Every finding on record at Four Roses, LLC

The Emergency Preparedness regulations were reviewed as part of the Medicare recertification survey completed on 12/31/2025. During the survey it was determined the home health provider is in compliance with the requirements of 42 CFR 484.102 Condition of Participation: Emergency Preparedness for Home Health Providers.

A partial extended survey for Medicare recertification for the home health provider was completed on 12/31/2025. The provider had 176 current patients.

A review of all current medications CFR(s): 484.55(c)(5) A review of all medications the patient is currently using in order to identify any potential adverse effects and drug reactions, including ineffective drug therapy, significant side effects, significant drug interactions, duplicate drug therapy, and noncompliance with drug therapy. This ELEMENT is not met as evidenced by: Based on policy review, record review, observation, and interview, the home health provider failed to ensure an accurate medication review and/or update of the patient medications was completed, in three of five full records reviewed (Records/Patients #1, #2, and #3). This deficient practice has the potential to affect all the patients served by the provider. Findings included: Review of the provider’s policy titled, “Named Provider” Policies and Procedures,” dated reviewed “9/2025”, under section: Comprehensive Assessments of Patients, beginning on page 21, showed in part: - “Named provider” will complete a review of all medications the patient is currently using in order to identify any potential adverse effects and drug reactions including duplicate drug therapy and noncompliance with drug therapy; - The clinical record will identify all medications the patient is taking as well as number of times a day and routes; - All drugs will be reconciled, and any discrepancies will be confirmed/resolved with the physician in a timely manner; -Upon completion of the drug regimen review, the clinician will use their professional judgement to determine whether any potential or actual issues warrant communication with a physician, physician designee or allowed practitioner and completion of prescribed/recommended actions to resolve the issue by either midnight of the next calendar day or within three business days after start of care day; and - As part of the initial assessment, when new medications are prescribed or discovered in the home, at least every 60 days, and on an ongoing basis, a provider nurse will review all patient medications, both prescription and non- prescription. RECORD/PATIENT #1: Review of the clinical record, showed, in part: The patient was admitted to home health services on 10/17/2025 with primary diagnosis of venous insufficiency (leg veins struggle to send blood back to the heart, causing blood to pool, often due to damaged valves, leading to leg swelling, aching, heaviness, skin discoloration, and eventually ulcers). The patient resided alone at his/her home. Observation and interview on 12/30/2025 at 1:30 PM showed: - The provider’s medication list had docusate sodium (stool softener) 50 milligrams (mg) once a day. The patient stated that he/she had been taking one capsule twice a day for nine months. RECORD/PATIENT #5: Review of the clinical record, showed, in part: The patient was admitted to home health services on 11/21/2025 with a primary diagnosis of hemiplegia (paralysis affecting one side of the body) and hemiparesis (muscular weakness on one side of the body) following cerebral infarction (stroke) affecting left non-dominant side, cerebral amyloid angiopathy (specific proteins deposit in the walls of small to medium blood vessels of the central nervous system and meninges), anemia, hyponatremia (low sodium in the blood), hypertension (elevated blood pressure), hypothyroidism (endocrine disease in which the thyroid does not produce enough thyroid hormones), peptic ulcer (a sore in the stomach or small intestine lining, leading to burning stomach pain that may worsen between meals or at night) without hemorrhage (excessive bleeding from a damaged blood vessel) or perforation (a hole or opening), and depression. The patient resided at an assisted living facility (ALF). Observation and interview on 12/29/2025 at 3:00 PM showed the following discrepancies between the provider’s current medication profile and the ALF medication list: - The provider’s profile showed Acetaminophen quick-melt (convenient, water-free forms of mild pain reliever that deliver powered acetaminophen directly to the tongue) 325 milligrams (mg) two every four hours as needed for mild pain. The ALF profile failed to list Acetaminophen quick-melt; - The provider’s profile showed levothyroxine (thyroid hormone to treat hypothyroidism) 25 micrograms (mcg) one daily. The ALF profile medication list had one tablet daily except Sunday; - The provider’s profile showed miconazole (antifungal medication) 2% topical powder, one application topically two times a day as needed for rash. The ALF medication list had apply topically once daily as needed, cleanse peri area with hygiene wipes and foam cleanser, pat dry. With gloved hands combine calmoseptine (provides a moisture barrier that prevents and helps heal skin irritations) and miconazole powder to form a paste (indications for use: skin), and the ALF medication list had apply topically twice daily as needed, cleanse peri area with hygiene wipes and foam cleanser, pat dry. With gloved hands combine calmoseptine and miconazole powder to form a paste (indications for use: skin); - The provider’s profile showed mirtazapine (antidepressant) 7.5 mg take once a day at bedtime. The ALF profile failed to list mirtazapine; - The provider’s profile showed ondansetron (antiemetic) 4 mg one every six hours as needed for nausea. The ALF profile failed to list ondansetron; - The provider’s profile showed pantoprazole (proton pump inhibitor that reduces stomach acid) 40 mg delayed release tablet, take one daily. The ALF profile failed to list pantoprazole; - The provider’s profile showed lidocaine (local anesthetic) 5% topical film, apply one patch topical once a day [comments: apply to low back]. The ALF medication list had lidocaine pain relief-4% patch, apply one patch topically every day for 12 hours, then leave off for 12 hours (indications for use: pain); and - The provider’s profile failed to show calmoseptine. The ALF medication listed combining with miconazole powder to form a paste. During an interview on 12/31/2025 at 12:30 PM the administrator stated that he/she would expect the clinician to get a medication list from the facility every two weeks and check the medications. The medications should match (what the patient was taking at the ALF/the current provider’s medication profile). RECORD/PATIENT #2: Review of the clinical record showed the patient was admitted to home health services on 12/07/2025 with a primary diagnosis of an acute exacerbation (a sudden, significant worsening of a chronic disease’s symptoms) of Myasthenia Gravis (A chronic autoimmune disease causing fluctuating weakness in voluntary muscles (eyes, face, chewing, swallowing, limbs, breathing) that worsens with activity and improves with rest, stemming from nerve signal disruption at the neuromuscular junction. The patient lived in his/her own with their spouse. Review of the initial plan of care dated 12/07/2025 to 02/04/2026 showed: - Aspirin (over the counter medication used to prevent blood clots from forming) 81 milligrams (mg) one tablet daily; and - Probiotic one capsule daily. Review of a physician’s order dated 12/07/2025 showed Eliquis (a prescription blood thinner used to prevent blood clots) 5 mg one tablet two times daily. Observation and interview on 12/30/2025 at 10:30 AM showed: - The provider’s medication list had Aspirin 81mg one tablet daily. The patient’s spouse stated that the patient had not taken the aspirin since the Eliquis was started (12/11/2025); and - The provider’s medication list had Probiotic (a beneficial microorganism that improves digestion) one capsule daily. The patient’s spouse stated that the patient had not taken the probiotic since he/she was in the hospital (prior to admission).

Promptly alert relevant physician of changes CFR(s): 484.60(c)(1) The HHA must promptly alert the relevant physician(s) or allowed practitioner(s) to any changes in the patient's condition or needs that suggest that outcomes are not being achieved and/or that the plan of care should be altered. This ELEMENT is not met as evidenced by: Based on policy review, record review, and interview, the home health provider failed to ensure clinicians promptly notified the patient's physician/allowed practitioner of any changes in the patient's condition or needs that suggested that outcomes were not being achieved and/or that the plan of care should be altered in one of five full records reviewed (Record/Patient #2). This deficient practice has the potential to affect all the patients served by the provider. Findings included: Review of the provider’s policy titled, “Named Provider” Policies and Procedures,” dated reviewed “9/2025”, under section: Care Planning, coordination of services, and quality of care, beginning on page 30, showed in part, “Named provider” will promptly alert the relevant physician or allowed practitioners 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 (POC) should be altered. RECORD/PATIENT #2: Review of the clinical record showed the patient was admitted to home health services on 12/07/2025 with a primary diagnosis of an acute exacerbation (a sudden, significant worsening of a chronic disease’s symptoms) of Myasthenia Gravis (A chronic autoimmune disease causing fluctuating weakness in voluntary muscles (eyes, face, chewing, swallowing, limbs, breathing) that worsens with activity and improves with rest, stemming from nerve signal disruption at the neuromuscular junction. The patient lived in his/her own home with their spouse. Review of the initial POC, dated 12/07/2025 to 02/04/2026, showed in part, the patient did not have orders for Tylenol (over the counter pain reliever). Review of the current medication list, provided to the state agent (SA) prior to the home visit, failed to include Tylenol. Review of the physician orders failed to show an order for Tylenol. Review of a physical therapy (PT) note, dated 12/16/2025, showed: - “Pt (patient) took one Tylenol last night, but no other meds for pain”; - Contacts made as a result of this visit: PT visit summary given to all of the home health (HH) disciplines, including primary nurse); and - The record failed to contain documentation that the physician was notified of the patient taking the Tylenol without an order. During an interview on 12/31/2025 at 11:50 AM, the clinical manager stated that he/she was unable to locate documentation that showed the physician had been notified that the patient was taking Tylenol.

Revised plan of care CFR(s): 484.60(c)(2) A revised plan of care must reflect current information from the patient's updated comprehensive assessment, and contain information concerning the patient's progress toward the measurable outcomes and goals identified by the HHA and patient in the plan of care. This ELEMENT is not met as evidenced by: Based on policy review, record review, observation, and interview, the home health provider failed to ensure the plan of care (POC) was revised/updated to address the patient's needs, in one of five full records reviewed (Record/Patient #2). This deficient practice has the potential to affect the care for all the patients served by the provider. Findings included: Review of the provider’s policy titled, “Named Provider” Policies and Procedures,” dated reviewed “9/2025”, under section: Care Planning, coordination of services, and quality of care, beginning on page 26, showed in part: - Each patient must receive the home health services that are written in an individualized POC that identifies patient specific measurable outcomes and goals and which is established, periodically reviewed, and signed by a Doctor of Medicine, osteopathy, or Podiatry, or allowed practitioner acting within the scope of his or her state license, certification or registration; - The individualized POC must include the types of services, supplies, and equipment required; and - The POC may include orders for treatment or services received from physicians other than the responsible physician, such orders must be approved by the responsible physician and incorporated into an updated POC. RECORD/PATIENT #2: Review of the clinical record showed the patient was admitted to home health services on 12/07/2025 with a primary diagnosis of an acute exacerbation (a sudden, significant worsening of a chronic disease’s symptoms) of Myasthenia Gravis (A chronic autoimmune disease causing fluctuating weakness in voluntary muscles (eyes, face, chewing, swallowing, limbs, breathing) that worsens with activity and improves with rest, stemming from nerve signal disruption at the neuromuscular junction. The patient lived in his/her own home with their spouse. Review of the POC dated 12/07/2025 to 02/04/2026 showed: - Physician A was the patient’s provider; and - There failed to be any other physicians listed. Review of a skilled nurse (SN) visit note dated 12/10/2025, showed “Patient has cardiologist appointment today. Primary care physician ordered chest X-ray and patient to wear Holter (cardiac monitor that continuously records your heart’s electrical activity) monitor for two weeks”. The POC failed to be updated with the cardiac monitor and/or the cardiologist. Review of a patient care order dated 12/11/2025 showed it was received from cardiology NP-A (a registered nurse with advanced education and clinical training). The plan of care failed to be updated to include the cardiologist and/or their delegated agent. Review of the SN visit note dated 12/15/ 2025 showed “since last skilled nurse visit, patient has obtained compression stockings, has been wearing them during the day, taking off at night”. The plan of care failed to be updated to include the use of compression stockings. Observation and interview on 12/30/2025 at 10:30 AM showed: - The patient was wearing compression stockings; - The patient was wearing a cardiac monitor; and - The patient’s spouse stated that the cardiac monitor was mailed to them a couple of weeks ago and the patient has been wearing it since that time. (The patient had been seen by the SN and physical therapy since that time).The POC failed to be updated with the cardiac monitoring device. During an interview on 12/31/2025 at 12:07 PM the administrator stated that: - He/she did not see the compression hose on the POC that the physician signed. He/she only saw it on the care plan and in the nurse’s note; - The care plan was not signed by the physician; - The Holter monitor was on the 12/10/2025 SN visit note, but was not updated on the POC; and - He/she thought that the care plan pulled over to the POC.

The Emergency Preparedness regulations were reviewed as part of the Medicare recertification survey completed on 01/05/2023. During the survey it was determined the home health provider is in compliance with the requirements of 42 CFR 44.102 Condition of Participation: Emergency Preparedness for Home Health Agencies.

A partial extended survey for Medicare recertification for the home health provider was completed on 01/05/2023. The agency had 175 current patients. The COVID-19 Health Care Staff Vaccination regulation was reviewed as part of the Medicare recertification survey. During the survey it was determined the agency was in compliance with the regulation.

Payment from federally funded programs CFR(s): 484.50(c)(7)(i, ii, iii, iv) Be advised, orally and in writing, of- (i) The extent to which payment for HHA services may be expected from Medicare, Medicaid, or any other federally-funded or federal aid program known to the HHA, (ii) The charges for services that may not be covered by Medicare, Medicaid, or any other federally-funded or federal aid program known to the HHA, (iii) The charges the individual may have to pay before care is initiated; and (iv) Any changes in the information provided in accordance with paragraph (c)(7) of this section when they occur. The HHA must advise the patient and representative (if any), of these changes as soon as possible, in advance of the next home health visit. The HHA must comply with the patient notice requirements at 42 CFR 411.408(d)(2) and 42 CFR 411.408(f). This ELEMENT is not met as evidenced by: Based on review of the agency's current patient rights information, home visit observations, and interview, the agency failed to update the written notice of patient rights to meet the requirements of the federal home health regulations to include the patient has the right to be advised orally and in writing of financial liability. This deficient practice has the potential to affect the knowledge and comprehension of the rights and responsibilities of all agency patients. Findings included: The agency's administrator provided an admission packet for review on 01/03/2023. The agency's notice of patient rights and other information given to a patient during the initial visit, contained no written information regarding the patient's right to be advised of financial liability orally and in writing. Observations on 01/04/2023, during patient #1's home visit at 1:40 PM, patient #2's at 11:40 AM, and patient #3's at 9:30 AM, showed the home folder information failed to include written notice that the patient has the right to be advised orally and in writing of financial liability. On 01/03/2023 at 2:55 PM, the findings were reviewed with the administrator and she stated that she did not find the information included in the handbook.

Freedom from discrimination or reprisal CFR(s): 484.50(c)(11) Be free from any discrimination or reprisal for exercising his or her rights or for voicing grievances to the HHA or an outside entity. This ELEMENT is not met as evidenced by: Based on review of the agency's current patient rights information, home visit observations, and interview, the agency failed to update the written notice of patient rights to include the patient has the right to be free from any discrimination or reprisal for exercising his or her rights or for voicing grievances to the home health agency or an outside entity. This deficient practice has the potential to affect the knowledge and comprehension of the rights and responsibilities of all agency patients. Findings included: The agency's administrator provided an admission packet for review on 01/03/2023. The agency's notice of patient rights and other information given to a patient during the initial visit, contained no written information regarding the patient's right to be free from any discrimination or reprisal for exercising his or her rights or for voicing grievances to the home health agency or an outside entity. Observations on 01/04/2023, during patient #1's home visit at 1:40 PM, patient #2's at 11:40 AM, and patient #3's at 9:30 AM, showed the home folder information failed to include written information regarding the patient's right to be free from any discrimination or reprisal, for exercising his or her rights or for voicing grievances to the home health agency or an outside entity. On 01/03/2023 at 2:55 PM, the findings were reviewed with the agency administrator and she stated that she did not find the information in the handbook.

A review of all current medications CFR(s): 484.55(c)(5) A review of all medications the patient is currently using in order to identify any potential adverse effects and drug reactions, including ineffective drug therapy, significant side effects, significant drug interactions, duplicate drug therapy, and noncompliance with drug therapy. This ELEMENT is not met as evidenced by: Based on policy review, record review, home visit observation, and interviews, the agency failed to ensure the patient's medications were reconciled during the start of care comprehensive assessment in, but not limited to, one (Record/Patient # 3) of five full records reviewed. This deficient practice has the potential to adversely affect the accuracy and safety of medication administration for all the agency's patients. Findings included: Review of the agency's policy titled, "Comprehensive Assessment of Patients" updated 2022, showed in part, the following: - Each patient must receive, and the agency will provide the comprehensive assessment that must accurately reflect the patient’s status, and must include, at a minimum, the following information: * Assessment of medical problems includes assessment of pain, includes level of pain, location of pain, pain medications and dosages, and effectiveness of treatments; - The agency will complete 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 effect, significant drug interactions, duplicate drug therapy, and noncompliance with drug therapy. The clinical record will identify all medications the patient is taking as well as number of times a day and routes. As part of the comprehensive assessment, the agency will consider and the clinical record should document that the agency considered each medication the patient is currently taking for possible side effects and the list of medications in its entirety for possible drug interactions. All drugs will be reconciled and any discrepancies will be confirmed/resolved with the physician in a timely manner. The agency utilizes [named electronic program] to check for interactions, and reports to the patient’s physician interactions that are identified as severe. The agency will also identify and educate on high risk medications when appropriate. In rehabilitation therapy only cases, the patient’s therapist must submit a list of patient medications, which the therapist must collect during the comprehensive assessment, to an agency nurse for review. The agency will contact the physician if indicated; and - As part of the initial assessment, when new medications are prescribed or discovered in the home, at least every sixty days, and on an on-going basis, an agency nurse will review all patient medications, both prescription and non-prescription. Review of the agency's policy titled, "Medication Review/Identification, Education and Management of High Risk Medications" updated 2022, showed in part, the following: - The agency adopts the Institute for Safe Medical Practice (ISMP) Community High Risk Med Alert list with Modifications to include all patients admitted will have a complete medication review (DRR - drug regimen review)) by a registered nurse at the SOC/ROC (start of care/resumption of care) and recertification. RECORD/PATIENT #3: Observation and interview on 01/04/2023 at 9:30 AM, during the patient's home visit, showed multiple discrepancies. The patient fills his or her med planner from a list he/she created, the bottles in the home did not match the patient's list or agency's medication list: - Jardiance (oral diabetes medication) 25 milligrams (mg), patient takes one daily. The agency's medication list showed Jardiance 10 mg take one by mouth two times a day; - K-Tab (potassium supplement)10 milliequivalent (mEq) two tablets once a day. The agency's medication list showed K-tab 10 mEq, tablet extended release, take one tablet by mouth once a day; - Levothyroxine (thyroid medication)100 microgram (mcg) patient takes one daily. The agency's medication list showed levothyroxine sodium 50 mcg (0.05 mg) oral tablet take one tablet by mouth once a day; - Lisinopril ((blood pressure medication) 20 mg patient takes one daily. The agency's medication list showed Lisinopril 10 mg take one tablet by mouth once a day at bedtime; - Metformin (oral diabetes medication) 500 mg patient takes two tablets (1000 mg) two times a day. The agency's medication list showed Metformin 500 mg take one tablet by mouth two times a day; and - Myrbetriq (medication for overactive bladder symptoms of urgency, frequency, and leakage), 50 mg patient takes one by mouth every other day. The agency's medication list showed Myrbetriq extended release 50 mg by mouth once a day in the evening. The evidence showed that the agency failed to accurately reconcile the patient's medications. The information was reviewed with the administrator and clinical manager on 01/05/2023 at 1:02 PM and they stated that staff should check the medications, and what the patient is taking should match the agency's medication profile.

Discharge or Transfer Summary Content CFR(s): 484.58(b)(1) Standard: Discharge or transfer summary content. The HHA must send all necessary medical information pertaining to the patient's current course of illness and treatment, post-discharge goals of care, and treatment preferences, to the receiving facility or health care practitioner to ensure the safe and effective transition of care. This STANDARD is not met as evidenced by: Based on record review, and interview, the agency failed to ensure/document the transfer summary was sent, for one (Record/Patient #6) of one record that was transferred from home health to a hospice agency. This deficient practice has the potential to affect the continuity of care for all patients served by the agency. Findings included: Review of the agency's policy titled, "Transfer and Discharge," updated 2022, showed in part: - The agency will only transfer or discharge a patient if the transfer or discharge is necessary for the patient’s welfare because the agency and the physician or allowed practitioner who is responsible for the home health plan of care agree that the agency can no longer meet the patient’s needs, based on the patient’s acuity; - The agency will arrange a safe and appropriate transfer to other care entities when the needs of the patient exceed the agency’s capabilities; and - Provide an appropriate transfer summary within the required time. RECORD/PATIENT #6: Review of the discharge summary for Patient #6 dated 11/10/2022 showed: - The patient transferred from home health to hospice care on 11/10/2022; and - There was no documentation found that the agency sent information for the transfer, or the comprehensive transfer summary, to the admitting hospice in the record. During an interview on 01/05/2023 at 3:20 PM, the administrator stated that the discharge summary was not sent to the receiving hospice, and agreed it should be sent to continuing care physician.

Only as ordered by a physician CFR(s): 484.60(b)(1) Drugs, services, and treatments are administered only as ordered by a physician or allowed practitioner. This ELEMENT is not met as evidenced by: Based on policy review, clinical record review, and interview, the agency failed to ensure staff followed physician orders and treatments as ordered, which affected two (Records/Patients #2 and #3) of five full records reviewed. This deficient practice has the potential to affect all patients served by the agency. Findings included: Review of the agency's policy, untitled, section §484.60(a)(3), updated 2022, showed in part: - Physician's must provide orders for all care provided. All patient care orders, including verbal orders, must be recorded in the plan of care. Review of the agency's policy, untitled, section §484.60(b), updated 2022, showed in part: - Conformance with physicians or allowed practitioner orders; - Drugs, services, and treatments are ordered by the physician that establishes and periodically reviews the plan of care, and are administered only as ordered by a physician or allowed practitioner. RECORD/PATIENT #2: Review of the plan of care (POC) dated 11/13/2022 through 01/11/2023 showed: - Diagnoses included but not limited to: wedge compression fracture of first lumbar vertebra and wedge compression fracture T (thoracic) 11-T12 vertebra, subsequent encounter for fracture with routine healing; - Skilled nurse (SN) 1-2 wk 8 wk (visit one or two times per week for eight weeks); - Physical therapist (PT) 1-3 wk 7 wk (visit one or three times per week for seven weeks); - Occupational therapist (OT) 1-3 wk 8 wk (visit one or three times per week for eight weeks); - SN to assess current pain management regimen including: effectiveness, relief measures, and side effects; - SN to perform wound care/dressing change: #1 bilateral breasts: H2O/soap, pat dry. Apply Ketoconazole (antifungal lotion) daily, primary care giver (PCG) daily on non SN days. SN 1-2 x weekly (visit one-two times weekly); - PT to assess current pain management regimen including: effectiveness, relief measures, and side effects; - OT to assess/re-assess pain; and - Signed by the physician on 12/16/2022. Review of a SN visit note dated 11/21/2022 showed documentation in the narrative note that care was provided under bilateral breasts, cleaned with soap and water, pat dry, applied Ketoconazole lotion to redness, all intact and applied Interdry (antimicrobial skin protectant). Review of the POC showed no order to apply Interdry. During an interview on 01/05/2023 at 3:13 PM, the clinical manager stated that there was no order to apply Interdry. Review of a PT visit note dated 11/21/2022 showed pain management relief measures: lidocaine patch at end of PT visit. Review of the POC showed no order for the lidocaine patch. During an interview on 01/05/2023 at 3:06 PM, the administrator stated that there was no order for the lidocaine patch. Review of an OT visit note dated 12/05/2022 showed documentation in narrative note that the patient reported pain in their ribs on this date. Per PT, the patient was hesitant to participate, and the patient’s son gave him/her tramadol for pain. Review of the POC showed no order for the tramadol. Review of a SN visit note dated 12/05/2022 showed documentation in the narrative note that SN educated the family on use of tramadol for pain management. During an interview on 01/05/2023 at 3:06 PM, the administrator stated that there was no order for the tramadol. RECORD/PATIENT #3: Review of the POC dated 12/10/2022 through 02/07/2023 showed: - Diagnoses included but not limited to: Encounter for change or removal of nonsurgical wound dressing, laceration without foreign body of right upper arm, laceration without foreign body of left upper arm, atheroscotic heart disease of native coronary artery without angina pectoris, and paroxysmal atrial fibrillation; - Skilled nurse (SN) 1-2 wk 8 wk (visit one or two times per week for eight weeks); and SN to perform wound care/dressing change: Left elbow: normal saline (NS), adaptic (protect the wound while preventing the dressing from adhering to the wound), and foam adhesive. Right elbow: NS, adaptic, ABD (Abdominal) gauze pads are used to absorb discharges from abdominal and other heavily draining wounds. Abdominal pads seal off the wound area and help prevent moisture), kerlix (provide wicking action, aeration and absorbency), and coban (self-adherent elastic wrap that functions like a tape, but sticks only to itself) by SN 2x weekly. Review of a SN visit note dated 12/10/2022 showed the left lateral distal outer arm elbow covered with coban, kerlix, and ABD (instead of the NS, adaptic and foam adhesive as ordered on the POC). Review of the SN visit note dated 12/14/2022 showed in the narrative note, skilled nurse visit for wound care to bilateral elbows as ordered. The patient refused treatment as ordered. The patient stated that the kelix just slides down his/her arm, and it’s too much when he/she tries to move his/her elbow. SN covered both elbows with foam dressing per the patient's request. Review of the POC showed: Left elbow: normal saline (NS), adaptic, foam adhesive. Right elbow: NS, adaptic, ABD, kerlix, and coban by SN 2x weekly. The wound care to the patient's right elbow not performed as ordered (SN used foam instead of ABD/kerlix and coban). Review of the SN visit note dated 12/16/2022 showed in narrative note, skilled nurse visit for wound care to bilateral elbows as ordered. Patient refused treatment as ordered. SN covered with foam dressing on both elbows as this was the only acceptable treatment for the patient. Review of the POC showed: Right elbow: NS, adaptic, ABD, kerlix, and coban by SN 2x weekly. The wound care to the right elbow not performed as ordered (SN used foam instead of ABD/kerlix and coban). During an interview on 01/05/2023 at 3:29 PM, the administrator stated that the dressing change is to be completed as ordered.

Promptly alert relevant physician of changes CFR(s): 484.60(c)(1) The HHA must promptly alert the relevant physician(s) or allowed practitioner(s) to any changes in the patient's condition or needs that suggest that outcomes are not being achieved and/or that the plan of care should be altered. This ELEMENT is not met as evidenced by: Based on policy review, record review, and interview, the agency failed to promptly alert the physician to changes in the patient's condition that may suggest a need to alter the plan of care (POC), in one (Record/Patient #2) of five records reviewed. This deficient practice has the potential to affect all patients served by the agency. Findings included: Review of the agency’s policy titled, "Coordination of Care” updated 2022, showed, in part, the following: - Premiere will assure communication with all physicians or allowed practitioners involved in the plan of care; - This includes any physicians or allowed practitioners who give orders that are directly related to home health skilled services; - The physician or allowed practitioner who initiates home health care is responsible for the ongoing plan of care; however, in order to assure the development and implementation of a coordinated plan of care, Premiere will collect contact information for as many other relevant physicians or allowed practitioners as are appropriate and related to the home health skilled services; - Premiere will integrate orders from all physicians or allowed practitioners involved in the plan of care to assure the coordination of all services and interventions provided to the patient; - Premiere will integrate services and communication processes 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; and - Premiere will 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. RECORD/PATIENT #2: Review of the POC dated 11/13/2022 through 1/11/2023, showed, in part the patient was admitted to home health services on 11/13/2022. Review of the physical therapist (PT) note dated 12/08/2022, showed in part, patient reports he/she isn’t feeling well and thinks he/she is “is coming down with something”. Per the patient’s son the patient is not drinking much and his/her urine looked darker last night. Case communication with occupational therapy (OT) and skilled nurse (SN) regarding the patient’s status and possibility of urinary tract infection (UTI) due to symptoms of confusion, fatigue, poor fluid intake and urine changes. Patient was hospitalized the next day with a UTI. The record review failed to show the physician was notified in the patient’s change of condition. During an interview on 01/05/2023 at 3:12 PM, the administrator stated that she called the physician to discuss the patient’s hospitalization and they all thought it might be medication related. She stated that the physician was not notified at time of episode and should have been. Review of the physical therapist (PT) note dated 12/27/2022, showed in part, therapist would inflate blood pressure cuff to 300 systolic (120 systolic - top number to show pressure in arteries when your heart beats, and 80 diastolic - bottom number to show when your heart rests between beats, is the normal range for most adults) and error out (not completed). Attempted two more times with same results. Therapist began to place call to primary care physician (PCP) office, but patient then grabbed chest and complained of heart pounding. Son assisted patient to bed and patient said he/she was going to pass out. Therapist contacted emergency medical systems (EMS). Paramedics assessed patient’s blood pressure in supine and it was low 100’s /60’s, They stated that patient may be had syncopal episode. The patient’s son refused transport to the emergency room (ER). Notified OT of the son’s request to cancel OT for today. Notified SN of patients status and he/she will be seeing patient this afternoon. The son requesting no PT visit tomorrow but will contact for 12/30/2022. During an interview on 01/05/2023 at 3:12 PM, the administrator stated that the physician was not notified on 12/27/2022 and should have been.

Visit schedule CFR(s): 484.60(e)(1) Visit schedule, including frequency of visits by HHA personnel and personnel acting on behalf of the HHA. This ELEMENT is not met as evidenced by: Based on review of the patient rights left in the home admission folder, home visit observation, and interview, the agency failed to provide a written visit schedule that included disciplines that would visit and the frequency of visits in two (Records/Patients #1 and #2) of three home visit observations performed. This deficient practice has the potential to affect all patients served by the agency. Findings included: Review of the Center for Medicare and Medicaid Services Conditions of Participation: Patient's Rights 484.50 (c) (4) found in the admission folder left in patient's homes at the time of admission to service showed: - The patient has the right to participate in, be informed about, and consent or refuse care in advance of and during treatment, where appropriate, with respect to, (but not limited to) the disciplines that will furnish care and the frequency of visits. RECORD/PATIENT #1: Review of the plan of care (POC) dated 11/27/2022 through 01/25/2023 showed: - Occupational therapist (OT) 1-2 wk 4 wk (one to two times a week for four weeks) start 12/07/2022; and - Physical therapist (PT) 1-3 wk 8 wk (one to three times a week for eight weeks) start during week of 11/29/2022. Observation on 01/04/2023 at 1:40 PM, during the patient's home visit, showed: - A monthly calendar in the home admission folder and no PT or OT discipline visits were recorded. During an interview on 01/04/2023 at 1:40 PM, the OT stated that he/she was not aware about filling in the visit frequency, but would begin documenting on the patient’s handbook folder. RECORD/PATIENT #2: Review of the POC dated 11/13/2022 through 01/11/2023 showed: - OT 1-3 wk 8 wk (one to three times a week for eight weeks) beginning during week of 11/14/2022. Observation on 01/04/2023 at 11:40 AM, during the patient's home visit, showed: - A visit calendar with only skilled nursing (SN) and PT visits documented; and - No OT visits documented on the calendar. During an interview on 01/04/2023 at 1:40 PM, the OT stated that he/she was not aware about filling in the visit frequency, but would begin documenting on the patient’s handbook folder. The record review findings were presented to the administrator and director of nursing (DON) on 01/05/2023 at 12:48 PM and both stated that the calendar should be filled out with the disciplines and frequency of visits.

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 nationally-recognized standards, policy review, home visit observation, and interview, the agency failed to ensure staff followed acceptable standards of practice for infection control in one (Record/Patient #3) of three home visit observations. This deficient practice has the potential to affect all patients served by the agency. Findings included: Review of the Centers for Disease Control and Prevention (CDC) website (cdc.gov/hand hygiene in healthcare settings) showed in part, that gloves are not a substitute for hand hygiene. If your task requires gloves, perform hand hygiene prior to donning gloves, before touching the patient or the patient environment and perform hand hygiene immediately after removing gloves. Review of the agency's policy titled, "Infection Prevention and Control," updated 2022, showed in part, to perform hand hygiene: - Standard precautions are based on the principle that all blood, body fluids, secretions, excretions, may contain transmissible infectious agents; - Hand hygiene should be performed at a minimum: * Before contact with a patient; * Before performing as aseptic task; * After contact with the patient or objects in the immediate vicinity of the patient; * After contact with blood, body fluids or contaminated surfaces; * Moving from a contaminated-body site to a clean body site during patient care; and * After removal of personal protective equipment; - Hand hygiene includes both hand-washing with either plain or antiseptic containing soap and water, and use of alcohol-based products that do not require the use of water; - In the absence of visible soiling of hands, approved alcohol-based products for hand disinfection are preferred over anti-microbial or plain soap and water because of their superior micro-biocidal activity, reduced drying of the skin, and convenience; - Premiere will provide sufficient supplies necessary for adherence to hand hygiene rules. RECORD/PATIENT #3: Observation on 01/04/2023 beginning at 9:30 AM, during the patient's home visit, showed: - The skilled nurse (SN) donned gloves and removed dressing from wound; - He/she cleaned the wound with the same gloves; - After changing his/her gloves, he/she touched phone to take picture of wound; - He/she removed gloves and did not perform hand hygiene; - He/she donned new gloves and rummaged in dressing bag touching items; - He/she did not change gloves after touching items in the bag and applied a dressing to the patient’s right elbow; - After removing the old dressing and bagging it up, he/she removed his/her gloves placing them into bag and tied bag up; - The SN did not perform hand hygiene and looked at the patient’s feet then washed his/her hands with soap and water; - He/she cleaned supplies and phone and moved them to a clean barrier, disposed of trash and put supplies away on a shelf; - He/she documented in the patient’s folder and opened the computer; - He/she did not perform hand hygiene and putting vital sign supplies away into a small bag, cleaned exterior of the bag and placed on clean barrier; - He/she documented assessment on his/her computer and without performing hand hygiene, cleaned pen and computer, performed hand hygiene and returned supplies. During an interview on 01/05/2023 beginning at 3:10 PM, the administrator stated that staff should wash or use hand sanitizer between clean and dirty, and follow CDC guidelines for handwashing.

In accordance with current clinical practice CFR(s): 484.105(f)(2) All HHA services must be provided in accordance with current clinical practice guidelines and accepted professional standards of practice. This ELEMENT is not met as evidenced by: Based on review of State and Federal law, employee file review, Alzheimer’s training programs, and interview, the agency failed to meet applicable Missouri state law. The agency failed to ensure two agency direct care staff (physical therapist and occupational therapist) completed required annual Alzheimer training as required in 19 CSR 30-26.010 (1) (B). The deficient practice has the potential to affect all patients on service with the agency. Findings included: Review of the agency's policy titled, "Employee Annual Credentialing Policy," updated 2022, showed in part: - In compliance with federal and state law, the agency will ensure the following for all current employees: annual Alzheimer’s/Dementia In-service. Review of 19 CSR 30-26.010 (1) (B) required: "Licensed home health agencies shall provide dementia-specific training about Alzheimer's disease and related dementias to their employees and those persons working as independent contractors who provide direct care to or may have daily contact with residents, patients, clients or consumers with Alzheimer's disease or related dementias. 1. The training for persons providing direct care shall address the following areas, at a minimum: A. An overview of Alzheimer's disease and related dementias; B. Communicating with persons with dementia; C. Behavior management; D. Promoting independence in activities of daily living; E. Understanding and dealing with family issues; 2. Employees or independent contractors who do not provide direct care for, but may have daily contact with, persons with Alzheimer's disease or related dementias shall receive dementia-specific training that includes, at a minimum: A. An overview of Alzheimer's disease and related dementias; B. Communicating with persons with dementia; and 3. Dementia-specific training about Alzheimer's disease and related dementias shall be incorporated into orientation for new employees with direct patient contact and independent contractors with direct patient contact. The training shall be presented by an instructor who is qualified by education, experience, and knowledge in the current standards of practice regarding individuals with Alzheimer's disease and other related dementias. The training shall be provided annually and updated as needed." Review of the Missouri Alliance for Home Care (MAHC) Alzheimer’s training program shows if the provider uses both the video and handouts on orientation and annually that the training program meets all of the Alzheimer’ training requirements. EMPLOYEE #2: Review of the employee file for Employee – E2 (an agency direct care staff – physical therapist), showed: - Hire date of 10/05/2020; and - Incomplete annual required Alzheimer's training, 12/18/2022, as required in 19 CSR 30-26.010 (1) (B). EMPLOYEE # 4: Review of the employee file for Employee – E4 (an agency direct care staff – occupational therapist), showed: - Hire date of 11/05/2021; and - Incomplete annual required Alzheimer's training, 12/17/2022, as required in 19 CSR 30-26.010 (1) (B). Review of the agency's email communication on 01/05/2023 at 12:17 PM and 12:32 PM, showed the executive director clarified that the handouts were mainly for resources explained in the video. They must do the video to meet the requirements of a qualified speaker, just using the handouts doesn't explain everything in the training video, and managing behaviors was addressed in the video under "Identifying Behaviors and Meeting Unmet Needs". The handout "Triggers for Behavioral Expression" was used in that section of the video. During an interview on 01/03/2023 at 2:30 PM, the administrator stated that the agency did not show the video annually for Alzheimer’s training, just on orientation.