Every finding on record at Freeman Health Systems

The Emergency Preparedness regulations were reviewed as part of the Medicare recertification survey completed on 07/10/2024. During the survey it was determined the home health provider is in compliance with the requirements of 42 CFR 484.102 Condition of Participation: Emergency Preparedness for Home Health Providers.

A partial extended survey for Medicare recertification for the home health provider was completed on 07/10/2024. The provider had 72 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, clinical record review, observation, and interview, the home health provider failed to ensure their patient’s medications were reconciled to include all of the medications the patient was currently using in three of six full records reviewed (Records/Patients #1, #2, and #7). This deficient practice has the potential to affect all of the provider’s patients. Review of the undated document titled, “Guidelines for Visit Documentation,” showed that the provider’s clinicians were to perform medication reconciliation activities every visit, to include, but not limited to: - Ask the patient if any medication changes have occurred, and document the changes; - Write orders if the patient is taking new medications, even over the counter; and - Check medication bottles every week for accuracy of the medication list. RECORD/PATIENT #2: Review of the clinical record showed the patient was admitted to home health services on 6/30/2024 with a primary diagnosis of aftercare following joint replacement of the right hip on 06/26/2024. The patient resided in their own home with the assistance of family members. Review of the document titled, “Discharge Summary,” dated 6/27/2024 showed the patient was to take aspirin 81mg by mouth twice a day for 30 days. Review of the skilled nurse evaluation visit documentation, for the visit performed 6/30/2024 showed the patient had, “taken some softeners and two doses of mineral oil” to manage constipation. The patient expected the mineral oil to start working. Review of the document titled, “Home Health Certification and Plan of Care,” with start of care date of 6/30/2024 showed: - The plan of care contained an order for aspirin 81 mg oral tablet, two times per day: - The plan of care failed to contain: * A stop date for the aspirin therapy; and * Orders for stook softeners and mineral oil as reported by the patient. During an interview on 7/10/2024 at 10:04 AM, the administrator stated that they expected the plan of care to contain a list of all the medications the patient was taking. RECORD/PATIENT #7: Review of the clinical record showed the patient was admitted to home health services on 6/19/2024 with a primary diagnosis of acute and chronic respiratory failure. The plan of care contained secondary diagnoses of long-term use of oral hypoglycemic drugs (medications used to lower blood sugar). The patient resided in their own home with the assistance of family. Review of the document titled, “Discharge Summary,” dated 06/14/2024 showed: - The patient was to take Bisacodyl 10mg at bedtime as needed for constipation, and Sennosides 1 tablet two times per day. Review of the start of care nursing visit documentation, for the visit dated 06/19/2024, showed the patient was a diabetic (a problem in the way the body regulates and uses sugar as a fuel), and did not check their blood sugars. Their diabetes was monitored at the physician’s office. Review of the document titled, “Plan of Treatment,” with a start date of 06/19/2024 showed: - Patient/caregiver to check daily blood glucose or as ordered by physician. SN to monitor and report any readings outside stated parameters of 250 to the physician; and - The document failed to contain list senna and bisacodyl as active medications for the patient. During an interview on 7/10/2024 at 10:36 AM, the administrator stated that: - They would expect the plan of care to reflect that the patient does not monitor blood sugars, and the orders for daily monitoring were inaccurate for this patient; and - They would expect the plan of care to contain a list of all the medications the patient was taking. RECORD/PATIENT #1: Observation on 07/09/2024 at 9:00 AM, during the patient's home visit, showed the following: -The patient was using Arnica gel as needed for back pain every day. This medication was not on the provider's medication profile; -The patient was taking Coenzyme Q10 (COQ10) (an antioxidant) 200 milligrams (mg) once a day. This medication was not on the provider's medication profile; -The patient was taking Beano (anti gas pill) one pill daily as needed for gastric distress. This medication was not on the provider's medication profile: -The provider's medication profile showed the patient was taking Trazodone 50 mg once daily at bedtime. The patient stated that he/she has not taken this medication in a few months; and -The provider's medication profile showed the patient was taking Cannabidiol (CBD) 10 mg oral gummies take 1/4 to 1 gummy as needed for pain. The patient stated that he/she has not taken this medication in a few months. During an interview on 07/09/2024 at 9:00 AM, the patient's nurse agreed that the patient's medication profile and the medications that the patient was taking did not match. During an interview on 07/10/2024 at 10:30 AM, the administrator stated that he/she would expect the medications to match the medication profile.

Plan of care must include the following CFR(s): 484.60(a)(2)(i-xvi) The individualized plan of care must include the following: (i) All pertinent diagnoses; (ii) The patient's mental, psychosocial, and cognitive status; (iii) The types of services, supplies, and equipment required; (iv) The frequency and duration of visits to be made; (v) Prognosis; (vi) Rehabilitation potential; (vii) Functional limitations; (viii) Activities permitted; (ix) Nutritional requirements; (x) All medications and treatments; (xi) Safety measures to protect against injury; (xii) A description of the patient's risk for emergency department visits and hospital re-admission, and all necessary interventions to address the underlying risk factors. (xiii) Patient and caregiver education and training to facilitate timely discharge; (xiv) Patient-specific interventions and education; measurable outcomes and goals identified by the HHA and the patient; (xv) Information related to any advanced directives; and (xvi) Any additional items the HHA or physician or allowed practitioner may choose to include. This ELEMENT is not met as evidenced by: Based on policy review, clinical record review, and interview, the home health provider failed to ensure the individualized plan of care contained the patient-specific interventions in one of six records reviewed (Record/Patient #2). This deficient practice has the potential to affect the care for all the provider’s patients. Findings included: Review of the provider’s policy titled, “Care Planning, Coordination of Services, and Quality of Care,” last revised 02/2024 showed: - Each patient must receive the home health services that are written in the individualized plan of care (POC) that identifies patient-specific measurable outcomes and goals; - The plan of care must contain patient specific interventions; and - Drugs, services, and treatments are administered only as ordered by a physician. Review of the undated document titled, “Total Hip Protocol for Dr. Miller and Dr. Black,” showed that: - With the Dermabond Prineo (a liquid adhesive with a self-adhering mesh) closure, avoid alcohol, soap or washing along incision site; - Do not cover dressing with anything but compression stockings. May shower, cover surgical dressing with plastic while showering; and - SN (skilled nurse) to remove dressing and apply new post-op occlusive surgical dressing every six to eight days post-op prior to surgeon follow-up visit. RECORD/PATIENT #2: Review of the clinical record showed the patient was admitted to home health services on 06/30/2024 with a primary diagnosis of aftercare following joint replacement of the right hip on 06/26/2024. The patient resided in their own home with the assistance of family members. Review of the document titled, “Discharge Summary,” dated 06/27/2024 showed: - If you have Dermabond Prineo skin closure dressing, leave dressing intact. Do not cover dressing with anything but compression stockings; - Cover your surgical dressing with plastic while showering; and - Home health to change the surgical dressing at six to eight days post op. Review of the SN evaluation visit documentation, for the visit performed 06/30/2024, showed the patient had a right hip surgical site: - The wound assessment showed: * Wound type: Surgical; * Dressing condition: intact; * Drainage: None; * Signs and symptoms of infection: None; and - Wound Note: Swollen to hip area but doing well and only a little bruising noted under dressing, no blisters. Review of the SN visit documentation, for the visit performed 07/03/2024, showed: - The SN changed Mepilex AG (an occlusive, silicone bordered, antibacterial impregnated dressing) dressing that day. No s/s (signs/symptoms) of infection or drainage noted; - Assessment of wound: Edges of wound well approximated with Dermabond intact. Review on 07/10/2024 of the POC, dated 06/30/2024, failed to contain an order for the Mepilex AG dressing. During an interview on 07/10/2024 at 10:31 AM, the administrator stated that: - The intent of the total hip protocol was to include treatment directives including: * The patient’s incision was closed with the Dermabond Prineo closure device; * The closure device is then covered (as a surgical dressing) with a Mepilex AG dressing; and * The clinicians were to change the Mepilex AG dressing six to eight days post-op, prior to the post-op surgeon’s visit; and - The protocol failed to contain directions that the Dermabond Prineo closure device was covered with a post-op, occlusive, bordered foam AG impregnated dressing.

Communication with all physicians CFR(s): 484.60(d)(1) Assure communication with all physicians or allowed practitioners involved in the plan of care. This ELEMENT is not met as evidenced by: Based on policy review, record review, and interview, the home health provider failed to ensure nursing staff documented coordination of care with all physicians in one of six full records reviewed (Record/Patient #4). This deficient practice has the potential to affect all patients served by the provider. Findings included: Review of the provider’s policy titled, “Care Planning, Coordination of Services, and Quality of Care,” reviewed 02/2024, showed in part that the provider must assure communication with all physician involved in the POC, integrate orders from all physicians involved in the POC to assure coordination of all services and interventions provided to the patient, integrate services to assure the identification of patient needs and factors that could affect patient safety, treatment effectiveness, and the coordination of care provided by all disciplines, and coordinate care delivery to meet the patient’s needs. RECORD/PATIENT #4: Review of the record showed the patient was admitted to home health service on 03/30/2024. The principal diagnosis was unspecified open wound to the left lower leg. The patient had been traveling in another state when he/she sustained an injury/wound to the left leg and was hospitalized. He/she returned and also received care through the local VA (veterans administration). The patient went for hyperbaric therapy (pure oxygen in a pressurized environment which increases the amount of oxygen your blood can carry) Monday through Friday and the local hospital wound care clinic on Wednesdays. The home health nurses saw the patient on the weekends for dressing changes. Review of the nursing admission visit dated 03/30/2024, showed under the medication reconciliation section, the nurse documented he/she had a faxed medication sheet from March 25 that showed active inpatient medications. The patient had a bottle of Benadyl (antihistamine) he/she had never taken. The patient would not take anything for bowels. He/she took clopidigrel (Plavix, blood thinner) and oxycodone (narcotic pain medication) one time but not currently. The spouse had a medication sheet he/she took a picture of before coming home with about six medications on it. The patient was not on about half of the medications on the sheet the nurse had. The patient knew his/her medications well and got everything from the VA (veterans administration). The patient was not on the clopidigel or oxycodone. The nurse failed to document he/she clarified the medications with the physician (s). Review of a nursing visit dated 06/07/2024, the patient had been to the cardiologist (heart doctor) who stated that he/she needed to take a blood thinner and was under the impression the patient took Plavix. The patient had not been taking since home from the hospital. Now the cardiologist said to get back on it even with the aspirin. The next day the patient saw another physician and was told to go off the blood thinners. The patient took one day of Plavix and his/her hematocrit (the amount of red blood cells in the blood) dropped 7000 points in a two-day period. The patient’s spouse had contacted the VA about lowering the aspirin dose. The patient stated that his/her physician at the VA said to get off the Plavix. The patient’s stories conflicted some. The nurse failed to document he/she clarified the medications with the physician (s). During an interview on 07/09/2024 at 3:55 PM, the quality RN (registered nurse) stated that he/she would expect the nurse to document he/she clarified the medications with the physician. During an interview on 07/10/2024 at 8:30 AM, the administrator stated that he/she talked with the nurse. The nurse stated that he/she knew he/she contacted the physician and got everything straightened out but did not have documentation of it. During an interview on 07/10/2024 at 8:30 AM, the patient’s nurse manager stated that the patient “messed” with his/her medications. He/she took one day of the Plavix. The other physician was an infectious disease physician, and that was who the patient listened to.

Provide services in the plan of care CFR(s): 484.75(b)(3) Providing services that are ordered by the physician or allowed practitioner as indicated in the plan of care; This ELEMENT is not met as evidenced by: Based on policy review, record review, and interview, the home health provider failed to ensure nursing staff followed the plan of care (POC) for frequency of visits for two patients (Records/Patients #1 and #5) and for wound monitoring in one of six full records reviewed (Record/Patient #4). This deficient practice has the potential to affect all patients served by the provider. RECORD/PATIENT #1: Review of the clinical record showed the patient admitted to home health services on 11/15/2023 with a primary diagnosis of encounter for orthopedic aftercare. Review of the document titled, "Home Health Certification and Plan of Care," showed the visit frequency for skilled nursing (SN) services as of 05/13/2024-07/11/2024 as the following: -5-6 visits a week for one week; and -6-7 visits a week for eight weeks. Review of the SN notes for the week of 06/23/2024-06/29/2024 showed: -A missed SN visit on 06/25/2024; and -A missed SN visit on 06/27/2024. During an interview on 07/10/2024 at 10:00 AM, the Quality Registered Nurse (RN) provided an order, dated 07/08/2024, for the two missed visits due to doctor's appointments. During an interview on 07/10/2024 at 10:15 AM, the administrator stated that he/she would expect the order for the missed visits to be obtained the same day as the missed visits. RECORD/PATIENT #5: Review of the clinical record showed the patient admitted to home health services on 02/20/2024 with a primary diagnosis of mechanical complication of other internal joint prothesis. Review of the document titled, "Home Health Certification and Plan of Care," showed the visit frequency for skilled nursing (SN) services as of 02/20/2024-03/09/2024 as two times a week for three weeks. Review of the SN notes for the week of 03/03/2024-03/09/2024 showed one visit for the week. During an interview on 07/09/2024 at 3:06 PM, the Quality RN stated that there was not a second visit for the week or an order for the missed visit. Findings included: Review of the provider’s policy titled, “Care Planning, Coordination of Services, and Quality of Care,” reviewed 02/2024, showed in part that each patient must receive an individualized POC. The POC must specify the care and services necessary to meet the patient-specific needs. Each patient must receive the home health services that are written in the individualized POC. Review of an undated document provided by the provider as their expectations titled, “Wound Assessments and Care,” showed in part that complete wound assessment documentation should include the location, measurements, appearance, tissue types, drainage, odor, and pain. Review of an undated document provided by the provider as their expectations titled, “Guidelines for Visit Documentation,” showed in part that documentation included that wounds should be assessed every visit, perform ordered wound care, measure weekly and as needed, and chart in the wound care section. RECORD/PATIENT #4: Review of the record showed the patient was admitted to home health service on 03/30/2024. The principal diagnosis was unspecified open wound to the left lower leg. The patient went for hyperbaric therapy (pure oxygen in a pressurized environment which increases the amount of oxygen your blood can carry) Monday through Friday and to the wound clinic on Wednesdays. The home health nurses saw the patient on the weekends for dressing changes. Review of the nursing admission visit dated 03/30/2024, showed the patient had a pressure ulcer to the left buttocks described as “skin bunched up”. The nurse took a picture, but their camera messed up the picture. The nurse failed to document further assessment of the area. Review of the POC dated 03/30/2024, included that the skilled nurse (SN) would monitor the pressure ulcer to the left buttock. Clean with soap and water as needed, apply zinc oxide (skin protectant), and cover with Mepilex border (foam dressing with an adhesive border) until healed. Review of the nursing visits showed: - From 04/06/2024 through 04/13/2024, the nurse failed to document an assessment of the left buttock pressure ulcer; and - On 04/14/2024, the nurse described the left buttock pressure as a small skin tear, not healing and skin bunched up. The nurse applied Mepilex. The nurse failed to document measurements, tissue type, drainage, and odor. Review of a physician order dated 04/14/2024, showed to apply Mepilex border to the buttock skin tear, change every three to five days per SN, spouse, or wound clinic. Review of the nursing visits showed: - On 04/20/2024, the nurse documented the left buttock pressure ulcer was healing without drainage and signs and symptoms of infection. The patient’s caregiver changed the pad yesterday so left in place. The wound procedure included to apply Mepilex border to the buttock skin tear, change every three to five days per skilled nurse, caregiver, or wound clinic; - On 04/21/2024, the caregiver would change the Mepilex border to the bottom tomorrow; and - From 04/27/2024 through 05/19/2024, the nurse failed to document an assessment of the left buttocks. Review of a physician order dated 05/22/2024, showed an order for the bilateral gluteals (both buttocks) to make sure clean and dry, apply thin layer of Triad (a zinc oxide based wound paste) to reddened areas and may cover with Mepilex. May use skin barrier wipes under adhesive. Reapply Triad as it comes off and may use on open areas also on gluteals. The order failed to include the frequency or who would provide the treatment. Review of the recertification nursing visit dated 05/25/2024, showed wound care for the bilateral gluteal included to make sure clean and dry, apply thin layer of Triad to reddened areas and may cover with Mepilex. May use skin barrier wipes under adhesive. Reapply Triad as it comes off and may use on open areas also on gluteals. The nurse failed to document an assessment of the gluteals. Review of the recertification POC dated 05/29/2024, showed an order for bilateral gluteals to make sure clean and dry, apply thin layer of Triad (a zinc oxide based wound paste) to reddened areas and may cover with Mepilex. May use skin barrier wipes under adhesive. Reapply Triad as it comes off and may use on open areas also on gluteals. Review of the nursing visits from 05/31/2924 through 06/14/2024, the nurses failed to document an assessment of the gluteal area. During an interview on 07/09/2024, beginning at 1:05 PM, the administrator stated that he/she would expect the nurses to document an assessment of the buttocks. During an interview on 07/09/2024, beginning at 1:05 PM, the administrator stated that he/she would expect the nurses to document an assessment of the buttocks. He/she would expect the nurses to document drainage, odor, redness, surrounding skin, tissue type and measurements once a week. During an interview on 07/10/2024, beginning at 8:30 AM, the patient’s nurse manager stated that there was never much of anything on the patient’s bottom. He/she thought they just put a patch on it. It was not open, and the caregiver did the dressings. He/she did not know of the patient ever having anything on both gluteal areas. The administrator stated assessments should be documented.

The Emergency Preparedness regulations were reviewed as part of the Medicare certification survey completed on 10/20/2021. During the survey it was determined Freeman Home Care Services is in compliance with the requirements of 42 CFR 484.102 Condition of Participation: Emergency Preparedness for Home Health Agencies.

A partial extended survey for Medicare certification for Freeman Home Care Services was completed on 10/20/2021. The agency had 89 current patients, 77 current patients at the parent agency and 12 current patients at the branch agency.

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 policy review, clinical record review, and interview, the agency failed to conduct a complete initial comprehensive assessment, when the registered nurse (RN) failed to assess and document the patient's use of an insulin pump in one (Record/Patient #2) of five full records reviewed. This deficient practice has the potential to affect all patients served by the agency. Findings included: Review of the agency's policy titled, "Comprehensive Assessment of patients," last revised December 11, 2017, showed that the comprehensive assessment must accurately reflect the patient’s status and must include at a minimum a review of all the medications and equipment used for medication that the patient is currently taking. RECORD/PATIENT #2: Review of the clinical record showed the patient’s comprehensive nursing admission assessment, completed by RN #2 on 10/07/2021, failed to include an assessment of the patient's insulin pump and failed to list the dosing of the patient’s insulin per the pump. During an in home visit on 10/19/2021 at 1:00 PM, the patient had an insulin pump that he/she used for his/her insulin dosage. During an interview on 10/19/2021 at 1:20 PM the patient said he/she had used an insulin pump for 12 years. During an interview on 10/20/2021 the administrator said the following: -The nurse failed to identify the patient's insulin pump; -The nurse should have found the patient’s insulin pump on the initial assessment but he/she failed to document the patient had an insulin pump; - The administrator checked all the electronic medical records (EMR) and the nurse never documented the patient's insulin pump and therefore there were no orders, coding, or plan of care for the patients insulin pump.

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 agency policy review, clinical record review, and home visit interview, the agency failed to ensure/maintain an accurate and complete review of all medications the patient was currently using in four (Records/Patients #1, #2, #3, and #5) of five records reviewed. This deficient practice has the potential to affect the safe and effective administration of medication for all the agency's patients. Findings included: Review of the agency's policy titled, "Drug Regimen Review (DRR) and Medication Reconciliation Policy," dated 10/30/2018 showed, DRR will be performed upon admission to home health and each time a new medication is added/changed to the list of patient's medications. The medication list from the hospital must match what the patient is taking at home. The SN (skilled nurse) will be required to check all of the patient's medication bottles/medications (to include both prescription, over the counter, including vitamins, herbals, oxygen, topicals, inhalants, IV's, patches, and inhalers) weekly to verify accuracy of current medication list. If therapy is the only discipline remaining, the PT (physical therapist) or PTA (physical therapist assistant) will be required to check medication bottles/medications weekly to verify ongoing accuracy of current medication list. RECORD/PATIENT #2: Review of the clinical record showed the patient was admitted on 10/07/2021 and the current plan of care (POC) was dated 10/07/2021 through 12/05/2021. During a home visit observation on 10/19/2021 beginning at 1:00 PM, the agency medication list showed: -Tylenol (acetaminophen) 500 milligrams (mg) two tablets every eight hours. During review of home medications the acetaminophen dosage was 250 mg. The patient stated he/she took two tablets of 250 mg every six hours as needed; - Cinnamon 500 mg one capsule every morning as needed. During review of the home medications the cinnamon bottle dosage was 1000 mg. The patient stated he/she took one capsule every morning; - Echinacea herb 380mg one capsule every morning. During review of the home medications showed Echinacea herb dosage was 760mg. The patient stated he/she took one of the 760 mg tablets every morning; and - Home visit medication observation showed the patient was on a insulin pump. The agency medication record failed to list the patient's insulin pump. The patient stated he/she had been on this insulin pump for 12 years. During an interview with the physical therapist, he/she said that he/she was not sure why the patient medication dosages weren’t updated and that the nurse should have updated them yesterday during his/her visit. During an interview on 10/20/2021 at 12:05 PM the administrator/clinical manager said he/she would expect all medications to be updated. RECORD/PATIENT #3: Review of the clinical record showed the patient was admitted on 10/04/2021 and the current plan of care (POC) was dated 10/04/2021 through 12/04/2021. During a home visit observation on 10/19/2021 beginning at 1:30 PM, the agency medication list showed: - Hydrocodone-acetaminophen 5-325 milligrams (mg) one tablet every four hours as needed for pain control. During review of home medications the hydrocodone-acetaminophen dosage was 10-325 mg. Caregiver (cg) stated that this medication dosage was changed on 10/08/2021. Patient record showed that the SN had visited on 10/12 and 10/15. SN documented able to reconcile all medications, no discrepancy noted. - Home visit medication observation showed Zofran (nausea and vomiting medication) four mg as needed for nausea and vomiting. Agency medication record failed to list Zofran. During an interview with the skilled nurse (SN) #3 at the home visit, SN #3 concurred with the findings and could offer no explanation for the inaccurate medication list. RECORD/PATIENT #5: Review of the clinical record showed the patient was admitted on 02/01/2021 and the current POC was dated 02/01/2021 through 04/01/2021. Review of the patient's medication list from the hospital for the start of care showed: - Prochlorperazine 10mg every six hours as needed for nausea/vomiting; and - Ondansetron eight mg as needed for nausea/vomiting. Review of the agency medication record failed to list either medication. During an interview with the clinical manager on 10/19/2021 at 11:30 AM, the clinical manger stated that the medications failed to show up on the agency medication list. RECORD/PATIENT #1: During the patient's home visit observation on 10/19/2021 beginning at 10:20 AM, review of the patient's home medication showed the following discrepancies with the agency's current medication profile: - Agency medication list showed Prilosec (prevents excess acid by reducing the acid production in your stomach) over the counter (OTC) 20 milligram (mg) by mouth (po) delayed release/enteric coated (DR/EC) daily in the AM. Patient stated that he/she no longer takes the Prilosec and that he/she stopped it when the intravenous (IV) was stopped. The drug regimen review completed by the pharmacist showed the physician signed on 9/10/2021 to stop the Prilosec; - Agency medication list showed Novolog (rapid acting insulin) RU-100 insulin aspart 100 unit/milliliter (ml), subcutaneous (SQ) 12 units before meals (AC) and at bedtime (HS). Patient stated he/she starts with 12 units plus additional per sliding scale (SS) after he/she performs a random blood sugar (RBS) (self test of blood sugar obtained by finger stick). Registered nurse (RN) #1 asked the patient when his/her Novolog changed to add the SS and he/she stated it had always been that way and the SS instructions were in the black bag on a piece of paper. The paper showed a typed sliding scale insulin (SSI) instructions for Novolog, 12 units to start with and BS 80-89 = subtract 1 unit, BS 90-140 = no change in insulin, BS 141-180 = add one unit, BS 181-220 = add two units, BS 221-280 = add three units, BS 280-340 = add four units, and BS greater than 341 = add five units. The sliding scale dosage was not on the agency medication list; - Agency medication list showed tramadol (pain medicine used to treat moderate to severe pain) 50 mg po every eight hours as needed (PRN). The medication bottle was labeled every six hours PRN. The patient stated he/she takes it every six hours PRN like the bottle is labeled; - Agency medication list showed Benadryl 25 mg po, take one capsule three times a day (TID). The patient had an OTC box of Benadryl 25 mg. The patient stated he/she takes PRN and is taking one daily. He/she took one TID when he/she was taking antibiotics and they were stopped on 9/28/2021; - Agency medication list showed sodium chloride (replace lost body fluids and salts) 0.9% flush (peripherally inserted central catheter (PICC), a long, thin tube that's inserted through a vein in your arm and passed through to the larger veins near your heart) injection syringe (PICC patency), 10 ml before and after antibiotics. The patient stated he/she was no longer on antibiotics and they were stopped on 9/28/2021 and PICC line was discontinued; - Agency medication list showed Heparin (anticoagulant) Lock Flush (PICC patency) 100 unit/ml intravenous syringe, 5 ml after antibiotic. The patient stated he/she was no longer on antibiotics and they were stopped on 9/28/2021; - Agency medication list showed Ventolin (inhaler used to prevent and treat wheezing and shortness of breath) HFA 90 mcg/inhaler, two puffs every 4 hours PRN. The patient stated he/she takes twice a day; - Agency medication list showed Tylenol (pain reliever) eight hour 650 mg po, extended release, 650 mg every six hours PRN. The patient’s medication bottle was 500 mg and the patient stated he/she takes 500 mg, one or two po every 6 hours PRN; - Agency medication list showed Basaglar (long acting insulin) KwikPen U-100 unit/ml insulin pen, 25 units at bedtime (HS). The patient stated he/she takes 30 units at HS; - Agency medication list showed ceftriaxone (antibiotic) 2 gram, injection recon solution, 2 gram daily. The patient stated he/she was no longer on antibiotics and they were stopped on 9/28/2021; - Agency medication list showed daptomycin (antibiotic) 500 mg, intravenous recon solution, 500 mg daily. The patient stated he/she was no longer on antibiotics and they were stopped on 9/28/2021; - Agency medication list showed venlafaxine (antidepressant) 37.5 mg, po capsule, ER 24 hour, one capsule daily. The patient stated he/she was no longer on venlafaxine and stopped it sometime in September; - Agency medication list showed 2 ACTIVASE (thrombolytic medication for PICC patency) mg, intravenous (IV), 2 mg PRN. The patient's PICC line was removed on 9/28/2021. During an interview on 10/20/2021 at 12:24 PM, the clinical manager stated that the medication profile should be up to date and the sliding scale insulin should be on the medication profile.

Plan of care must include the following CFR(s): 484.60(a)(2)(i-xvi) The individualized plan of care must include the following: (i) All pertinent diagnoses; (ii) The patient's mental, psychosocial, and cognitive status; (iii) The types of services, supplies, and equipment required; (iv) The frequency and duration of visits to be made; (v) Prognosis; (vi) Rehabilitation potential; (vii) Functional limitations; (viii) Activities permitted; (ix) Nutritional requirements; (x) All medications and treatments; (xi) Safety measures to protect against injury; (xii) A description of the patient's risk for emergency department visits and hospital re-admission, and all necessary interventions to address the underlying risk factors. (xiii) Patient and caregiver education and training to facilitate timely discharge; (xiv) Patient-specific interventions and education; measurable outcomes and goals identified by the HHA and the patient; (xv) Information related to any advanced directives; and (xvi) Any additional items the HHA or physician or allowed practitioner may choose to include. This ELEMENT is not met as evidenced by: Based on policy review, record review, and interview, the agency failed to ensure the plan of care (POC) included all medications the patient was taking in one (Record/Patient #1) of three 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, “Care Planning, Coordination of Services, and Quality of Care,” revised December 2018 showed in part: - 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; and - The individualized plan of care must include all medications and treatments. RECORD/PATIENT #1: Review of the clinical record showed: - The skilled nurse admission visit on 09/09/2021 had documentation that the patient checks his/her blood sugar (BS) before meals (AC) and at bedtime (HS) and had sliding scale insulin for those times; and - The plan of care dated 09/09/2021 failed to include sliding scale insulin parameters. During an interview on 10/20/2021 at 12:24 PM, the clinical manager stated that all medications including the sliding scale insulin should be on the plan of care.

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 record review, home visit observation, and interview, the agency failed to ensure each patient received written information related to visit schedule/instructions in two (Record/Patient #1 and #2) of three home visits made. This deficient practice has the potential to affect all patients served by the agency. Findings included: Review of the agency’s policy titled, "Care Planning, Coordination of Services, and Quality of Care,” revised December 2018 showed in part, the home health agency must provide the patient and caregiver with a copy of written instructions outlining visit schedule, including frequency of visits by home health personnel. RECORD/PATIENT #1: Review of the clinical record showed the patient was admitted to home health services on 09/09/2021 for adjustment and management of vascular access device, fragmentation of right posterior tibial artery (PTA-one of two branches of the tibioperoneal trunk in the lower leg, providing oxygenated blood to the posterior compartments of the leg and plantar surface of the foot), percutaneous approach and change or removal of surgical wound dressing. Review of the plan of care (POC) dated 09/09/2021 through 11/07/2021, showed that the physician ordered skilled nursing (SN) two times a week for general assessment with special attention to cardiovascular, pulmonary, neurological, GI/GU, integumentary and right outer foot wound and left heel wound healing, nutrition/hydration status, vital signs and oxygen saturation checks. To change wound vacuum-assisted closure (VAC) dressing two times per a week and as needed and educate patient and/or caregiver on intravenous (IV) antibiotic therapy self-administration, care and maintenance. The home visit made on 10/19/2021 starting at 10:20 AM, showed the home folder was reviewed and the agency failed to provide a written frequency of visits for the skilled nurse. The registered nurse stated he/she verbally tells the patient when visits will be made and the patient/caregiver writes it down. During an interview on 10/20/2021 at 12:24 PM, the clinical manager acknowledged the findings and stated a blue calendar is in the admission folder and expected it to be completed. RECORD/PATIENT #2 Review of the clinical record showed the patient was admitted to home health services on 10/07/2021 with a principal diagnoses of after care following joint replacement, right knee joint replacement. Review of the POC dated 10/07/2021 through 12/05/2021, showed that the physician ordered skilled nursing (SN) one time a week for one week and two times a week for two weeks. Physical therapy was ordered for once a week for one week, three times a week for one week, and two times a week for one week. During a home visit on 10/19/2021 starting at 1:00 PM, review of the home folder showed the agency failed to provide a written frequency of visits for the physical therapist and failed to show a weekly visit schedule. During an interview on 10/20/2021 at noon, the clinical manager acknowledged the findings and stated that each home folder contained a blue calendar in the patient's admission folder and this is the place each discipline is to list their visit information.

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 review of the agency's policy, observation, and interview, the agency failed to put in place a program for screening visitors/non-employees who entered the home health agency office for COVID-19 (pandemic infection) signs and symptoms. The agency also failed to ensure staff followed infection control standards of practice in one (Record/Patient #3) of three home visit observations. This deficient practice has the potential to affect the health and safety of all patients served by the agency. Findings included: Observation on the first day of the survey, 10/18/2021 showed: - No signage on the entry door of the agency to advise visitors of COVID-19 information; - No signage on the entry door of the agency to provide visitation restrictions and screening procedures; and - No signage posted at the entrance related to the use of masks. During an interview with the administrator on 10/18/2021 at approximately 3:30 PM, the administrator stated that they rarely had non-staff entering the agency. The administrator stated that agency staff performed a COVID-19 self screening prior to reporting to work. The administrator stated that he/she felt the signage for the HHA had gotten forgotten. Review of the agency policy titled, "Infection Prevention and Control Policy in Home Care," dated 06/01/1984 showed general infection control measures in care of equipment and supplies. Staff should store items carried by the visiting staff in such a manner as to preserve cleanliness and/or sterility of the item. RECORD/PATIENT #3: Observation of staff maintenance of patient folder information during a home visit on 10/19/2021 at approximately 1:30 PM showed registered nurse (RN) #3 place a manila folder with patient records on the arm of the sofa, next to the patient during care. Patient care included tracheostomy (airway provided by an incision in patient's throat) care. Care stimulated patient's coughing. During an interview with RN #3 following patient care, RN #3 stated that he/she had not considered placing a barrier under the manila folder.

Discharge and transfer summaries CFR(s): 484.110(a)(6)(i-iii) (i) A completed discharge summary that is sent to the primary care practitioner or other health care professional who will be responsible for providing care and services to the patient after discharge from the HHA (if any) within 5 business days of the patient's discharge; or (ii) A completed transfer summary that is sent within 2 business days of a planned transfer, if the patient's care will be immediately continued in a health care facility; or (iii) A completed transfer summary that is sent within 2 business days of becoming aware of an unplanned transfer, if the patient is still receiving care in a health care facility at the time when the HHA becomes aware of the transfer. This ELEMENT is not met as evidenced by: Based on policy review, clinical record review, and interview, the agency failed to ensure a complete comprehensive discharge summary containing relevant information was sent to the primary care practitioner or other health care professional who will be responsible for providing care to the patient after discharge within five business days of the patient's discharge for one (Record/Patient #5) of two discharge 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, "Transfer and Discharge Policy in Home Care," dated12/04/2017, showed that all professional personnel will complete a discharge summary upon patient's discharge from service to be included in the patient's clinical record. A completed discharge summary will be sent to the primary care physician or other health care professional who will be responsible for providing care and services to the patient after discharge from the HHA (if any) within five business days of the patient's discharge. RECORD/PATIENT #5: Review of the patient record showed a discharge date of 10/12/2021. The clinical record failed to show a discharge summary and failed to show that the discharge information was sent to the attending physician. During an interview on 10/19/2021 at 11:40 AM, the clinical manager stated that he/she did not see a discharge summary in the patient's record and that he/she was unable to find a record that a summary was sent to the physician.