinic does not involve the agency in the monitoring of the patient’s INR results. S1DON confirmed the agency does not monitor the patient’s INR results and confirmed that there was no coordination of care done by the clinic in regards of the patient’s INR results.

The entity is in compliance with the federal emergency preparedness requirements.

Recertification Survey

Document complaint and resolution CFR(s): 484.50(e)(1)(ii) (ii) Document both the existence of the complaint and the resolution of the complaint; and This ELEMENT is not met as evidenced by: Based on record review and interview, the agency failed to provide evidence of both the existence of the complaint and the resolution of the complaint that was made by Patient #10 of a complaint voiced on 10/14/2021 with an investigation and a resolution of the complaint for 1 out of a total of 17 sampled records. (#10) Findings: The agency’s policy was reviewed and revealed in part the following documentation – Title: Patient grievance Procedure …..5. If a complaint is reported: a. The patient/caregiver shall be informed regarding when they may expect a response from ___ (agency). B. All complaints will be forwarded to the Administrator or designee. C. Patient/caregiver shall receive a response from the Administrator or designee within 1 business day. d. Patient and or representative will receive follow up communication periodically via telephone, in person, or via email or texting as needed until final resolution is reached. E. A telephone or personal follow-up shall occur in 1 week after resolution reached to determine if problem has been solved or if a new course of action is indicated. f. The patient and/or patient representation will receive documentation of complaint process, findings and resolution via email, telephone, in writing, etc. g. A Quality Assessment report shall be completed in the event of a patient/caregiver complaint. h. _____ (agency) management will maintain a complaint log. i. A summary of grievances and resultant action shall be included in the year-end Performance Improvement Summary. Patient #10. The patient was admitted to the agency on 9/15/2021 with the diagnoses that included Diabetes Mellitus Type 2 With Foot Ulcer, Non-pressure Chronic Ulcer Other Part Left Foot, Cellulitis of Left Lower Limb, Chronic Osteomyelitis Left Ankle and Foot, and Presence of Aortocoronary Bypass Graft. The certification period reviewed was 9/15/2021 to 11/13/2021. The patient’s electronic medical records was reviewed and revealed the following documentation – Prep Notes Communication – 10/14/2021 10:48:37 AM – Received call from patient on Monday. He was upset that he called service over weekend and left message with ___ (worker) at answering service, and did not receive a call back. He went to ____ (local hospital) and received antibiotics for cellulitis of legs. I tried to get a nurse to see him today, but when ____ (S8LPN) called with a time, he was eating lunch and refused visit so visit moved to Tuesday. Apologized for no one calling him back on Saturday and told him next time ask for a manager on call. Upon entrance to the agency on 10/18/2021 the grievance/complaint binder was requested and the investigation of the agency’s grievances/complaints were reviewed. There was no evidence found of an investigation of the above listed complaint for Patient #10. On 10/21/2021 at 2:08 pm, an interview was conducted with S2ADON and she stated that there was no evidence that a thorough investigation done concerning the patient’s grievance/complaint.

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 record review and interview, the agency failed to ensure the individualized plan of care (PoC) included all pertinent diagnoses and ensure required equipment was obtained for 1 patient (#11) as evidenced by no evidence found on the PoC for the monitoring of Diabetes Mellitus, including foot care, or monitoring of a stage 1 pressure ulcer, and the agency failed to secure a glucometer machine for the patient out of a total of 17 (#1-17) sampled patients. Findings: Patient #11: The patient was admitted to the agency on 9/14/2021 with diagnoses including DM (Diabetes Mellitus) and a Stage 1 pressure ulcer of the sacral region. A review of Patient #11’s OASIS (Outcome and Assessment Information Set) assessment dated 9/27/1021 was conducted. Active diagnosis assessed included DM and a Stage 1 pressure ulcer to her bilateral buttock/coccyx area. The patient’s PoC was reviewed and revealed that the SN (skilled nurse) was to see the patient once a week for 8 weeks (SN1WK8) beginning on 9/20/2021 and ending on 11/22/2021. Further review of the PoC failed to reveal that the agency addressed Patient #11’s diagnoses of DM or the Stage 1 pressure ulcer to the patient’s sacral area. A review of a skilled nurse visit conducted on 9/28/2021 revealed that the nurse indicated that the patient was diagnosed with Diabetes Mellitus Type 11. The narrative of the note included “Pt voiced has no meter in her home”. Further review of staff documentation on Patient #11 from 9/28/21 to 10/21/2021 failed to reveal evidence that staff attempted to procure a glucometer for the patient. On 10/21/21 at 1:15 PM, an interview was conducted with S1DON. She confirmed that the agency had failed to address Patient #11’s diagnoses of DM, including diabetic foot care, the Stage 1 sacral pressure ulcer and the prevention of further skin breakdown for the patient on her PoC, and they should have. S1DON further stated that there was no evidence that the agency had attempted to contact Patient #11’s doctor, her insurance company, or her MD to attempt to get a glucometer for her. S1DON stated that the nurse knew they had to do this and it was not done.

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 record review and interview, the agency failed to 1. The agency’s staff failed to obtain the physician’s signature within 30 days on 5 (#9, 10, 11, 12, 15) Plans of Care (POC); 2. The agency failed to ensure the patient’s (#1) POC contained an order for the skilled nurse to change the patient’s suprapubic catheter weekly For 6 (#1, 9, 10, 11, 12, 15) patient out of a total of 17 (#1-17) sampled patients. Cross reference with State Regulations 9123. Patient Care Standards C. Plan of Care. The plan of care (PoC) for each patient must be individualized to address the patient’s problems, goals, and required services. 1. The PoC, telephone and/or verbal orders must be signed by the physician within a timely manner, not to exceed 30 days. Findings: 1. Patient #9: The patient was admitted to the agency on 9/17/21 with diagnoses including management of implanted device, long term use of antibiotics, and acute osteomyelitis of left ankle and foot. The certification period reviewed was 9/17/2021 – 11/15/2201. The patients PoC (Plan of Care) was reviewed and revealed SN (skilled nurse) to administer IV antibiotic, assess central venous access for pain, redness, edema, bleeding, draining, problems with patency, or other complications daily for 59 days (1D59) beginning on 9/18/21 and ending on 11/15/21. SN infusion orders to administer and instruct on the administration of IV (intravenous) Cefepime (antibiotic) 2 gms (grams) q (every) 8 hours x 6 weeks via PICC (Peripherally inserted central catheter) via infusion pump. The physician had not signed the PoC. On 10/22/2021 at 9:40 AM, an interview was conducted with S1DON. She confirmed that the agency failed to ensure that Patient #9’s PoC been signed by the physician within 30 days. S1DON further stated that this has been an ongoing issue in the agency. Patient #10: The patient was admitted to the agency on 9/15/2021 with the diagnoses that included Diabetes Mellitus Type 2 With Foot Ulcer, Non-pressure Chronic Ulcer Other Part Left Food, Cellulitis of Left Lower Limb, Chronic Osteomyelitis Left Ankle and Foot, and Presence of Aortocoronary Bypass Graft. Review of the certification period from 9/15/2021 to 11/13/2021 revealed the agency did not have evidence that the patient’s physician signed the POC as of 10/22/2021. On 10/21/2021 at 1:06 pm, an interview was conducted with S1DON and after a review of the patient’s electronic medical records, she verified there was no evidence that the patient’s POC had been returned to the agency and signed by the physician within 30 days. Patient #11: The patient was admitted to the agency on 9/14/2021 with diagnoses including DM (Diabetes Mellitus), malignant neoplasm of unspecified ovary, neutropenia, anemia, malnutrition, dehydration, and Stage 1 pressure ulcer of the sacral region. The patient’s PoC was reviewed and revealed that the SN (skilled nurse) was to see the patient once a week for 8 weeks (SN1WK8) beginning on 9/20/2021 and ending on 11/22/2021. The PT (physical therapist) was to see the patient twice weekly for three weeks (2WK3) beginning the week of 9/29/2021. The certification period reviewed was 9/14/2021 – 11/12/2021. The PoC had been signed by the physician on 10/20/2021, which was not within 30 days. On 10/22/2021 at 9:40 AM, an interview was conducted with S1DON. She confirmed that the agency failed to ensure that Patient #11’s PoC was signed by the physician within 30 days. S1DON further stated that this has been an ongoing issue in the agency. Patient #12: The patient was admitted to the agency on 05/30/2019 with the diagnoses that included Diabetes Mellitus Type 2, Hypertension, and Vascular Dementia. Review of the certification period of 9/15/2021 to 11/13/2021 revealed the agency did not have evidence that the patient’s physician signed the POC as of 10/22/2021. On 10/21/2021 at 1:57 pm, an interview was conducted with S2ADON and after a review of the patient’s electronic medical records, she verified there was no evidence that the patient’s POC had been returned to the agency and signed by the physician within 30 days. Patient #15: The patient was admitted to the agency on 07/22/2019 with the diagnoses that included Diabetes Mellitus Type 2, Hypertension, and Vascular Dementia. Review of the certification period from 7/22/2021 to 8/3/2021 revealed the agency did not have evidence that the patient’s physician signed the POC as of 10/22/2021. On 10/22/2021 at 10:18 am, an interview was conducted with S2ADON and after a review of the patient’s electronic medical records, she verified there was no evidence that the patient’s POC had been returned to the agency and signed by the physician within 30 days. 2. Patient #1. The patient was admitted to the agency on 05/07/2019 with the diagnoses that included Encounter For Attention to Cystostomy, Encounter For Fitting and Adjustment of Urinary Device, and Long Term Use of Anticoagulants. The certification period reviewed was 08/19/2021 to 10/17/2021. The patient’s POC was reviewed and revealed the following order – CNA; 0W1 (0 time a week for 1 week), 3W8 (3 times a week for 8 week). The SN (skilled nurse) frequency was revealed as followed- SN: 1W9 (1 time a week for 9 weeks). The patient’s POC was reviewed and the skilled nurse frequency was as followed - SN: 1W9 (1 times a week for 9 weeks). The patient’s skilled nurse visits was reviewed and there was documentation found of the nurses changing the resident’s suprapubic catheter once weekly. There was no evidence found on the POC of an order for the skilled nurse to change the suprapubic catheter weekly. On 10/20/2021 at 12:19 pm, an interview was conducted with S3RN (Registered Nurse) and she stated that she was the case coordinator for the patient. She stated the patient had a suprapubic catheter that had an order for the catheter to be changed weekly since 11/5/2020 and that the order never changed. She then provided the order for the catheter to be changed dated 11/5/2020. After a review of the patient’s current POC she verified there was no evidence of an order for the skilled nurse to change the suprapubic catheter on the POC for the certification period 8/19/2021 to 10/17/2021. S3RN stated there should have been an order on the patient’s POC for the skilled nurse to perform the suprapubic catheter weekly.

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 record review and interview, the agency failed to ensure the agency’s staff promptly alerted the physician to any changes in the patient’s condition or needs that suggest the plan of care should be altered as evidenced by: 1. No evidence that S7LPN notified the patient’s (#10) physician on 10/8/2021 that upon assessment there was new findings that the patient’s left leg was red and the left foot was slightly swollen; 2. No evidence that on 9/14/2021 S7LPN notified patient #7’s physician that the patient was having wheezing in the RUL (right upper lobe) of her lung which was a new finding from the assessment for 2 ( #7, #10) patients out of a total of 17 (#1-#17) sampled patients. Findings: The agency’s policy and procedure for Care Planning and Coordination was reviewed and revealed in part the following documentation……11. The home health promptly alerts the relevant physician (s) to any change the patient ‘s condition or needs that suggest that outcomes are not being achieved and/or that the plan should be altered. 1. Patient #10. The patient was admitted to the agency on 9/15/2021 with the diagnoses that included Diabetes Mellitus Type 2 With Foot Ulcer, Non-pressure Chronic Ulcer Other Part Left Food, Cellulitis of Left Lower Limb, Chronic Osteomyelitis Left Ankle and Foot, and Presence of Aortocoronary Bypass Graft. The certification period reviewed was 9/15/2021 to 11/13/2021. The patient’s POC (plan of care) was reviewed and revealed the following order – Skilled Nursing; 1 wk 1 wk (1 time a week for 1 week), 2 wk 2 wk (2 times a week for 2 week), 2 wk 6 wk (2 times a week for 6 weeks)….….. Wound care to left foot planter/lateral diabetic ulcers….. SN (skilled nurse) to assess every visit; report any s/s (signs/symptoms) decline to wound care MD (medical doctor)…. The patient’s Skilled Nursing Visit Note dated 10/8/2021 revealed in part the following documentation – Narrative Notes: …….L (left) leg noted red and L (left) foot slightly swollen. States he called ____ ____ (wound care facility) and nurse instructed him to go there for her to check it out. Pt (patient) states he was instructed to elevate LE (left extremity) and go to ED (emergency department) if worsens……….. There was no evidence found that S7LPN notified Patient #10’s physician of her findings of the patient’s left leg that was red and the left foot that was slightly swollen. The patient’s electronic medical records was reviewed and revealed the following documentation – Prep Notes Communication – 10/14/2021 10:48:37 AM – Received call from patient on Monday. He was upset that he called service over weekend and left message with ___ (worker) at answering service, and did not received a call back. He went to ____ (local hospital) and received antibiotics for cellulitis of legs……………… The patient was seen on 10/13/2021 and the Skilled Nursing Visit Note revealed in part the following documentation – Narrative Notes: Pt (patient) went to ____ (local hospital) ED (emergency department) Saturday for c/o (complaint of) pain, redness and swelling to L leg. States he was dx (diagnosed) with cellulitis and was prescribed Clindamycin (antibiotic). …Slight c/o diarrhea reported. Redness, pain and swelling remains to leg……… On 10/21/2021 at 3:22 pm, an interview was conducted with S1DON and the above skilled notes were reviewed. S1DON stated the patient went to the ER on 10/9/2021 and the patient called on Saturday to let the facility know he went to the ER for leg pain and redness. S1DON reviewed the skilled noted dated 10/8/2021 and verified that S7LPN should have called the patient’s physician to notify of her findings. On 10/22/2021 at 10:06 am, an interview was conducted with S7LPN and she stated she had reviewed her documentation of the visit conducted on 10/8/2021. S7LPN stated the patient physician was not notified of her findings because the patient had gone to wound care a couple of days before her visit. S7LPN stated she did not call the patient’s physician because the patient told her he was going to see the wound care nurse for his foot. S7LPN stated she forgot to send a case conference to notify her DON of her findings during the visit on 10/8/2021. S7LPN stated the agency’s policy was to notify the patient physician of her findings and she verified that she did not notify the patient’s physician. 2.Patient #7. The patient was admitted to the agency on 8/29/2021 with the diagnoses that included Hypoxemia, Essential Hypertension, Unspecific Asthma, History of COVID-19, Dementia and Dependence on Supplemental Oxygen. The certification period reviewed was 8/29/2021 to 10/27/2021. The patient’s plan of care (POC) was reviewed and revealed the following documentation – SNV (skilled nurse visit) to admit patient, assess pt (patient) every visit, monitor vs (vital signs), pulse ox (oximetry), respiratory status……………. The skilled nurse visit dated 9/14/2021 was reviewed and revealed in part the following documentation – Narrative: SNV for assessment and observation. Pt has dementia, so husband present during HH visit. ………Wheezing heard in RUL on auscultation……….. There was no evidence found that S7LPN notified the patient’s physician of the patient’s wheezing to her RUL found by S7LPN during the home visit. On 10/21/2021 at 12:13 pm, a phone interview was conducted with S7LPN and the above listed findings was discussed. S7LPN verified that the patient’s physician was not notified of the new finding of the patient’s wheezing to her RUL during the home visit.

Communication with all physicians CFR(s): 484.60(d)(1) Assure communication with all physicians or allowed practitioners involved in the plan of care. This ELEMENT is not met as evidenced by: Based on record review, interview and observation, the agency failed to ensure communication with all physicians involved in the plan of care (POC) for each patient as evidenced by: 1. There was no evidence found for Patient #4 of the physician being notified of multiple visits that were not conducted by the skilled nurse; 2. There was no evidence found for Patient #6 that the skilled nurse performed feet inspections during the visits dated 10/12/2021, 10/13/2021 and on 10/18/2021 and no evidence found the physician was made aware that the feet were not inspected as ordered; 3. Patient #10’s physician was not notified that a skilled nurse visit was not conducted on 10/15/2021; 4. Patient #16’s physician was not notified of visits that were not conducted on 8/25/2021, 9/1/2021, 9/16/2021, 9/23/2021, 9/25/2021 and 9/26/2021; 5. No evidence found for Patient #17 of the physician being notified of 2 missed skilled visits not conducted for the week of 5/23/2021, 2 skilled visits not conducted for the week of 5/30/2021 and 3 physical therapy visits not conducted for the week of 5/30/2021; 6. No evidence found that the physician had been made aware that 2 skilled nurse visits had not been conducted during the week of 9/26/2021 for Patient #3; 7. No evidence found that the physician had been made aware that no skilled nurse visit had been conducted during the weeks of 9/20/2021 or 10/10/2021, and that no PT visits had been conducted during the week 0f 10/10/2021 for Patient #11 for 7 (#4, 6, 10, 16, 17, 3, and 11) patients out of a total of 17 (#1-#17) sampled patients reviewed. 1. Patient #4. The patient was admitted to the agency on 7/9/2021 with the diagnoses that included Chronic Venous Hypertension With Ulcer to Left Low Extremity, Chronic Venous Hypertension With Ulcer to Left Right Extremity, Long Term Use of Anticoagulants, and Heart Disease. The certification period reviewed was 9/7/2021 to 11/5/2021. The patient’s plan of care (POC) was reviewed and revealed the following order dated 10/13/2021 – Skilled Nursing; 1 day 24 d (one time a day for 24 days) SN to resume care of patient from ___ (local hospital) for anemia, leg wounds……Wound care: Cleanse left leg with NS (normal saline) apply Ca (calcium) alginate to open areas Vitamin A&D to dry areas an wrap with Kerlix and Coban form toes to knee in spiral fashion. RLE (right lower extremity) no compression, apply A&D ointment to RLE wrap with Kerlix. The patient’s certification period was reviewed and there was no evidence of skilled visits conducted with the patient on 9/10/2021, 9/20/2021, 9/21/2021, 9/22/2021, 10/6/2021, 10/7/2021, and 10/14/2021. On 10/20/21 at 2:27 pm, an interview was conducted with S2ADON (Assistant Director of Nursing) and after review of the patient’s electronic medical records, she verified the skilled nurse visits were not made as ordered and the physician was not notified of the missed visits. S2DON (Director of Nursing) stated the nurse that was responsible for notifying the physician was no longer employed with the agency and she was not aware that the missed visit had not been faxed to the physician. 2. Patient #6. The patient was admitted to the agency on 10/12/2021 with the diagnoses that included Hemiplegia Following Cerebral Infraction Affecting Left Non Dominant Side, Dysphagia, Hypertensive Chronic kidney Disease and Diabetes Mellitus Type 2 With Diabetic cataract. The certification period reviewed was 10/12/2021 to 11/10/2021. The patient’s plan of care (POC) was reviewed and revealed the following order – SN (skilled nurse) 1 wk 1wk (1 time a week for 1 week, 2 wk 2 wk (2 times a week for 2 weeks, 1 wk 7 wk (1 time a week for 7 weeks). SN to document feet inspection every visit. There was no evidence found of the inspection of the patient’s feet on the skilled nurse visits dated 10/12/2021 (admit), 10/13/2021, and on 10/18/2021. There was no evidence found that the physician was made aware that the patient's feet were inspected as ordered. On 10/21/2021 at 8:56 am, an interview was conducted with S1DON and after a review of the patient’s electronic medical records, she verified there was no evidence that the skilled nurse performed feet inspections on the skilled visits. 3. Patient #10. The patient was admitted to the agency on 9/15/2021 with the diagnoses that included Diabetes Mellitus Type 2 With Foot Ulcer, Non-pressure Chronic Ulcer Other Part Left Foot, Cellulitis of Left Lower Limb, Chronic Osteomyelitis Left Ankle and Foot, and Presence of Aortocoronary Bypass Graft. The certification period reviewed was 9/15/2021 to 11/13/2021. The patient’s POC (plan of care) was reviewed and revealed the following order – Skilled Nursing; 1 wk 1 wk (1 time a week for 1 week), 2 wk 2 wk (2 times a week for 2 week), 2 wk 6 wk (2 times a week for 6 weeks). There was no evidence found that the skilled nurses conducted 2 visits as order for the week of 10/10/2021. On 10/21/2021 at 3:22 pm, an interview was conducted with S1DON and after a review of the patient’s electronic medical records, she verified there was no evidence that the patient’s physician had been notified of the 2 missed skilled nurse visits for the week of 10/10/2021. On 10/21/2021 at 11:57 am, an interview was conducted with S1DON. She stated that the agency was in the process of transitioning to new electronic medical records system which began on 8/31/2021. She stated she called the IT department for the new system and was told that the system had not been correctly set up for the automatic emails to be sent to the patient’s physician when a missed visit occurred. 4. Patient #16. The patient was admitted to the agency on 8/19/2021 with the diagnoses that included Psoriasis, Hypertension and History of Falling. The certification period reviewed was 8/19/2021 to 10/17/2021. The patient’s POC was reviewed and revealed the following order – Skilled Nursing: 1D60 (1 visit for 60 days). There was no evidence found that the skilled nurses conducted visits as order on 8/25/2021, 9/1/2021, 9/16/2021, 9/23/2021, 9/25/2021 and on 9/26/2021. On 10/22/2021 at 12:07 pm, an interview was conducted with S2ADON and after a review of the patient’s electronic medical records, she verified there was no evidence that the patient’s physician had been notified of the missed skilled visits for the above listed dates. 5. Patient #17. The patient was admitted to the agency on 5/22/2021 with the diagnoses that included Dislocation of Internal Left Hip Prosthesis, Hypokalemia, and Hypothyroidism. The certification period reviewed was 5/22/2021 to 7/20/2021. The patient’s POC was reviewed and revealed the following order – 5/22/2021 Skilled Nursing; 1W1 (1 time a week for 1 week), 4W1 (4 times a week for 1 week), 2W2 (2 times a week for weeks), 1W6 (1 time a week for 6 weeks). Physical Therapy 1wk1 (1 time a week for 1 week) then 3x/wk (3 times a week) for 2 week for gait training. There was no evidence found that the skilled nurses conducted 2 visits as order for the week of 5/23/2021 and the week of 5/30/2021. There was no evidence found that physical therapy conducted 2 visits with the patient for the week of 5/30/2021. On 10/22/2021 at 12:00 pm, an interview was conducted with S2ADON and after a review of the patient’s electronic medical records, she verified there was no evidence that the patient’s physician had been notified of the 2 missed skilled visits for the week of 5/23/2021 and 5/30/2021. S2ADON verified there was no evidence that the physician had been notified of the 2 missed physical therapy visits for the week of 5/30/2021. 6. Patient #3: The patient was admitted to the agency on 9/24/21 with diagnoses including Pneumonia and Acute Respiratory Failure. A review of her PoC revealed orders for the skilled nurse to see her once during the first week (SN 1WK1), three times weekly for 2 weeks (3WK2), then once weekly for 7 weeks (1WK7) beginning on 9/24/2021 and ending on 11/22/2021 A review of electronic chart visits for the patient’s second week starting on 9/26/2021 through 10/2/2021, revealed documentation that a skilled nurse visit had only been conducted on 10/1/2021. On 10/19 at 2:15 PM, an interview was conducted with S6RN (Registered Nurse). She reviewed Patient #3’s PoC and confirmed the order for the agency to provide 3 skilled nurse visits to be conducted during the week of 9/26/2021. S6RN reviewed the patients skilled nurse visits and confirmed that there was only 1 skilled nurse visit documented for that week. On 10/20/21 at 11:45 AM, an interview was conducted with S6RN. She confirmed that the agency had conducted only one skilled nurse visit during the week of 9/26/2021, not 3 as ordered. SRN further confirmed that there was no evidence that Patient #3’s physician had been notified of the missed visits. 7. Patient #11: The patient was admitted to the agency on 9/14/2021 with diagnoses including DM (Diabetes Mellitus), malignant neoplasm of unspecified ovary, neutropenia, anemia, malnutrition, dehydration, and Stage 1 pressure ulcer of the sacral region. The patient’s PoC was reviewed and revealed that the SN (skilled nurse) was to see the patient once a week for 8 weeks (SN1WK8) beginning on 9/20/2021 and ending on 11/22/2021. The PT (physical therapist) was to see the patient twice weekly for three weeks (2WK3) beginning the week of 9/29/2021. A review of the patient’s electronic chart failed to reveal that a skilled nurse visit had been conducted during the weeks of 9/20/2021 or 10/10/2021. The review failed to reveal that PT visits had been conducted during the week of 10/10/2021. On 10/21/21 at 1:15 PM, an interview was conducted with S1DON. She reviewed the patient’s PoC and confirmed the order to provide skilled nursing once a week beginning on 9/20/2021, and the order for physical therapy twice weekly beginning the week of 9/29/2021. She reviewed the patient’s electronic chart and confirmed that there was no evidence that the nurse had conducted a visit during the weeks of 9/20/1021 or 10/10/2021. She confirmed that there was no evidence that the physical therapist had conducted any visits during the week PT visit on 10/10/2021. She further confirmed that there was no evidence that Patient #11’s physician had been made aware that the visits had not been conducted.

Integrate all services CFR(s): 484.60(d)(3) Integrate services, whether services are provided directly or under arrangement, to assure the identification of patient needs and factors that could affect patient safety and treatment effectiveness and the coordination of care provided by all disciplines. This ELEMENT is not met as evidenced by: Based on record review and interview, the agency failed to integrate services provided by physical therapy to assure the identification of patient needs, factors that could affect the patient safety, treatment effectiveness, and the coordination of care provided by all disciplines. The agency’s staff did not request a therapy evaluation for the patient as per the documentation in the registered nurses admit assessment for 1 (#10) patient out of a total of 17 sampled patients. Findings: Patient #10. The patient was admitted to the agency on 9/15/2021 with the diagnoses that included Diabetes Mellitus Type 2 with Foot Ulcer, Non-pressure Chronic Ulcer Other Part Left Food, Cellulitis of Left Lower Limb, Chronic Osteomyelitis Left Ankle and Foot, and Presence of Aortocoronary Bypass Graft. The certification period reviewed was 9/15/2021 to 11/13/2021. The patient’s POC (plan of care) was reviewed and revealed the following order – Skilled Nursing; 1 wk 1 wk (1 time a week for 1 week), 2 wk 2 wk (2 times a week for 2 week), 2 wk 6 wk (2 times a week for 6 weeks). A review of the patient’s admit assessment dated 9/15/2021 revealed, under the section Narrative: Patient would benefit from physical therapy to improve muscle strength, endurance and safety. There was no evidence found that the skilled nurse requested an evaluation by the physical therapy staff for the patient’s benefit during the certification period. On 10/21/2021 at 3:19 pm, an interview was conducted with S1DON and after a review of the patient’s electronic medical records; she verified there was no evidence that the agency’s staff requested a physical therapy evaluation for the patient as per the documentation in the registered nurses admit assessment. S1DON stated the nurse did not tell her that a therapy consult was needed for the patient.

Executive responsibilities for QAPI CFR(s): 484.65(e)(1)(2)(3)(4) Standard: Executive responsibilities. The HHA's governing body is responsible for ensuring the following: (1) That an ongoing program for quality improvement and patient safety is defined, implemented, and maintained; (2) That the HHA-wide quality assessment and performance improvement efforts address priorities for improved quality of care and patient safety, and that all improvement actions are evaluated for effectiveness; (3) That clear expectations for patient safety are established, implemented, and maintained; and (4) That any findings of fraud or waste are appropriately addressed. This STANDARD is not met as evidenced by: Based on record review and interview, the agency failed to ensure the home health agency’s administrator and director of nursing ensured an ongoing monitoring of the agency’s QAPI (Quality Assurance Performance Improvement) program and implementation of the agency’s program as evidenced by findings identified during the recertification/relicensing survey. Findings: On 10/22/2021 at 2:15 PM, a review of the facility’s QAPI (Quality Assessment and Performance Improvement) binder was conducted with S1DON. The review revealed that the agency’s ongoing QA included falls, fall prevention, and safety. S1DON stated rehospitalization, and adverse medication errors were a focus for the agency. Further review of the QA binder failed to reveal that the agency was QA’ing the deficient practice identified during the survey. S1DON confirmed that these issues had not been identified and were not part of the QAPI for the agency. S1DON stated the person responsible for QA’ing the skilled nurse notes had been out for the facility for the last 6 weeks. S1DON stated that person was responsible for pulling the skilled notes and reviewing the plan of care (POC). S1DON stated the field nurses are to report to the case coordinator any problems they find on the visits or if they call the physician for any reason. S1DON stated the case coordinators are responsible to ensure that the visits are being done by the field nurses. S1DON stated if the skilled notes are not closed in 24 hours the case coordinators needs to check with the field nurse as to why they are not closed. S1DON stated concerning the visits identified by the surveyors as not being made, the case coordinators should have been on top of the missed visits. S1DON stated, “I am the DON and take responsible for the missed visits. The case coordinators should have called the nurse and asked why the notes are not done for the visit. It was a big transition for the new system and case coordinator should have identified the notes were not complete. I did not see that happen with the case coordinators. The new system started on 8/30/2021 and there was supposed to be automatic communication to the md if the visits were missed. That is how the system was explained to us. The faxes are coming in but there were no confirmation of the faxes for the missed visits. The case coordinator should have checked to see why there was no md response.” S2DON verified there was no documentation of the missed visits to the physician. S1DON stated the case coordinators failed to do what they were supposed to do. S1DON stated the staff failed to do their role and get the faxes to the md done. S1DON stated that concerning the orders not found on the POC, that the case coordinators have oversight over the POCs and the diagnoses not addressed on the POC should have been caught by the case coordinator. S1DON verified that prior to this survey, this issue was not identified by her or the case coordinators. S1DON stated when asked why the POC were not signed within 30 days, that the agency’s secretary had been tracking the md signatures and will start making calls to get them signed. She stated the secretary would have the marketing team deliver the POC to the physician’s office and that it was her responsibility to make sure they were signed timely. She stated the office manager would alert her on the 21st of the month, if a POC was not signed and she would try to get them from the physician. S1DON stated she was not always able to get physicians to cooperate and sign the POCs on time. S1DON stated her staff had failed do what they should have to get the POCs signed timely. S1DON stated the case coordinators work in the office unless they are unable to find staff to see the patient. She verified for Patient #10 that there was no documentation of the skilled nurse preforming wound care during the visits. She stated the wound care was ordered on the POC and the md should have been made aware if the SN was not performing the wound care. S1DON stated the case coordinators should have picked up on the review of the notes that no wound care was being done by the skilled nurse. S1DON stated the field nurse should have notified the case coordinators if the patient was not getting wound care doing the visits. S1DON stated the patient was getting one skilled visit per week for wound care to assess if the wound was healing and if they were not doing the wound care then the case coordinator should have be notified. S1DON stated it is the field nurse’s responsibility to report any adverse findings or anything that is not normal to the case coordinator and this was not done for this patient. S1DON stated the staff should have let her know what was going on with the patient. S1DON stated from a leadership perspective that she was responsible for making sure the wound care for the patient was done by the field staff. S1DON stated concerning their IDG (interdisciplinary group) weekly meeting the issues in the facility are discussed with the staff. S1DON stated there were no issues that she was aware of concerning wound care not being performed as ordered until it was brought to her attention by the surveyors. S1DON stated she had not identified wound care as an issue in the agency. S1DON stated the nurses were not doing the wound care and it was not reported to her. S1DON stated the agency has a lot of patients with many issues and a lot of patient that are cancelling appointments with the nurses due to the patient being afraid for the nurses to come into the home due to COVID. She stated the patients are scared to go to the physician’s office too. S1DON stated it was the agency’s responsibility to let the physician know about missed visits. S1DON stated concerning home health aide supervisory visits that this was not identified as an issue in the facility and the issue was not addressed during the IDG meeting. S1DON verified that none of the issues identified by the surveyors during the survey were issues identified by her or the staff in the agency prior to the survey.

Skilled professional services CFR(s): 484.75 Condition of participation: Skilled professional services. Skilled professional services include skilled nursing services, physical therapy, speech-language pathology services, and occupational therapy, as specified in §409.44 of this chapter, and physician or allowed practitioner and medical social work services as specified in §409.45 of this chapter. Skilled professionals who provide services to HHA patients directly or under arrangement must participate in the coordination of care. This CONDITION is not met as evidenced by: Based on electronic record review, observation and interview, the provider failed to meet the Condition of Participation for Skilled Professional Services as evidenced by: 1. Failing to provide services that were ordered by the physician as indicated in the plan of care; a. There was no evidence for Patient #1 that the skilled nurses assessed the patient’s ostomy site as ordered on the PoC during the skills visit and no evidence found the skilled nurse changed the patient’s suprapubic catheter on the skilled visit dated 9/17/2021; b. No evidence for Patient #4 that the skilled nurse provided wound care to the patient’s left leg as ordered; no evidence on multiple skilled visits that the skilled nurse provided wound care to the patient right lower extremity and no evidence the skilled nurse obtained vital signs during the skilled visit dated 9/11/2021; c. No evidence of feet inspections on each skilled nurse visits for Patient #6 who had a diagnosis of Diabetes Mellitus Type 2; d. There was no evidence found for Patient #10 that the skilled nurses was performing wound care as ordered; e. No evidence found on Patient #11’s PoC that the skilled nurse monitored the patient’s Diabetes Mellitus, including foot care, or monitoring of a stage 1 pressure ulcer; f. No evidence found for Patient #5 that an assessment was conducted as ordered during a skilled nurse visit on 10/15/2021; g. No evidence found for Patient #9 that a skilled nurse visit was conducted as ordered on 10/14/2021. (Refer to G710) 2. Failing to ensure the patient received education for self-infusion of an IV (intravenous) antibiotic. (Refer to G714) 1. The agency failed to provide services that were ordered by the physician as indicated in the plan of care as evidenced by: a. There was no evidence for Patient #1 that the skilled nurses assessed the patient’s ostomy site as ordered on the PoC during the skills visit; b. No evidence for Patient #4 that the skilled nurse provided wound care to the patient’s left leg as ordered; no evidence on multiple skilled visits that the skilled nurse provided wound care to the patient right lower extremity and no evidence the skilled nurse obtained vital signs during the skilled visit dated 9/11/2021; c. No evidence of feet inspections on each skilled nurse visits for Patient #6 who had a diagnosis of Diabetes Mellitus Type 2; d. There was no evidence found for Patient #10 that the skilled nurses was performing wound care as ordered; e. No evidence found on Patient #11’s PoC that the skilled nurse monitored the patient’s Diabetes Mellitus, including foot care, or monitoring of a stage 1 pressure ulcer; f. No evidence found for Patient #5 that an assessment was conducted as ordered during a skilled nurse visit on 10/15/2021; g. No evidence found for Patient #9 that a skilled nurse visit was conducted as ordered on 10/14/2021. (See findings in G710) 2. The agency failed to ensure patient and caregiver education as evidenced by: a. The agency failed to ensure the patient received education for self-infusion of an IV (intravenous) antibiotic. (See findings in G714)

Provide services in the plan of care CFR(s): 484.75(b)(3) Providing services that are ordered by the physician or allowed practitioner as indicated in the plan of care; This ELEMENT is not met as evidenced by: Based on record review and interview, the agency failed to ensure the agency’s skilled nursing provided services that were ordered by the physician as indicated in the plan of care as evidenced by: 1. There was no evidence for Patient #1 that the skilled nurses assessed the patient’s ostomy site as ordered on the PoC during the skills visit and no evidence found the skilled nurse changed the patient’s suprapubic catheter on the skilled visit dated 9/17/2021; 2. No evidence for Patient #4 that the skilled nurse provided wound care to the patient’s left leg as ordered; no evidence on multiple skilled visits that the skilled nurse provided wound care to the patient right lower extremity and no evidence the skilled nurse obtained vital signs during the skilled visit dated 9/11/2021; 3. No evidence of feet inspections on each skilled nurse visits for Patient #6 who had a diagnosis of Diabetes Mellitus Type 2; 4. There was no evidence found for Patient #10 that the skilled nurses was performing wound care as ordered and failed to conduct 2 skilled nurse visits during the week of 10/10/2021; 5. No evidence found for Patient #5 that an assessment was conducted as ordered during a skilled nurse visit on 10/15/2021; 6. No evidence found for Patient #9 that a skilled nurse visit was conducted as ordered on 10/14/2021; 7. Patient #16 did not have visits on 8/25/2021, 9/1/2021, 9/16/2021, 9/23/2021, 9/25/2021 and 9/26/2021; 8. No evidence found for Patient #17 that 2 skilled visit were conducted for the week of 5/23/2021 and 2 skilled visits were conducted for the week of 5/30/2021 and 3 physical therapy visits were conducted for the week of 5/30/2021; 9. No evidence found for Patient #3 that 3 skilled nurse visits were conducted during the week of 9/26/2021; and 10. No evidence found for Patient #11 that a skilled nurse visits was conducted during the weeks of 9/20/2021 or 10/10/2021, and no evidence that PT visits had been conducted during the week of 10/10/2021 out of 10 (#1, #3, #4 ,#5, #6, #9, #10, #11, #16, and #17) of a total sample of 17 patients (#1-17). Findings: 1. Patient #1. The patient was admitted to the agency on 05/07/2019 with the diagnoses that included Encounter For Attention to Cystostomy, Encounter For Fitting and Adjustment of Urinary Device, and Long Term Use of Anticoagulants. The certification period reviewed was 08/19/2021 to 10/17/2021. The patient’s POC was reviewed and revealed the following order – CNA; 0W1 (0 time a week for 1 week), 3W8 (3 times a week for 8 week). The SN (skilled nurse) frequency was revealed as followed- SN: 1W9 (1 time a week for 9 weeks). SN to instruct on care of the colostomy. Assess the stoma every visit for signs of bleeding or other complications, and advise them that the stoma will slowly begin to shrink. Assess the skin surrounding the stoma for excoriation and instruct on skin protectants for prevent of those complications. The physician’s order dated 11/5/2020 revealed the following order – Change suprapubic catheter weekly, pt/fmly to continue irritation daily at home. The skilled nurse visits for the certification period were reviewed and there was no evidence found that the skilled nurses assessed the patient stoma sites during the visits. The skilled nurse’s note dated 9/17/2021 was reviewed and revealed no evidence that the nurse changed the patient suprapubic catheter during the skilled visit. On 10/21/2021 at 10:50 am, an interview was conducted with S1DON and after a review of the patient’s skilled notes for the certification period, she verified there was no evidence of an assessment of the patient’s stoma during the skilled visits. S1DON also verified that no evidence on the skilled nurse’s note dated 9/7/2021 that the nurse changed the patient’s suprapubic catheter. 2. Patient #4. The patient was admitted to the agency on 7/9/2021 with the diagnoses that included Chronic Venous Hypertension With Ulcer to Left Low Extremity, Chronic Venous Hypertension With Ulcer to Left Right Extremity, Long Term Use of Anticoagulants, and Heart Disease. The certification period reviewed was 9/7/2021 to 11/5/2021. The patient’s plan of care (POC) was reviewed and revealed the following order dated 10/13/2021 – Skilled Nursing; 1 day 24 d (one time a day for 24 days) SN to resume care of patient from ___ (local hospital) for anemia, leg wounds……Wound care: Cleanse left leg with NS (normal saline) apply Ca (calcium) alginate to open areas Vitamin A and D to dry areas and wrap with Kerlix and Coban from toes to knee in spiral fashion. RLE (right lower extremity) no compression, apply A and D ointment to RLE wrap with Kerlix. The skilled nurse visits for the certification period were reviewed and there was no evidence found that the skilled nurse provided wound care to the patient right lower leg during the visit dated 9/11/2021. There was no evidence found that the skilled nurse preformed wound care to the patient’s right leg on 9/30/2021, 10/1/2021, 10/3/2021, 10/8/2021, 10/9/2021 and on 10/18/2021. On 10/20/2021 at 1:36 pm, an interview was conducted with S1DON and after a review of the patient’s electronic medical record, she verified the nurse notes listed above had no evidence wound care was provided. 3. Patient #6. The patient was admitted to the agency on 10/12/2021 with the diagnoses that included Hemiplegia Following Cerebral Infraction Affecting Left Non Dominant Side, Dysphagia, Hypertensive Chronic kidney Disease and Diabetes Mellitus Type 2 With Diabetic cataract. The certification period reviewed was 10/12/2021 to 11/10/2021. The patient’s plan of care (POC) was reviewed and revealed the following order – SN (skilled nurse) 1 wk 1wk (1 time a week for 1 week, 2 wk 2 wk (2 times a week for 2 weeks, 1 wk 7 wk (1 time a week for 7 weeks). SN to document feet inspection every visit. There was no evidence found on the skilled nurse visits dated 10/12/2021 (admit), 10/13/2021 and 10/18/2021that the skilled nurse performed the feet inspections. On 10/21/2021 at 8:56 am, an interview was conducted with S1DON (Director of Nursing) and after a review of the patient’s electronic medical records, she verified there was no evidence that the skilled nurse performed feet inspections on the skilled visits. 4. Patient #10. The patient was admitted to the agency on 9/15/2021 with the diagnoses that included Diabetes Mellitus Type 2 With Foot Ulcer, Non-pressure Chronic Ulcer Other Part Left Foot, Cellulitis of Left Lower Limb, Chronic Osteomyelitis Left Ankle and Foot, and Presence of Aortocoronary Bypass Graft. The certification period reviewed was 9/15/2021 to 11/13/2021. The patient’s POC (plan of care) was reviewed and revealed the following order – Skilled Nursing; 1 wk 1 wk (1 time a week for 1 week), 2 wk 2 wk (2 times a week for 2 week), 2 wk 6 wk (2 times a week for 6 weeks)….….. Wound care to left foot planter/lateral diabetic ulcers….. SN (skilled nurse) to assess every visit; report any s/s (signs/symptoms) decline to wound care MD (medical doctor)…. The skilled nurse visits for the certification period were reviewed and there was no evidence found that the skilled nurses provided wound care to the patient's left lower leg on 9/24/2021. There was no evidence found that the patient’s physician was informed that the skilled nurse had not provided wound care during the skilled visit. There was no evidence found that the skilled nurses conducted 2 visits as order for the week of 10/10/2021. On 10/21/2021 at 3:22 pm, an interview was conducted with S1DON and the patient’s electronic records were discussed. S1DON stated the nurse told her that the patient was going to a wound care clinic and this was the reason the nurses were not preforming wound care during their visits. S1DON verified there was no evidence that the skilled nurse performed 2 skilled visits for the week of 10/10/2021 5. Patient #5: The patient was admitted to the agency on 9/24/2021 with diagnoses including malignant neoplasm of connective and soft tissue. The patient's PoC was reviewed and the following documentation was found - Orders for Discipline and Treatments: SN (skilled nurse) IV Unasyn (antibiotic) 3 gms (grams) q (every) 6 hours via PICC. Start 9/24/2021. Further review revealed that orders were received on 9/25/2021, 10/1/2021, 10/8/2021, and 10/15/2021 to continue the daily IV infusion, with an end date of 10/24/2021. Further review of the PoC revealed that the SN was to assess Patient #5’s appetite, diet, caloric intake, eating patterns, hydration, central venous site for pain, redness, edema, bleeding, draining, problems with patency or other complications. SN was to assess vital signs, oxygen saturation, general status, s/s (signs and symptoms) of exacerbations, s/s complications of infusion therapy, monitor weight, teach/reinforce purpose of IV (intravenous) therapy, dosage, administration of medications, solutions, flushes, possible side effects, possible complications, and s/s to report to RN/MD. SN to flush PICC w 10-20 ml (milliliters) ns (normal saline) and 3-5 ml heparin using strict asepsis, SN to perform sterile central line care using alcohol/chloraprep cleanser, and cover with a transparent dressing. SN to assess all body systems, turgor, s/s circulatory compromise, pedal pulses, and capillary refill on all extremities, edema, integumentary, cardiopulmonary, Gastrointestinal, and Genitourinary status, pain, and intervene as necessary. SN to assess vital signs each visit. The patient’s electronic record was reviewed and no evidence of a Skilled Nurse Visit was found on 10/15/2021. S3RN’s name was noted in the entry area where the visit documentation should have been. On 10/20/2021 at 12:30 PM, an interview was conducted with S1DON. She reviewed Patient #5’s electronic record and confirmed the order for a daily skilled nurse visit for the administration of an IV (intravenous) antibiotic. She reviewed the visits conducted and stated that there was an indicator that revealed that a visit had not been conducted on 10/15/2021. She stated that S3RN’s name was noted as scheduled to have conducted the visit. On 10/20/2021 at 12:34 PM, an interview was conducted with S3RN. S3RN stated that on 10/15/2021, she had conducted the IV infusion here in the agency as S6RN had arranged for the patient to come here to the agency after she saw her doctor in town. She stated that she did not conduct any assessments on the patient, including body system, PICC line insertion site, or vital signs, or any other assessments or monitoring ordered on the PoC. S3RN stated that she only discarded the IV bag in the patient’s pump and started a new bag of IV antibiotics infusing into the PICC line and then the patient left the agency. 6. Patient #9: The patient was admitted to the agency on 9/17/2021 with diagnoses including management of implanted device, long term use of antibiotics, and cute osteomyelitis of left ankle and foot. The patients PoC was reviewed and revealed SN (skilled nurse) Infusion orders to administer IV antibiotic Cefepime 2 gms q 8 hours x 6 weeks via PICC (Peripherally inserted central catheter) via infusion pump. SN orders to assess central venous access for pain, redness, edema, bleeding, draining, problems with patency, or other complications daily for 59 days (1D59) beginning on 9/18/2021 and ending on 11/15/2021 were noted. SN interventions on the PoC included- Assess risk factors which facilitate infection transmission, general status, s/s (signs and symptoms) of exacerbations, complications of infusion therapy. SN to assess VS (vital signs) and all body systems. SN to assess all body systems, assess for s/s circulatory compromise, assess pedal pulses, capillary refill for all extremities, assess for edema, assess integumentary, GI (gastrointestinal), GU (genitourinary) status, nutrition and hydration status, and assess pain. A review of Patient #9’s electronic record visits failed to reveal that a SN visit had been conducted on 10/14/2021. On 10/21/2021 at 3:00 PM, an interview was conducted with S6RN. She stated that S3RN was scheduled to conduct a skilled nurse visit on 10/14/2021 to administer Patient #9’s IV antibiotic infusion. She stated that in the evening of 10/14/2021 she texted S3RN to see how it went and S3RN stated she did not go to the home to conduct the skilled nurse visit. On 10/22/2021 at 9:30 AM, an interview was conducted with S3RN, and she confirmed that on 10/14/2021, she had been scheduled to administer Patient #9’s IV antibiotic in his home. She stated that she did not conduct this skilled nurse visit with the patient. She confirmed that she did not conduct an assessment of patient’s central venous site, extremities for edema, s/s complications related to the infusion, respiratory distress, VS, integumentary, GI or GU status, nutrition and hydration status, or assess his pain as ordered on his PoC. On 10/22/2021 at 9:40 AM, an interview was conducted with S1DON. She confirmed that no skilled nurse visit was conducted on 10/14/2021 with Patient #9 as ordered in his PoC. 7. Patient #16. The patient was admitted to the agency on 8/19/2021 with the diagnoses that included Psoriasis, Hypertension and History of Falling. The certification period reviewed was 8/19/2021 to 10/17/2021. The patient’s POC was reviewed and revealed the following order – Skilled Nursing: 1D60 (1 visit for 60 days). There was no evidence found that the skilled nurses conducted visits as order on 8/25/2021, 9/1/2021, 9/16/2021, 9/23/2021, 9/25/2021 and on 9/26/2021. On 10/22/2021 at 12:07 pm, an interview was conducted with S2ADON and after a review of the patient’s electronic medical records, she verified there was no evidence that the skilled nurse performed skilled visits for the above listed dates. 8. Patient #17. The patient was admitted to the agency on 5/22/2021 with the diagnoses that included Dislocation of Internal Left Hip Prosthesis, Hypokalemia, and Hypothyroidism. The certification period reviewed was 5/22/2021 to 7/20/2021. The patient’s POC was reviewed and revealed the following order – 5/22/2021 Skilled Nursing; 1W1 (1 time a week for 1 week), 4W1 (4 times a week for 1 week), 2W2 (2 times a week for weeks), 1W6 (1 time a week for 6 weeks). Physical Therapy 1wk1 (1 time a week for 1 week) then 3x/wk (3 times a week) for 2 week for gait training. There was no evidence found that the skilled nurses conducted 2 visits as order for the week of 5/23/2021 and the week of 5/30/2021. There was no evidence found that physical therapy conducted 2 visits with the patient for the week of 5/30/2021. On 10/22/2021 at 12:00 pm, an interview was conducted with S2ADON and after a review of the patient’s electronic medical records, she verified there was no evidence that the skilled nurse performed 2 skilled visits as ordered for the week of 5/23/2021 and 5/30/2021. S2ADON verified there was no evidence that physical therapy performed 2 visits for the week of 5/30/2021. 9. Patient #3: The patient was admitted to the agency on 9/24/21 with diagnoses including Pneumonia, and Acute Respiratory Failure. A review of her PoC revealed orders for the skilled nurse to see her once during the first week (SN 1WK1), three times weekly for 2 weeks (3WK2), then once weekly for 7 weeks (1WK7) beginning on 9/24/2021 and ending on 11/22/2021 A review of electronic chart visits for the patient’s second week starting on 9/26/2021 through 10/2/2021, revealed documentation of a skilled nurse visit conducted on 10/1/2021 only. An entry dated 9/27/2021 with S4LPN’s name was noted, but could not be accessed. No other evidence of additional skilled nurse visits were noted for this week. On 10/19 at 2:15 PM, an interview was conducted with S6RN. She reviewed Patient #3’s electronic chart visits and confirmed that S4LPN’s name was noted on an incomplete entry dated 9/27/2021. She confirmed that there was only one visit documented for the patient’s second week and the PoC order was for 3 skilled nurse visits to be conducted. On 10/20/21 at 11:45 AM, an interview was conducted with S6RN. She confirmed that S4LPN had not conducted a visit on 9/27/2021. She further confirmed that the agency failed to provide services as ordered on the PoC, and that they had only conducted one skilled nurse visit and the PoC order was for 3 visits. 10. Patient #11: The patient was admitted to the agency on 9/14/2021 with diagnoses including DM (Diabetes Mellitus), malignant neoplasm of unspecified ovary, neutropenia, anemia, malnutrition, dehydration, and Stage 1 pressure ulcer of the sacral region. The patient’s PoC was reviewed and revealed that the SN (skilled nurse) was to see the patient once a week for 8 weeks (SN1WK8) beginning on 9/20/2021 and ending on 11/22/2021. The PT (physical therapist) was to see the patient twice weekly for three weeks (2WK3) beginning the week of 9/29/2021. A review of the patient’s electronic chart failed to reveal that a skilled nurse visit had been conducted during the week of 9/20/2021 or 10/10/2021. The review failed to reveal that PT visits had been conducted during the week of 10/10/2021. On 10/21/2021 at 1:15 PM, an interview was conducted with S1DON. She reviewed the patient’s PoC and confirmed the order to provide skilled nursing once a week beginning on 9/20/2021, and the order for physical therapy twice weekly beginning the week of 9/29/2021. She reviewed the patient’s electronic chart and confirmed that there was no evidence that the nurse had conducted a visit during the weeks of 9/20/2021 or 10/10/2021. She confirmed that there was no evidence that the physical therapist had conducted any visits during the week PT visit on 10/10/2021.

Patient and caregiver education CFR(s): 484.75(b)(5) Patient and caregiver education; This ELEMENT is not met as evidenced by: Based on record review and interview, the agency failed to ensure each patient and caregiver received education for 1 patient (Patient #9), on self-infusion of an IV (intravenous) antibiotic out of a total sample of 17 (#1-17) patients reviewed. Findings: Patient #9 was admitted to the agency on 9/17/2021 with diagnoses including management of implanted device, long-term use of antibiotics, and acute osteomyelitis of left ankle and foot. The patients PoC (Plan of Care) was reviewed and revealed infusion orders for SN (Skilled Nurse) as follows: administer and instruct on the administration of IV (intravenous) Cefepime (antibiotic) 2 gms (grams) q (every) 8 hours x 6 weeks via PICC (Peripherally inserted central catheter) via infusion pump. SN interventions on the PoC included: Teach care/protection of central line and or other venous access device, potential complications, and teach reinforce aseptic technique and Infection Control. A review of Patient #9’s electronic record visits failed to reveal that a SN visit had been conducted on 10/14/2021. On 10/21//2021 at 3:00 PM, an interview was conducted with S6RN regarding the lack of evidence that a skilled nurse visit had been conducted for the patient on 10/14/2021. She presented a communication note dated 10/14/21 at 5:20 PM, which included - pt mother called at 1:40 pm to let me know that nurse –(name)-- did not show up for administration of IV antibiotic. She states she “is not a nurse” and could not administer it. Called and spoke with patient and he states nurse did not show up for visit and he was not able to administer IV antibiotic. Arranged for another RN to go out to administer IV antibiotic this afternoon. –S3RN’s name- reported to me that patient told her he administered his IV antibiotic this afternoon. During the interview, S6RN stated that S3RN told her that while she was on her way to the patient’s home he let her know that he had changed the IV bag and had started the infusion himself. S6RN confirmed that Patient #9 had not been successfully taught to do his own IV infusion. She further stated that both Patient #9 and his mother informed her themselves that neither were able to self-administer the infusion. On 10/22/21 at 9:30 AM, an interview was conducted with S3RN. She stated that she did not conduct this skilled nurse visit with the patient on 10/14/2021 because he informed her that he had self administered the antibiotic infusion himself.

Onsite supervisory visit every 14 days CFR(s): 484.80(h)(1)(i) If home health aide services are provided to a patient who is receiving skilled nursing, physical or occupational therapy, or speech-language pathology services, a registered nurse or other appropriate skilled professional who is familiar with the patient, the patient's plan of care, and the written patient care instructions described in §484.80(g), must make an onsite visit to the patient's home no less frequently than every 14 days. The home health aide does not have to be present during this visit. This ELEMENT is not met as evidenced by: Based on record review and interview, the agency failed to ensure that home health aide services were provided for patients receiving skilled services and the agency failed to ensure RN (Registered Nurse) made onsite supervisory visits to the patient’s home no less frequently than every 14 days as evidenced by the agency not providing evidence for 2 (#1, #12) out of 2 (#1, #12) patients receiving aide services out of a total of 17 sampled patients. Findings: 1. Patient #1. The patient was admitted to the agency on 05/07/2019 with the diagnoses that included Encounter For Attention to Cystostomy, Encounter For Fitting and Adjustment of Urinary Device, and Long Term Use of Anticoagulants. The certification period reviewed was 08/19/2021 to 10/17/2021. The patient’s POC (Plan of Care) was reviewed and revealed the following order – CNA; 0W1 (0 time a week for 1 week), 3W8 (3 times a week for 8 weeks). The SN (skilled nurse) frequency was revealed as followed- SN: 1W9 (1 time a week for 9 weeks). The patient’s skilled visits were reviewed there was a supervisory visit conducted on 9/3/2021 and on 9/29/2021. This was 26 days between the dates. There was no evidence found that the skilled nurse conducted supervisory visits for the home health aide every 14 days for the certification period reviewed. On 10/21/2021 at 10:50 am, an interview was conducted with S1DON and after a review of the patient’s electronic medical records, she verified there was no evidence the skilled nurse performed supervisory visits every 14 days for the home health aide. 2. Patient #12. The patient was admitted to the agency on 05/30/2019 with the diagnoses that included Diabetes Mellitus Type 2, Vascular Dementia and Hypertension. The certification period reviewed was 09/15/2021 to 11/13/2021. The patient’s POC was reviewed and revealed the following order – Aide; 1W9 (1 time a week for 9 week). The SN (skilled nurse) frequency was revealed as followed- SN: 1 m 1 m(1 time a month for 1 month; 2 m 1 m (2 times a month for 1 month); 1 m 1 m (1 time a month for 1 month). Start date 9/15/2021 – End date 11/13/2021. The patient’s skilled visits were reviewed there was a supervisory visit conducted on 10/14/2021. This is the only supervisory visit conducted in the 6 weeks of skilled notes reviewed. There was no evidence found that the skilled nurse conducted supervisory visits for the home health aide every 14 days during the certification period. On 10/21/2021 at 2:05 pm, an interview was conducted with S2ADON and after a review of the patient’s electronic medical records, she verified there was no evidence the skilled nurse performed supervisory visits every 14 days for the home health aide.

Required items in clinical record CFR(s): 484.110(a)(1) The patient's current comprehensive assessment, including all of the assessments from the most recent home health admission, clinical notes, plans of care, and physician or allowed practitioner orders; This ELEMENT is not met as evidenced by: Based on record review and interview, the agency failed to ensure the agency’s staff had a current assessment and documentation of clinical note as evidenced by the following: 1. No evidence found that the skilled nurse performed a visit to discharge the patient from the agency for Patient #15; 2. The skilled nurse failed to document a skilled nurse visit on 10/15/2021, when she administered IV medication via a PICC line for Patient #5; and 3. The skilled nurses failed to follow the agency’s policy when they failed to ensure their skilled nurse visits were completed within 24 hours after the visit was conducted, and the skilled nurse failed to ensure the correct assessment date was documented on a handwritten skilled nurse visit note dated 10/14/2021 that was for a visit conducted on 9/24/2021, and the skilled nurse failed to complete a skilled nurse visit conducted on 9/24/2021 until 10/22/2021, 28 days after the skilled nurse visit had been conducted for Patient #9, out of a total of 17 sampled patients. Patient #15. The patient was admitted to the agency on 07/22/2019 with the diagnoses that included Diabetes Mellitus Type 2, Hypertension, and Vascular Dementia. The certification period reviewed was 7/22/2021 to 8/3/2021. Review of the certification period revealed the skilled nurse made a visit on 7/22/2021, 7/23/2021 and on 8/3/2021. There was no documentation found that the skilled nurse conducted a visit with the patient to discharge the patient from the agency. On 10/22/2021 at 11:40 am, an interview was conducted with S2ADON and after a review of the patient’s electronic medical records, she verified there was no evidence that the skilled nurse made a visit to discharge the patient from the facility. 2. Patient #5: The patient was admitted to the agency on 9/24/2021 with diagnoses including malignant neoplasm of connective and soft tissue. The certification period reviewed was 9/24/2021 – 11/22/2021. The patient's PoC revealed an order for Orders for the skilled nurse to administer an antibiotic, Unasyn 3 gms (grams) q (every) 6 hours IV (intravenously) via Patient #5’s PICC (Peripherally inserted central catheter). A review of the patient’s electronic record revealed no evidence that a Skilled Nurse Visit was conducted on 10/15/2021. S3RN’s name was noted next to the area where the note should have been. Further review revealed a note dated 10/16/2021 with S5RN’s name on the note. The note could not be accessed and a message “editing” was noted when attempts were made to read the note. On 10/20/2021 at 12:30 PM, an interview was conducted with S1DON. She reviewed Patient #5’s record and confirmed that there was no evidence that a visit had been conducted on 10/15/2021, and further confirmed that S3RN was associated with that date. S1DON further confirmed that S5RN’s note for the skilled nurse visit conducted on 10/16/2021 was not available as “editing” meant that the skilled nurse visit note had not been completed by the nurse. She stated the agency policy is that the visit notes should be completed within 24 hours of the home visits and confirmed that S5RN had failed to do so. The agency’s policy titled Authentication, Review, and Documentation was presented by S1DON. It included 4. a) Documented as close to the time of the actual event as feasible (within 24-hour time span of visit). On 10/20/2021 at 12:34 PM, an interview was conducted with S3RN. She confirmed that she saw Patient #5 on 10/15/2021 and had administered her IV antibiotic using her PICC line. She confirmed that she failed to document the visit conducted on 10/15/2021 and stated that she should have. S1DON was present during interview with S3RN. She stated that every skilled nurse visit should be documented and confirmed that S3RN had failed to do so. 3. Patient #9: The patient was admitted to the agency on 9/17/2021 with diagnoses including management of implanted device, long term use of antibiotics, and cute osteomyelitis of left ankle and foot. The patients PoC was reviewed and revealed SN (skilled nurse) to administer IV antibiotic, assess central venous access for pain, redness, edema, bleeding, draining, problems with patency, or other complications daily for 59 days (1D59) beginning on 9/18/21 and ending on 11/15/2021. SN infusion orders to administer and instruct on the administration of IV (intravenous) Cefepime (antibiotic) 2 gms (grams) q (every) 8 hours x 6 weeks via PICC (Peripherally inserted central catheter) via infusion pump. On 10/22/2021, a review of Patient #9’s electronic record visits revealed skilled nurse visits dated 9/24/2021, 10/16/2021, and 10/19/2021 that were not able to be viewed. The message “editing” was received when attempts to view the notes were made. On 10/22/2021 at 9:40 AM, an interview was conducted with S1DON. She confirmed that the skilled nurse visit notes were not accessible for viewing. She stated that the nurses who conducted the skilled nurse visits on 9/24/2021, 10/16/2021, and 10/19/2021 had failed to follow the agency’s policy and ensure their visit notes were completed within 24 hours. On 10/22/2021 at 1:00 PM, S3RN presented a hand written document titled Private Duty Skilled Nursing. Review of this document revealed that it was an assessment dated 10/14/2021, and signed by S3RN. Concurrently she presented a printed electronic skilled nurse visit note, with the date of visit documented as 9/24/2021. The visit note dated 9/24/2021 was electronically signed on 10/22/2021 at 12:53 by S3RN. She stated that the handwritten visit note dated 10/14/2021 was actually the assessment and skilled nurse visit she had conducted on 9/24/2021. S3RN confirmed that she had not conducted a skilled nurse visit with Patient #9 on 10/14/2021, as the handwritten note stated. S3RN stated that she had not completed the documentation for the 9/24/2021 visit until today, 10/22/2021 at 12:53 PM, 28 days after she had made the skilled nurse visit. S3RN stated that this is why no 9/24/2021 skilled nurse visit note was not available for review in the patient’s electronic record. S1DON was present during the interview.