Every finding on record at Franklin County Medical Center Home Care

The Medicare recertification survey of your facility, conducted from 11/27/23 - 11/30/23, included Emergency Preparedness. Franklin County Home Health was found to be in substantial compliance for the regulations found at 42 CFR 494.62.

The following deficiencies were cited during the Medicare recertification survey of your agency conducted on 11/27/23 - 11/30/23. Acronyms used in this report include: APRN – Advance Practice Registered Nurse APS – Adult Protective Services CHF – Congestive Heart Failure IV - Intravenous MG - Milligrams PCS – Personal Care Service PT/INR – Prothrombin Time / International Normalized Ratio MSW – Medical Social Worker OASIS – Outcome and Assessment Information Set OT – Occupational Therapy PCP – Primary Care Physician POC – Plan of Care PT – Physical Therapy RNCM – Registered Nurse Case Manager SN – Skilled Nursing SOC - Start of Care TPN – Total Parenteral Nutrition

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 review of medical records, agency policy, Idaho state statue review, and staff interview, it was determined the agency failed to ensure patients were free from all forms of neglect. Additionally, the agency failed to ensure patients received all services as outlined in their POCs. This resulted in patients' rights not being upheld. Findings include: Refer to G436 as it relates to the failure of the agency to ensure patients received all services as outlined in their plan of care. Refer to G488 as it relates to the failure of the agency to ensure patients were free from verbal abuse, neglect, and injuries of unknown source. The cumulative effect of these systemic issues impeded the ability of the agency to protect the rights of patients.

Receive all services in plan of care CFR(s): 484.50(c)(5) Receive all services outlined in the plan of care. This ELEMENT is not met as evidenced by: Based on medical record review and staff interview, it was determined the agency failed to ensure that patients received all services outlined in the plan of care for 1 of 7 patients (Patient #2) whose records were reviewed. This had the potential for unmet patient needs. Findings include: Patient #2 was a 64 year old male admitted to the agency on 9/26/23, with a primary diagnosis of malignant neoplasm of the esophagus. Additional diagnoses included chronic embolism, and type 2 diabetes mellitus. He received SN and PT services. His record, including the POC, for the certification period 9/26/23 to 11/24/23, was reviewed. Patient #2’s medical record included a Physician order dated 10/24/23. The order included, “Increase Warfarin to 6mg daily and recheck PT/INR on Friday 10/27/23.” Patient #2’s medical record did not have a documented PT/INR documented until 10/31/23. Patient #2’s RNCM was interviewed on 11/28/23 beginning at 3:40 PM. She confirmed there was no documentation the PT/INR was completed until 10/31/23. Patient #2 did not receive services as outlined in his POC.

Immediate reporting of abuse by all staff CFR(s): 484.50(e)(2) Any HHA staff (whether employed directly or under arrangements) in the normal course of providing services to patients, who identifies, notices, or recognizes incidences or circumstances of mistreatment, neglect, verbal, mental, sexual, and/or physical abuse, including injuries of unknown source, or misappropriation of patient property, must report these findings immediately to the HHA and other appropriate authorities in accordance with state law. This ELEMENT is not met as evidenced by: Based on medical record review, Idaho state statute review, and staff interview, it was determined the agency failed to ensure staff reported and documented potential patient neglect to appropriate authorities in accordance with state law for 1 of 1 patient (Patient #1) who had documented potential neglect and whose record was reviewed. This resulted in a missed opportunity to uphold patient rights. Findings include: "IDAHO STATUTES TITLE 39 HEALTH AND SAFETY CHAPTER 53 ADULT ABUSE, NEGLECT AND EXPLOITATION ACT," updated 7/01/18, states "39-5303. Duty to report cases of abuse, neglect or exploitation of vulnerable adults. (1) Any physician, nurse, employee of a public or private health facility, or a state licensed or certified residential facility serving vulnerable adults, medical examiner, dentist, osteopath, optometrist, chiropractor, podiatrist, social worker, police officer, pharmacist, physical therapist, or home care worker who has reasonable cause to believe that a vulnerable adult is being or has been abused, neglected or exploited shall immediately report such information to the commission. Provided however, that nursing facilities defined in section 39-1301(b), Idaho Code, and employees of such facilities shall make reports required under this chapter to the department. When there is reasonable cause to believe that abuse or sexual assault has resulted in death or serious physical injury jeopardizing the life, health or safety of a vulnerable adult, any person required to report under this section shall also report such information within four (4) hours to the appropriate law enforcement agency." This statute was not followed. An agency policy “Abuse, Neglect and Exploitation undated, stated, "Any Employee of [agency] who has reasonable cause to believe that a vulnerable child or adult is being or has been abuse, neglected or exploited shall immediately report such information to their Department Manager.” Additionally, the policy stated, “Criteria to identify possible victims…Inadequate supervision with resulting effect on ADL provision, e.g., bathing toileting, food, etc.” This policy was not followed. An example includes Patient #1 was a 77 year old female admitted to the agency on 2/18/23, with a primary diagnosis of a left foot fracture. Additional diagnoses included chronic respiratory failure, and CHF. She received SN, PT, OT, and aide services. Her record, including the POC, for the certification period of 2/18/23 to 4/18/23, was reviewed. Patient #1's medical record included a OASIS SOC assessment," dated 2/18/23, signed by the RNCM, which included: “The Patient Lives at her house and is usually alone. She currently has her son living with her who just got out of jail… The sun[sic] said that he is available to take care of her during the daytime and night…The son however, does not appear to be taking care of his mother [Patient #1]. The patient was soaked with urine on the day of the admit and stated that she was hungry and had not eaten all day…. SM [sic SN] went to look in her bathroom and found piles of feces all throughout her bedroom and bathroom. They appear to be both human feces and dog feces. … The daughter in law stated that she is only able to assist the patient for small amounts of time due to her busy work schedule and raising four children on her own.” Additionally, the SOC assessment included: “It is my assessment that the patient is not safe at home. She cannot take care of herself, and she does not have a capable sitter to watch her during the day and night. She is neglected by her family and seems to be unable to see the situation she is in.” Patient #1 started Physical Therapy the same day on 2/18/23, Occupational Therapy on 2/21/23 and Home Health Aide services after this assessment. There was no documentation in Patient #1’s medical record that APS was called and notified of the above issues of potential neglect. Additionally, there was no documentation in Patient #1’s medical record the department manager was made aware of the above issues. The Home Health Manager and Compliance Director were interviewed together on 11/29/23, beginning at 1:00 PM, and Patient #1's medical record was reviewed in their presence. The Home Health Manager stated she was aware of the above issues and have contacted APS multiple times prior to the SOC assessment. She stated Patient#1 was on PCS service that the Home Health agency also operated. She confirmed there was no documentation in Patient #1’s medical record APS was contacted. The Home Health Manager confirmed the RNCM should have documented the conversation with her and should have documented APS was called and aware of the ongoing situation. There was no documentation Patient #1's potential neglect was reported to appropriate authorities in accordance with Idaho state law.

Content of the comprehensive assessment CFR(s): 484.55(c) Standard: Content of the comprehensive assessment. The comprehensive assessment must accurately reflect the patient's status, and must include, at a minimum, the following information: This STANDARD is not met as evidenced by: Based on medical record review, and staff interview, it was determined the agency failed to ensure the comprehensive assessment was accurate to reflect the patients status for 1 of 7 patients (Patient #2) whose records were reviewed. This had the potential to interfere with the accuracy of patients' initial assessments. Findings include: Patient #2 was a 64 year old male admitted to the agency on 9/26/23, with a primary diagnosis of malignant neoplasm of the esophagus. Additional diagnoses included chronic embolism, and type 2 diabetes mellitus. He received SN and PT services. His record, including the POC, for the certification period 9/26/23 to 11/24/23, was reviewed. Patient #2’s medical record included a SOC assessment dated 9/26/23 signed by the RNCM. The SOC assessment included conflicting documentation on the current status of Patient #2. Examples include: 1. Patient #2's SOC assessment included that he had a feeding tube for nutrition needs. Under the OASIS question K0520 "Nutritional Approaches," the assessment indicated he had no feeding tube. Additionally, under the section titled "Physicians order" diet requirements it showed that he was on a regular diet. Patient #2's RNCM was interviewed 11/28/23 beginning at 3:10 PM, and Patient #2's medical record was reviewed in her presence. She stated Patient #2 did not have a feeding tube. She confirmed the assessment data was conflicting information and not accurate. It was unclear how Patient #2's nutritional needs were being met. 2. Patient #2's SOC assessment included the question, "does the patient have IV access?" The answer to the above question was marked "no." However, in the same section the RNCM marked that the patient had a "port," with an insertion date of 9/22/23. A port is used as IV access for long term usage. Patient #2's RNCM was interviewed 11/28/23 beginning at 3:10 PM, and Patient #2's medical record was reviewed in her presence. She stated Patient #2 did have an IV port. She confirmed the assessment data was conflicting information and not accurate. The agency failed to ensure the comprehensive assessment for Patient #2 was accurate.

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 medical record review, policy review, and staff interview it was determined the agency failed to ensure POCs were accurate, included all pertinent items, and physicians were alerted to changes in patient condition. These failures resulted in unmet patient needs and negatively impacted the continuity, safety, and quality of patient care for 2 or 7 patients (Patient #1 and #2) whose records were reviewed. Findings include: 1. Refer to G574, as it relates to the failure of the agency to ensure POCs included all pertinent information. 2. Refer to G590, as it relates to the failure of the agency to alert physicians to changes in patient's conditions or needs. The cumulative effect of these practices impeded the agency's ability to provide quality care.

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 medical record review and staff interview, it was determined the agency failed to ensure the POCs included all interventions, measurable outcomes, medications, and goals for 2 of 7 patients (Patient#1 and #2) whose records were reviewed. This failure resulted in incomplete POCs and had the potential to result in unmet patient needs. Findings include: 2. Patient #2 was a 64 year old male admitted to the agency on 9/26/23, with a primary diagnosis of malignant neoplasm of the esophagus. Additional diagnoses included chronic embolism, and type 2 diabetes mellitus. He received SN and PT services. His record, including the POC, for the certification periods 9/26/23 to 11/24/23, was reviewed. Patient #2’s POC for the cert period 9/26/23 to 11/24/23 did not include all medications, and necessary interventions for identified problems. Examples include: a. Patient #2’s Medical record included a SOC assessment dated 9/26/23 signed by the RNCM. The assessment included that Patient #2 had a diagnosis of type 2 diabetes. The assessment listed Patient #2’s type 2 diabetes as a severity code of 4, which indicated that symptoms poorly controlled; history of re-hospitalizations. Patient #2’s POC did not include necessary interventions related to his Type 2 diabetes. Patient #2’s RNCM was interviewed on 11/29/23 beginning at 1:15 and Patient #2’s medical record was reviewed in her presence. The RNCM confirmed that the POC did not have any interventions to manage or monitor Patient #2’s diabetes. b. Patient #2’s medical record included a SOC assessment dated 9/26/23 signed by the RNCM. The assessment included that Patient #2 had a diagnosis of “chronic embolism and thrombus.” The assessment listed Patient #2’s chronic embolism and thrombus as a severity code of 4, which indicated that symptoms poorly controlled; history of re-hospitalizations. Patient #2’s POC did not include necessary interventions or goals related to his need for the use of anticoagulation medications. Patient #2’s RNCM was interviewed on 11/29/23 beginning at 1:15 PM and Patient #2’s medical record was reviewed in her presence. The RNCM confirmed that Patient #2’s POC did not have any interventions to manage or monitor Patient #2’s chronic embolism or coagulation status. c. Patient #2 Medical record included a SOC assessment dated 9/26/23 signed by the RNCM. The assessment included that Patient #2 was at “moderate nutritional risk.” Additionally, it was documented that Patient #2 “without reason, has lost more than 10 lbs. [pounds], in the last 3 months, has an illness or condition that made pt change the type and/or amount of food eaten, and eats fewer than 2 meals a day.” Patient #2’s medical record included a form titled, “Nutritional assessment of Tube Fed Resident,” dated 9/26/23, documented by the discharging hospital dietician. The note included “It TPN not started at home recommend Clinimix 4.25% 75 cc/hr [times] 24 hours [clinimix IV nutritional medication].” Patient #2’s medical record included a Nutrition referral from the hospital when he was discharged from the hospital to home health on 9/25/23. There was no documentation a dietician was involved with Patient #2’s home care. Additionally, there were no documented nutritional interventions on Patient #2’s POC. The home health agency’s Registered Dietician was interviewed on 11/29/23 beginning at 11:05 AM and Patient #2’s medical record was reviewed in her presence. The Dietician confirmed she did not perform a nutritional consult as ordered for home health. Additionally, the Dietician confirmed that TPN should have started on 9/26/23. The Dietician confirmed she was unaware that TPN did not start until 8 days later. Patient #2’s RNCM was interviewed on 11/28/23 beginning at 3:10 PM and Patient #2’s medical record was reviewed in her presence. She confirmed no dietician consult was done and no nutritional interventions were documented for Patient #2. Patient #2’s POC did not include necessary interventions, goals, and medications related to his nutritional risk. d. Patient #2's medical record included. Patient #2’s medical record included a form titled, “Nutritional assessment of Tube Fed Resident,” dated 9/26/23, documented by the discharging hospital dietician. The note included “It TPN not started at home recommend Clinimix 4.25% 75 cc/hr [times] 24 hours [clinimix IV nutritional medication].” Patient 32's medical record included an order for his physician. the order included to start TPN electrolytes. Patient #2's order for TPN included "lipids 35 gm/day, 175ml/day of 20 percent smoflipids" Patient #2's medical record included a SN nursing visit on 10/07/23, signed by an APRN. The note included that Patient #2 received TPN. The narrative note it included: "Noted new administration tubing has no filter and is easier to no [sic] allow air into the line." There was no documentation on why tubing without a filter was used. Patient #2's medical record included a coordination note on 10/12/23 signed by an ARPN. The note included that Patient #2 was receiving TPN. Patient #2's Medication record did not include an order for TPN in current or discontinued medications. Patient #2’s RNCM was interviewed on 11/29/23 beginning at 1:15 PM. The RNCM confirmed TPN and heparin were not documented on Patient #2’s MAR (Medication administration record). Patient #1 was a 77 year old female admitted to the agency on 2/18/23, with a primary diagnosis of a left foot fracture. Additional diagnoses included chronic respiratory failure, and CHF. Patient #1 was on home health for SN medication management and OT, PT rehab. She received SN, PT, OT, and aide services. Her record, including the POC, for the certification periods 2/18/23 to 4/18/23, was reviewed. Patient #1's medical record included a OASIS SOC assessment," dated 2/18/23, signed by the RNCM, which included the following identified needs: - OASIS question A1250 “Transportation: Has lack of transportation kept you from medical appointments, meetings, work of from getting things needed for daily living?” The Question was answered yes. - Under the section titles Psychosocial the assessment included. “The patient lives in her home with her son who does not take care of her. She was left alone for over 24 hours in a chair without using the bathroom. Patient was soaked through her clothes and onto the chair. Patient does not seem to mind and just hold[sic] her little dog. The patience [sic] has human feces and dog feces all over in the bedroom and bathroom and cannot get out of the chair physically. The patient needs max assistance and is not getting it.” - Under the section titled “Patient Mood interview” which was a depression screening to see if the patient was depressed. The screening included 2 of the 9 questions answered. The 2 questions that were answered were. “Little interest or pleasure in doing things.” Patient #1 answered “yes” “Feeling down, depressed, or hopeless.” Patient #1 answered “yes.” It was unclear why the other 7 questions of the assessment were not answered. - OASIS question M1745 “Frequency of disruptive Behavior symptoms (reported of observed) Any physical, verbal, or other disruptive/dangerous symptoms that are injurious to self or others or jeopardize personal safety.” The question was answered that Patient #1 experienced the above “at least daily.” The SOC assessment indicated that the patient was at risk or experiencing psychosocial issues and required a MSW assessment. There was no documented MSW referral or psychosocial interventions or Patient #1’s POC. The Compliance Director and Home Health Manager were interviewed together on 11/29/23 beginning at 12:30 PM, and Patient #1’s medical record was reviewed in her presence and the above identified issues were reviewed with them. When asked if a Social Work referral was made. The Home Health Manager stated she didn’t think so. When asked if a Social Worker should have been involved with Patient #1 she stated “yes.” When asked if there were any psychosocial interventions or goals on Patient #1’s POC. The Compliance Director and Home Health Manager were unable to identify interventions or goals. Patient #1’s POC did not include necessary interventions and goal to address her identified psychosocial issues

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 review of medical records, and staff interview, it was determined the agency failed to ensure physicians were promptly alerted to changes in patients' conditions or needs that suggested a need to alter the POC for 1 of 7 patients (Patient #2) whose medical records was reviewed. This had the potential to result in unaddressed patient conditions or needs. Findings include: Patient #2 was a 64 year old male admitted to the agency on 9/26/23, with a primary diagnosis of malignant neoplasm of the esophagus. Additional diagnoses included chronic embolism, and type 2 diabetes mellitus. He received SN and PT services. His record, including the POC, for the certification period 9/26/23 to 11/24/23, was reviewed. Patient #2’s medical record, including lab values were reviewed. Patient #2’s magnesium level from 9/27/23 and 9/28/23 were 1.3 and 1.4. The reference ranges documented from the agency are 1.6-2.3 mg/dL. Patient #2's magnesium levels were out of the reference ranges. There was no documentation Patient #2's low magnesium level was reported to Patient #2's physician. The Compliance Director, RN was interviewed on 11/28/23 beginning at 3:10 PM. She confirmed the RNCM should have documented that Patient #2’s PCP was made aware of low magnesium level. Patient #2’s RNCM was interviewed on 11/29/23 beginning at 1:15 PM. She confirmed there was no documentation that Patient #2’s PCP was made aware of low magnesium levels for 9/27/23 and 9/28/23. Patient #2's low magnesium level was not documented as discussed with the physician to determine if any changes to his POC were needed.

Services by skilled professionals CFR(s): 484.75(a) Standard: Provision of services by skilled professionals. Skilled professional services are authorized, delivered, and supervised only by health care professionals who meet the appropriate qualifications specified under §484.115 and who practice according to the HHA's policies and procedures. This STANDARD is not met as evidenced by: Based on medical record review, policy review, and staff interview, it was determined the agency failed to ensure skilled services were provided in accordance with established agency polices, for 1 of 7 patients (Patient #2). This had the potential to result in unmet patient needs. Findings include: Patient #2 was a 64 year old male admitted to the agency on 9/26/23, with a primary diagnosis of malignant neoplasm of the esophagus. Additional diagnoses included chronic embolism, and type 2 diabetes mellitus. He received SN and PT services. His record, including the POC, for the certification period 9/26/23 to 11/24/23, was reviewed. An agency policy titled, "Total Parenteral Nutrition Infusion," undated, included: "When TPN is indicated the following procedure will be followed." The patient receiving TPN with have a "dietary consult." Additionally, the policy included "TPN tubing must have a 1.2um filter for solutions containing albumin or lipids." This policy was not followed. Examples include: 1. Patient #2 did not have a dietary consult. Patient #2’s medical record included a form titled, “Nutritional assessment of Tube Fed Resident,” dated 9/26/23, documented by the discharging hospital dietitian. The note included “If TPN not started at home recommend Clinimix 4.25% 75 cc/hr [times] 24 hours [clinimix IV nutritional medication].” Patient #2’s medical record included a Nutrition referral from the hospital when he was discharged from the hospital to home health on 9/25/23. There was no documentation a dietitian was involved with Patient #2’s home care. Additionally, there were no documented nutritional interventions on Patient #2’s POC. The home health agency’s Registered Dietitian was interviewed on 11/29/23 beginning at 11:05 AM and Patient #2’s medical record was reviewed in her presence. The Dietitian confirmed she did not perform a nutritional consult as ordered for home health. Additionally, the Dietitian confirmed that TPN should have started on 9/26/23. The Dietitian confirmed she was unaware that TPN did not start until 8 days later. 2. Patient #2's nurse did not use a filter for TPN with lipids. Patient #2's order for TPN included "lipids 35 gm/day, 175ml/day of 20 percent smoflipids" Patient #2's medical record included a SN nursing visit on 10/07/23, signed by a APRN. The note included that Patient #2 received TPN. The narrative note included: "Noted new administration tubing has no filter and is easier to no [sic] allow air into the line." There was no documentation on why tubing without a filter was used. Patient #2’s RNCM was interviewed on 11/28/23 beginning at 3:10 PM and Patient #2’s medical record was reviewed in her presence. She confirmed the TPN should have been administered with filter in the tubing per policy. The Agency failed to follow policy on the administration of TPN for Patient #2.

A Medicare recertification survey of your agency, including Emergency Preparedness, was conducted from 1/25/21 to 1/27/21, and was found in compliance for the regulations found in Appendix Z of the State Operations Manual. Surveyors conducting the survey were: Brian Osborn, RN, HFS, Team Lead Robin Connelly, RN, MA, HFS

The following deficiencies were cited during your agency's Medicare recertification and focused COVID-19 infection control surveys conducted from 1/25/21 to 1/27/21. Surveyors conducting the surveys were: Brian Osborn, RN, HFS, Team Lead Robin Connelly, RN, MA, HFS Acronyms used in this report include: APS - Adult Protective Services CDC - Centers for Disease Control and Prevention CEO - Chief Executive Officer CKD - Chronic Kidney Disease COPD - Chronic Obstructive Pulmonary Disease COVID-19 - Coronavirus Disease 2019 DM - Diabetes Mellitus HR - Human Resources IC - Infection Control IV - Intravenous LPN - Licensed Practical Nurse MSW - Medical Social Worker OT - Occupational Therapy PICC - Peripherally Inserted Central Catheter POC - Plan of Care PT - Physical Therapy RN - Registered Nurse RNCM - Registered Nurse Case Manager SN - Skilled Nursing SOC - Start of Care

Written notice of patient's rights CFR(s): 484.50(a)(1)(i) (i) Written notice of the patient's rights and responsibilities under this rule, and the HHA's transfer and discharge policies as set forth in paragraph (d) of this section. Written notice must be understandable to persons who have limited English proficiency and accessible to individuals with disabilities; This ELEMENT is not met as evidenced by: Based on review of medical records and staff interview, it was determined the agency failed to ensure patients were provided a written notice of patients' rights and responsibilities in advance of furnishing care for 2 of 7 patients (#1 and #5) whose SOC records were reviewed. This had the potential for patients not being informed of all their rights. Findings include: 1. Patient #1 was a 61 year old male admitted to the agency on 1/22/21, with a primary diagnosis of chronic pancreatitis. Additional diagnoses included DM type 2, COPD, CKD, tube feeding, and depression. He received SN services. His record, including the POC, for the certification period of 1/22/21 to 3/22/21, was reviewed. Patient #1's medical record included a treatment consent form which documented information regarding his rights and responsibilities. The consent was signed by Patient #1 and dated 1/22/21, however was not timed. It could not be determined if Patient #1 signed his consent and was informed of his rights and responsibilities prior to care being rendered. The Clinical Manager and office LPN were interviewed together on 1/27/21, beginning at 9:32 AM, and Patient #1's medical record was reviewed in their presence. They confirmed Patient #1's consent was not timed. The Clinical Manager stated treatment consents included a section to document signature times and should be completed by clinicians prior to rendering care. The agency failed to ensure Patient #1 received written notice of his rights and responsibilities in advance of furnishing care. 2. Patient #5 was a 76 year old female admitted to the agency on 1/22/21, with a primary diagnosis of hip replacement. She received SN and PT services. Her record, including the POC, for the certification period of 1/22/21 to 3/22/21, was reviewed. Patient #5's medical record included a treatment consent form which documented information regarding her rights and responsibilities. The consent was signed by Patient #5 and dated 1/22/21, however was not timed. It could not be determined if Patient #5 signed her consent and was informed of her rights and responsibilities prior to care being rendered. The Clinical Manager and office LPN were interviewed together on 1/27/21, beginning at 9:51 AM, and Patient #5's medical record was reviewed in their presence. They confirmed Patient #5's consent was not timed. The Clinical Manager stated treatment consents included a section to document signature times and should be completed by clinicians prior to rendering care. The agency failed to ensure Patient #5 received written notice of her rights and responsibilities in advance of furnishing care.

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 observation, medical record review, agency patient rights information review, and staff interview, it was determined the agency failed to ensure patients were informed in writing of their specific financial responsibilities for 1 of 3 patients (Patient #5) whose care was observed and whose records were reviewed. This had the potential to result in a financial responsibility not previously revealed to the patient. Findings include: Patient #5 was a 76 year old female who was admitted to the agency on 1/22/21, with a primary diagnosis of hip replacement. She received SN and PT services. Her record, including the POC, for the certification period of 1/22/21 to 3/22/21, was reviewed. Patient #5's medical record included a treatment consent, dated 1/22/21, signed by her. The consent included, "Medicare: fee for service (project 100% covered)." The consent did not include what the potential costs would be if the services were not 100% covered. An observation was conducted in Patient #5's home on 1/26/21, beginning at 11:34 AM, during a scheduled SN visit. During the visit, Patient #5's admission packet was reviewed. The admission packet included a section listing potential costs for SN, aide, PT, OT, ST, and MSW visits. This section was blank. It could not be determined what Patient #5 would potentially have to pay out of pocket for services if her insurance did not cover the total amount. The Clinical Manager and office LPN were interviewed together on 1/27/21, beginning at 9:51 AM, and Patient #5's medical record and observations were reviewed in their presence. The Clinical Manager stated Patient #5's RNCM should have filled out the potential service costs in her admission packet. The agency failed to ensure Patient #5 was informed in writing of her specific financial responsibilities.

Document complaint and resolution CFR(s): 484.50(e)(1)(ii) (ii) Document both the existence of the complaint and the resolution of the complaint; and This ELEMENT is not met as evidenced by: Based on agency policy review, patient grievance log review, and staff interview, it was determined the agency failed to ensure grievance resolutions were documented and provided for 2 of 2 documented patient grievances reviewed. This had the potential for patients' or their representatives' concerns not being addressed by agency staff. Findings include: An agency policy, "Patient Grievance," dated 9/08/20, stated, "The final response letter shall be approved by the Hospital's claims representative when possible (a 'Final Letter')." This policy was not followed. Examples include: 1. A patient "Complaint/Concern Form," dated 5/11/20, documented a patient's concerns regarding care delivery. The form included the patient's grievance and the investigative steps the agency took to address the patient's concerns. However, a resolution letter to the patient as to the findings of the investigation was not documented. It could not be determined if the patient received written correspondence as to the outcome of their grievance. 2. A patient "Complaint/Concern Form," dated 3/05/20, documented a patient's concerns regarding care delivery. The form included the patient's grievance and the investigative steps the agency took to address the patient's concerns. However, a resolution letter to the patient as to the findings of the investigation was not documented. It could not be determined if the patient received written correspondence as to the outcome of their grievance. The Office Manager was interviewed on 1/27/21, and the agency's grievance log was reviewed in her presence. She confirmed written correspondence to patients as to the outcome of their grievances was not done. The agency failed to ensure grievance resolutions were documented and provided to patients.

Immediate reporting of abuse by all staff CFR(s): 484.50(e)(2) Any HHA staff (whether employed directly or under arrangements) in the normal course of providing services to patients, who identifies, notices, or recognizes incidences or circumstances of mistreatment, neglect, verbal, mental, sexual, and/or physical abuse, including injuries of unknown source, or misappropriation of patient property, must report these findings immediately to the HHA and other appropriate authorities in accordance with state law. This ELEMENT is not met as evidenced by: Based on medical record review, Idaho state statute review, and staff interview, it was determined the agency failed to ensure staff reported potential patient neglect to appropriate authorities in accordance with state law for 1 of 1 patient (Patient #1) who had documented potential neglect and whose record was reviewed. This resulted in a missed opportunity to uphold patient rights. Findings include: "IDAHO STATUTES TITLE 39 HEALTH AND SAFETY CHAPTER 53 ADULT ABUSE, NEGLECT AND EXPLOITATION ACT," updated 7/01/18, states "39-5303. Duty to report cases of abuse, neglect or exploitation of vulnerable adults. (1) Any physician, nurse, employee of a public or private health facility, or a state licensed or certified residential facility serving vulnerable adults, medical examiner, dentist, osteopath, optometrist, chiropractor, podiatrist, social worker, police officer, pharmacist, physical therapist, or home care worker who has reasonable cause to believe that a vulnerable adult is being or has been abused, neglected or exploited shall immediately report such information to the commission. Provided however, that nursing facilities defined in section 39-1301(b), Idaho Code, and employees of such facilities shall make reports required under this chapter to the department. When there is reasonable cause to believe that abuse or sexual assault has resulted in death or serious physical injury jeopardizing the life, health or safety of a vulnerable adult, any person required to report under this section shall also report such information within four (4) hours to the appropriate law enforcement agency." This statute was not followed. Patient #1 was a 61 year old male admitted to the agency on 1/22/21, with a primary diagnosis of chronic pancreatitis. Additional diagnoses included DM Type 2, COPD, CKD, tube feeding, and depression. He received SN services. His record, including the POC, for the certification period of 1/22/21 to 3/22/21, was reviewed. Patient #1's medical record included an SN SOC, dated 1/22/21, signed by the RNCM, which stated: - "Home if [sic] very cluttered. There are multiple pathways that are starting to fill in [due to] no room to place things. Patient is at risk for falls [due to] clutter." - "Psychosocial...Poor Home Environment...Poor Coping Skills...Depressed Mood." - "Over the last two weeks, how often have you been bothered by any of the following problems...Little interest or pleasure doing things?...Several Days 2 - 6 days...Feeling down, depressed, or hopeless?...Several Days 2 - 6 days." - "Food that should be refrigerated is not at this time because there is no room in the refrigerator." - "The home is very cluttered with multiple pathways. Multiple broken furniture, and foods left out some are moldy and starting to decay. When looking for the patient's previous feeding it was noted that the box with the formula was leaking. Patient states he thinks mice got into them." Patient #1's medical record did not document if Idaho APS was notified of his potential neglect. The Clinical Manager and office LPN were interviewed together on 1/27/21, beginning at 9:51 AM, and Patient #1's medical record was reviewed in their presence. They confirmed the RNCM should have contacted Idaho APS regarding Patient #1's potential neglect. Patient #1's potential neglect was not reported to appropriate authorities in accordance with Idaho state law.

Health, psychosocial, functional, cognition CFR(s): 484.55(c)(1) The patient's current health, psychosocial, functional, and cognitive status; This ELEMENT is not met as evidenced by: Based on medical record review and staff interview, it was determined the agency failed to ensure SOC comprehensive assessments accurately reflected patients' psychosocial needs for 1 of 1 patient (Patient #1) who had documented unaddressed psychosocial needs and whose record was reviewed. This resulted in a missed opportunity to address the patient's needs on his POC. Findings include: Patient #1 was a 61 year old male admitted to the agency on 1/22/21, with a primary diagnosis of chronic pancreatitis. Additional diagnoses included DM Type 2, COPD, CKD, tube feeding, and depression. He received SN services. His record, including the POC, for the certification period of 1/22/21 to 3/22/21, was reviewed. Patient #1's medical record included an SN SOC, dated 1/22/21, signed by the RNCM, which stated: - "Home if [sic] very cluttered. There are multiple pathways that are starting to fill in [due to] no room to place things. Patient is at risk for falls [due to] clutter." - "Psychosocial...Poor Home Environment...Poor Coping Skills...Depressed Mood." - "Over the last two weeks, how often have you been bothered by any of the following problems...Little interest or pleasure doing things?...Several Days 2 - 6 days...Feeling down, depressed, or hopeless?...Several Days 2 - 6 days." - "Food that should be refrigerated is not at this time because there is no room in the refrigerator." - "The home is very cluttered with multiple pathways. Multiple broken furniture, and foods left out some are moldy and starting to decay. When looking for the patient's previous feeding it was noted that the box with the formula was leaking. Patient states he thinks mice got into them." - "Ability of patient to handle finances...Needs assistance." - "MSW referral indicated for...No." It could not be determined why an MSW referral for evaluation of Patient #1's documented issues was not entered by the RNCM. The Clinical Manager and office LPN were interviewed together on 1/27/21, beginning at 9:58 AM, and Patient #1's medical record was reviewed in their presence. They confirmed a referral for an MSW evaluation of Patient #1's documented psychosocial needs should have been done. Patient #1's SOC comprehensive assessment did not accurately reflect his identified psychosocial needs.

Update of the comprehensive assessment CFR(s): 484.55(d) Standard: Update of the comprehensive assessment. The comprehensive assessment must be updated and revised (including the administration of the OASIS) as frequently as the patient's condition warrants due to a major decline or improvement in the patient's health status, but not less frequently than- This STANDARD is not met as evidenced by: Based on medical record review, observation, patient interview, and staff interview, it was determined the agency failed to ensure recertification comprehensive assessments were updated to include necessary information for 1 of 3 patients (patient #7) whose care was observed and whose records were reviewed. This resulted in incomplete assessment information to staff providing care and directly affected patient care and treatment. Findings include: Patient #7 was a 63 year old male admitted to the agency on 12/02/20, with a primary diagnosis of malignant neoplasm of thyroid gland with metastasis. Additional diagnoses included DM type 2, hypertensive heart disease, and heart failure. He received SN, PT, and OT services. Patient #7's medical record included an SN SOC comprehensive assessment, dated 12/02/20, signed by an RN, which documented initial medication reconciliation at that time. However, an updated medication reconciliation had not been performed for Patient #7 since that initial visit, a period of 55 days. An observation was conducted in Patient #7's home on 1/26/21 beginning at 10:00 AM, during a scheduled recertification visit with PT. Patient #7's wife stated he started a new medication for dry mouth last week and showed the bottle of pilocarpine to the physical therapist. The physical therapist was not observed reconciling the new medication or Patient #7's previous medications. Patient #7 and his wife were interviewed at the end of the PT visit, beginning at 10:40 AM. Patient #7's wife stated his cardiac medications had been discontinued a few weeks ago. She reviewed Patient #7's medications with surveyor. During the medication review, Patient #7's wife presented bottles of olanzapine and pilocarpine, stating that these medications had been initiated last week; however, Patient #7 was no longer taking olanzapine due to side effects. The Clinical Manager and office LPN were interviewed together on 1/27/21, beginning at 9:50 AM. Patient #7's medical record and observations were reviewed in their presence. They confirmed their expectations of the physical therapist completing the recertification visit included a complete medication reconciliation. The office LPN confirmed that Patient #7's medical record did not include an updated medication reconciliation. The office LPN stated Patient #7's medication changes would have triggered an SN visit. The office LPN confirmed that there had been no SN visit since Patient #7's initial SOC. Patient #7's POC was not updated to reflect current medications or his identified needs.

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 medical record review and staff interview, it was determined the agency failed to ensure patients' POC included patient-specific interventions and education for 1 of 1 patient (Patient #1) who was receiving hemodialysis and whose records were reviewed. This resulted in an incomplete POC and had the potential to interfere with quality and completeness of patient care. Findings include: Patient #1 was a 61 year old male admitted to the agency on 1/22/21, with a primary diagnosis of chronic pancreatitis. Additional diagnoses included DM Type 2, COPD, CKD, tube feeding, and depression. He received SN services. His record, including the POC, for the certification period of 1/22/21 to 3/22/21, was reviewed. Patient #1's medical record included and SOC comprehensive assessment, dated 1/22/21, singed by his RNCM, which stated, "Is patient on dialysis?...[yes]." The RNCM documented Patient #1 received hemodialysis treatment 3 days per week at a hospital in a neighboring state. Patient #1's medical record included a POC, dated 1/22/21, signed by his physician. The POC did not include patient-specific interventions and education related to Patient #1's hemodialysis. It could not be determined if agency staff played a role in Patient #1's hemodialysis or vascular access management. The Clinical Manager and office LPN were interviewed together on 1/27/21, beginning at 9:58 AM, and Patient #1's medical record was reviewed in their presence. They confirmed Patient #1's POC should have included patient-specific interventions and education related to his hemodialysis. Patient #1's POC was not complete.

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 medical record review and staff interview, it was determined the agency failed to ensure medications were administered only as ordered by the physician for 1 of 7 patients (Patient #2) whose records were reviewed. This resulted in an unauthorized medication and had the potential to negatively impact the safety and quality of patient care. Findings include: Patient #2 was an 89 year old female admitted to the agency on 10/11/20, with a primary diagnosis of COVID-19 acute respiratory disease. Additional diagnoses included viral pneumonia, hypoxemia, anorexia, asthma, and bilateral primary osteoarthritis of knee. She received SN, PT, and aide services. Her record, including the POC, for the certification period starting 12/10/20, was reviewed. Patient #2's record included notes from aide visit 12/31/20. Note stated, "Under both breasts are red. Antifungal cream applied." Antifungal cream was not included on Patient #2's POC or medication profile. During an interview on 1/27/21, beginning at 9:50 AM with Clinical Manager and office LPN, it was confirmed the antifungal cream was not added to Patient #2's POC and medication profile. The agency failed to ensure physician orders for all patient 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 observation, medical record review, policy review, CDC IC guidelines review, and staff interviews, it was determined the agency failed to ensure accepted IC standards of practice were followed for 2 of 3 patients (#3 and #7) whose visits were observed and whose records were reviewed. This had the potential for an increased risk of infection transmission. Findings include: The CDC IC guidelines website, accessed 2/02/21, stated, "When and how to perform hand hygiene...before touching a patient...before procedures...before gloving...after gloving." These guidelines were not followed. Examples include: 1. Patient #3 was an 82 year old male admitted to the agency on 1/12/21, with a primary diagnosis of DM type 2 with other skin ulcer. Additional diagnoses included chronic kidney disease, chronic peripheral venous insufficiency, and unspecified visual loss (blind). Patient #3 was hospitalized and readmitted 1/20/21, with primary diagnosis of gangrenous wound to L [left] heel with IV antibiotics for treatment. He received SN visits daily for antibiotic infusion via newly implanted PICC line. A visit was made to Patient #3's home on 1/26/21 beginning at 12:00 PM, to observe an SN visit. a. The RN did not perform hand hygiene before or after donning gloves for Patient #3's PICC line infusion. b. During Patient #3's PICC line infusion, the RN went to his car to retrieve his medical bag. The RN did not perform hand hygiene after returning to Patient #3. The Clinical manager and office LPN were interviewed on 1/27/21, beginning at 9:50 AM. They stated it is the agency's expectation proper hand hygiene be performed prior to donning of gloves prior to PICC line use. CDC IC guidelines were not followed for Patient #3. 2. Patient #7 was a 63 year old male admitted to the agency on 12/02/20, with a primary diagnosis of malignant neoplasm of thyroid gland with metastasis. Additional diagnoses included DM type 2, hypertensive heart disease, and heart failure. He received SN, PT, and OT services. A visit was made to Patient #7's home on 1/26/21 beginning at 10:00 AM to observe a recertification visit by PT. The physical therapist discussed Patient #7's progress with the patient and his wife. He then performed routine exercises with the Patient #7. Patient #7 was unable to rise from chair independently; physical therapist went to his car to retrieve a gait belt. The physical therapist did not perform hand hygiene during his visit in the home with Patient #7. The Clinical Manager and office LPN were interviewed on 1/27/21, beginning at 9:50 AM. They confirmed it is the agency's expectations proper hand hygiene be performed prior to any patient care and stated, "he [the physical therapist] knows better than that". CDC IC guidelines were not followed for Patient #7.

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 agency document review, organizational chart review, personnel file review, contract review, and staff interview, it was determined the Governing Body failed to ensure overall management of the agency. This had the potential for unclear expectations, roles, and responsibilities for leadership and frontline staff. Findings include: 1. The home health Administrator appointed by the Governing Body was documented as the CEO of the agency's affiliated critical access hospital. The Administrator's personnel file was reviewed in the presence of the HR Director on 1/26/21, beginning at 12:37 PM. The file did not include a home health job description for the Administrator, but did include a contract between the CEO and the agency affiliated critical access hospital, dated 2017. The contract outlined numerous CEO critical access hospital duties and responsibilities, but did not reference the home health agency. It could not be determined what expectations, roles, and responsibilities the CEO fulfilled in his home health Administrator position. 2. The agency's organizational chart, "Franklin County Medical Center," undated, was reviewed. The chart included the agency as a department of the affiliated critical access hospital structure; listed as "Home Health." The agency itself did not have its own organizational structure. It could not be determined what delineated lines of authority were approved by the Governing Body for the agency; to include all agency staff, leadership, and disciplines. It was unclear if the agency had a separate organizational structure from the affiliated critical access hospital. 3. Job descriptions for physical therapists, occupational therapists, physical therapist assistants, registered dieticians, and speech therapists were reviewed. Each of the job descriptions documented their roles and responsibilities as they related to services rendered in the agency's affiliated critical access hospital, but they did not include reference to the agency itself. It was unclear what roles and responsibilities these disciplines fulfilled while performing home health duties. The Vice Chair of the agency's affiliated critical access hospital, who was a member of the agency's Governing Body, and the Office Manager were interviewed together on 1/27/21, beginning at 1:57 PM. The Office Manager confirmed the critical access hospital's CEO home health roles and responsibilities were not documented in his personnel file contract. Additionally, the Officer Manager confirmed the agency did not have its own organizational structure outside their departmental role in the affiliated critical access hospital. Further, the Office Manager confirmed therapy job descriptions were not specific for the roles and responsibilities they fulfilled for home health services. The Vice Chair stated these items would be amended. The Governing Body failed to ensure overall management of the agency.