Every finding on record at Floyd Homecare, LLC

A Recertification survey was conducted at Floyd Homecare on November 12, 2024, and concluded on November 14, 2024. At the time of the survey, the agency was in compliance with 42 CFR Part 418.113, Emergency Preparedness and Covid-19 infection control.

A Recertification survey was conducted at Floyd Homecare on November 12, 2024, and concluded on November 14, 2024. At the time of the survey, the agency was not in compliance with Chapter 42 CFR Part 418, Rules and Requirements for Home Health and Hospice Agencies. The census was 309. The following deficiency was cited.

Encoding and transmitting OASIS CFR(s): 484.45(a) Standard: An HHA must encode and electronically transmit each completed OASIS assessment to the CMS system, regarding each beneficiary with respect to which information is required to be transmitted (as determined by the Secretary), within 30 days of completing the assessment of the beneficiary. This STANDARD is not met as evidenced by: Based on the Centers for Medicare & Medicaid Services (CMS) Home Health Agency (HHA) Error Summary by agency report, agency policy, and staff interview, it was determined that the agency failed to electronically transmit monthly Outcome and Assessment Information Set (OASIS) data collected to the CMS system every 30 days. Findings include: Review of the policy titled “Reporting of OASIS DATA CAPTURE, TRASMISSION, VERIFICATION, DISPLAY AND REPORTS,” revised 03/01/21 revealed the following: 2. Transmittal of OASIS data a. At least monthly, Agency will electronically transmit accurate, completed, encoded and locked OASIS data to the state agency. All OASIS assessments completed must be transmitted within thirty (30) DAYS OF M0090 date (date the assessment is actually completed). Review of CMS report titled “HHA Error Summary by Agency,” with a run date of 10/31/2024, revealed the agency failed to transmit OASIS data to the CMS system within 30 days. On 11/13/2024 at 2:00 p.m., an in-office video call interview was conducted with the Quality Review Manager and the Administrator. The Quality Review Manager confirmed awareness of the 30-day OASIS submission timeframe requirements not met in August 2023. The Quality Review Manager acknowledged during August 2023, OASIS data gathering was in process of being centralized to one department and the process was slow which caused some delay in submitting OASIS data in a timely manner but has since been corrected.

An Abbreviated/Partial Extended Survey was initiated on September 3, 2024, and concluded on September 5, 2024, at Floyd Homecare for complaint #106751. The census was 108. On September 4, 2024, and Immediate Jeopardy (IJ) was identified related to CFR 484.50 Patient’s Rights; Can no longer meet patient needs; Discharge Plans Communication, 484.75 Skilled Professional Services, and 484.105 Organization and Administration. The agency Executive Director (ED) was informed of the immediate jeopardy on September 5, 2024, at 1:45 p.m. The noncompliance related to the immediate jeopardy was identified to have existed on March 13, 2024. Floyd Homecare was found not to be in compliance with CFR 484.50 Patient’s Rights; Can no longer meet patient needs; Discharge Plans Communication, 484.75 Skilled Professional Services, and 484.110 Discharge and Transfer Summaries. An acceptable removal plan was received during the time of the survey. On September 5, 2024, at 5:00 PM, the HHA Removal Plan was found acceptable by verifying the implementation of the following corrective actions. · 1. Beginning 9/6/24, the Executive Director, Clinical Director, and Patient Care Manager will identify pending discharges. For those patients being discharged due to the inability to meet the patient’s needs, the physician will be notified that the provider cannot meet the needs of the patient, and the agency will assist the patient/patient representative in choosing an alternate provider that can meet the patient’s needs. Documentation will support that the patient will be informed that the agency can no longer meet his/her needs and alternatives provided to patient. 2. Beginning 9/6/24, the Executive Director, Clinical Director, and Patient Care Manager will identify pending discharges and ensure the patient will be notified discharge no later than 2 calendar days before the proposed end of services, discharge will be coordinated with the attending physician and patient/family, the patient will be provided the reason for transfer or discharge, and ongoing psychosocial or physical care needs were identified, and appropriate referrals made. · Beginning 9/6/24, the Executive Director, Clinical Director, and Patient Care Manager will review the Discharge Report in Home Care Home Base (HCHB) daily to identify discharged patients and ensure a discharge summary was sent to the physician and/or other healthcare provider within 5 days of discharge. · Beginning 9/6/24, the Executive Director, Clinical Director, and Patient Care Manager will review the Discharge Report in Home Care Home Base (HCHB) daily to identify discharged patients and ensure the patient received discharge instructions from the clinician at the time of discharge, to include anticipated needs for continued care, treatment and services. A complete and reconciled list of medications is provided directly to the patient and as needed, the family, and the list is explained to patient and /or family. 3. Provider currently not accepting wound care referrals effective 9/6/24. · 100% of patients receiving wound care by the provider will be identified by 9/5/24. · Executive Director held meeting with all clinical and office staff 9/5/24, instructing on verifying wound care orders are accurate, wound care is completed as ordered, physician notified of non-adherence to wound care and/or need for updated orders, proper documentation of wound care in the Integumentary Command Center (ICC), RN re-assessment visits scheduled per policy, and use of care types when scheduling wound care patients. · 100% medical record review of all active patients receiving wound care will be completed by 9/6/24 to ensure care is being provided according to physician orders. Physician will be notified of any non-adherence to the plan of care. · 100% patients receiving wound care by nursing will be evaluated by an RN on 9/5 or 9/6, or on next scheduled wound care visit to ensure orders are accurate and up to date, proper supplies are in the home, and patient/caregivers performing wound care in skilled nurse absence are competent. · Director of Wound and Ostomy Management to conduct a mandatory wound care in-service for all clinical staff completing wound care on 9/10/24. 4. All active patients receiving wound care will be completed by 9/6/24 to ensure care is being provided according to physician orders. Physician will be notified of the inability to provide required wound care, and if discharge is necessary because the agency can no longer meet the needs of the patient, the agency will assist the patient/patient representative in choosing an alternate provider that can meet the patient’s needs. Documentation will support that the patient was informed that the agency can no longer meet his/her needs and alternatives provided to patient. 5. A discharge summary including admission and discharge dates, reason for admission to home health, reason for discharge, services provided to the patient, patient’s condition at time of discharge, a brief summary of care provided, progress towards goals, patient’s discharge goals of care, patient’s treatment preferences, a list of community resources or referrals made, along with a current medication list is sent to the physician or other healthcare professional responsible for care after discharge from the agency within 5 business days of patient’s discharge. 6. By 9/6/24, Executive Director will review all complaints from past 30 days to ensure they were investigated. · Beginning 9/6/24, staff receiving complaints either in person, by phone, or through the mail shall document the patient complaint within the information system. The Executive Director will receive an automated workflow regarding the complaint for follow-up, and complete the investigation and analysis, interviewing the patient, family, and involved staff or other individuals and taking appropriate actions to resolve the issue. · After the investigation and analysis is completed, but no later than 30 days after the complaint/grievance filing, the Executive Director will follow-up with the patient and/or complainant and document within the information system. · On 9/5/24, Executive Director will notify staff on call the evening of 9/5/24 on the expectation to ensure home visits are made to address afterhours clinical needs. · On 9/6/24, the Executive Director will instruct all on call staff on the expectation to complete after hours home visits to address clinical needs that arise. · Backup administrator will be available on call in event of high volume of calls. · Executive Director will ensure an RN is on call each day with nursing coverage to provide afterhours visits as indicated. In event of staff illness or vacancy, staff will be pulled from other branches to assist with on call coverage. · Beginning 9/6/24, the Executive Director will review the daily on call logs to ensure that any afterhours calls were properly addressed. The immediate jeopardy was abated on 9/5/2024. Conditions remaining out of compliance are CFR 484.50 Patient’s Rights; Can no longer meet patient needs; Discharge Plans Communication, 484.75 Skilled Professional Services, and 484.110 Discharge and Transfer Summaries. The following deficiencies were cited: · ·

Condition of Participation: Patient rights. CFR(s): 484.50 Condition of participation: Patient rights. The patient and representative (if any), have the right to be informed of the patient's rights in a language and manner the individual understands. The HHA must protect and promote the exercise of these rights. This CONDITION is not met as evidenced by: Based on record reviews and staff interviews, it was determined that the agency's skilled professional staff failed to provide services as ordered by the physician in the plan of care for one patient (P) (P1). Specifically, the Registered Nurse (RN) failed to provide wound care for P1 and investigate the complaint filed by P1. Findings include: The clinical record for P1 revealed that the RN was required to visit the patient two times a week, Tuesday and Friday, for wound vac (a treatment that uses suction to help wounds heal) changes however, P1 was seen at the time of admission on 3/13/2024. P1 was made a non-admit (notice that the patient is not going to be having home health services) on 3/15/24. Review of document titled Clinical Coordination Note Report dated 3/17/24 as a late entry for 3/16/24, revealed P1 placed call to agency on 3/16/24 at 6:23 pm requesting a visit for wound care to change wound vac (a treatment that uses suction to help wounds heal) dressing. The on-call nurse documented that she made multiple calls and left a message for P1 but did not send a nurse to perform wound care. The physician was not notified. P1 placed a second call at 10:07 pm to request a visit for wound care to change wound vac. The on-call nurse documented that she was told by the Patient Care Manager (PCM) to send P1 to the emergency room for wound care. The doctor was not notified. No resolution was documented. Clinical record for P1 revealed that agency failed to inform the physician that agency cannot meet the needs of the patient. Agency failed to assist the patient in choosing an alternative entity by identifying those entities in the patient’s geographic area that may be able to meet the patient’s wound care needs. On 9/3/2024 at 12:30 pm an interview with the Clinical Director confirmed that P1 was admitted to home health services on 3/13/2024, however P1 was made a non-admission on 3/15/2024 as the agency did not have sufficient staff to provide wound care. P1 failed to receive further visits and failed to be transferred to another provider to assume care. On 9/4/24 at 9:00 am, the Clinical Director further revealed that the agency had had only one Registered Nurse and one Licensed Practical Nurse to provide care. The clinical director stated that there were no reported cases of Covid with their nursing staff at that time, but that there were safety concerns as P1 lived in an isolated area with no cell phone service and also that the agency did not have sufficient staff to provide care. On 9/4/2024 at 9:30 am, an interview conducted with the Patient Care Manager (PCM) revealed that P1 was referred to emergency services for a dressing change as the agency did not have sufficient staff to provide wound care. The PCM further acknowledged that P1 was referred to emergency services for a dressing change as there was not sufficient staff to provide wound care.

HHA can no longer meet the patient's needs CFR(s): 484.50(d)(1) The transfer or discharge is necessary for the patient's welfare because the HHA and the physician or allowed practitioner, who is responsible for the home health plan of care agree that the HHA can no longer meet the patient's needs, based on the patient's acuity. The HHA must arrange a safe and appropriate transfer to other care entities when the needs of the patient exceed the HHA's capabilities; This ELEMENT is not met as evidenced by: Based on record reviews and staff interviews, it was determined that the agency's skilled professional staff failed to provide services as ordered by the physician in the plan of care for one patient (P) (P1), Specifically, the skilled nurse (SN) failed to provide wound care for P1. Findings include: The clinical record for P1 revealed that SN was required to visit the patient two times a week, Tuesday and Friday, for wound vac (a treatment that uses suction to help wounds heal) changes however, P1 was seen at the time of admission on 3/13/2024. P1 was made a non-admit (notice that the patient is not going to be having home health services) on 3/15/24. Clinical record for P1 revealed that agency failed to inform the physician that agency cannot meet the need of the patient. On 9/3/2024 at 12:30 pm an interview with the Clinical Director confirmed that P1 was admitted to home health services on 3/13/2024, however P1 was made a non-admission on 3/15/2024 as the agency did not have sufficient staff to provide wound care. P1 failed to receive further visits and failed to be transferred to another provider to assume care. On 9/4/24 at 9:00 am an interview with the Clinical Director revealed that agency had only one Registered Nurse and one Licensed Practical Nurse to provide care. The clinical director revealed that there were safety concerns as P1 lived in an isolated area with no cell phone service and also that the agency did not have sufficient staff to provide care. On 9/4/2024 at 9:30 am, an interview conducted with the Patient Care Manager (PCM) revealed that P1 was referred to emergency services for a dressing change as the agency did not have sufficient staff to provide wound care. Cross references G0406 as it relates to P#1- Patient's Rights

Investigate complaints made by patient CFR(s): 484.50(e)(1)(i) The HHA must— (i) Investigate complaints made by a patient, the patient's representative (if any), and the patient's caregivers and family, including, but not limited to, the following topics: (A) Treatment or care that is (or fails to be) furnished, is furnished inconsistently, or is furnished inappropriately; (B) Mistreatment, neglect, or verbal, mental, sexual, and physical abuse, including injuries of unknown source, and/or misappropriation of patient property by anyone furnishing services on behalf of the HHA. This ELEMENT is not met as evidenced by: Based on review of clinical records and staff interviews, the agency failed to investigate complaints made of care furnished inconsistently and neglect. The agency failed to send Registered Nurse (RN) to visit patient (P) (P1) for wound care assistance. Cross references L0406 as it relates to P1- Patient's Rights

Care planning, coordination, quality of care CFR(s): 484.60 Condition of participation: Care planning, coordination of services, and quality of care. Patients are accepted for treatment on the reasonable expectation that an HHA can meet the patient's medical, nursing, rehabilitative, and social needs in his or her place of residence. Each patient must receive an individualized written plan of care, including any revisions or additions. The individualized plan of care must specify the care and services necessary to meet the patient-specific needs as identified in the comprehensive assessment, including identification of the responsible discipline(s), and the measurable outcomes that the HHA anticipates will occur as a result of implementing and coordinating the plan of care. The individualized plan of care must also specify the patient and caregiver education and training. Services must be furnished in accordance with accepted standards of practice. This CONDITION is not met as evidenced by: Based on record review, review of policy titled “Patient Discharge/Transfer Process,” and staff and patient interview, it was determined the agency failed to provide wound care per the physician order and the care plan and communicate discharge plans for one patient (P) (P1) prior to discharge from the agency. Findings include: Review of the policy titled “Patient Discharge/Transfer Process,” revised date 10/01/23 revealed the following: 3. Revisions to plan for patient’s discharge will be communicated to : a. Patient b. Patient’s representative if any c. Caregiver if any d. All physicians issuing orders e. Patient’s primary care practitioner of health care professional who will provide care and services to patient after discharge, if any 4. If a patient is discharged because the agency can no longer meet the needs of the patient, the agency will assist the patient/patient representative in choosing an alternate provider that can meet the patient’s needs. Documentation will support that the patient was informed that the agency can no longer meet his/her needs and alternatives provided to patient. Review of the clinical record revealed the agency failed to provide discharge communication to P1 prior discharge. The clinical record failed to reveal documented discharge instructions, and the agency failed to notify the physician of P1 discharge. An interview on 9/4/2024 at 10:45 am with P1 revealed that (P1) was not told that the agency had discharged (P1) and did not receive a call from the agency to let (P1) know that (P1) would be receiving care from another agency. An interview on 9/4/2024 at 11:00 am with the Executive Director revealed that P1 was a non-admission, and a discharge summary was not completed. The Executive Director could not confirm whether P1 had been informed that he was made a non-admission.

Discharge plans communication CFR(s): 484.60(c)(3)(ii) (ii) Any revisions related to plans for the patient's discharge must be communicated to the patient, representative, caregiver, all physicians or allowed practitioner's issuing orders for the HHA plan of care, and the patient's primary care practitioner or other health care professional who will be responsible for providing care and services to the patient after discharge from the HHA (if any). This ELEMENT is not met as evidenced by: Based on record review, review of policy titled “Patient Discharge/Transfer Process,” and staff and patient interview, it was determined the agency failed to communicate discharge plans for one patient (P) (P1) prior to discharge from the agency. Review of the policy titled “Patient Discharge/Transfer Process,” revised date 10/01/23 revealed the following: 3. Revisions to plan for patient’s discharge will be communicated to : a. Patient b. Patient’s representative if any c. Caregiver if any d. All physicians issuing orders e. Patient’s primary care practitioner of health care professional who will provide care and services to patient after discharge, if any 4. If a patient is discharged because the agency can no longer meet the needs of the patient, the agency will assist the patient/patient representative in choosing an alternate provider that can meet the patient’s needs. Documentation will support that the patient was informed that the agency can no longer meet his/her needs and alternatives provided to patient. Review of the clinical record revealed the agency failed to provide discharge communication to P1 prior discharge. The clinical record failed to reveal documented discharge instructions, and the agency failed to notify the physician of P1 discharge. An interview on 9/4/2024 at 10:45 am with P1 revealed that (P1) was not told that the agency had discharged and that (P1) did not receive a call from the agency to let (P1) know that (P1) would be receiving care from another agency. Cross references G0570 as it relates to P1- care planning, coordination, and quality of care.

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 record review, review of policy titled “Plan of Care (POC), and patient and staff interviews, it was determined that the agency failed to provide services as ordered by the physician in the plan of care and to communicate and coordinate wound care management with physician and other health care practitioners for one patient (P) (P1). Findings include: Review of the policy titled “Plan of Care (POC),” revised 09/01/24 reveals the following: PURPOSE: To assure an appropriate plan of care is developed and revised in a timely manner for each patient. To ensure that physician/authorized practitioner’s orders are followed. The clinical record revealed that a skilled nurse was required to visit P1 two times a week, Tuesday and Friday, for wound vac (a treatment that uses suction to help wounds heal) changes, however, patient was seen at the time of admission on 3/13/24, and no further visits revealed. Review of document titled “Client Coordination Note Report,” dated 3/17/2024 failed to reveal the physician was notified of agency not able to provide wound care to the patient and advising P1 to seek emergent care. Further review of the clinical record failed to reveal that the agency assisted P1 in choosing an alternative entity by identifying those entities in the patient’s geographic area that may be able to meet the patient’s wound care needs. Clinical record failed to reveal physician was notified of not meeting the patient’s wound care needs. On 9/3/2024 at 12:00 pm an interview with the Executive Director confirmed that P1 was admitted on 3/13/2024 and made a non-admission on 3/15/2024. On 9/3/2024 at 12:30 pm an interview with the Clinical Director confirmed that P1 was admitted to home health services on 3/13/2024 however he was made a non-admission on 3/15/2024 as the agency did not have sufficient staff to provide wound care. P1 failed to receive further visits and failed to be transferred to another provider to assume care. A call was placed on 9/3/2024 1:33 pm to P1. It was confirmed that an initial visit had been made. P1 states that on 3/16/2024 P1 made several calls to the agency to request a nursing visit for wound care as (P1) supplies had been delivered. P1 stated that (P1) was told that someone was coming. P1 called again on 3/16/2024 as the nurse did not arrive and was told to go to the emergency room and was transported via ambulance. P1 was not admitted and returned home. P1 was unable to give exact dates but stated that (P1) had been to the emergency room on three different times seeking care for (P1) wound. P1 states that (P1) primary care doctor made a referral to another agency and was admitted on 3/29/2024. On 9/4/24 at 9:00 am, an interview with the Clinical Director revealed that the agency had only one Registered Nurse and one Licensed Practical Nurse to provide care. The clinical director revealed that there were safety concerns as P1 lived in an isolated area with no cell phone service and also that the agency did not have sufficient staff to provide care. On 9/4/2024 at 9:30 am an interview conducted with the Patient Care Manager (PCM) revealed that P1 was referred to emergency services for a dressing change as the agency did not have sufficient staff to provide wound care.

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, review of policy titled “Plan of Care (POC), and patient and staff interviews, it was determined that the agency failed to provide services as ordered by the physician in the plan of care for patient (P) (P1). Findings Include: Review of the policy titled “Plan of Care (POC),” revised 09/01/24 reveals the following: PURPOSE: To assure an appropriate plan of care is developed and revised in a timely manner for each patient. To ensure that physician/authorized practitioner’s orders are followed. The clinical record revealed that a skilled nurse was required to visit the patient two times a week, Tuesday and Friday, for wound vac (a treatment that uses suction to help wounds heal) changes, however, patient was seen at the time of admission on 3/13/24, and no further visits revealed. Cross reference G0700 as it relates to P1- Skilled professional services.

Communication with physicians CFR(s): 484.75(b)(7) Communication with all physicians involved in the plan of care and other health care practitioners (as appropriate) related to the current plan of care; This ELEMENT is not met as evidenced by: Based on record review and staff interview, the agency failed to communicate and coordinate wound care management with physician and other health care practitioners for one patient (P) (P1). Findings include: Review of document titled “Client Coordination Note Report,” dated 3/17/2024 failed to reveal the physician was notified of agency not able to provide wound care to the patient and advising P1 to seek emergent care. Cross references G0700 as it relates to P1- Skilled professional services.

Organization and administration of services CFR(s): 484.105 Condition of participation: Organization and administration of services. The HHA must organize, manage, and administer its resources to attain and maintain the highest practicable functional capacity, including providing optimal care to achieve the goals and outcomes identified in the patient's plan of care, for each patient's medical, nursing, and rehabilitative needs. The HHA must assure that administrative and supervisory functions are not delegated to another agency or organization, and all services not furnished directly are monitored and controlled. The HHA must set forth, in writing, its organizational structure, including lines of authority, and services furnished. This CONDITION is not met as evidenced by: Based on record review, review of policy titled “Plan of Care (POC), policy titled, “Patient Discharge/Transfer Process,” and patient and staff interviews, it was determined that the agency failed to provide services as ordered by the physician in the plan of care and to communicate and coordinate wound care management with physician and other health care practitioners for one patient (P) (P1). Findings include: Review of the policy titled “Plan of Care (POC),” revised 09/01/24 reveals the following: PURPOSE: To assure an appropriate plan of care is developed and revised in a timely manner for each patient. To ensure that physician/authorized practitioner’s orders are followed. Review of the policy titled “Patient Discharge/Transfer Process,” revised date 10/01/23 revealed the following: 3. Revisions to plan for patient’s discharge will be communicated to : a. Patient b. Patient’s representative if any c. Caregiver if any d. All physicians issuing orders e. Patient’s primary care practitioner of health care professional who will provide care and services to patient after discharge, if any The clinical record revealed that a skilled nurse was required to visit the P1 two times a week, Tuesday and Friday, for wound vac (a treatment that uses suction to help wounds heal) changes, however, patient was seen at the time of admission on 3/13/24, and no further visits revealed. Review of document titled “Client Coordination Note Report,” dated 3/17/2024 failed to reveal the physician was notified of agency not able to provide wound care to the patient and advising P1 to seek emergent care. Further review of the clinical record failed to reveal that the agency assisted P1 in choosing an alternative entity by identifying those entities in the patient’s geographic area that may be able to meet the patient’s wound care needs. Clinical record failed to reveal physician was notified of not meeting the patient’s wound care needs. On 9/3/2024 at 12:00 pm an interview with the Executive Director confirmed that P1 was admitted on 3/13/2024 and made a non-admission on 3/15/2024. On 9/3/2024 at 12:30 pm an interview with the Clinical Director confirmed that P1 was admitted to home health services on 3/13/2024 however he was made a non-admission on 3/15/2024 as the agency did not have sufficient staff to provide wound care. P1 failed to receive further visits and failed to be transferred to another provider to assume care. A call was placed on 9/3/2024 1:33 pm to P1. It was confirmed that an initial visit had been made. P1 states that on 3/16/2024 (P1) made several calls to the agency to request a nursing visit for wound care as (P1) supplies had been delivered. P1 stated that (P1) was told that someone was coming. P1 called again on 3/16/2024 as the nurse did not arrive and was told to go to the emergency room and was transported via ambulance. P1 was not admitted and returned home. P1 was unable to give exact dates but stated that (P1) had been to the emergency room on three different times seeking care for wound. P1 states that (P1) primary care doctor made a referral to another agency and was admitted on 3/29/2024. On 9/4/2024 at 9:00 am, an interview with the Clinical Director revealed that the agency had only one Registered Nurse and one Licensed Practical Nurse to provide care. The clinical director revealed that there were safety concerns as P1 lived in an isolated area with no cell phone service and also that the agency did not have sufficient staff to provide care. On 9/4/2024 at 9:30 am an interview conducted with the Patient Care Manager (PCM) revealed that P1 was referred to emergency services for a dressing change as the agency did not have sufficient staff to provide wound care.

Governing body CFR(s): 484.105(a) Standard: Governing body. A governing body (or designated persons so functioning) must assume full legal authority and responsibility for the agency's overall management and operation, the provision of all home health services, fiscal operations, review of the agency's budget and its operational plans, and its quality assessment and performance improvement program. This STANDARD is not met as evidenced by: Based on record review, review of policy titled “Plan of Care (POC), policy titled, “Patient Discharge/Transfer Process,” and patient and staff interviews, it was determined that the agency failed to provide services as ordered by the physician in the plan of care and to communicate and coordinate wound care management with physician and other health care practitioners for one patient (P) (P1). Cross reference G0940 as it relates to P1-Organization and administration of services.

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 record reviews, review of policy titled “Patient Discharge/Transfer Process,” and staff interviews, it was determined that the agency failed to complete a discharge summary which includes, admission and discharge dates, physician responsible for the Home Health plan of care, reason for admission to home health, types of services provided to the patient, medications the patient is on at the time of discharge, patient’s discharge condition, patient outcomes in meeting the goals in the pan of care and patient and family post-discharge instructions. Specifically, the agency failed to provide the discharge summary to the physician and to the health care provider who will be responsible for care and services to the patient after discharge from the current agency. Findings include: Review of the agency policy titled ““Patient Discharge/Transfer Process,” revised 10/01/23 reveals the following: 21. A discharge summary including admission and discharge dates, reason for admission to home health, reason for discharge, services provided to the patient, patient’s condition at time of discharge, a brief summary of care provided, progress towards goals, patient’s discharge goals of care, patient’s treatment preferences, a list of community resources or referrals made, along with a current medication list is sent to the physician or other healthcare professional responsible for care after discharge from the agency within 5 business days of patient’s discharge. Review of P1's record revealed that P1 was admitted to home health agency on 3/13/2024 and P1 was made a non-admit (notice that the patient is not going to be having home health services) on 3/15/2024. On 9/3/24 at 12:30 pm, an interview with the Clinical Director confirmed that P1 was admitted to home health services on 3/13/2024. However, P1 was made a non-admission on 3/15/2024. On 9/4/24 at 11:00 am, an interview with the Executive Director revealed that P1 was a non-admission, and a discharge summary was not completed. Clinical record failed to reveal a completed discharge summary for P1.

A Recertification survey was conducted at Floyd Homecare Rome, Georgia, on 11/4/21. As a result of the Recertification survey, it was revealed that the agency is in compliance with Chapter 42 CFR Part 418, Rules and Requirements for Home Health and Hospice Agencies. The census was 1,061.

A Recertification survey was conducted at Floyd Homecare Rome, Georgia, on 11/4/21 . As a result of the Recertification survey, it was revealed that the agency is in compliance with Chapter 111-8-37 Rules and Requirements for Home Health and Hospice Agencies. The census was 1,061.

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 clinical record reviews, observations, and staff interviews, it was determined that the agency failed to ensure that patient's medication profile was updated to reflect current medications at the time of the comprehensive assessment for four (4) of seventeen (17) Patients (P#1, P#2, P#3 and P#5). The findings include: 1.Patient #1 was admitted to the agency on 9/14/21, the patients diagnose included hypertension, cognitive decline, Vitamin D deficiency, osteoporosis, low back pain, hyperlipidemia, and osteoarthritis. During a home visit observation on 11/2/21, at approximately 8:30 p.m., with License Practical Nurse (LPN) BB, P#1’s current medication list in the Assisted Living Facility (ALF) was compared to the home health agency's plan of care. P#1 was taking Zoloft 50mg oral daily at bedtime for depression, however this medication was not listed in agency medication profile and plan of care. During an interview on 11/2/21, at 8:50 a.m., with LPN BB, she stated that she was not aware that P#1 was taking Zoloft 50mg oral daily at bedtime. 2. On 11/2/21, at 9:00 a.m., during home visit with P#2 with LPN BB, it was revealed that P#2 was admitted to the agency on 9/19/21, with a diagnosis of hypertension, cognitive decline, Vitamin D deficiency, osteoporosis, low back pain, hyperlipidemia and Osteoarthritis. The agency medication profile did not correspond with ALF Medication Administration Record (MAR). Patient #2 was taking Potassium Chloride Extended Release (ER), 8 milliequivalent (MEQ), take three tablets by mouth daily for supplement. Sodium Chloride 1gram (GM), take one tablet oral daily to help with low sodium. Vitamin B-12 500 microgram (MCG), take one tablet oral once a day for supplement. Vitamin D (Ergocaiciferol) 1.25mg capsule take one capsule oral every week on Thursdays; Cranberry 450mg take two capsules oral daily for supplement. Dialyvite Vitamin D 5000 125mcg take one capsule by mouth once a week on Thursdays for eight weeks. Fish oil 645mg take one capsule by mouth daily supplement. During an interview on 11/2/21, at 9:00 a.m., with LPN BB, she stated that she was not the assigned nurse. LPN BB stated that Registered Nurse (RN) AA was the one assigned to P#2. RN AA was not available for interview. 3. On 11/2/21, at 9:30 a.m., during home visit with P#3 with agency Physical Therapy (PT) it was revealed that P#3 was admitted to the agency on 8/10/21, with a diagnosis of osteoarthritis of knee, hypertension, atrial fibrillation, and major depressive disorder. The agency medication profile did not correspond with the ALF MAR. Patient #3 was taking Celecoxib 100mg take one capsule by mouth every morning with food. Losartan 100mg take one tablet by mouth at bedtime for high blood pressure. Methylphendate 5mg take two tablets oral every morning and one tablet six hours later to control the symptoms of attention deficit. Minoxidil 2.5mg take one tablet oral at bedtime for hypertension. Venlafaxine Extended Release (ER) 75mg take one capsule a day at dinner for depression. During an interview on 11/2/21, at 9:40 a.m., with (PT) CC, he stated that he was not aware of the above listed medications were being taken by P#3. (PT) CC confirmed that he did not update P#3 agency medication profile to match ALF MAR. 4. On 11/2/21, at 11:15 a.m., during home visit to P#5 with agency LPN DD, it was revealed that P#5 was admitted to the agency on 10/19/21, with a diagnosis of hypertensive heart disease with heart failure, anxiety, depressive, obesity and open wound left lower leg. Patient #5 was taking Isosorbide Extended Release (ER) 60mg take one tablet by mouth twice daily to prevent angina (chest pain) dated on 8/29/21. Benadryl 25mg take one tablet by mouth daily as needed for itching. Neurontin 100mg take one capsule by mouth daily as needed for neuropathy pain. Guaifenesin ER 600mg take one tablet by mouth daily for cough. Tylenol 500mg take one tablet by mouth daily for pain. On 11/2/21, at 11:40 a.m., an interview was conducted with LPN DD, who stated that she was not aware that P#5 was taking the above listed medications.

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 clinical record reviews, observations, and staff interviews, it was determined that the agency failed to ensure that patient's plan of care was updated to reflect current medications at the time of the comprehensive assessment for four (4) of seventeen (17) Patients (P#1, P#2, P#3 and P#5). The findings include: 1.Patient #1 was admitted to the agency on 9/14/21, the patients diagnose included hypertension, cognitive decline, Vitamin D deficiency, osteoporosis, low back pain, hyperlipidemia, and osteoarthritis. During a home visit observation on 11/2/21, at approximately 8:30 p.m., with License Practical Nurse (LPN) BB, P#1’s current medication list in the Assisted Living Facility (ALF) was compared to the home health agency's plan of care. P#1 was taking Zoloft 50mg oral daily at bedtime for depression, however this medication was not listed in agency medication profile and plan of care. During an interview on 11/2/21, at 8:50 a.m., with LPN BB, she stated that she was not aware that P#1 was taking Zoloft 50mg oral daily at bedtime. 2. On 11/2/21, at 9:00 a.m., during home visit with P#2 with LPN BB, it was revealed that P#2 was admitted to the agency on 9/19/21, with a diagnosis of hypertension, cognitive decline, Vitamin D deficiency, osteoporosis, low back pain, hyperlipidemia and Osteoarthritis. The agency medication profile did not correspond with ALF Medication Administration Record (MAR). Patient #2 was taking Potassium Chloride Extended Release (ER), 8 milliequivalent (MEQ), take three tablets by mouth daily for supplement. Sodium Chloride 1gram (GM), take one tablet oral daily to help with low sodium. Vitamin B-12 500 microgram (MCG), take one tablet oral once a day for supplement. Vitamin D (Ergocaiciferol) 1.25mg capsule take one capsule oral every week on Thursdays; Cranberry 450mg take two capsules oral daily for supplement. Dialyvite Vitamin D 5000 125mcg take one capsule by mouth once a week on Thursdays for eight weeks. Fish oil 645mg take one capsule by mouth daily supplement. During an interview on 11/2/21, at 9:00 a.m., with LPN BB, she stated that she was not the assigned nurse. LPN BB stated that Registered Nurse (RN) AA was the one assigned to P#2. RN AA was not available for interview. 3. On 11/2/21, at 9:30 a.m., during home visit with P#3 with agency Physical Therapy (PT) it was revealed that P#5 was admitted to the agency on 8/10/21, with a diagnosis of osteoarthritis of knee, hypertension, atrial fibrillation, and major depressive disorder. The agency medication profile did not correspond with the ALF MAR. Patient #3 was taking Celecoxib 100mg take one capsule by mouth every morning with food. Losartan 100mg take one tablet by mouth at bedtime for high blood pressure. Methylphendate 5mg take two tablets oral every morning and one tablet six hours later to control the symptoms of attention deficit. Minoxidil 2.5mg take one tablet oral at bedtime for hypertension. Venlafaxine Extended Release (ER) 75mg take one capsule a day at dinner for depression. During an interview on 11/2/21, at 9:40 a.m., with (PT) CC, he stated that he was not aware of the above listed medications were being taken by P#3. (PT) CC confirmed that he did not update P#3 agency medication profile to match ALF MAR. 4. On 11/2/21, at 11:15 a.m., during home visit to P#5 with agency LPN DD, it was revealed that P#5 was admitted to the agency on 10/19/21, with a diagnosis of hypertensive heart disease with heart failure, anxiety, depressive, obesity and open wound left lower leg. Patient #5 was taking Isosorbide Extended Release (ER) 60mg take one tablet by mouth twice daily to prevent angina (chest pain) dated on 8/29/21. Benadryl 25mg take one tablet by mouth daily as needed for itching. Neurontin 100mg take one capsule by mouth daily as needed for neuropathy pain. Guaifenesin ER 600mg take one tablet by mouth daily for cough. Tylenol 500mg take one tablet by mouth daily for pain. On 11/2/21, at 11:40 a.m., an interview was conducted with LPN DD, who stated that she was not aware that P#5 was taking the above listed medications.

Infection Prevention CFR(s): 484.70(a) Standard: Infection Prevention. The HHA must follow accepted standards of practice, including the use of standard precautions, to prevent the transmission of infections and communicable diseases. This STANDARD is not met as evidenced by: Based on clinical record reviews and staff interviews, it was determined that the agency staff failed to use standard precautions to prevent infection for one (1) of thirteen (13) sampled patients (P#5). The finding include: On 11/2/21, at 11:51 a.m., during observation of wound care performed by Licensed Practical Nurse (LPN) DD, during a home visit, LPN DD cleaned P#5’s left lower leg wound with wound cleanser and dried the area with gauze. LPN DD then applied xeroform gauze to open skin, applied zinc impregnated gauze in a fan folded method from P#5’s left toes to the left knee. LPN DD applied two layers of compression wrap in according to the physician’s order. She removed the old wound dressing from P#5’s left lower leg wound and continued the procedure without washing her hands and changing gloves, she opened a new xeroform dressing and applied it to the left lower leg wound. On 11/2/21, at 12:05 p.m., an interview was conducted with LPN DD, and she said, "I take the blame for not changing the dirty gloves after removing the old dressing and before opening a new clean xeroform dressing that was applied to the left lower leg wound." LPN DD also stated that she should have changed her dirty gloves to prevent wound infection.