Every finding on record at Good Samaritan Society Home Care

A Recertification Survey was conducted by the Department of Inspections, Appeals and Licensing from 2/5/26 through 2/12/26 and the home health agency was found to be operating in compliance with the requirements of the Establishment of Emergency Preparedness.

A Recertification Survey was conducted by the Department of Inspections, Appeals and Licensing from 2/5/26 through 2/12/26. The recertification survey found the agency operating out of compliance with the following standard level regulatory requirements: The agency reported a census of 63 patients at the time of the survey.

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 agency policy review, clinical record review and agency staff interview, 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 for Care for 3 of 5 sampled patients with orders for Physical Therapy services. (Patients #1, #4 and #5) Failure to follow a Plan of Care established by a physician placed patients at risk of not receiving safe, individualized and consistent care designed to meet each patient's health care needs. Findings: According to the agency policy, titled Provider Orders and Notification, dated 5/27/25, the nurse or qualified practitioner responsible for furnishing/supervising the ordered services, must document orders in the patient’s medical record. Verbal orders must be authenticated by the provider. The provider must be notified of any missed visits. Documentation in the clinical record must reflect this notification. During an interview on 2/11/26 at 11:45 AM, Staff A, Administrator, reported missed visits are documented in a coordination note, the staff documenting the missed visit is responsible for notifying the physician of the missed visit and this should be documented in that coordination note. 1. Patient #1 had a start of care date of 12/26/25. Clinical record review revealed: a. Plan of Care, dated 12/26/25 to 2/23/26, included orders for skilled nursing, physical therapy and occupational therapy services. Physical therapy effective 12/28/25 for one time a week for one week. b. PT visit note, dated 1/4/26, completed by Staff E, PT, identified evaluation completed. One week after the order, dated 12/28/25. No documentation why evaluation visit not completed week of 12/28/25 as ordered. c. PT interim physician order, dated 2/11/26, completed by Staff A, Administrator, included documentation initial PT evaluation to be completed on 1/4/26. During an interview on 2/11/26 at 3:15 PM, Staff A, Administrator provided surveyor with a copy of Webex communication (electronic communication program used by agency staff) dated 1/2/26 by Staff E, PT, requesting evaluation be moved to 1/4/26. The agency failed to provide PT services as ordered. 2. Patient #5 had a start of care date of 1/6/26. Clinical record review revealed Plan of Care, dated 1/6/26 to 3/6/26, included orders for skilled nursing, physical therapy and occupational therapy services. Physical therapy effective 1/11/26 for one time a week for one week. The clinical record lacked documentation of a PT evaluation visit or documentation of a reason why PT evaluation was not completed. The agency failed to provide PT services as ordered. 3. Patient #4 had a start of care date of 10/29/25. Clinical record review revealed: a.Plan of Care (POC), dated 12/27/25 to 2/24/26, included the patient's diagnosis of chronic obstructive pulmonary disease (COPD) and orders for Physical Therapy (PT) to evaluate the patient. b.Physical Therapy (PT) visit note, dated 12/23/25, completed by Staff E, Physical Therapist (PT), identified evaluation completed. No documentation why the Physical Therapy (PT) evaluation visit was not completed after 12/27/25 as ordered. c.The next Physical Therapy (PT) visit took place on 1/8/26 with Staff G, Physical Therapy Assistant (PTA). The agency failed to complete a Physical Therapy (PT) evaluation visit after 12/27/25 as ordered. d.Physical Therapy (PT) interim physician order, signed by Staff H, Nurse Practitioner, dated 12/23/25, included orders for Physical Therapy (PT) as follows: Physical Therapy (PT) effective 12/28/25 for 1 visit per week for 3 weeks and 2 visits per week for 1 week. e.Physical Therapy (PT) visit note, dated 12/23/25, completed by Staff E, Physical Therapist (PT), identified a visit completed. f.The next Physical Therapy (PT) visit took place on 1/8/26 with Staff G, Physical Therapy Assistant (PTA). No documentation of why a Physical Therapy (PT) visit was not completed the week of 12/28/25. The agency failed to complete a Physical Therapy (PT) visit the week of 12/28/25 as ordered. g.Physical Therapy (PT) interim physician order, signed by Staff H, Nurse Practitioner, dated 1/22/25, included orders for physical therapy as follows: Physical Therapy (PT) effective 1/25/25 for 1 visit per week for 1 week, 2 visits per week for 1 week, and 1 visit per week for 2 weeks. h.Physical Therapy (PT) visit notes, dated 1/14/26 and 1/22/26 completed by Staff E, Physical Therapist (PT), identified visits were completed. No documentation of why a second Physical Therapy (PT) visit was not completed the week of 1/18/26. The agency failed to complete a second Physical Therapy (PT) visit the week of 1/18/26. i.The Physical Therapy (PT) visit note, dated 1/22/26, completed by Staff E, Physical Therapist (PT) and the Physical Therapy (PT) visit note, dated 2/3/26, completed by Staff I Physical Therapy Assistance (PTA) identified visits were completed. No documentation of why a visit was not completed the week of 1/25/26. The agency failed to complete 1 Physical Therapy (PT) visit the week of 1/25/26. The agency failed to provide physical therapy (PT) services as ordered. The above findings were shared with the Administrator and the Senior Administrative Assistant. According to the agency policy, titled Provider Orders and Notification, dated 5/27/25, the nurse or qualified practitioner responsible for furnishing/supervising the ordered services, must document orders in the patient’s medical record. Verbal orders must be authenticated by the provider. The provider must be notified of any missed visits. Documentation in the clinical record must reflect this notification. During an interview on 2/11/26 at 11:45 AM, Staff A, Administrator, reported missed visits are documented in a coordination note. The staff documenting the missed visit is responsible for notifying the physician of the missed visit and this should be documented in the coordination note. 1. Patient #1 had a start of care date of 12/26/25. Clinical record review revealed: a. Plan of Care, dated 12/26/25 to 2/23/26, included orders for skilled nursing, physical therapy and occupational therapy services. Physical therapy (PT) effective 12/28/25 for one time a week for one week. b. PT visit note, dated 1/4/26, completed by Staff E, Physical therapist (PT), identified evaluation completed. One week after the order, dated 12/28/25. No documentation why evaluation visit not completed week of 12/28/25 as ordered. c. PT interim physician order, dated 2/11/26, completed by Staff A, Administrator, included documentation initial PT evaluation to be completed on 1/4/26. During an interview on 2/11/26 at 3:15 PM, Staff A, Administrator provided surveyor with a copy of communication by electronic communication program used by agency staff dated 1/2/26 by Staff E, PT, requesting evaluation be moved to 1/4/26. The agency failed to provide PT services as physician ordered. 2. Patient #5 had a start of care date of 1/6/26. Clinical record review revealed Plan of Care, dated 1/6/26 to 3/6/26, included orders for skilled nursing, physical therapy and occupational therapy services. Physical therapy effective 1/11/26 for one time a week for one week. The clinical record lacked documentation of a PT evaluation visit or documentation of a reason why PT evaluation was not completed. The agency failed to provide PT services as physician ordered. Patient #1 had a start of care date of 8/3/21. Clinical record review revealed: a. Plan of Care, dated 11/9/25 to 1/7/26, included primary diagnosis of mild intellectual disability and physician orders for skilled nursing services one time per week and home health aide services seven times per week. b. There was no home health aide visit note, dated 12/7/25, 12/13/25 or 12/14/25, or documentation notifying the physician why no visit was completed on 12/7/25. 12/13/25 or 12/14/25. c. There was no home health aide note, dated 1/3/26, or documentation notifying the physician why no visit was completed on 1/3/26. The agency failed to provide home health aide services as ordered in the plan of care or notify the physician why the services were not provided as ordered. 3. Patient #4 had a start of care date of 10/29/25. Clinical record review revealed: a. Plan of Care (POC), dated 12/27/25 to 2/24/26, included the patient's diagnosis of chronic obstructive pulmonary disease (COPD) and orders for Physical Therapy (PT) to evaluate the patient. b. The agency failed to complete a Physical Therapy (PT) evaluation visit after 12/27/25 as ordered. c .Physical Therapy (PT) interim physician order, signed by Staff H, Nurse Practitioner, dated 12/23/25, included orders for Physical Therapy (PT) as follows: Physical Therapy (PT) effective 12/28/25 for 1 visit per week for 3 weeks and 2 visits per week for 1 week. d.The next Physical Therapy (PT) visit took place on 1/8/26 with Staff G, Physical Therapy Assistant (PTA). There was no physical therapy visit note, for the week of 12/28/25, or documentation notifying the physician why no visit was completed and No documentation of why a second Physical Therapy (PT) visit was not completed the week of 1/18/26. f.The next Physical Therapy (PT) visit took place on 1/8/26 with Staff G, Physical Therapy Assistant (PTA). No documentation of why a Physical Therapy (PT) visit was not completed the week of 12/28/25. The agency failed to complete a Physical Therapy (PT) visit the week of 12/28/25 as ordered. g.Physical Therapy (PT) interim physician order, signed by Staff H, Nurse Practitioner, dated 1/22/25, included orders for physical therapy as follows: Physical Therapy (PT) effective 1/25/25 for 1 visit per week for 1 week, 2 visits per week for 1 week, and 1 visit per week for 2 weeks. h.Physical Therapy (PT) visit notes, dated 1/14/26 and 1/22/26 completed by Staff E, Physical Therapist (PT), identified visits were completed. No documentation of why a second Physical Therapy (PT) visit was not completed the week of 1/18/26. The agency failed to complete a second Physical Therapy (PT) visit the week of 1/18/26. i.The Physical Therapy (PT) visit note, dated 1/22/26, completed by Staff E, Physical Therapist (PT) and the Physical Therapy (PT) visit note, dated 2/3/26, completed by Staff I Physical Therapy Assistance (PTA) identified visits were completed. No documentation of why a visit was not completed the week of 1/25/26. The agency failed to complete 1 Physical Therapy (PT) visit the week of 1/25/26. The agency failed to provide physical therapy (PT) services as ordered. The above findings were shared with the Administrator and the Senior Administrative Assistant.

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 patient interview, staff interview, agency policy, clinical record, and observation, the agency failed to include all supplies/equipment and medications in Plans of Care for 1 of 3 sampled patients with home visit observations, Patient #3. Failure to maintain complete and accurate Plans of Care with current orders placed the patients at risk to not receive services according to assessed needs and physician orders. Findings include: According to the agency policy, titled Care Planning and Care Coordination, Home Health and Therapy, dated 11/12/25, the plan of care should be patient-specific and include complete medication and treatment orders, equipment and supplies. In an interview on 2/11/26 at 10:30 AM, when asked if the Plan of Care (POC) should include all of the patient’s current medications, the Administrator reported that she will educate the nurse on medication reconciliation. Patient #3 had a start of care date of 11/26/25. Clinical record review, home visit observation, and patient interview revealed the following: a. The POC, dated 1/25/26 to 3/25/26, had a diagnosis of surgical aftercare following surgery of the digestive system and congestive heart failure (CHF, heart muscle is unable to pump blood efficiently, causing blood to back up and fluid to build up in the lungs, legs, and other tissues) and orders for skilled nursing services and the following medications: ferrous sulfate 325 mg 1 tablet daily, furosemide 20 mg 1 tablet daily and Nystop powder100,000 units one application per day when needed for skin rash. b. During home observation on 2/10/26 at 10:00 AM, Patient #3 reported they used the medications since before they started home health care with the agency and showed the surveyor the medication containers of ferrous sulfate, furosemide, and Nystop powder. The above findings were reported to the Administrator and Senior Administrative Assistant.

Required items in clinical record CFR(s): 484.110(a)(1) The patient's current comprehensive assessment, including all of the assessments from the most recent home health admission, clinical notes, plans of care, and physician or allowed practitioner orders; This ELEMENT is not met as evidenced by: Based on staff interview, policy review, and clinical record review, the agency failed to comprehensively provide wound assessments for 1 of 2 sampled patients with wounds, Patient #3. Failure to accurately and thoroughly complete wound assessments placed patients at an increased risk of unidentified condition changes. Findings include: Review of the agency' s policy, titled Wound Care, Home Health, Hospice, and Assisted Living, last revised 9/23/25, wounds will be measured in centimeters (length x width x depth) at least weekly unless covered with a non-removable dressing during the nurse visit. Wound and peri-wound appearance will be assessed each visit unless covered with a non-removable dressing. Wound assessment will include but is not limited to; color, odor, drainage, tunneling/undermining, and character of wound bed tissue. In an interview on 2/10/26 at 10:40 AM, when asked about frequency and content of wound assessment, the Administrator reported that wound assessment are performed the first visit of every week. The assessment would be documented in an area under the visit notes, to include length, width, and depth, and a general description of the wound, odor, drainage. Patient #3 had a start of care date of 11/26/25. Clinical record review revealed the following: a.The patient had a Plan of Care (POC), dated 1/25/26 to 3/25/26, and had a diagnosis of surgical aftercare following surgery of the digestive system. The patient had weekly skilled nursing visits. b.The skilled nursing visits completed by Staff B, Registered Nurse (RN) failed to include comprehensive wound assessments and wound measurements for the weeks of 12/12/25, 12/19/25, 12/24/25, and 12/31/25. c. The skilled nursing visit completed by Staff B, RN on 1/30/26 failed to include measurement of the wound. d.In an interview on 2/10/26 at 10:00 AM, Staff B, RN, reported that she measures the patient’s wound weekly unless the patient just had the dressing changed at the wound clinic. The agency failed to obtain weekly wound assessment including measurements. The above findings were shared with the Administrator and the Senior Administrative Assistant.

An investigation of complaint #96123 was conducted by the Department of Inspections and Appeals from 2/16/23 through 3/2/23. The complaint survey identified the following findings regarding the intake allegations: 1. 42 CFR 484.60 Care planning, Coordination and Quality of Care, triaged as Immediate Jeopardy. The agency failed to ensure each patient received services written in the Plan of Care (refer to G0572)The surveyor notified the agency of the Immediate Jeopardy situation on 3/1/23 at 10:00 AM. The Immediate Jeopardy was abated on 3/2/23 at 11:150 AM. The survey found the agency operating out of compliance with the Condition of Participation: 484.60 Care Planning, Coordination, and Quality of Care and the complaint was substantiated with related condition level deficiencies. 2. The survey found the agency operating in compliance with the Condition of Participation 42 CFR 484.50 Patient Rights and with no related deficiencies related to the complaint. The agency reported a current census of 48 patients at the time of the survey. As a result of the agency's noncompliance with Medicare Conditions of Participation for home health agencies, the home health agency and its registered nurses are prohibited from providing basic skills competency training and prohibited from providing evaluation of home health aide written basic skills testing and evaluation of demonstrated competency of the hands on basic skills for the agency's home health aides for 2 years, beginning on 3/2/23 and ending on 3/2/25.

Care planning, coordination, quality of care CFR(s): 484.60 Condition of participation: Care planning, coordination of services, and quality of care. Patients are accepted for treatment on the reasonable expectation that an HHA can meet the patient's medical, nursing, rehabilitative, and social needs in his or her place of residence. Each patient must receive an individualized written plan of care, including any revisions or additions. The individualized plan of care must specify the care and services necessary to meet the patient-specific needs as identified in the comprehensive assessment, including identification of the responsible discipline(s), and the measurable outcomes that the HHA anticipates will occur as a result of implementing and coordinating the plan of care. The individualized plan of care must also specify the patient and caregiver education and training. Services must be furnished in accordance with accepted standards of practice. This CONDITION is not met as evidenced by: Based on agency policy review, clinical record review, police report review, patient caregiver/family interview, Medical examiner interview and staff interviews, the agency failed to ensure each patient received home health services that are written in the individualized plan of care (See G572). The cumulative systemic practice resulted in the the failure to ensure the organizational framework of the agency promoted and supported the coordination of safe and effective delivery of care to agency patients.

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 agency policy review, clinical record review, patient caregiver and agency staff interviews, the agency failed to follow a Plan of Care established and periodically reviewed by a physician for 1 of 4 sampled patient's (Patient #4). Failure to follow a Plan of Care established by a physician placed patients at risk of not receiving safe, individualized and consistent care designed to meet each patient's health care needs. Findings include: According to the undated agency policy, titled Home Care Policy on Advance Directives, the agency is to accept patient's for care, regardless of the presence or absence of an advance directive. Clients are to be informed, upon admission of the following: the availability of the state Department of Health Hotline phone number, the need to report any complaints concerning the implementation of advance directive legislation by the agency, upon request, the agency's willingness to provide public education about advance directives, if a patient has not made a decision regarding CPR/no CPR, the patient will be informed the staff will initiate CPR and the policy and procedure are available upon request. According to agency policy, titled Death in the Home-Home Health and dated 3/30/22, an unanticipated (unexpected) death of the home health patient if encountered by staff other than an Registered Nurse (RN), staff should note vital signs, or lack of blood pressure, pulse, respiration, pupil status, note degree of rigor mortis, mottling, position of the body, or any unusual placement of possessions. Staff are to leave the body and possessions as found and note whether any other person was in attendance at the time of death. Staff are to call and report findings to the agency. When the agency is notified of the patient's death, the case manager will discharge the patient from home health services. If the patient dies in their home, the Death at Home OASIS discharge assessment is completed. Information from the last skilled nurse visit will be used to complete the assessment. The assessment should be completed within 24 hours of the agency receiving notification. Regarding notification of County Medical Examiner, staff are to determine the specific state requirements for notification of the county medical examiner of a patient death in the home with Advanced Directives, upon admission to the agency, a patient in end-stage disease process who expressed the wish to die at home and whose provider has written "Do Not Resuscitate" orders, should be listed with the county medical examiners office, and contact the county medical examiner's office regarding the correct process to follow and make note of those instructions in the patient's medical record. According to agency policy, titled Care Planning and Coordination of Care-Home Health and Therapy and dated 3/30/22, the Plan of Care should be patient specific and include Advance Directive information. Patient #4 had a start of care date of 12/27/22 and was discharged from agency on 2/14/23 due to death at home. The Plan of Care identified diagnoses of hypertensive chronic kidney disease stage 1-4 and liver cell carcinoma and urinary tract infection. Clinical record review and associated interviews revealed the following: a. The Plan of Care, dated 12/27/22 through 2/24/23, identified "Do Resuscitate". The Admission and Service Agreement, completed 12/27/22 documented the patient did not have a living will or Power of Attorney. The Resuscitation Status sheet, completed 12/27/22, identified during an emergency situation involving an agency client and staff member, CPR will be initiated and the emergency medical system will be activated. The box was marked that in an emergency situation, the patient does wish to be resuscitated. b. A clinical note, completed by Staff D, Licensed Practical Nurse (LPN), dated 2/14/23 , documented the LPN went to the patient's home to complete a skilled nurse visit and obtain bloodwork to obtain the patient's Protime /International Normalized Ratio level (used to assess the patient's blood clotting). The LPN documented upon arrival the patient's caregiver stated the patient was up at 4:00 AM and had some nausea and gastroesophageal reflux disease (GERD) symptoms. The caregiver stated the patient was slightly confused this morning and was hallucinating, thinking there were needles on the patient's bed. The caregiver reported the patient didn’t feel well the past weekend and had received the second radiation treatment for the spine the day before the visit. The patient had an appointment with dermatology later that afternoon to get sutures removed from patient's left hand and also was to receive another radiation treatment later that day. When Patient #4 woke up at 4:00 AM per caregiver report, the patient appeared to be in pain and the caregiver gave the patient tramadol to control the pain. The caregiver informed the nurse the patient started Dexamethasone 4 mg four times daily, the previous day. When the LPN and and the caregiver went into patients bedroom to perform the nursing visit, the patient was in bed, skin pale and cold and stiff with no apical pulse or respirations noted. The patient had been deceased. The LPN placed a call to the patient's primary care physician's office for notification of patient’s death. The LPN also placed a call to the oncologist to inform of the patient's death and call placed to the cardiologist's office to notify patient death. The LPN then contacted the county coroner to notify of the patient’s death. The caregiver and 2 other family members were in the home and requested the family be the ones to call non emergent 911 to notify of patient’s death when the family was ready for patient to be taken to the funeral home. c. The LPN's time sheet, included a note documenting the LPN went to the patients home from 8:03 AM until 9:15 AM. The timesheet included the patient was deceased, the LPN contacted the coroner. Surveyor interview on 2/21/23 at 4:00 PM with Staff D, LPN reported the LPN had went to do a visit and had arrived at the patient's home and spent 15 minutes while the patient caregiver updated the LPN on what was going on with the patient. The caregiver had given the patient 2 Tramadol for pain around 4 AM. The patient was suppose to go for a radiation session later that day, along with getting stitches removed from hand by the dermatologist, so the LPN told the caregiver to let the patient rest. The doctor just prescribed prednisone therapy as well. The LPN was getting the INR machine ready and told the caregiver they could go in the patient's room together. The caregiver went in before the LPN. The patient was deceased; stiff, cold, hand reaching out to the left, pale, with no teeth in. The LPN checked the patient's apical pulse using a stethoscope and also checked for a radial pulse. The LPN went out and two other family members arrived. The LPN contacted all the patient’s doctor’s. The family requested 911 not to be called as they wanted to wait and have more family come. The LPN then contacted the agency Administrator to notify the office. The family said they would call 911 after all family members had arrived. When the LPN left the patient home, the patient, caregiver and 2 family members were present. Family members asked the LPN several times to wait to call 911 and was adamant to wait on calling 911 until after all family members had arrived. The LPN called the physician before contacting the agency Administrator. The Administrator informed the LPN to contact the Medical Examiner. The LPN left a message for the Medical examiner. The LPN did not attempt CPR, but she knew by the patient's physical appearance and no apical pulse or respirations, the patient had been deceased for awhile and it would not have done any good. The reason the LPN did not stay in the patient's home, was the LPN felt like the LPN was intruding. Family kept looking at the LPN like it was time for the nurse to go. Family kept reiterating they would call 911 when all family members had arrived. Staff D, LPN thought they were waiting for LPN to leave. When the Medical Examiner (ME) contacted the LPN, the ME informed the LPN only Emergency Medical Services (EMS) can pronounce the patient. Surveyor interview on 2/21/23 at 11:03 AM, Agency Administrator reported the LPN did not complete an assessment form and only documented a clinical note. The nurse’s time log did not have any time entered into it. Later the receptionist came in and said the nurse could not finalize the time log because the Clinical Manager would not have been able to complete the required discharge assessment for the patient. The LPN did document a clinical note stating the LPN visited the patient and the patient was deceased, then the nurse contacted the Coroner and went to visit another patient at 9:15 AM. The LPN comforted the caregiver and the caregiver and family members did not want 911 called until all the family got there and requested they (the family) would notify 911. The Administrator reported the LPN and the Administrator had discussed the situation at the time of the patient's death. The Administrator told the nurse to call the coroner and the coroner informed the LPN only Emergency Medical Services (EMS) can pronounce the patient. The Administrator reported the LPN left because it was just very uncomfortable with the LPN just sitting there, so the LPN honored the family’s wishes. Surveyor interview on 2/21/23 at 2:28 PM with Medical Examiner (ME) reported a call was received from the LPN on 2/14/22 at 9:14 AM. The ME was busy with another case. The LPN called and the ME informed the nurse, the ME was busy and called the LPN back at 9:21 AM. The ME asked for the address. The LPN told the ME the LPN left the residence. The ME asked the nurse for the name and address. The nurse said no vital signs were taken and the nurse visibly pronounced the patient. The ME had a police officer with me them with the other case, so had them call 911 and ME provided the address. EMS was dispatched. The nurse said no vitals were taken and the nurse left as had other patients. The EMS medic pronounced the patient dead at 9:38 AM. The ME finished the other case and went to the patient’s home and met with the patient’s caregiver and a couple of other family members. The ME did call and talk to the deputy. ME called the nurse later in the afternoon. The nurse told the ME what the nurse's job was and stated it was just to take vitals. The ME informed the nurse what the protocol for the county is, to take vitals, call 911. The ME informed the nurse to stay with the patient until the ambulance arrives if sees something wrong with a patient in the future. The ME did not ask the family what they wanted. The ME recalled the family was waiting for more family to arrive before wanting the body to go to the funeral home. The LPN informed the ME the LPN called agency supervisor and they told the nurse to call the medical examiner. The family told the ME what funeral home they wanted, but did not want the patient’s body to leave until more family arrived. The ME assessed the patient's body was already 90.5 degrees which meant the patient had been dead for 4-4 ½ hours and knew the patient would be having several changes start happening fast and informed the family the importance of getting the patient's body to the funeral home. d. The police report, dated 2/14/23 at 9:26 AM, documented the officer responded to the home of a possible deceased patient. While the officer was in route, dispatch informed the officer the Medical Examiner (ME) had received a call from a nurse informing the ME there was a deceased patient at the home. The officer arrived and noticed several family members were present with the patient's caregiver. The caregiver informed the officer the patient had liver and bone cancer. The caregiver woke the patient up at 4:00 AM and sat up and asked for pain medications due to pain. The caregiver provided the pain medication and the patient returned to bed around 5:00 AM. The caregiver reported around 8:00 AM, the caregiver went to check on the patient, but the LPN arrived. They both went into the bedroom and noticed the patient was deceased. The officer asked the caregiver if the LPN did anything and the caregiver stated no and the LPN left around 9:10 AM. The wife informed the officer the patient did not have a Do Not Resuscitate Order, was not part of hospice, and had just received a second round of chemotherapy. The report stated when the ME arrived, the ME informed the officer of the call received from the LPN. The ME asked the LPN if the nurse pronounced the patient and the LPN stated no. The ME asked how the LPN knew the patient was deceased and the LPN stated by looking at the patient. The LPN informed the ME the LPN had left the home to see another patient and did not contact 911. The ME then contacted dispatch. The ME did later contact the agency to speak to the LPN and LPN informed the ME the office told the LPN to contact the medical examiner instead of 911. The ME explained the State of Iowa Protocols to the LPN. Surveyor interview on 2/21/23 at 1:26 PM with caregiver reported the patient had been receiving Physical Therapy for awhile, but felt like it wasn't needed, so ended therapy. The day the patient passed, the nurse came to do INR blood draws and vital signs. At 7:50 AM, the caregiver went into the bedroom and the patient didn’t look right. The caregiver touched the patient's cheek and yelled for the nurse to come in there as the nurse was still setting up the computer. The LPN and caregiver were just talking about the patient a few minutes before that. The nurse was going to check the patient's INR. The caregiver reported feeling so thankful the patient was home when it happened (patient's death). The nurse came in and listened for a pulse (the nurse looked at patient and felt the chest). When the medical examiner came, the ME didn’t think the patient had been gone too long. Patient #4 had chosen no chemotherapy, but the doctor said radiation might allow a longer life. The caregiver called the other two family members and they came right away. The deputy sheriff came first. The LPN was there for 40-50 minutes. The LPN did call the doctors. The caregiver knew the patient was gone, as skin was cold. Family member was talking in the background during interview and reported the family did not want 911 called as they were waiting for 4 more family members to arrive before having the body released. Family was happy the patient was able to decease at home. Agency staff failed to follow the Plan of Care in an emergency situation to resuscitate the patient and follow agency policy to activate the emergency medical system and left the patient's home before emergency medical services staff arrived. On 3/1/23 at 10:00 AM the agency Administrator and Clinical Manager were notified an Immediate Jeopardy situation was identified. Staff formulated a removal plan and educated all staff on updated policies regarding advance directives and death in the home. Staff interviews were completed by the surveyor to ensure all staff received the education and could identify plan for current and future patients regarding advance directives and death at home. On 3/2/23 at 11:50 AM, the agency Administrator and Clinical Manager was informed of the immediacy of the Immediate Jeopardy regarding Care Planning, Coordination of Services, and Quality of Care was removed. No further information was provided prior to the end of the survey.

The Department of Inspections and Appeals conducted a recertification survey, dated 1/23/23 to 1/26/23, and found the agency to be operating in substantial compliance under the Emergency Preparedness Condition of Participation.

The Department of Inspections and Appeals conducted a recertification survey for the home health agency, dated 1/23/23 to 1/26/23. The survey identified the following standard level deficient practices. The agency reported a census of 52 patients at the time of the survey.

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 clinical record review, agency policy review and agency staff interview, the agency failed to include an individualized assessment relating to the patient's current health status when completing comprehensive assessments for 2 of 4 sampled patients with wounds (Patients #1 and #2). Failure to complete an individualized patient comprehensive assessment which identified the extent of patient wounds placed agency patients at risk for unidentified worsening of conditions, inappropriate treatments, or unmet home health care needs. Findings include: Review of the agency policy, titled Wound Care, dated 12/2/22, identified agency professional staff wound measure wounds at least weekly and include a length, width and depth. Review of the agency policy, titled Comprehensive Assessment, dated 3/7/22, agency professional staff must complete a patient-specific comprehensive assessment on each patient that accurately reflects the patient's health status. On 1/24/23 at 9:34 AM, during an interview, the Clinical Manager reported agency nursing staff were responsible for measuring wounds weekly. 1. Patient #1 had a start of care date of 10/11/22. Review of the clinical record revealed the following: a. The Plans of Care (POCs), dated 10/11/22 to 12/9/22 and 12/10/22 to 2/7/23, identified the patient had chronic left lower extremity leg wounds, included an order for skilled nursing services and an order for the skilled nurse to complete wound care. The POCs included orders for the skilled nurse to assess the wounds including location, size, drainage, wound bed and peri-wound. The POC, dated 12/10/22 to 2/7/23, identified the patient had 2 wounds on the left lower leg, a lateral wound and a posterior wound. b. The update to the comprehensive assessment completed at the time of recertification, dated 12/6/22, identified the patient had 2 left lower leg wounds, a lateral leg wound and a posterior calf wound. The nurse assessed both wounds had small amount of blood-tinged drainage and the wound beds were pink with 75 percent slough (dead tissue). The assessment lacked documentation the nurse measured the wounds. 2. Patient #2 had a start of care date of 8/17/22. Review of the clinical record revealed the following: a. The POC, dated 8/17/22 to 10/15/22, identified the patient had a wounds on both lower legs and a buttocks wound and included orders for the skilled nurse to provide wound care to the the lower legs and buttocks. The POC included an order for the skilled nurse to the wounds including location, size, drainage, wound bed and peri-wound. The comprehensive assessment completed at the start of care, dated 8/17/22, included documentation the nurse assessed the patient had a venous stasis ulcer on the right and lower legs and a buttocks shearing wound. The assessment included documentation of wound measurements for the buttocks wound, but lacked measurements of the right and left lower leg venous stasis ulcer wounds. b. The POC, dated 12/15/22 to 2/12/22, identified the patient had multiple small left lower leg venous stasis ulcer wounds and included orders for the skilled nurse to provide treatment to the wound area. The POC included an order for the skilled nurse to the wounds including location, size, drainage, wound bed and peri-wound. The update to the comprehensive assessment completed at the time of recertification, dated 12/13/22, identified the patient a left lower leg venous stasis ulcer with a pink wound bed and a small amount of clear drainage. The assessment lacked documentation the nurse measured the left lower leg wound. The assessment did not identify multiple wounds on the left lower leg. The Administrator and Clinical Manager received the above findings and agency staff provided no further information prior to the end of the survey.

Last 5 days of every 60 days unless: CFR(s): 484.55(d)(1)(i,ii,iii) The last 5 days of every 60 days beginning with the start-of-care date, unless there is a- (i) Beneficiary elected transfer; (ii) Significant change in condition; or (iii) Discharge and return to the same HHA during the 60-day episode. This ELEMENT is not met as evidenced by: Based on clinical record review and agency policy review, the agency failed to ensure accurate completion of all required components of the recertification comprehensive assessments between day 56 and 60 of each 60 day certification period for 1 of 5 sampled patients requiring a recertification assessment (Patient #3). Failure to accurately and thoroughly complete recertification comprehensive assessments in a timely manner increased the potential that patients might not receive services in a manner to meet individualized patient needs. Findings include: According to the agency policy, titled Comprehensive Assessment Home Health, Therapy and Rehab, dated 3/7/22, the comprehensive assessment must be updated any time there is an unanticipated decline or improvement in the patient's health status, but no less frequently then the last 5 days of ever 60 days beginning with the start of care date unless there is a transfer, significant change in condition or discharge and return to the agency during the 60-day episode, and at discharge. Patient #3 had a start of care date of 9/2/20. The patient's clinical record included the following: a. Update to the Comprehensive Assessment, dated 8/23/22 (day 1 of the new certification period), 1 day after the end of the previous certification period. The certification period ended on 8/22/22. The assessment was not completed in the last 5 days of the certification period as required by regulation. b. Update to the Comprehensive Assessment, dated 12/14/22 (day 54 of the certification period), 7 days before the start of the new certification period. The certification period ended on 12/20/22. The assessment was not completed in the last 5 days of the certification period as required by regulation. The above findings were reviewed with the agency Administrator and Clinical Manager. The agency provided no additional information prior to the end of the survey.

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 agency policy review, clinical record review and agency staff interview, 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 for Care for 4 of 7 sampled patients (Patients #2, #3, #5 and #7). Failure to follow a Plan of Care established by a physician placed patients at risk of not receiving safe, individualized and consistent care designed to meet each patient's health care needs. Findings include: 3. Patient #7 had a start of care date on 4/8/22 and died on 5/10/22. Review of the clinical record revealed the following: a. The Plan of Care (POC), dated 4/8/22 to 6/6/22, included orders for skilled nursing services 2 times per week and home health aide services 1 time per week for 8 weeks. b. The clinical record lacked documentation of a home health aide visit the week of 5/1/22, and lacked documentation agency staff notified the physician of the missed visit. 4. Patient #2 had a start of care date of 8/17/22. Review of the clinical record revealed the following: a. The POC, dated 10/16/22 to 12/14/22, included orders for skilled nursing services. b. An interim physician order, dated 11/18/22, included an order for the nurse to provide wound care to multiple small venous stasis ulcers on the right lower leg. The physician ordered the skilled nurse to cleanse the wounds with Normal Saline, apply Silver Alginate to the wound bed, cover the wounds with a 4 x 4 gauze dressing or abdominal wound (ABD) pad, wrap with Kerlix, secure with tape and apply Tubigrip over the top of the dressing. c. A skilled nursing visit note, dated 11/29/22, included documentation the patient refused the dressing ordered by the physician. The clinical record lacked documentation the nurse notified the physician of the inability to provide wound care treatment as ordered. The Administrator and Clinical Manager received the above findings and agency staff provided no further information prior to the end of the survey. According to the agency policy, titled Care Planning and Care Coordination, Home Health and Therapy, dated 3/30/22, formulating the plan of care is a collaborative effort amongst the patient, the provider and all members of the team. Everyone should have access to the plan of care in order to facilitate coordination of care. The plan of care should be patient-specific and include services and disciplines involved, along with the frequency and duration of each. On 1/25/23 at 12:05 PM, the Clinical Manager reported the home health aide was responsible for completing the missed visit notification form to the physician. 1. Patient #3 had a start of care date of 9/2/20. Clinical record review revealed the following: a. The Plan of Care, dated 12/21/22 to 2/18/23, included physician orders for Registered Nurse 1 time a week. b. The clinical record lacked documentation of a Registered Nurse visit completed the week of 12/19/22 to 12/24/22. The clinical record lacked documentation of notification to the physician that the services were not completed the week of 12/19/22 through 12/24/22. 2. Patient #5 had a start of care date of 2/27/18. Clinical record review revealed the following: a. The Plan of Care, dated 12/3/22 to 1/31/23, included physician orders for home care aide 2 time a week. b. The clinical record included documentation of only 1 home care aide visit completed the week of 12/25/22 to 12/30/22 and 1/8/23 to 1/14/23. The clinical record lacked documentation of notification to the physician that the services were not completed for 1 additional HCA visit the week of 12/25/22 through 12/30/22 and 1/8/23 to 1/14/23.

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 agency policy review, clinical record review, home visit observation and patient and staff interviews, the agency failed to ensure the accurate completion of all components compromising the Plan of Care, including all supplies/equipment and medications used by the patient for 3 of 3 sampled patients with surveyor home visit observation (Patients #1, #2 and #3). 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 physicians orders. Findings include: 2. Patient #1 had a start of care date of 10/11/22. Review of the clinical record revealed the following: a. The Plan of Care (POC), dated 12/10/22 to 2/7/23, included an order for skilled nursing services to provide wound care to 2 left lower leg wounds, a lateral leg wound and a posterior leg wound. The POC also included orders for the nurse to provide wound care to a left posterior thigh wound by cleansing the wound with Normal Saline, applying Silver Calcium Alginate, and cover with a foam border dressing twice per week and as needed. b. The update to the comprehensive assessment completed at the time of recertification, dated 12/6/22, identified the patient had 2 left lower leg wounds, a lateral leg wound and a posterior calf wound. The assessment did not identify the patient had any other wounds. The POC inaccurately identified and included wound care orders for a wound the patient did not have. On 1/25/23 at 4:11 PM, during an interview, the Clinical Manager confirmed the POC included orders for a left posterior thigh wound the patient no longer had. 3. Patient #2 had a start of care date of 8/17/22. a. On 1/23/23 at 2:40 PM, during a home visit observation with Staff D, Occupational Therapist (OT), the surveyor observed the patient had a medication box and a reacher. The surveyor observed the patient had a bottle of Magnesium 250 mg tablets with the patient's other medication bottles and a Breztri inhaler on a nearby end table. The surveyor assessed the patient used grab bars in the bathroom, but had not other medical equipment in the bathroom. In an interview, during the same home visit observation, the patient reported having had the medication box since getting out of the hospital and starting services with the home health agency. The patient reported using the reacher on a daily basis for several years. The patient reported not using a toilet riser for several months. The The patient reporting using the Breztri inhaler twice per day for 2 months and taking Magnesium 250 mg 1 tablet every day since getting out of the hospital and just prior to starting agency services. Review of the clinical record revealed the following: The POC, dated 12/10/22 to 2/7/23, identified the patient used a toilet riser. The POC failed to identify the patient took Magnesium and used the Breztri inhaler. The POC failed to identify the patient used a reacher and medication box. b. The POC, dated 8/17/22 to 10/15/22, included conflicting orders for oxygen. The POC included an order for oxygen 3 liters per minute continuous and also included an order for the skilled nurse to assess the patient's respiratory status and use of oxygen at 4 liters continuous. c. An interim physician order (IPO), dated 8/24/22, identified the patient had a new open wound to the left gluteal fold and included orders for the skilled nurse to cleanse the open area on the left gluteal fold with Normal Saline and cover with Mepilex 3 times per week and as needed. 1) An IPO, dated 9/16/22, included orders for the skilled nurse to assess the left gluteal fold weekly and as needed and may apply a Mepilex border dressing for preventative measure. The POC, dated 10/16/22 to 12/14/22, included an order for the skilled nurse to assess the left gluteal fold weekly and as needed and may apply a Mepilex border dressing for preventative measure. The POC included the following conflicting statement by the nurse: right gluteal fold wound healed on 9/16/22; skilled nurse covered with foam border dressing for preventative measures. The POC contained inaccurate/conflicting wound care information. d. The POC, dated 12/15/22 to 2/12/23, identified the patient had a new open wound to the left gluteal fold and included orders for the skilled nurse to cleanse the open area on the left gluteal fold with Normal Saline and cover with Mepilex 3 times per week and as needed. The update to the comprehensive assessment completed at the time of recertification, dated 12/13/22, identified the patient had a left lower leg venous stasis ulcer and no the wounds. The POC inaccurately included orders for a wound the patient no longer had. The Administrator and Clinical Manager received the above findings and agency staff provided no further information prior to the end of the survey. According to the agency policy, titled Care Planning and Care Coordination, Home Health and Therapy, dated 3/30/22, the plan of care should be patient-specific and include medications, treatments, equipment, supplies and limitations (functional, nutritional and safety needs). 1. Patient #3 had a start of care date of 9/2/20. Clinical record review, home visit observation and accompanying interviews revealed the following: walker, shower chair, grab bars, handheld shower, medi planners, briefs, glucometer, test strips, lancets, emergency response system. a. The Plan of Care, dated 1/5/23 to 3/5/23, included the following durable medical equipment (DME): walker, shower chair, grab bars, handheld shower, medi planners, briefs, glucometer, test strips, lancets, emergency response system. During a home visit observation on 1/24/23 at 1:10 PM, with Staff E, Registered Nurse (RN), the patient reported they also utilized a nebulizer and supplies, CPAP and supplies and did not use a shower chair. The items utilized since the beginning of home health services. The plan of care failed to include the nebulizer and supplies and CPAP and supplies as equipment utilized by the patient and failed to remove the shower chair. b. The plan of care included the following medications. Senna (laxative) 8.6 mg (milligram) 50 mg 1 tablet daily as needed for constipation. During the same home visit, the patient stated they had not taken senna for a long time and identified it had been greater than 1 year.

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 clinical record review, agency policy review and home visit observation, the agency failed to ensure agency staff provided wound care treatments only as ordered by the physician for 3 of 4 sampled patients (Patients #1, #2 and #7) with wounds. Failure to ensure staff obtain/follow physician orders for wound care treatments placed agency patients at risk for inconsistent care/treatment and possible harm. Findings include: Review of the agency policy, titled Care Planning and Care Coordination, dated 3/30/22, identified the Plan of Care (POC) should be patient-specific and include treatments. Review of the agency policy, titled Wound Care, dated 12/2/22, identified staff will provide wound care treatments per the POC. Wound care orders should include the dressing type, frequency, medications to treat and wound cleansing agent. 1. Patient #1 had a start of care date of 10/11/22. Review of the clinical record revealed the following: a. The POC, dated 10/11/22 to 12/9/22, included orders for the skilled nurse to perform wound care to the left lower leg wounds 2 times per week by cleansing the wounds with a non-cytotoxic agent, cover the wound bed with Calcium Alginate, wrap with Kerlix and place Tubigrip over the dressing. b. The POC, dated 12/10/22 to 2/7/23, included orders for the skilled nurse to perform wound care to the left lower lateral and posterior leg wounds 2 times per week by cleansing the wound bed and peri-wound with a non-cytotoxic agency, cover the wound bed with Silver Alginate, cover with Opti-lock and apply a 2 layer compression wrap dressing. On 1/23/23 at 12:35 PM, during a home visit observation, Staff C, Staff C, Licensed Practical Nurse (LPN), completed an assessment of the patient and performed wound cares to the left lateral lower leg wound and left posterior calf wound. Staff C, LPN, removed the 2 layers of compression dressing covering the left lower leg from the patient's foot to just below the patient's left knee. The surveyor observed the patient had Kerlix wrapped from the foot to just below the knee just under the compression dressing layer. Staff C, LPN, continued to remove the Opti-lock dressing and Silver Calcium Alginate wound dressing. Staff C, LPN, cleansed the wounds with on the left lateral and posterior calf with a wound cleanser. Staff C, LPN, applied Silver Calcium Alginate, Opti-lock, then wrapped the entire area from the patient's foot to just below the left knee with Kerlix roll dressing prior to applying the 2 layer compression dressing. Staff C, LPN, applied a Kerlix dressing without specific wound care orders to apply this type of dressing. 2. Patient #2 had a start of care date of 8/17/22. Review of the clinical record revealed the following: a. An interim physician order (IPO), dated 11/18/22, identified the patient had multiple small venous stasis ulcers on the right lower leg and included orders for the skilled nurse to perform wound care 2 times per week and as needed by cleansing the wounds with Normal Saline, applying Silver Alginate to wound bed, cover with 4 x 4 gauze or abdominal (ABD) pad, wrap with Kerlix, secure with tape and apply Tubigrip to cover. b. The update to the comprehensive assessment completed at the time of recertification, dated 12/13/22, identified the patient had a left lower leg venous ulcer wound, but the right lower leg wounds had healed. c. The POC, dated 12/15/22 to 2/12/23, included orders for the skilled nurse to perform would care to the left lower venous ulcer wound. The POC did not identify a right lower leg wound or include any orders to treat. d. A skilled nursing visit, dated 12/15/22, identified the patient's right lower leg wounds had healed. e. The skilled nursing visits, dated 12/20, 12/27 and 12/30/22, 1/6 and 1/20/23, included documentation the skilled nurse provide wound care treatment per the POC for a right lower leg wound. The visits, dated 12/20/22, 12/27/22, 1/6/23 and 1/10/23, included documentation of a wound assessment and measurements of a right lower leg wound. f. An IPO, dated 1/13/23, identified the patient had multiple small venous stasis ulcers on the right lower leg and included orders for the skilled nurse to perform wound care 2 times per week and as needed by cleansing the wounds with Normal Saline, applying Silver Alginate to wound bed, cover with 4 x 4 gauze or abdominal (ABD) pad, wrap with Kerlix, secure with tape and apply Tubigrip to cover. The clinical record lacked documentation of wound care orders or notification of the physician of a right lower leg wound or wounds from 12/20/22 until 1/13/23. 3. Patient #7 had a start of care date of 4/8/22 and died on 5/10/22. Review of the clinical record revealed the following: a. The POC, dated 4/8/22 to 6/6/22, identified the patient had a gastrostomy (opening in the stomach) and gastric tube (GT) for feeding. The POC included orders for the skilled nurse to assess the skin around the stoma (gastric opening) and instruct on care. The POC included a summary in which the nurse informed the physician the patient had been unable to perform a dressing change to the GT site due to being too weak. The nurse documented she cleansed the area with soap and water, applied a 4 x 4 gauze dressing and secured the dressing with tape. The nurse completed the treatment without obtaining specific orders for cleansing the site and applying the dressing. 1) The skilled nursing clinical notes, dated 4/12, 4/15, 4/19, 4/22, 4/26, 4/29, 5/6 and 5/9/22, included documentation the skilled nurse cleansed the GT site with soap and water and applied a 4 x4 dressing. 2) The clinical record lacked an order to perform treatment to the GT site which included a frequency, cleansing agent and dressing type. b. The skilled nursing clinical notes, dated 4/12, 4/15, 4/22, 4/26, 5/3 and 5/6/22, included documentation the nurse applied a cushion dressing (Mepilex) to a reddened area on the patient's buttocks/coccyx area. 1) The skilled nursing clinical notes, dated 4/29 and 5/9/22, included documentation the nurse applied Mepilex to reddened areas on the patient's left heel and coccyx. 2) The clinical record lacked documentation of a physician order for the application of Mepilex or a cushion dressing to the coccyx/buttock area and left heel. The Administrator and Clinical Manager received the above findings and agency staff provided no further information prior to the end of the survey.

Patient medication schedule/instructions CFR(s): 484.60(e)(2) Patient medication schedule/instructions, including: medication name, dosage and frequency and which medications will be administered by HHA personnel and personnel acting on behalf of the HHA. This ELEMENT is not met as evidenced by: Based on patient, family and staff interview, the agency failed to provide medication lists to the patient/caregiver that included medication name, dosage, frequency, administration times for 3 of 3 sampled patients (Patients #1, #2 and #3) with a home visit observation. Failure to ensure a medication list in the patient's home puts the patient and caregiver at risk for not knowing all current medications the patient is taking and puts the patient at risk for inappropriate medication administration. Findings include: 1. Patient #1 had a start of care date of 10/11/22. Review of the clinical record revealed the following: a. The Plan of Care (POC), dated 10/11/22 to 12/9/22, included orders for skilled nursing, physical and occupational therapy services and medications. The POC included the signature of Staff E, Registered Nurse (RN). b. The POC, dated 12/10/22 to 2/7/23, included orders for skilled nursing and physical therapy services and medications. The POC included the signature of Staff E, RN. On 1/23/23 at 12:40 PM, during a home visit observation, Staff C, Licensed Practical Nurse (LPN), assessed the patient, completed wound care and reviewed the patient's medications with the patient's family member. In an interview, during the same home visit observation, the patient reported the patient's family member set up the patient's medications. Both the patient's family member and the patient reported not having received a medication list from the agency since the start of agency services. They did not know where the agency admission packet was that contained that information. Staff C, LPN, was unsure if the registered nurse had provided this to the patient, and explained she was not responsible for doing this. 2. Patient #2 had a start of care date of 8/17/22. Review of the clinical record revealed the following: a. The POC, dated 8/17/22 to 10/15/22, included orders for skilled nursing, physical and occupational therapy services and medications. The POC included the signature of Staff E, RN. b. The POCs, dated 10/16/22 to 12/14/22 and 12/15/22 to 2/12/23, included orders for skilled nursing and medications. The POC included the signature of Staff E, RN. On 1/23/23 at 2:40 PM, during a home visit observation, Staff D, Occupational Therapist (OT), assessed the patient and completed a lymphedema wrap on the left lower leg. In an interview, during the same home visit observation, the patient reported the patient had not received a medication list from agency staff since the start of services. Staff D, OT, did not know anything about this, but reported patient's typically got information on treatments the agency provides at the start of care. 3. Patient #3 had a start of care date of 9/20/20. Clinical record review revealed the following: The plan of care, dated 12/21/22 to 2/18/23, included orders for skilled nursing services 1 time a week. The plan of care also included orders for 21 medications. During an observation home visit on 1/24/23 at 1:10 PM with Staff E, RN (Registered Nurse), Staff E reconciled the agencies medications with a medication list from the VA (veterans administration system). Staff E then set up the patient's medications for a 1 week supply and placed the medications in a medi planner. She did not leave a copy of the agency medication list in the patient's home. During an interview during the same observation home visit the patient stated the agency does not provide a list of medication but all medication lists they receive are from the VA. During an interview on 1/24/23 at 2:00 PM Staff E, RN stated she will update the Physician if there is a new order. The new order will be written down for the patient. Staff discuss with the patient the side effects and teach back which includes having the patient repeat the side effects. The next visit, staff will bring up the medication and follow up with the teaching. The agency failed to provide a list of medications to the patient. The above findings were reviewed with the agency Administrator and Clinical Manager. The agency provided no additional information prior to the end of the survey.

Treatments and therapy services CFR(s): 484.60(e)(3) Any treatments to be administered by HHA personnel and personnel acting on behalf of the HHA, including therapy services. This ELEMENT is not met as evidenced by: Based on patient/family interview and staff interview, the agency failed to ensure agency staff provided written information on treatments to be administered by agency staff to the patient/caregiver for 3 of 3 sampled patients (Patients #1, #2 and #3) with a home visit observation. Failure to ensure agency staff provided patients/caregivers with written information on treatments that the agency staff plan to administer to the patient placed agency patients at risk to be unaware of, or not fully informed of treatments the patient needs in order to reach maximum wellness potential. Findings include: 3. Patient #3 had a start of care date of 9/20/20. Clinical record review revealed the following: The plan of care, dated 12/21/22 to 2/18/23, included orders for skilled nursing services 1 time a week. Orders included .providing the treatment of medication set up. During an observation home visit on 1/24/23 at 1:10 PM with Staff E, RN (Registered Nurse), Staff E set up the patient's medications for a 1 week supply and placed the medications in a medi planner. During an interview on 1/24/23 at 2:00 PM Staff E, RN stated she will update the Physician if there is a new order for medications or treatments. The new treatment will be written down for the patient. The next visit, staff will bring up the treatment and follow up with the teaching. The agency failed to provide a list of treatments to the patient. The above findings were reviewed with the agency Administrator and Clinical Manager. The agency provided no additional information prior to the end of the survey. 1. Patient #1 had a start of care date of 10/11/22. Review of the clinical record revealed the following: a. The Plan of Care (POC), dated 10/11/22 to 12/9/22, included orders for skilled nursing, physical and occupational therapy services and medications. The POC included the following wound treatment orders for wounds on the patient's left lower leg: skilled nurse to perform wound care to the left lower leg wounds 2 times per week by cleansing the wounds with a non-cytotoxic agent, cover the wound bed with Calcium Alginate, wrap with Kerlix and place Tubigrip over the dressing. The POC included the signature of Staff E, Registered Nurse (RN). b. The POC, dated 12/10/22 to 2/7/23, included orders for skilled nursing and physical therapy services. The POC included the following wound treatment orders for wounds on the patient's left lower leg: the skilled nurse to perform wound care to the left lower lateral and posterior leg wounds 2 times per week by cleansing the wound bed and peri-wound with a non-cytotoxic agency, cover the wound bed with Silver Alginate, cover with Opti-lock and apply a 2 layer compression wrap dressing. The POC included the signature of Staff E, RN. On 1/23/23 at 12:40 PM, during a home visit observation, Staff C, Licensed Practical Nurse (LPN), assessed the patient, completed wound care and reviewed the patient's medications with the patient's family member. In an interview, during the same home visit observation, both the patient's family member and the patient reported not having received any written information on treatments the agency provided since the start of agency services. Staff C, LPN, was unsure if the registered nurse had provided this to the patient, and explained she was not responsible for doing this. 2. Patient #2 had a start of care date of 8/17/22. Review of the clinical record revealed the following: a. The POC, dated 8/17/22 to 10/15/22, included orders for skilled nursing, physical and occupational therapy services. The POC included the following wound care treatment orders for the skilled nurse to perform: cleanse bilateral lower leg venous stasis ulcers with a non-cytotoxic agent, apply Silver Alginate and wrap with Kerlix; cleanse buttocks wound with non-cytotoxic agency and apply Z-Guard to excoriated areas. The POC included the signature of Staff E, RN. b. An interim physician order (IPO), dated 8/24/22, identified the patient had a new open wound to the left gluteal fold and included orders for the skilled nurse to cleanse the open area on the left gluteal fold with Normal Saline and cover with Mepilex 3 times per week and as needed. c. An IPO, dated 9/16/22, included orders for the skilled nurse to assess the left gluteal fold weekly and as needed and may apply a Mepilex border dressing for preventative measure. d. The POC, dated 10/16/22 to 12/14/22, included orders for skilled nursing and wound care treatment as follows: the skilled nurse to assess the left gluteal fold weekly and as needed and may apply a Mepilex border dressing for preventative measure; cleanse left lower leg venous stasis ulcer with a non-cytotoxic agent, Normal Saline, apply Silver Alginate to wound bed, apply Mepilex foam border dressing and Tubigrip 2 times per week and as needed. The POC included the signature of Staff E, RN. e. An IPO, dated 11/18/22, identified the patient had multiple small venous stasis ulcers on the right lower leg and included orders for the skilled nurse to perform wound care 2 times per week and as needed by cleansing the wounds with Normal Saline, applying Silver Alginate to wound bed, cover with 4 x 4 gauze or abdominal (ABD) pad, wrap with Kerlix, secure with tape and apply Tubigrip to cover. f. The POC, dated12/15/22 to 2/12/23, included orders for skilled nursing and wound care treatment as follows: wound care to left lower leg multiple small venous stasis ulcers 2 times per week and as needed, cleanse with Normal Saline, apply Silver Alginate to wound bed, cover with 4 x 4 gauze or abdominal (ABD) pad, wrap with Kerlix, secure with tape and apply Tubigrip. g. An IPO, dated 1/13/23, identified the patient had multiple small venous stasis ulcers on the right lower leg and included the wound care orders for the skilled nurse 2 times per week and as needed, cleanse with Normal Saline, apply Silver Alginate to wound bed, cover with 4 x 4 gauze or abdominal (ABD) pad, wrap with Kerlix, secure with tape and apply Tubigrip. On 1/23/23 at 2:40 PM, during a home visit observation, Staff D, Occupational Therapist (OT), assessed the patient and completed a lymphedema wrap on the left lower leg. In an interview, during the same home visit observation, the patient reported the patient had not received any written information from agency staff on treatments the agency staff provided since the start of services. Staff D, OT, did not know anything about this, but reported patient's typically got information on treatments the agency provides at the start of care. Staff D, OT, explained they did not give anything in writing to the patient on the lymphedema wrap treatment they started to provide the patient on 1/6/23 two times per week.

Services provided by HH aide CFR(s): 484.80(g)(2) A home health aide provides services that are: (i) Ordered by the physician or allowed practitioner; (ii) Included in the plan of care; (iii) Permitted to be performed under state law; and (iv) Consistent with the home health aide training. This ELEMENT is not met as evidenced by: Based on clinical record review, agency policy review and staff interview, the agency failed to ensure home health aides provided care to agency patients only as ordered by the physician and/or as directed by the skilled professional assigning the home health aide to the patient for 1 of 3 sampled patients receiving home health aide services (Patient #4). Failure to ensure that home health aide services are provided only as ordered by the physician and according to the home health aide care plan increased the risk that patient's personal care needs were not adequately met According to the agency policy, titled Home Health Aide Supervision and Delegation of Duties, Home Health, dated 3/30/22, the patient's care plan for the Home Health Aide to follow will be developed by the Case Manager or RN. A written copy of the care plan will be provided to the aide and revised periodically as the care plan changes as well as at recertification. 1. Patient # 4 had a start of care date of 10/8/21. Review of the clinical record revealed the following: a. The POCs (Plan of Care), dated 10/3/22 to 12/1/22 and 12/2/22 to 1/30/23, included physician orders for skilled nursing and home health aide services. b. The home health aide care plan, dated 10/4/22, included RN instructions to the home health aide to complete the following tasks: assist with activities of daily living, partial/complete bed bath per patient request, nail care non-diabetic per patient request, assist with dressing, undressing per patient request and apply lotion. c. The home health aide visit note, dated 12/20/22, included documentation the home health aide completed the task of reapplied tubi grips to the patient's lower legs. d. The home health aide visit note, dated 12/27/22, included documentation the home health aide completed the task of providing good catheter cares. e. Review of the clinical record lacked documentation the aide contacted the Registered Nurse prior to completing the task. The tubi grips and catheter cares not added to the aide assignment/care plan. During an interview on 1/24/23 at 12:20 PM, the Administrator confirmed catheter care should be on the home care aide assignment. The above findings were reviewed with the agency Administrator and Clinical Manager. The agency provided no additional information prior to the end of the survey.

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 and staff interview, the agency failed to ensure agency staff included documentation on all interventions for treatments and services and patient responses to the interventions for 2 of 4 patients with wound measurement requirements and 2 of 3 patients with home health aide services (Patient #1, #2, #4 & 7). Failure to ensure that documentation of services and treatments provided and the patient's response to the interventions not documented increased the risk that patient's medical needs and personal care needs were not adequately met. Findings include: Review of the agency policy, titled Wound Care, dated 12/2/22, identified agency professional staff wound measure wounds at least weekly and include a length, width and depth. On 1/24/23 at 9:34 AM, during an interview, the Clinical Manager reported agency nursing staff were responsible for measuring wounds weekly. 2. Patient #1 had a start of care date of 10/11/22. Review of the clinical record revealed the following: a. The update to the comprehensive assessment completed at the time of recertification, dated 12/6/22, identified the patient had a left lateral lower leg wound and a left posterior calf wound. b. The Plan of Care (POC), dated 12/10/22 to 2/7/23, included orders for skilled nursing services and for the skilled nurse to complete wound care on the left lower leg lateral wound and left leg posterior calf wound. The POC included orders for the nurse to assess the size of the patient's wounds weekly. c. The clinical record included documentation of 2 skilled nursing visits the week of 12/18/22, dated 12/19 and 12/23/22. The skilled nursing visit, dated 12/19/22, included documentation of a wound measurement for the left lateral leg wound, but lacked documentation of measurements for the left posterior calf wound. The skilled nursing visit, dated 12/23/22, included documentation the nurse completed wound care on the left lateral and left posterior leg wounds, but did not include any wound measurements. Agency nursing staff failed to document the measurements of the patient's left posterior calf wound the week 12/18/22. 2. Patient #2 had a start of care date of 8/17/22. Review of the clinical record revealed the following: a. The update to the comprehensive assessment completed at the time of recertification, dated 12/13/22, identified the patient had a left lower leg venous stasis ulcer. b. The POC, dated 12/15/22 to 2/12/23, included orders for skilled nursing services and wound care treatment orders for multiple small venous stasis ulcer wounds on the left lower leg. The POC included an order for the skilled nurse to assess the size of the wounds weekly. c. A skilled nursing visit, dated 1/10/23, included documentation the nurse assessed a left lower leg venous stasis ulcer which measured 3.5 centimeters (cm) in length, 3.0 cm in width and less than 0.2 cm in depth. The nurse documented the right lower leg had multiple small pinpoint venous stasis ulcers. d. The clinical record included documentation of 2 skilled nursing visits the week of 1/15/23, dated 1/17 and 1/20/23. Both visit notes lacked documentation of any type of measurement of the wounds. 3. Patient #7 had a start of care date of 4/8/22 and died on 5/10/22. Review of the clinical record revealed the following: a. The POC, dated 4/8/22 to 6/6/22, included orders for home health aide services weekly and skilled nursing services. b. The clinical record included documentation of a 3 home health aide visits, dated 4/14, 4/21 and 4/28/22. The visits included documentation of two separately assigned tasks, shampooing and shaving, on the same line with only one answer, a plus sign for completion. The visit note failed to identify if the home health aide completed both tasks or just one of the 2 assigned tasks. The Administrator and Clinical Manager received the above findings and agency staff provided no further information prior to the end of the survey. According to the agency policy, titled Documentation Standards, Home Health and Therapy/Rehab, dated 12/13/22, the documentation in the clinical record must be accurate and reflect the physical condition of the client, the psychosocial status of the client and family and the care provided from admission through discharge. 1. Patient #4 had a start of care date of 10/8/21. Clinical record review revealed: a. The Plans of Care, dated 10/3/22 to 12/1/22 and 12/2/22 to 1/30/22, included physician orders for skilled nursing visits 3 times every 60 days and home health aide visits 1 time weekly. b. The home health aide care plan, dated 10/8/21, directed the aides to assist the patient with activities of daily living, partial/complete bed bath per patient request, shaving/shampooing hair per patient request, nail care, assist with dressing, undressing, and apply lotion. c. The home health aide visit notes, dated 12/6, 12/13, 12/20, 12/27/22, 1/3, 1/10/23, documented shampooing but failed to include documentation of shaving offered, completed or refused by the patient. d. The home health aide visit notes, dated 11/29/22, failed to document which specific task of shaving or shampooing or both had been completed. Agency staff failed to document tasks completed for the patient for personal care including shampooing and shaving. The above findings were reviewed with the agency Administrator and Clinical Manager. The agency provided no additional information prior to the end of the survey.

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 clinical record review, agency policy review and agency staff interview, the agency failed to complete and send a transfer/discharge summary to the receiving facility in 2 business days of the patient's transfer for 1 of 2 sampled transferred patients (Patient #6). Failure to send the physician and other health care professionals a summary of the patient's care while receiving services from the agency in a timely manner may result in inadequate or inappropriate follow-up after the patient transfers. Findings include: Review of the agency policy, titled Discharge and Transfer, dated 3/7/22, identified agency staff would sent a transfer summary within 2 business days of being aware of an unplanned transfer. Patient #6 had a start of care date of 9/1/22, and transferred on 9/13/22 to the hospital. Review of the clinical record revealed the following: a. The Plan of Care, dated 9/1/22 to 10/30/22, included orders for skilled nursing, occupational and physical therapy services. b. A clinical note completed by agency staff, dated 9/14/22, included documentation the agency spoke with hospital staff and the hospital had admitted the patient on 9/13/22 for bilateral pneumonia and hypoglycemia. c. An agency transfer summary, dated 9/20/22, included documentation the agency staff completed the summary on 9/20/22. d. A clinical note, dated 9/20/22, included documentation agency staff discharged the patient on 9/13/22 due to a hospitalization and they faxed the discharge summary to the patient's physician on 9/20/22 (4 days late). On 1/25/23 at approximately 10:25 AM, during an interview, the Clinical Manager reported she thought the patient had not been admitted to the hospital right away, but had been under observation and this was why they completed the transfer summary late. The Administrator and Clinical Manager received the above information and agency staff provided no further information prior to the end of the survey.