Every finding on record at Gentiva Certified Healthcare Corp

A Recertification Survey was conducted by the Department of Inspections, Appeals and Licensing from 9/30/24 through 10/8/24 and the home health agency was found to be operating in compliance with the regulatory requirements for the Establishment of Emergency Preparedness.

A Recertification Survey was conducted by the Department of Inspections, Appeals and Licensing from 9/30/24 through 10/8/24. The recertification survey found the agency operating out of compliance with the following standard level regulatory requirements: The agency reported a census of 165 patients at the time of the survey.

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 home visit observations, patient interviews, staff interviews, clinical record reviews and agency policy review, the agency failed to perform complete and accurate drug regimen reviews with each comprehensive assessment and identify patient specific medication issues for 5 of 17 sampled patients (Patients #2, #4, #5, #6 and #17). Failure to ensure medications reviewed at the time of each drug regimen review are current and accurate placed the patients at risk for increased potential unidentified medication interactions, side effects and duplication of medications. Findings include: 5. Patient #6 had a start of care date of 7/8/24. The clinical record review revealed the recertification comprehensive assessment, dated 9/4/24, lacked documentation of a drug regimen review. The skilled nurse failed to complete a drug regimen review with the recertification comprehensive assessment. The surveyor reviewed the above findings with the Administrator and Clinical Manager. 4. Patient #3 had a start of care date of 8/29/24. Clinical record review revealed the following: a. The POC, dated 8/29/24 to 10/27/24, included orders for medications and skilled nursing services. b. The agency medication list, dated 10/1/24, included orders for levothyroxine 75 mcg 1 time weekly on Sunday. The list documented a DRR completed on 8/31/24 and 9/2/24. c. The assisted living medication list, dated 10/1/24, included orders for levothyroxine 75 mcg 1 time weekly on Sunday and levothyroxine 150 mcg on Monday, Tuesday, Wednesday, Thursday, Friday and Saturday. The agency failed to include all medications during the DRR. According to the agency policy titled Medication Review and Documentation, dated 10/2022, the home health agency will assess all medications the patient is taking, both prescription and over the counter (OTC). A drug regimen review (DRR) and medication reconciliation will include all patient medications and will be performed during the initial comprehensive assessment, each comprehensive assessment thereafter and when a new medication is added to the patient plan of care. All medication and all issues/concerns will be reported to the patient's physician/allowed practitioner to include the following: dosage errors, omissions, drug reactions, duplicate therapy, ineffective drug therapy, non compliance issues, side effects and drug interactions. On 10/1/24 at 1:39 PM, an interview with the Administrator and Clinical Manager identified DRRs are completed at start of care, recertifications, resumptions of care and discharges. 1.Patient #2 had a start of care date of 7/29/24. Clinical record review revealed the following: a. The Plan of Care (POC), dated 9/27/24 to 11/25/24 included physician orders for medications and skilled nursing services. b. The recertification comprehensive assessment, dated 9/23/24, completed by Staff G, Registered Nurse (RN), identified a DRR was completed and no changes were made to medications. c. During a home visit observation on 10/1/24 at 8:00 AM, with Staff E, Licensed Practical Nurse (LPN), an interview with the patient revealed the patient sets up his/her own medication. The patient identified the following medication discrepancies: 1)The POC identified the patient takes Gabapentin 600 milligram (mg) tablets with instructions to take one tablet by mouth three times a day. The bottle in the home is Gabapentin 400mg capsules take one capsule by mouth three times a day. The bottle was last filled on 8/8/24. Patient reports taking the medication per the instruction on the bottle. 2) The POC identified the patient has a Lidocaine pain relief 4% topical patch with instructions to apply one patch every morning. The patient reported he/she does not have pain patches in the home and hasn't utilized them since returning from the hospital on 9/20/24. 3) The POC identified the patient takes Melatonin 3mg tablets with instructions to take one tablet by mouth at bedtime. The patient reported that he/she has not taken melatonin for one or two months. 4) The POC identified the patient takes Methocarbamol 750mg tablets with instructions to take one tablet by mouth three times daily. The patient reported he/she didn't know what that medication was and thinks it was something he/she was given while hospitalized. 5) The POC identified the patient takes Tylenol extra strength 500mg tablets with instructions to take two tablets by mouth three times daily. The patient reported he/she takes Tylenol 325 mg tablets as needed. The DRR failed to include an accurate review of all the medications taken by the patient. 2.Patient #5 had a start of care date of 6/4/24. Clinical record review revealed the following: a. The POCs, dated 8/3/24 to 10/1/24 and 10/2/24 to 11/30/24 included physician orders for medications and skilled nursing visits. b. The recertification comprehensive assessments, dated 7/30/24 and 9/27/24, completed by Staff G, RN, identified a DRR was completed and no changes were made to medications. c. During a home visit observation and interview on 10/2/24 at 10:00 AM, with Staff G, RN, an interview with the patient revealed the patient's daughter sets up his/her medication. The surveyor identified the following medication discrepancy: The POCs identified the patient takes Oxybutynin Chloride 2.5mg tablets with instructions to take one tablet by mouth three times a day. The bottle in the home is Oxybutynin Chloride 5mg tablets take one tablet by mouth one time a day. The bottle was last filled on 6/3/24. An interview with Staff G, RN, revealed she was unaware of the discrepancy. The DRR failed to include an accurate review of medications taken by the patient. 3.Patient #7 had a start of care date of 9/17/24. Clinical record review revealed the following: a. The POC, dated 9/17/24 to 11/15/24, included physician orders for medications, skilled nursing visits, physical therapy and occupational therapy. b. The initial comprehensive assessment, dated 9/17/24, completed by Staff C, RN, included documentation a DRR was completed. c. During a home visit observation on 10/1/24 at 11:30 AM, with Staff D, Occupational Therapist (OT), an interview with the patient revealed the patient sets up his/her own medication. The patient identified the following medication discrepancies: 1) The POC identified the patient takes Eliquis 2.5mg tablets with instructions to take one tablet by mouth two times daily. The patient reported this was discontinued upon discharge from the nursing home on 9/10/24. 2) The POC identified the patient takes Ergocalciferol (Vitamin D2) 1,250 micrograms (mcg) capsules with instructions to take one capsule by mouth two times a week; Sunday and Thursday. The bottle in the home says Ergocalciferol 1,250mcg capsules take one capsule by mouth once a week. The bottle was last filled on 6/20/24. The patient reported he/she has taken the medication per the instruction on the bottle for several years. 3) The POC identified the patient takes Metformin Extended Release (ER) 500mg tablets with instructions to take two tablets by mouth every evening. The bottle in the home says Metformin ER 500mg tablets take four tablets by mouth every evening. The medication was last filled on 6/19/24. The patient reported he/she has taken the medication per the instruction on the bottle for several years. 4) The POC failed to identify the patient is taking Pioglitazone Hydrocholoride (HCL) 30mg tablets with instructions to take one tablet by mouth every day. The bottle was filled last on 6/4/24. Patient reported he/she has taken this medication for several years. 5) The POC failed to identify the patient is taking Pantoprazole Sodium (SOD) 40mg tablets with instructions to take one tablet by mouth every day. The bottle was filled last on 9/30/24. Patient reported he/she has taken this medication for several years. 6) The POC failed to identify the patient is taking Simvastatin 20mg tablets with instructions to take one tablet by mouth at bedtime. The bottle was filled last on 5/16/24. Patient reported he/she has taken this medication for several years. 7) The POC failed to identify the following supplements the patient is taking: Fish Oil 1000mg softgels, Psyllium Husk 500mg capsules, Ceylon Cinnamon 1800mg capsules, CoQ10 200mg capsules and Chromium Picolinate 200mcg tablets. The agency failed to identify the medication discrepancies during the DRR on 9/17/24.

Plan of care CFR(s): 484.60(a)(1) Each patient must receive the home health services that are written in an individualized plan of care that identifies patient-specific measurable outcomes and goals, and which is established, periodically reviewed, and signed by a doctor of medicine, osteopathy, or podiatry acting within the scope of his or her state license, certification, or registration. If a physician or allowed practitioner refers a patient under a plan of care that cannot be completed until after an evaluation visit, the physician or allowed practitioner is consulted to approve additions or modifications to the original plan. This STANDARD is not met as evidenced by: Based on staff interviews, clinical record reviews and agency policy review, the agency failed to follow a Plan of Care established and periodically reviewed by a physician or notify the physician of the need to vary frequency of visits or inability to perform treatments/services as originally ordered on the Plan of Care for 9 of 17 sampled patients (Patients #1, #3, #4, #6, #10, #11, #13, #15 and #16). Failure to follow a Plan of Care established by home health clinical associates in collaboration with the patient's physician, placed patients at risk of not receiving safe, individualized and consistent care designed to meet each patient's health care needs. Findings include: 7. Patient #3 had a start of care date of 8/10/24. The clinical record review revealed: a. Plan of Care, dated 8/10/24 to 10/8/24, included orders for skilled nurse to observe/assess cardiovascular system and to report weight gain of 2-3 pounds per day or 5 pounds per week. b. Start of Care comprehensive assessment, dated 8/10/24, included a weight of 209 pounds. c. Skilled nurse visit notes, dated 9/3/24, 9/9/24, 9/18/24 and 9/24/24, lacked documentation of a weight obtained by the skilled nurse or weights obtained by the patient on days the skilled nurse did not visit. The skilled nurse failed to assess the patient weight on skilled nurse visits. 8. Patient #6 had a start of care date of 7/8/24. The clinical record review revealed: a. Plans of Care, dated 7/8/24 to 9/5/24 and 9/6/24 to 11/4/24, included orders for skilled nurse to observe/assess cardiovascular system and to report weight gain of 2-3 pounds per day or 5 pounds per week. b. Recertification comprehensive assessment, dated 9/4/24, lacked documentation of a weight obtained by the skilled nurse or weights obtained by the patient on days the skilled nurse did not visit. c. Skilled nurse visit notes, dated 9/9/24, 9/16/24, 9/23/24 and 9/30/24, lacked documentation of a weight obtained by the skilled nurse or weights obtained by the patient on days the skilled nurse did not visit. The skilled nurse failed to assess the patient weight on skilled nurse visits. 9. Patient #13 had a start of care date of 4/3/24 and a discharge date of 5/24/24. The clinical record review revealed: a. Plan of Care, dated 4/3/24 to 6/1/24, included orders for skilled nurse to observe/assess cardiovascular system and to report weight gain of 2-3 pounds per day or 5 pounds per week. b. Start of Care comprehensive assessment, dated 4/3/24, included a weight of 183 pounds. c. Skilled nurse visit notes, dated 4/8, 4/19, 4/26, 5/3, 5/10, 5/17 and 5/24/24, lacked documentation of a weight obtained by the skilled nurse or weights obtained by the patient on days the skilled nurse did not visit. The skilled nurse failed to assess the patient weight on skilled nurse visits. The surveyor reviewed the above findings with the Administrator and Clinical Manager. 2. Patient #1 had a start of care date of 5/23/24. The clinical record review revealed: a. The Plans of Care, dated 7/10/24 to 9/7/24 and 9/8/24 to 11/6/24, included orders for skilled nurse to observe/assess cardiovascular system and to report weight gain of 2-3 pounds per day or 5 pounds per week. b. The skilled nurse notes, dated 7/30/24, 8/2, 8/7, 8/14, 8/21, 8/27/24, 9/4, 9/12 and 9/19/24, lacked documentation of a weight obtained by the skilled nurse or weights obtained by the patient on days the skilled nurse did not visit. The skilled nurse failed to assess the patient weight on skilled nurse visits. 3. Patient #4 had a start of care date of 8/29/24. The clinical record review revealed: a. The POC, dated 8/29/24 to 10/27/24, included orders for skilled nurse to observe/assess cardiovascular system and to report weight gain of 2-3 pounds per day or 5 pounds per week. b. The skilled nurse note on admission, dated 8/29/24, included documentation of the patient's weight of 127 pounds. c. The skilled nurse notes, dated 9/3, 9/6, 9/12, 9/16, 9/20 and 9/26/24, lacked documentation of a weight obtained by the skilled nurse or weights obtained by the patient on days the skilled nurse did not visit. The skilled nurse failed to assess the patient weight on skilled nurse visits. 4. Patient #10 had a start of care date of 8/12/24. The clinical record review revealed: a. The POC, dated 8/12/24 to 10/10/24, included orders for skilled nurse to observe/assess cardiovascular system and to report weight gain of 2-3 pounds per day or 5 pounds per week. b. The skilled nurse note on admission, dated 8/29/24, included documentation of the patient's weight of 170 pounds. c. The skilled nurse notes, dated 9/1, and 9/3/24, lacked documentation of a weight obtained by the skilled nurse or weights obtained by the patient on days the skilled nurse did not visit. The skilled nurse failed to assess the patient weight on skilled nurse visits. 5. Patient #4 had a start of care date of 5/23/24 to 7/21/24 and date of discharge of 6/27/24. The clinical record review revealed: a. The POC, dated 5/23/24 to 7/21/24, included orders for skilled nurse to observe/assess cardiovascular system and to report weight gain of 2-3 pounds per day or 5 pounds per week. b. The skilled nurse note on admission, dated 5/23/24, included documentation of the patient's weight of 98 pounds . c. The skilled nurse notes, dated 5/26, 5/28, 5/31/24, 6/3, 6/6, 6/10, 6/13, 6/17, 6/20 and 6/27/24, lacked documentation of a weight obtained by the skilled nurse or weights obtained by the patient on days the skilled nurse did not visit. The skilled nurse failed to assess the patient weight on skilled nurse visits. 6. Patient #16 had a start of care date of 2/21/24 and discharge date of 3/7/24. The clinical record review revealed: a. The POC, dated 2/21/24 to 4/20/24, included orders for skilled nurse to observe/assess cardiovascular system and to report weight gain of 2-3 pounds per day or 5 pounds per week. b. The skilled nurse note on admission, dated 8/29/24, included documentation of the patient's weight of 110 pounds. c. The skilled nurse notes, dated 6/26/24, lacked documentation of a weight obtained by the skilled nurse or weights obtained by the patient on days the skilled nurse did not visit. The skilled nurse failed to assess the patient weight on skilled nurse visits. According to the agency policy titled Care Planning, dated 9/2024, the Plan of Care (POC) serves to ensure effective utilization and management of services, resources, discipline specific visit frequency and duration as needed to address a patient's condition, skilled needs or unique situation in accordance with physician/allowed practitioner written orders. The professional disciplines must assume responsibility for providing services ordered by the physician/allowed practitioner as indicated in the POC/interim orders. 1.Patient #11 had a start of care date of 9/17/24. Clinical record review revealed the following: a. The POC, dated 9/17/24 to 11/15/24, included physician orders for skilled nursing services one time per week for one week, two times per week for four weeks and one time a week for three weeks effective 9/22/24. b. An interim physician order, dated 9/28/24, identified skilled nurse to assess/instruct on daily weight and keeping a log. Notify physician of weight gain of 2-3 pounds in 24 hours or 5 pounds in a week. If patient is unable to weigh, obtain lower extremity circumference each visit and notify physician of increase of 2 centimeters (cm) or greater. c. The skilled nurse visit note, dated 10/1/24, completed by Staff E, Licensed Practical Nurse (LPN) failed to document a weight or lower extremity circumference. The agency failed to follow interim physician orders on the POC.

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 home visit observations, patient interviews, clinical record reviews and agency policy reviews, the agency failed to ensure the accurate completion of all components comprising the Plan of Care, including all supplies/equipment used by the patient for 5 of 17 sampled patients (Patients #2, #4, #7, #15 and #16). Failure to maintain complete and accurate Plans of Care with current orders placed patients at risk to not receive services, medications, supplies and/or treatments according to assessed needs and physician orders. Findings include: 3. Patient #4 had a start of care date of 8/29/24. Clinical record review revealed the following: a. The POC, dated 8/29/24 to 10/27/24, included the following DME used by the patient: cane, elevated toilet seat, quad cane, rails/grab bars, Reacher, scale, shower/tub equipment, support surfaces, table/chair, vital sign equipment, walker, wheelchair, dressing-alginate/hydro fiber, foam, gauze, gauze border, gauze rolled, honey, hydrocolloid, silver alginate, silver foam, gloves, moisturizer, skin protectant, wound cleanser. b. The skilled nurse visit note at admission, dated 8/29/24, identified the patient incontinent of urine. c. During a home visit observation on 10/1/24 at 10:30 AM, with Staff F, Physical Therapist, the surveyor identified the following DME in the home: incontinent briefs. The POC failed to include the DME incontinent briefs. 4. Patient #15 had a start of care date of 5/23/24 and discharge from the agency on 6/27/24. Clinical record review revealed the following: a. The POC, dated 5/23/24 to 7/22/24, included the following DME used by the patient: cane, commode, elevated toilet seat, rails/grab bars, Reacher, scale, shower/tub equipment, walker-rolling, wheelchair, wheelchair cushion, wheelchair-powered, alginate/hydro fiber, cotton applicator, foam dressing, gauze, hydrofera and cleanser b. The skilled nurse visit note at admission, dated 5/23/24, identified the patient incontinent of bowel and bladder. The note also identified the patient utilized a shoe horn, sock aide and leg lifting strap. The POC failed to include the DME incontinent supplies, shoe horn, sock aide and leg lifting strap. 5. Patient #16 had a start of care date of 2/21/24 and discharge from the agency on 3/7/24. Clinical record review revealed the following: a. The POC, dated 2/21/24 to 4/20/24, included the following DME used by the patient: commode, roho w/c cushion, scale, vital signs equipment, walker, foam dressing, gauze, wound cleanser. b. The skilled nurse visit note at admission, dated 2/21/24, identified the patient utilized grab bars and a wheelchair. The POC failed to include the DME grab bars and wheelchair. The above items shared with the Administrator and clinical manager. According to the agency policy titled Care Planning, dated 9/2024, the individualized plan of care is developed for the patient 60 day episode of care and must include (but is not limited to): types of services, supplies and equipment required, all medications and treatments, discipline specific visits, frequency and duration, rehabilitation potential and nutritional requirements. 1.Patient #2 had a start of care date of 7/29/24. Clinical record review revealed the following: a. The Plans of Care (POC), dated 7/29/24 to 9/26/24 and 9/27/24 to 11/25/24 included the following durable medical equipment (DME) used by the patient: Diabetic supplies, elevated toilet seat, oxygen/oxygen supplies, rails/grab bars, reacher (grabbing device), respiratory supplies, scooter, shower/tub equipment, supports/braces, lift chair, walker with wheels and wheelchair. b. During a home visit observation on 10/1/24 at 8:00 AM, with Staff E, Licensed Practical Nurse (LPN), the surveyor identified the following DME in the home: Medication cassette (container for holding medication), blood pressure cuff, scale and lifeline button. During this same visit, an interview with the patient revealed he/she has been utilizing the medication cassette, blood pressure cuff, scale and lifeline button for approximately 5 months (when he/she moved into the assisted living facility). The POC failed to include the DME medication cassette, blood pressure cuff, scale and lifeline button. 2.Patient #7 had a start of care date of 9/17/24. Clinical record review revealed the following: a. The POC, dated 9/17/24 to 11/15/24, included the following DME used by the patient: Diabetic supplies, commode, continuous positive airway pressure (CPAP) machine, elevated toilet seat, glucometer, grab bars, reacher, respiratory supplies, roho cushion (pressure ulcer prevention) for wheelchair, scale, shower/tub equipment, supports/braces, vital sign equipment, walker and incontinent supplies. b. During a home visit observation on 10/1/24 at 11:30 AM, with Staff D, Occupational Therapist (OT), the surveyor identified the patient was using medication cassettes. During this same visit, an interview with the patient revealed he/she has been utilizing the medication cassettes for years. The POC failed to identify the DME medication cassettes.

All orders recorded in plan of care CFR(s): 484.60(a)(3) All patient care orders, including verbal orders, must be recorded in the plan of care. This ELEMENT is not met as evidenced by: Based on observations, staff interviews, clinical record reviews and agency policy reviews, the agency failed to update the Plan of Care with new physician orders for 8 of 17 sampled patients with interim physician orders (Patients #1, #3, #6, #9, #11, #12, #13 and #15). Failure to update the Plan of Care increased the potential for medication errors in administration and/or inaccurate provision of care. Findings include: 4. Patient #3 had a start of care date of 8/10/24. The clinical record review revealed: a. Plan of Care, dated 8/10/24 to 10/8/24, included orders for skilled nurse to perform/teach wound care to right lower extremity and left lower extremity stasis ulcer, cleanse with normal saline, apply wound gel, cover with nonstick pad, secure with rolled gauze and tape. b. Interim physician order, dated 8/13/24, included orders for wound location right lower foot, left foot malleolus and inner sole of foot, cleanse with normal saline, periwound skin prep, apply aquacell, apply small amount saline to activate, gauze pad, secure with roll gauze and paper tape; and left inner ankle, cleanse with normal saline, periwound skin prep, apply medihoney (medical grade honey used for wound care), non-woven gauze 4x4, roll gauze, secure with paper tape. c. Interim physician order, dated 8/30/24, included orders for left medial ankle, left lateral ankle, right lateral calcaneus and right lateral lower leg, clean with normal saline, mepilex AG foam (antimicrobial foam dressing with silver), conforming rolled gauze, secure with paper tape. d. Interim physician order, dated 9/16/24, included orders for left medial ankle, left lateral ankle, right lateral calcaneus, right lateral lower leg and left posterior lower leg, clean with normal saline, paint peri-wound with iodine and allow to dry, AG foam dressing cut slightly larger than wound, ABD pad, conforming rolled gauze secured with paper tape. e. Interim physician order, dated 9/20/24, included orders for left medial ankle, clean with normal saline, AF foam cut slightly larger than wound, ABD pad, conforming rolled gauze and paper tape; left lateral ankle, clean with normal saline, AG foam cut slightly larger than wound, conforming rolled gauze and paper tape; right lateral calcaneus, right lateral lower leg, left posterior lower leg, paint peri-wound with iodine and allow to dry, conforming rolled gauze and secure with paper tape. f. Interim physician order, dated 9/27/24, included orders for left medial ankle and left lateral ankle, clean with normal saline, AG foam cut slightly larger than wound, conforming rolled gauze and paper tape; right lateral calcaneus, right lateral lower leg and left posterior lower leg, paint peri-wound with iodine and allow to dry, conforming rolled gauze and secure with paper tape. g. Updated Plan of Care, dated 10/3/24, lacked documentation of the current wound care orders. The skilled nurse failed to update the plan of care with all interim physician orders. 5. Patient #6 had a start of care date of 7/8/24. The clinical record review revealed: a. Plan of Care, dated 9/6/24, included orders for skilled nurse to perform/teach wound care to right posterior lower leg, right medial lower leg and right lateral distal lower leg, clean with normal saline, aquacel AG, ABD pad, wrap with kerlix, secure with paper tape, apply tubigrip (compression stocking) size G 2 layers; right medial ankle and right anterior lower leg, clean with normal saline or vashe (wound cleanser), aquacel AG, ABD, wrap with kerlix, secure with paper tape, apply tubigrip size G 2 layers; left medial lower leg, clean with normal saline or vashe, aquacel AG, ABD pad and multilayer compression wrap lite. b. Interim physician order, dated 9/6/24, included orders for left medial lower leg, cleanse with normal saline or vashe as directed, aquacel AG, ABD pad, rolled gauze and tape, compression tubigrip size F 2 layers; right posterior lower leg, right medial lower leg, right lateral distal lower leg and right posterior lower leg, clean with normal saline, aquacel AG, multilayer compression wrap lite. c. Interim physician order, dated 9/13/24, included orders for left medial lower leg, clean with normal saline or vashe as directed, aquacel AG, ABD pad, secure with rolled gauze and tape, apply tubigrip size F 2 layers; right posterior lower leg, right medial lower leg, right lateral distal lower leg, right lower leg, right posterior lower leg, clean with normal saline, AG foam dressing, ABD pad, secure with kerlix and tape, apply tubigrip size F 2 layers. d. Interim physician order, 9/27/24, included orders for left medial lower leg, right medial lower leg, right lateral distal lower leg, right lower leg, right posterior lower leg, left lateral lower leg, cleanse with normal saline, AG foam dressing, ABD pad, secure with rolled gauze and tape, apply tubigrip size F 2 layers. e. Updated Plan of Care, dated 10/3/24, lacked documentation of the current wound care orders. 6. Patient #9 had a start of care date of 8/28/24. The clinical record review revealed: a. Plan of Care, dated 8/28/24 to 10/25/24, included orders for skilled nurse to perform/teach pressure ulcer care to posterior left leg and right lateral leg, cleanse with soap and water, rinse, pat dry, apply triad hydrophilic wound paste to the wound bed and skin directly around the wound bed, cut plain foam (mepilex dressing) to be 2 centimeters (cm) larger than wound base on all sides and apply, secure in place with kerlix and tape; right posterior heel, left posterior proximal leg and left posterior heel, cleanse with normal saline, pat dry, cut plain foam to be 2 cm larger than wound base on all sides and apply, secure in place with kerlix and tape. Skilled nurse to perform/teach wound care to right lateral thigh surgical wound, cleanse with soap and water, rinse and let dry, apply triad hydrophilic wound paste to wound bed and skin directly around wound bed, cut plain foam to be 2 cm larger than wound base on all sides and apply, secure with tape. b. Interim physician order, dated 9/5/24, included orders patient allowed 50 pounds weight bearing the next 2 weeks, then 100 pounds until follow up appointment. Pull back if painful, must use brace when up, modalities okay. c. Interim physician order, dated 9/10/24, included orders for right lateral upper leg, clean with normal saline or soap and water, dermacol AG (antimicrobial silver dressing) to wound bed, cover with ABD pad, secure with medipore tape; left posterior lower leg, clean with normal saline or soap and water, apply triad paste to wound bed, calmoseptine to periwound, cover with foam dressing, secure with roll gauze and tape; right heel and left heel, cleanse with normal saline or soap and water, cover with foam dressing, secure with roll gauze and tape. Heel suspension boot to bilateral feet or float heels at all times. d. Interim physician order, dated 9/16/24, included orders for skilled nurse to remove foley catheter due to leaking, if further problems with urination, patient will need to be seen by physician. e. Interim physician order, dated 9/18/24, included orders for right heel and left heel, cleanse with normal saline or soap and water, place collagen AG into wound, cover with foam dressing, secure with roll gauze and tape. f. Interim physician order, dated 9/26/24, included orders for right lateral upper and lower leg, clean with normal saline or soap and water, dermacol AG to wound bed, cover with ABD pad, secure medipore tape; left posterior lower leg, wound vac applied, leave in place for 1 week. g. Updated Plan of Care, dated 10/3/24, lacked documentation of the current wound care orders and all interim physician orders. 7. Patient #12 had a start of care date of 8/5/24. The clinical record review revealed: a. Plan of Care, dated 8/5/24 to 10/3/24, included orders for physical therapy and occupational therapy services. b. Interim physician order, dated 8/15/24, included order for missed physical therapy visit on 8/15/24 and make up missed visit the week of 8/18/24. c. Interim physician order, dated 9/24/24, included order for missed occupational therapy visit on 9/20/24, visit to not be made up. d. Updated Plan of Care, dated 10/3/24, lacked documentation of the missed and extra therapy visits. 8. Patient #13 had a start of care date of 4/3/24 and a discharge date of 5/24/24. The clinical record review revealed: a. Plan of Care, dated 4/3/24 to 6/1/24, included orders for skilled nurse to perform/teach wound care to left lower extremity stasis ulcer, cleanse with normal saline, apply Silvadene cream, cover with ABD pads, secure with rolled gauze and tape. b. Interim physician order, dated 4/10/24, included order to left lower leg, clean with saline, Silvadene cream, cover with ABD pad, wrap with kerlix, secure with tape, apply tubigrip size F on during the day may remove at bedtime. c. Interim physician order, dated 4/19/24, included order for skilled nurse to check INR (International Normalized Ratio-blood test measuring how long it takes for blood to clot) 4/29/24 during next scheduled skilled nurse visit. d. Interim physician order, dated 4/29/24, included order for skilled nurse to check INR on 5/28/24. e. Interim physician order, dated 5/17/24, included order for skin tear to right arm, cleanse with saline, apply bordered foam dressing. f. Interim physician order, dated 5/24/24, included order for missed physical therapy visit 5/17/24 that will not be made up due to discharge plan. g. Interim physician order, dated 5/24/24, included order for missed occupational therapy visit 5/17/24 that will not be made up due to patient request. h. Updated plan of care, dated 10/7/24, lacked documentation of the current wound care orders and all interim physician orders. The surveyor reviewed the above findings with the Administrator and Clinical Manager. 2. Patient #1 had a start of care date of 7/10/24. Clinical record review revealed the following: a. The POC, dated 7/10/24 to 9/7/24 and 9/8/24 to 11/6/24, included physician orders for skilled nursing and physical therapy services. b. The interim physicians order, dated 7/11/24, included orders to teach intermittent catheterization with 16 size Fr catheter daily and as needed for urinary retention. c. The updated plan of care, dated 7/10/24 to 9/7/24, failed to include the interim order for catheter size. The clinical record lacked documentation of plan of care updates for the catheter order. 3. Patient #15 had a start of care date of 5/23/24 and discharge date of 6/27/24. Clinical record review revealed the following: a. The POC, dated 5/23/24 to 7/21/24, included physician orders for skilled nursing, physical therapy, occupational and home care aide services. b. The interim physicians order, dated 6/24/24, included orders to cleanse the pressure ulcer to sacral region with saline. Pat dry, apply sacral foam bordered dressing of size. Change dressing twice weekly and as needed if loose or soiled. The order also included to cleanse the blister to right great toe with saline, pat dry. Apply idosorb gel to wounds. Cover with non woven gauze and secure with tape. Change dressing twice weekly and as needed if loose or soiled. c. The updated plan of care, dated 5/27/24 to 7/21/24, failed to include the orders for wound care. The clinical record lacked documentation of plan of care updates for the catheter order. According to the agency's policy titled Care Planning, dated 9/2024, the Plan of Care (POC) will be developed in collaboration with the physician/allowed practitioner and home health clinical associates following the initial/comprehensive assessment and will contain integrated orders from all physicians or allowed practitioners involved in the POC to assure coordination of all services and interventions provided to the patient. The POC will be reviewed and updated as necessary to meet the changing needs of the patient in the most effective and efficient manner to achieve desired outcomes. The POC will be sent to the physician/allowed practitioner for review and signature when updates occur (examples: change orders, interim orders) and at time of recertification. 1.Patient #11 had a start of care date of 9/17/24. Clinical record review revealed the following: a. The POC, dated 9/17/24 to 11/15/24, included physician orders for skilled nursing, physical therapy and occupational therapy services. b. The resumption of care comprehensive assessment, dated 9/28/24, completed by Staff C, Registered Nurse (RN), identified the patient was discharged from the hospital on antibiotics and Furosemide. c. During an interview on 10/3/24 at 11:10 AM, the Administrator printed the patient's discharge instructions, dated 9/26/24, from the hospital that identified the patient is to take Furosemide 40 milligram (mg) tablets with instructions to take one tablet orally one time a day and Cephalexin 500mg capsules with instructions to take one capsule four times daily. The clinical record lacked documentation of plan of care updates for the medication changes.

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 agency staff interview, clinical record review and agency policy review, the agency failed to follow physician orders for wound care for 3 of 12 sampled patients with wounds (Patient's #3, #6 and #13). Failure to ensure staff obtain and follow physician orders for treatments provided by agency staff placed agency patients at risk for inconsistent care/treatment and possible harm. Findings include: According to the agency policy, titled Wounds: Assessment/Care/Clinical Oversight, dated 08/2024, for all wound/post-operative care/dressings, a physician/allowed practitioner order will be obtained a part of the patient plan of care. Physician/allowed practitioner written orders will specify: cleansing agent, products/treatments, specific sites/locations, outer dressing to be applied, treatment frequency, and discipline to perform treatment. During an interview on 10/1/24 at 1:39 PM, Clinical Manager reported clinicians document wound care provided on visit notes. 1. Patient #3 had a start of care date of 8/10/24. The clinical record review revealed: a. Plan of Care, dated 8/10/24 to 10/8/24, included orders for skilled nursing visits one time a week. b. Interim physician order, dated 9/27/24, included wound location left medial ankle, cleanse with normal saline, primary dressing AG foam (antimicrobial foam dressing with silver) cut slightly larger than wound, secure with conforming rolled gauze and paper tape; wound location left lateral ankle, cleanse with normal saline, primary dressing AG foam cut slightly larger than wound, secure with conforming rolled gauze and paper tape. During a home observation visit on 10/1/24 at 9:00 AM with Staff C, RN (registered nurse), surveyor observed Staff C, RN complete wound care to left medial and lateral ankle. Staff C, RN, cleansed wounds with normal saline, cut AG foam dressing and placed on wounds, placed ABD (abdominal gauze) pad over medial ankle wound and secured with conforming gauze and paper tape. Staff C, RN, applied ABD pad to left medial ankle wound. Staff C, RN, failed to complete wound care as ordered to the left medial ankle wound. 2. Patient #6 had a start of care date of 7/8/24. The clinical record review revealed: a. Plan of Care, dated 9/6/24 to 11/4/24, included orders for skilled nursing visits one time a week. b. Interim physician order, dated 9/27/24, included wound location left medial lower leg, clean with normal saline, AG foam dressing, ABD pad, secure with rolled gauze and tape, compression tubigrip size F 2 layers; and wound location left lateral lower leg, right medial lower leg, right lateral distal lower leg, right lower leg, right posterior lower leg; clean with normal saline, AG foam dressing, ABD pad, secure with kerlix and tape, compression tubigrip size F 2 layers. During a home observation visit on 10/2/24 at 2:00 PM with Staff C, RN, surveyor observed Staff C, RN complete wound care to all wounds. Staff C, RN, removed the old dressings and cleaned all wounds with Vashe wound cleanser, placed AG foam dressing, covered with ABD pad, secured with rolled gauze and tape, applied compression tubigrip size F 2 layers. Staff C, RN, cleaned all wounds with Vashe wound cleanser instead of normal saline. Staff C, RN, failed to complete wound care as ordered. 3. Patient #13 had a start of care date of 4/3/24 and a discharge date of 5/24/24. The clinical record review revealed: a. Interim physician order, dated 4/18/24, included wound location left lower leg, clean with saline, Silvadene cream, cover with ABD pad, wrap with kerlix, secure with tape, cover with tuibgrip size F during the day may remove at bedtime. b. Skilled nurse visit note, dated 4/19/24, included wound cleansed with saline, Silvadene cream, covered with ABD pad, wrapped with kerlix, secured with tape. c. Interim physician order, dated 5/1/24, included wound location left lower leg, clean with saline, Silvadene cream, cover with 2 ABD pads, wrap with kerlix, secure with tape, cover with tuibgrip size F during the day may remove at bedtime. d. Skilled nurse visit note, dated 5/3/24, included wound cleansed with saline, Silvadene cream, covered with 2 ABD pads, wrapped with kerlix, secured with tape. e. Interim physician order, dated 5/8/24, included wound location left lower leg, clean with saline, Silvadene cream, cover with 2 ABD pads, wrap with rolled gauze, secure with tape, cover with tuibgrip size F during the day may remove at bedtime. f. Skilled nurse visit note, dated 5/10/24, included wound cleansed with saline, Silvadene cream, covered with 2 ABD pads, wrapped with rolled gauze, secured with tape. g. Interim physician order, dated 5/16/24, included wound location left lower leg, clean with saline, dakins dampened gauze dressing, cover with 2 ABD pads, secure with rolled gauze and tape, cover with tubigrip size F during the day may remove at bedtime. h. Skilled nurse visit note, dated 5/17/24, included wound cleansed with saline, Silvadene cream, covered with 2 ABD pads, wrapped with rolled gauze, secured with tape. The skilled nurse failed to complete wound care as ordered. The above findings were reviewed with the Administrator and Clinical Manager.

Interventions and patient response CFR(s): 484.110(a)(2) All interventions, including medication administration, treatments, and services, and responses to those interventions; This ELEMENT is not met as evidenced by: Based on observation, clinical record review, agency policy review and staff interview, the agency failed to ensure the patients clinical record included accurate and specific documentation of interventions and maintained pertinent current information in the patient record for 6 of 12 sampled patients (Patients #1, #2, #6, #8, #9 and #15) with wounds. Failure to ensure the patient's clinical record included pertinent current and accurate documentation of interventions placed agency patients at risk for not receiving the correct interventions and for other disciplines providing services to have unclear or inaccurate information regarding the patient's condition. 5. Patient #6 had a start of care date of 7/8/24. The clinical record review revealed: a. Plan of Care, dated 9/6/24, included orders for skilled nurse to perform/teach wound care. b. Skilled nurse visit note, dated 9/23/24, included wound measurements for right mid pretibial and right multi/scat mid pretibial wounds and documentation wound measurements not due for left mid pretibial wound. Skilled nurse failed to document weekly wound measurements. 6. Patient #9 had a start of care date of 8/28/24. The clinical record review revealed: a. Plan of Care, dated 8/28/24 to 10/25/24, included orders for skilled nurse to perform/teach pressure ulcer care and wound care. b. Start of Care comprehensive assessment, dated 8/28/24, included documentation of right heel pressure ulcer, measured 1.4 centimeters (cm) x 1.5 cm x 0 cm, with a depth description of partial thickness; and left medial proximal calf pressure ulcer, measured 0.3 cm x 0.3 cm x 0 cm, with a depth description of partial thickness. c. Skilled nurse visit note, dated 9/4/24, included documentation of right heel pressure ulcer, measured 1.5 cm x 2 cm x 0 cm, with a depth description of full thickness; and left heel pressure ulcer, measured 0.7 cm x 1.2 cm x 0 cm, with a depth description of full thickness. d. Skilled nurse visit note, dated 9/19/24, included documentation of left heel pressure ulcer, measured 0.5 cm x 1 cm x 0 cm, with a depth description of partial thickness. e. Skilled nurse visit note, dated 9/24/24, included documentation of left heel pressure ulcer, measured 0.3 cm x 0.3 cm x 0 cm, with a depth description of partial thickness. The skilled nurse failed to accurately document wound depth. The surveyor reviewed the above findings with the Administrator and Clinical Manager. 2. Patient #1 had a start of care date of 7/10/24. The clinical record review revealed: a. The POCs, dated 7/10/24 to 9/7/24 and 9/8/24 to 11/6 24, included orders for skilled nurse to perform/teach wound care. b. Skilled nurse visit note, dated 8/27/24, included wound measurements for the wound to the right buttock. The wound measured 0.1 centimeters (cm) length by 0.1 cm width by 0 cm depth. The wound identified the depth of the wound a partial thickness. c. Skilled nurse visit note, dated 9/12/24, included wound measurements for the wound to the right buttock that measured 0.2 cm length by 0.2 cm width by 0 cm depth with partial thickness wound identified. The wound to the left lower buttock measured 0.6 cm by 0.8 cm by 0 with partial thickness wound identified. The skilled nurse failed to document complete weekly wound measurements to include depth measurements. 3. Patient #1 had a start of care date of 8/5/24. The clinical record review revealed: a. The POC, dated 8/5/24 to 10/3/24, included orders for skilled nurse to perform/teach wound care. b. The skilled nurse visit note, dated 8/5/24, included wound measurements for the wound to the right anterior pretibial mid venous stasis ulcer. The wound measured 4 cm length by 4 cm width by 0 cm depth. The wound identified the depth of the wound a partial thickness. The skilled nurse failed to document complete weekly wound measurements to include depth measurements. 4. Patient #15 had a start of care date of 5/23/24 and discharge date of 6/27/24. The clinical record review revealed: a. Plan of Care, dated 5/23/24 to 7/21/24, included orders for skilled nurse to perform/teach wound care. b. The skilled nurse visit note, dated 6/13/24, included documentation the patient had a new intact blister on the left great toe. The note lacked documentation of measurements of the wound. c. The skilled nurse visit note, dated 6/20/24, included documentation the patient had a new non intact blister on the top of the left great toe and a non intact blister on the bottom of the right great toe. The note also identified the sacral area deteriorated and had an open area. The note lacked documentation of measurements of any of the wounds. The skilled nurse failed to document complete weekly wound measurements to include depth measurements. According to the agency policy titled Wounds: Assessment/Care/Clinical Oversight, dated 8/2024, Registered Nurses (RNs) perform the initial assessment for open wounds and surgical incisions upon admission and as ordered by the physician. Wound dressings will be removed to assess wounds unless a physician order is received restricting dressing removal. A Licensed Practical Nurse (LPN) may provide treatment and collect data on wound status as assigned by the RN. Wound assessments will be performed as ordered by the physician but no less than once weekly. Wound assessments will include general observations, drainage amount and type, wound bed appearance and surrounding skin condition. At least weekly, the assessments will include wound measurements (length by width by depth in centimeters). Review of the agency's policy titled Care Planning, dated 9/2024, identified the LPN may collect data on wound status. The RN is responsible for reassessment visits every two week to include verification of data collected/reported and evaluate effectiveness of the current care regimen to ensure progress toward goals. 1.Patient #2 had a start of care date of 7/29/24. a. The Plan of Care (POC), dated 9/27/24 to 11/25/24, included physician orders for skilled nursing services one time a week to observe skin tear to left arm weekly for skin integrity monitoring effective 9/29/24. b. During a home visit observation on 10/1/24 at 8:00 AM, with Staff E, LPN, Staff E identified the wound was covered and she would not uncover it; she would communicate with the assisted living staff regarding the wound. c. A skilled nurse visit note, dated 10/1/24, completed by Staff E, LPN, identified she observed the wound, the assisted living facility staff is providing daily wound care, and the patient tolerated wound observation without complaints of pain or discomfort. Staff E, LPN reported the wound was not due to be measured. The agency failed to remove the dressing to observe the wound weekly per physician orders and failed to obtain weekly measurements per the agency policy.

The Iowa Department of Inspections and Appeals conducted a recertification survey in conjunction with a COVID-19 Focused Infection Control Survey from 11/1/21 through 11/3/21. The survey found the agency operating in substantial compliance with the requirements of the Establishment of Emergency Preparedness.

The Iowa Department of Inspections and Appeals conducted a recertification survey in conjunction with a COVID-19 Focused Infection Control Survey from 11/1/21 through 11/3/21. The survey found the agency to be in substantial compliance in relation to CMS and Centers for Disease Control and Prevention (CDC) recommended practices to prepare for COVID-19. The survey found the the agency operating out of compliance with the following standard level regulatory requirements.

A review of all current medications CFR(s): 484.55(c)(5) A review of all medications the patient is currently using in order to identify any potential adverse effects and drug reactions, including ineffective drug therapy, significant side effects, significant drug interactions, duplicate drug therapy, and noncompliance with drug therapy. This ELEMENT is not met as evidenced by: Based on clinical record review, agency policy review, home visit observation and agency staff interview, the agency failed to perform complete and accurate drug regimen reviews with corresponding comprehensive assessments for 7 of 13 sampled patients (Patients #4, #6, #10, and #17). The agency reported a census of 192 patients at the time of the survey. Failure to ensure medications reviewed at the time of each drug regimen review are current and accurate increased the potential for unidentified medication interactions and side effect risks to the patient at the time of each comprehensive assessment. Findings Include: 3. Patient #6 had a start of care date of 10/25/21. The POC dated 10/21/21 to 12/23/21, revealed the patient had orders for ondanstron 4 mg as needed for nausea and prednisone (steroid) 5 mg, take 2 tablets daily. The medical record identified a drug regimen review (DRR) completed by the nurse on 10/25/21. During a home visit observation, on 11/1/21 beginning at 2:30 PM, with Staff G, Registered Nurse (RN), the nurse identified the patient administered his/her own medications that had been set up by the pharmacist. The patient had the following medications identified in the home: colace, 100 mg (milligrams) 1 every evening, prednisone 20 mg with orders to taper down and no ondansetron available. The agency failed to identify the medication discrepancies during the DRR on 10/25/21. 4. Patient #4 had a start of care date of 10/21/21. The POC dated 10/21/21 to 12/19/21, revealed the patient had orders for tramadol 50 mg 1 tablet every 6 hours as needed for pain, oxybutynin (for bladder incontinence) 5 mg every morning and senna with docusate sodium 8.6 mg/50 mg every morning as needed for constipation. The medical record identified a drug regimen review (DRR) completed by the nurse on 10/21/21. During a home visit observation, on 11/2/21 beginning at 11:00 AM, with Staff H, RN, identified the patient administered his/her own medications. The patient had the following medications identified in the home: colace, 250 mg 1 daily as needed, oxybutynin 10 mg every morning and tramadol 1 to 2 tablets every 6 hours as needed for pain. The agency failed to identify the medication discrepancies during the DRR on 10/21/21 The above stated concerns for patients were identified to the Administrator and Clinical Manager and no further information presented prior to the end of the survey. Review of the agency policy, titled Initial and Comprehensive Assessments, dated 6/2021, indicated the initial comprehensive assessment and updates to the comprehensive assessment will include a review of all medications, including prescription and over-the-counter, the patient is currently using in order to determine any potential adverse effects, ineffective drug therapy, significant drug interactions, duplicate drug therapy and noncompliance. The Clinical Manager, pharmacist or designee will complete the drug regiment review (DRR) for therapists if not permitted by State law for a therapist to complete the DRR. 1. Patient #10 had a start of care date of 9/22/21. Review of the clinical record revealed the following: a. The Plan of Care (POC), dated 9/22/21 to 11/20/21, included physician orders for medications and skilled nursing services. b. The initial comprehensive assessment, dated 9/22/21, included documentation of a DRR of medications identified on the POC. On 11/3/21 at 12:00 PM, in an interview during a home visit observation with Staff F, Licensed Practical Nurse (LPN), the patient's spouse reported being responsible for setting up the patient's medications. The patient's spouse reported the following medication discrepancies: 1) The POC identified the patient took Cholecalciferol (Vitamin D-3) 50000 units one tablet every morning orally. The patient's spouse reported the patient had not been taking the Vitamin D-3 since prior to the start of care on 9/22/21. 2) The POC identified the patient took Zinc 50 mg one tablet every morning orally. The patient's spouse reported the patient had not taken the medication for the last year. 3) The patient's spouse reported the patient took Docusate (a stool softener) 1 tablet daily by mouth for a long time (prior to the start of care). The POC failed to include an order for Docusate Sodium. 4) The patient's spouse reported the patient had been using a Stiolto Inhaler (medication used to help treat difficulty with breathing). Observation of the prescription on the inhaler revealed a prescribing date of 8/12/21. The DRR failed to include an accurate review of the medications taken by the patient. 2. Patient #17 had a start of care date of 4/30/21 and discharged from agency services on 6/22/21. Review of the clinical record revealed the following: a. The POC, dated 4/30/21 to 6/28/21, included orders for skilled nursing services, occupational and physical therapy services. b. An update to the comprehensive assessment completed at the time of discharge, dated 6/22/21, included documentation the physical therapist completed a DRR along with the assessment. c. The discharge summary report, dated 6/22/21, included documentation the physical therapist completed the DRR and reviewed any concerns with the patient and patient's physician. The clinical record lacked documentation a registered nurse completed a DRR on the patient with the update to the comprehensive assessment completed at the time of discharge per federal regulations.

Plan of care must include the following CFR(s): 484.60(a)(2)(i-xvi) The individualized plan of care must include the following: (i) All pertinent diagnoses; (ii) The patient's mental, psychosocial, and cognitive status; (iii) The types of services, supplies, and equipment required; (iv) The frequency and duration of visits to be made; (v) Prognosis; (vi) Rehabilitation potential; (vii) Functional limitations; (viii) Activities permitted; (ix) Nutritional requirements; (x) All medications and treatments; (xi) Safety measures to protect against injury; (xii) A description of the patient's risk for emergency department visits and hospital re-admission, and all necessary interventions to address the underlying risk factors. (xiii) Patient and caregiver education and training to facilitate timely discharge; (xiv) Patient-specific interventions and education; measurable outcomes and goals identified by the HHA and the patient; (xv) Information related to any advanced directives; and (xvi) Any additional items the HHA or physician or allowed practitioner may choose to include. This ELEMENT is not met as evidenced by: Based on clinical record review, agency policy, home visit observation, and patient interview, the agency failed to ensure the accurate completion of all components comprising the Plan of Care, including all supplies and equipment used by the patient to meet his/her needs and an accurate list of the patient's current medications for 9 of 17 sampled patients (Patients #2, #3, #4, #5, #6, #10, #13, #15, and #17). The agency reported a current census of 192 patients at the time of the survey. Failure to maintain complete and accurate Plans of Care with current orders placed the patients at risk to not receive services, medications and/or treatments according to assessed needs and physician orders. 8. Patient #3 had a start of care date of 9/15/21. The Plan of Care, dated 9/15/21 to 11/13/21, included physician order for tetrabenazine 12.5 milligrams (mg). During a home visit observation, on 11/1/21 at 2:45 PM, with Staff D, registered nurse (RN), the surveyor observed Staff D review the medications with the patient and spouse. The patient’s spouse reported giving the patient 2 tablets of the tetrabenazine to equal the dose of 25 mg, a dose that was started prior to home care admission when the patient was in the care facility. Clinical record review revealed a faxed medication sheet from the care facility with a faxed date of 9/9/21, that included the medication tetrabenazine 25 mg with a start date of 8/17/21. The Plans of Care failed to identify the correct medication dose for the tetrabenazine taken by the patient. 9. Patient #15 had a start of care date of 9/28/2020 and a discharge date of 2/8/21. Clinical record review revealed: a. The Plan of Care, dated 11/27/2020 to 1/25/21, included physician orders for skilled nursing services one time a week for wound care to the medial right lower leg with a frequency 1 time a week for 7 weeks and 4 times a week for 1 week. b. Interim physician order, dated 1/21/21, included orders for wound care to the right gluteal fold every Monday, Wednesday and Friday with a frequency of 5 times a week for 1 week and 1 time a week for 1 week. c. The week of 1/21/21 included documentation for skilled nursing visits, dated 1/21/21 and 1/22/21. The documentation failed to include 5 skilled nursing visits as ordered. During an interview on 11/3/21 at 3:10 PM, the Administrator reported the EMR (electronic medical record) places PRN (as needed) visits at the end of the certification period. The order dated 1/21/21, included 3 PRN visits scheduled on Saturday 1/23/21 creating the frequency of 5 times a week. The Administrator confirmed the order failed to identify the specific number of scheduled visits and the specific number of PRN visits. The agency failed to follow the skilled nurse order frequency for the week of 1/21/21. The Administrator received the above findings and agency staff provided no further information prior to the end of the survey. 6. Patient #10 had a start of care date of 9/22/21. Review of the clinical record revealed the following: a. The POC, dated 9/22/21 to 11/20/21, identified the patient used the following: "adaptive living aides", cane, rails/grab bars, shower/tub equipment, walker and "protective equipment". b. The initial comprehensive assessment, dated 9/22/21, identified the patient used grab bars, a cane, tub chair and walker. On 11/3/21 at 12:00 PM, in an interview during a home visit observation with Staff F, Licensed Practical Nurse (LPN), the patient and patient's spouse reported the patient had not used a walker for a long time (since prior to admit to agency services). The patient and spouse reported the patient used a cane, grab bars, blood pressure cuff and built in seated shower seat. The POC failed to identify the specific medical equipment used by the patient. 7. Patient #17 had a start of care date of 4/30/21 and discharged from agency services on 6/22/21. Review of the clinical record revealed the following: a. The POC, dated 4/30/21 to 6/28/21, identified the patient used the following medical equipment and supplies: bedside commode, rails/grab bars, walker, "shower/tub equipment" and "vital signs equipment". b. The initial comprehensive assessment, dated 4/30/21, identified the patient used grab bars, tub chair and walker. c. The initial physical therapy assessment, dated 5/2/21, identified the patient used an elevated toilet seat, grab bars, tub chair and walker. The POC failed to specify all of the medical equipment/supplies used by the patient. 2. Patient #2 had a start of care date of 10/25/21. The Plan of Care, dated 10/25/21 to 12/13/21, identified durable medical equipment (DME) that included the following: rails/grab bars, shower/tub equipment, walker and wheelchair. During a home visit observation, on 11/1/21 beginning at 2:30 PM, with Staff G, Registered Nurse (RN), the surveyor observed the patient had a handheld shower. The patient stated he/she utilized the handheld shower since the start of services. The agency failed to include the handheld shower, on the Plan of Care as equipment used by the patient. 3. Patient #4 had a start of care date of 10/21/21. The POC, dated 10/21/21 to 12/19/21, identified the DME that included the following: adaptive living aids, reacher, shower/tub equipment, walker, dressing-gauze, rolled gauze, wound cleanser. During a home visit observation, on 11/2/21 beginning at 11:00 AM, with Staff H, RN, the surveyor observed the patient had a wheelchair, wheelchair cushion and pill planner. The patient stated he/she utilized the wheelchair, wheelchair cushion and pill planner since the start of services. The agency failed to include the wheelchair, wheelchair cushion and pill planner, on the POC as equipment used by the patient. 4. Patient #6 had a start of care date of 7/28/21. The POC, dated 7/28/21 to 9/25/21 and 9/26/21 to 11/24/21, identified the DME that included the following: diabetic supplies, adaptive living aids, cane, glucometer, rails/grab bars, shower/tub equipment, table/chair, walker, protective equipment, skin protectant. During a home visit observation, on 11/3/21 beginning at 10:30 AM, with Staff I, Licensed Practical Nurse, the surveyor observed the patient had a lift chair. The patient stated he/she utilized the lift chair since the start of services. The agency failed to include the lift chair, on the POC as equipment used by the patient. 5. Patient #13 had a start of care date of 4/26/21 and discharge date of 6/15/21. The POC, dated 4/26/21 to 6/24/21, identified the DME that included the following: diabetic supplies, cane, glucometer, shower/tub equipment and walker. The skilled nurse visit note, dated 4/27/21 identified the patient utilized tub chair. The agency failed to include the tub chair, on the POC as equipment used by the patient. Findings include: According to the agency policy, titled Care Planning and dated 06/21/21, each patient must receive an individualized written Plan of Care (POC), including any revisions or additions. The individualized POC must specify: All medications and treatments. Patient medication schedule/instructions, to include medication name, dosage, frequency, and which medications will be administered by HHA associates and personnel acting on behalf of the HHA. Types of services, supplies and equipment required. 1. Patient #5 had a start of care date of 10/22/21. a. The Plan of Care (POC), dated 10/22/21 to 12/20/21, identified equipment: catheter, catheter drain bag, catheter insertion kit, rails/grab bars, shower/tub equipment, table/chair, glucometer, dressing wound care misc., skin care topical barrier, moisturizer, skin protectant, walker, wheelchair, diabetic supplies and adaptive living aids as equipment and supplies the patient was using. During a home visit observation, on 11/02/21 beginning at 10:28 AM, with Staff E, physical therapist, the surveyor observed the patient used a wheel chair, walker, gait belt, lift chair, shower bench, hand held shower and medication box. During the same home visit the patient reported that the assisted living facility staff used the gait belt every time they assisted the patient with ambulation. Staff E demonstrated use of the gait belt during the visit. The agency failed to identify the hand held shower, shower bench, gait belt, lift chair and medication box, on the POC as equipment used by the patient. b. The POC dated 10/22/21 to 12/20/21, and printed on 11/2/2021 identified medications: acetaminophen, aspirin, brinzolamide, calcium with vitamin D, ciprofloxacin, cyanocobalamin, cyclosporine, ezetimibe, famotidine, chewable multivitamin tablet, folic acid, lecithin, levetiracetam, levothyroxine, metoprolol, miralax, pravastatin, senna, sulfamethoxazole, tamsulosin, ursodiol, and warfarin 3.5 mg tablet daily. The physician order sheet from the assisted living facility dated 11/2/21 identified medications: acetaminophen, aspirin, brinzolamide, calcium with vitamin D, ciprofloxacin, cyanocobalamin, cyclosporine, ezetimibe, famotidine, multivitamin chewable tablet, folic acid, lecithin, levetiracetam, levothyroxine, metoprolol, miralax, pravastatin, senna, sulfamethoxazole, tamsulosin, ursodiol, triad wound dressing paste, lidocaine patches and warfarin 5 mg on Monday and Thursday, and warfarin 2.5 mg on Sunday, Tuesday, Wednesday, Friday and Saturday. During the same home visit observations the patient stated the assisted living facility staff sets up medications and the patient reviews the medication list as the medications are placed in the medication box. The POC failed to identify the triad wound dressing paste, lidocaine patches, and the updated dose for the warfarin.

All orders recorded in plan of care CFR(s): 484.60(a)(3) All patient care orders, including verbal orders, must be recorded in the plan of care. This ELEMENT is not met as evidenced by: Based on clinical record review and agency staff interview, the agency failed to update the Plan of Care with all new physician orders during the Plan of Care's certification period for 5 of 17 sampled patients (Patients #7, #10, #14, #15 and #17). The agency reported a current census of 192 patients at the time of the survey. Failure to update the Plan of Care increased the potential for medication errors or inaccurate provision of care. Findings include: 5. Patient #15 had a start of care date of 9/28/2020 and a discharge date of 2/8/21. Clinical record review revealed: a. The Plans of Care, dated 11/27/2020 to 1/25/21 and 1/26/21 to 2/8/21, included orders for skilled nursing services. i. Interim physician orders for mepilex, dated 12/1/2020; enluxtra and kerlix, dated 12/24/2020; and medihoney, dated 1/21/21. ii. The Plan of Care update for the certification period, dated 11/27/2020 to 1/25/21, included documentation the interim physician orders dated 12/1/2020, 12/24/2020 and 1/21/21, were wrote but failed to identify the verbiage identifying what supply or treatment the order was wrote for. iii. Interim physician order for mepilex to left buttock crease, dated 2/1/21. iv. The Plan of Care update for the certification period, dated 1/26/21 to 2/8/21, included documentation the interim physician order dated 2/1/21, was wrote but failed to identify the verbiage identifying what treatment the order was wrote for. The Plan of Care updates failed to include documentation of all interim physician orders. The Administrator received the above findings and agency staff provided no further information prior to the end of the survey. Review of the agency policy, titled Care Planning, dated 6/2021, identified each patient must receive an individualized written Plan of Care (POC), including any additions or revisions. The POC must specify care and services to meet the individualized needs of the patient. A registered nurse (RN), therapist or social worker will develop the patient's POC in conjunction with the physician. Agency clinicians will review/revise the POCs to meet the changing needs of the patient. The POC will serve as the care planning document. 1. Patient #7 had a start of care date of 5/19/21. Review of the clinical record revealed the following: a. The POC, dated 9/16/21 to 11/14/21, included order for skilled nursing services to complete the following wound care on the bilateral lower legs: cleanse with Normal Saline, pat dry, apply Povidone Iodine Prep Solution/Betadine dampened gauze, cover with rolled gauze, Abdominal (ABD) pads, Kerlix (roll gauze), use paper tape and use Coban (type of adhesive wrap dressing) to hold dressing in place twice weekly on Monday and Wednesdays on the weeks the patient goes to the wound clinic and three times per week, Monday, Wednesday and Friday, the weeks the patient does not go to the wound clinic. b. An interim physician order, dated 9/20/21 and 10/1/21, included the following change in wound care orders for the right and left lower legs: change dressing every day, clean with Normal Saline, may shower without wound dressing, a primary dressing of Povidone Iodine Prep Solution, a secondary dressing of Kerlix, woven gauze sponge (non-sterile), ABD pad, Coban adhesive bandage twice weekly on Monday and Wednesdays on the weeks the patient goes to the wound clinic and three times per week, Monday, Wednesday and Friday, the weeks the patient does not go to the wound clinic. c. An interim physician order, dated 10/4/21, included an order for the skilled nurse to see the patient on Monday, Tuesday and Wednesday this week instead of Monday, Wednesday, Friday due to the caregiver not being available. The order directed the caregiver to provide wound care on all other days of the week. d. An interim physician order, dated 10/14/21, included the following change in wound care orders for the right lower leg: change the dressing every 3 days, may shower without wound dressing, Medihoney Colloid dressing for the primary wound dressing, ABD pad for the secondary dressing, Kerlix, woven gauze sponge, non-sterile 4 by 4, Coban adhesive dressing two times per week by skilled nurse and teach family how to do dressing change. The left lower leg dressing remained as follows: change dressing every day, a primary dressing of Povidone Iodine Prep Solution, a secondary dressing of Kerlix, woven gauze sponge (non-sterile), ABD pad, Coban adhesive bandage twice weekly by skilled nurse and teach family how to do the dressing changes. e. An interim physician order, dated 10/17/21, included the following: the nurse reported she cleansed with Normal Saline, applied Medihoney "HCS" (Hydrogel Colloidal Sheet), applied ABD pads and secured with Kerlix and Coban. The nurse did not clarify if this was done on both wounds or just one of the wounds. f. An interim physician order, dated 10/18/21, included the following: okay to use regular Medihoney sheets until the order comes in for Medihoney HCS. g. An interim physician order, dated 10/21/21, included the following change to the right lower leg wound care: change the dressing every day, may shower without wound dressing, a primary dressing of Povidone Iodine Prep Solution, a secondary dressing of Kerlix, woven gauze sponge (non-sterile), ABD pad, Coban adhesive bandage twice weekly on Monday and Wednesdays on the weeks the patient goes to the wound clinic and three times per week, Monday, Wednesday and Friday, the weeks the patient does not go to the wound clinic. h. An interim physician order, dated 10/28/21, included the following continued wound care orders for the right and left lower legs: change dressing daily, clean with Normal Saline, may shower without wound dressing, a primary dressing of Povidone Iodine Prep Solution, a secondary dressing of Kerlix, woven gauze sponge (non-sterile), ABD pad, Coban adhesive bandage twice weekly on Monday and Wednesdays on the weeks the patient goes to the wound clinic and three times per week, Monday, Wednesday and Friday, the weeks the patient does not go to the wound clinic. i. The updated POC for the current certification period, dated dated 9/16/21 to 11/14/21, failed to include the interim physician orders, dated 9/20, 10/1, 10/4, 10/17, 10/18, 10/21 and 10/28/21. On 11/3/21 at 1:25 PM, during an interview, the Clinical Manager reported the nurse enters an order in the computer for any faxed or verbal orders. The Administrator agreed to look into why the text part of the orders was not coming over to the updated POC. On 11/3/21 at 3:02 PM, during an interview, the Administrator reported they had to open each order to see any interim physician order. Any order with documented text would not roll over to the updated POC; only frequency changes and medication changes. The updated POC would identify the date of any interim physician ordered received and entered in the electronic system, but not the actual information in the order. 2. Patient #10 had a start of care date of 9/22/21. Review of the clinical record revealed the following: a. The POC, dated 9/22/21 to 11/20/21, identified a diagnosis of atrial fibrillation, included medication orders for Warfarin (a medication used to prevent blood clot formation and associated with laboratory testing for clotting rates) and included an order for the skilled nurse to obtain Protime (PT)/International Normalizing Ratio (INR) fingerstick blood tests when ordered by the physician. b. An interim physician order, dated 9/22/21, included an order for the nurse to obtain the next INR blood draw on 10/13/21. c. An interim physician order, dated 10/13/21, included an order for the nurse to obtain the next INR blood draw on 10/20/21. d. An interim physician order, dated 10/20/21, included an order for the nurse to obtain the next INR blood draw on 10/27/21. e. An interim physician order, dated 10/27/21, included an order for the nurse to obtain the next INR blood draw on 11/3/21. f. The updated POC for the current certification period, dated dated 9/22/21 to 11/20/21, failed to include the interim physician orders, dated 9/22, 10/13, 10/20 and 10/27/21, for the INR blood draws. 3. Patient #14 had a start of care date of 5/28/21 and discharged from agency services on 6/26/21. Review of the clinical record revealed the following: a. The POC, dated 5/28/21 to 7/26/21, included physician orders for skilled nursing, occupational therapy (OT) and physical therapy (PT) services. b. An interim physician order, dated 6/9/21, included orders for a frequency of PT effective 6/6/21 for 1 every 6 weeks for 6 weeks and then 1 time per week for 1 week. The order included a statement of the nurse receiving a verbal order to place PT services on hold per the family's request. c. An interim physician order, dated 6/18/21, included orders to reduce skilled nursing visits to one time per week per the family's request in order for the patient to focus on OT services. The order included a change in frequency effective 6/13/21 to 2 times per week for one week and then one time per week for 4 weeks. d. An interim physician order, dated 6/21/21, included orders to move OT visits up from the last 2 weeks of the certification period to "front load" OT visits to this week, week of 6/21/21 and week of 6/28/21. The order included a change in frequency effective 6/20/21 for 2 times per week for 2 weeks and 1 time per week for 1 week. e. The updated POC for the certification period, dated dated 5/28/21 to 7/26/21, included the frequency changes identified in the interim physician orders, dated 6/9, 6/18 and 6/21/21, but failed to include any of the rest of the information in the orders. 4. Patient #17 had a start of care date of 4/30/21 and discharged from agency services on 6/22/21. Review of the clinical record revealed the following: a. The POC, dated 4/30/21 to 6/28/21, included physician orders for OT services effective 5/2/21 for one time during that week. b. An interim physician order, dated 5/4/21, included a physician order for OT services one time every 2 weeks for 2 weeks. The interim order included an order for the OT evaluation and treatment to take place the next week (week of 5/9/21) per the patient's request. c. An interim physician order, dated 5/11/21, included an order for no additional OT visits and identified the completion of the OT evaluation. d. The updated POC for the certification period, dated 4/30/21 to 6/28/21, included the frequency changes for OT ordered by the physician on 5/4/21, but lacked any of the other information in the order. The updated POC lacked documentation of the interim physician order, dated 5/11/21.

Interventions and patient response CFR(s): 484.110(a)(2) All interventions, including medication administration, treatments, and services, and responses to those interventions; This ELEMENT is not met as evidenced by: Based on clinical record review, agency policy review and staff interview, the agency failed to ensure the patients clinical record included accurate and specific documentation of interventions and maintained pertinent current information in the patient record for 1 of 3 sampled patients (Patient #15) with wounds. The agency reported a census of 192 patients at the time of the survey. Failure to ensure the patient's clinical record included pertinent current and accurate documentation of interventions placed agency patients at risk for not receiving the correct interventions and for other disciplines providing services to have unclear or inaccurate information regarding the patient's condition. Findings include: Review of the agency's policy, titled Wound Care Assessment and Clinical Oversight, dated 03/2021, identified the Licensed Practical Nurse (LPN) can provide treatments and collect data on wound status as assigned by the Registered Nurse (RN). Wound assessments will be performed as ordered by the physician but no less than once weekly. Wound assessments will include general observations, drainage amount and type, wound bed appearance and surrounding skin condition. At least weekly, the assessment will include wound measurements (length by width by depth in centimeters). Review of the agency's policy, titled Care Planning, dated 06/2021, identified the LPN may collect data on wound status. When assigning wound care to an LPN, the RN is responsible for reassessment visits every two weeks, verification of data collected and reported by the LPN, and evaluation of the effectiveness of the current care regimen to ensure progress toward goals. Patient #15 had a start of care date of 9/28/2020 and a discharge date of 2/8/21. Clinical record review revealed: a. The Plan of Care, dated 11/27/2020 to 1/25/21, included orders for skilled nursing services one time a week for wound care. i. Skilled nursing visit note completed by an LPN, dated 12/23/2020, included documentation the wound was assessed but no measurements were taken due to assessment completed by LPN. ii. Skilled nursing visit note completed by an LPN, dated 1/6/21, included documentation the wound was assessed but no measurements were taken due to assessment completed by LPN. b. The Plan of Care, dated 1/26/21 to 2/8/21, included orders for skilled nursing services two times a week for one week and three times a week for two weeks. i. Skilled nursing visit note completed by an LPN, dated 2/1/21, included documentation the wound was assessed but no measurements were taken due to assessment completed by LPN. ii. Skilled nursing visit note completed by an RN, dated 2/3/21, included documentation the wound was not assessed due to cares completed by caregiver. iii. Skilled nursing visit note completed by an LPN, dated 2/5/21, included documentation two wounds were assessed but no measurements were taken due to assessments completed by LPN. On 11/3/21 at 3:10 PM, during an interview, the Administrator reported after review of the clinical record she was unable to find missing wound measurements. The clinical record lacked documentation of weekly wound measurements per agency policy. The Administrator received the above findings and agency staff provided no further information prior to the end of the survey.