Every finding on record at Grace Health Systems, Inc.

A recertification survey was conducted in conjunction with the evaluation of Emergency Preparedness requirements on 09/20/24. The Agency was in compliance with 42 CFR 484, Conditions of Participation for Home Health Agencies, for this survey.

A recertification survey was conducted in conjunction with the evaluation of Emergency Preparedness requirements on 09/20/24. Standard level deficiencies cited. Abbreviations: > = greater than # = number lbs. = pounds AM = morning PM = afternoon POC = Plan of Care PsOC =Plans of Care Pt./Pts. = Patient/Patients RN = Registered Nurse SN = Skilled Nurse MSW = Medical Social Worker PT = Physical Therapist/Therapy OT = Occupational Therapist/Therapy ST = Speech Therapist/Therapy OASIS = Outcome and Assessment Information Set

Encoding and transmitting OASIS CFR(s): 484.45(a) Standard: An HHA must encode and electronically transmit each completed OASIS assessment to the CMS system, regarding each beneficiary with respect to which information is required to be transmitted (as determined by the Secretary), within 30 days of completing the assessment of the beneficiary. This STANDARD is not met as evidenced by: Based on the review of the Error Summary report and staff interview, it was determined in 164 of 722 reports submitted for the last 12 months, the Agency failed to submit all timely reports, resulting in a warning. Findings include: 1. The Error Summary report for 06/2023 to 05/2024, was reviewed on 09/16/24 at 11:30 AM. The report included error # -3330 for 164 of 722 late submissions, 22.71 % of the OASIS reports submitted, were more than 30 days after the M0090. 2. During an interview with the Office Manager, Director of Nursing and QA Staff on 09/18/24 at 2:30 PM, the Director of Nursing confirmed that the error occurred.

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 clinical record review and staff interviews, it was determined for 3 of 7 (Pts. # 2, 3 and 7) clinical records reviewed, the Agency failed to ensure care and/or services were provided as ordered by the Physician and as indicated in the POC. 2. Pt. #3 was admitted to the home health services on 05/09/24 with the diagnosis of: Unspecified Atrial Fibrillation. The clinical record was reviewed on 09/18/24. The clinical record contained a recertification POC dated 07/08/24 and 09/06/24, that required the SN to assess the patient, 1 time a week for 9 weeks. The SN did not assess/visit the patient during the week of 07/13/24 (week #1) and 07/20/24 (week #2). The same PsOC required the OT and PT evaluations. As of 09/18/24, the OT and PT did not evaluate the patient as ordered in the PsOC. 3. Pt. #7 was admitted to the home health services on 01/16/24 with the diagnoses of: Chronic Atrial Fibrillation Unspecified and Type 2 Diabetes Mellitus with Diabetic Polyneuropathy. The clinical record was reviewed on 09/18/24. The clinical record contained a POC dated 01/16/24, that required the SN to notify the physician of the blood sugar greater than 200 or less than 70, 1 time a week for 9 weeks. The SN lacked the blood sugar assessment for weeks #1, 4, 5 and 9. 4. The findings were confirmed with the during the interview with the Office Manager, Director of Nursing and QA staff, on 09/18/24 between 1:30 PM – 3:00 PM. Findings include: 1. Pt. #2 was admitted for home health services on 07/25/24 with the diagnosis of Anemia. The clinical record reviewed on 09/18/24. The record included a Physician order dated 07/25/24 which required, “PT to check patient’s weight every visit, instruct patient to weigh daily and report weight changes of greater >2 lbs./day or >5 lbs./week.” The PT notes from the week of 07/21/24 through the week of 09/08/24 lacked Pt. #2’s weight. Pt. #2’s POC effective 7/25/24 also included documentation, “Occupational Therapy to assess functional status, home environment to eliminate structural barriers and improve safety, need for home modifications to promote functional independence…OT to establish a home exercise program and plan of care as approved by the physician…” As of 09/18/24, the clinical record lacked an OT evaluation.

Integrate all services CFR(s): 484.60(d)(3) Integrate services, whether services are provided directly or under arrangement, to assure the identification of patient needs and factors that could affect patient safety and treatment effectiveness and the coordination of care provided by all disciplines. This ELEMENT is not met as evidenced by: Based on clinical record review, and staff interviews, it was determined that for 3 of 7 (Pts. # 5, 6, and 7) clinical records reviewed, the Agency failed to ensure that concerns are communicated/coordinated within the healthcare team to ensure Pt. needs were identified and addressed. 3.Pt. #7 was admitted to the home health services on 01/16/24 with the diagnoses of: Chronic Atrial Fibrillation Unspecified and Type 2 Diabetes Mellitus with Diabetic Polyneuropathy. The clinical record was reviewed on 09/18/24. The clinical record contained a POC dated 01/16/24, that required SN assess the patient’s blood pressure and weight 1 time a week for 1 week and 2 prn (as needed visits). The SN visit notes on 01/16/24 included a BP of 132/62. The SN exceeded/conducted 2 additional visits without orders. The SN visit notes 02/07/24, 02/15/24 and 02/20/24 included a continued decreasing Blood Pressure. On 03/14/24, the patient was discharged with the decreased BP of 104/68. The record lacked of coordination /integration orders with the physician regarding significant findings of the declining BP, with the use of Metoprolol 25 mg twice a day, prior to discharging the patient. 4.The findings were confirmed with the during the interview with the Office Manager, Director of Nursing and QA staff on 09/18/24 between 1:30 PM – 3:00 PM. Findings include: _Pt. #6 was discharged from home health services on 9/27/23 with the diagnosis of Essential (Primary) Hypertension. The clinical record was reviewed on 9/18/24. The MSW note included, “Pt has been referred to IDOA for community services that can help decrease stressors affecting pt’s health and wellbeing. Pt and family educated on following up with service providers.” The evaluation was conducted on 11/16/23, but the MSW did not coordinate with the patient and the RN related to the services. _During the interview with the Director of Nursing and Quality Assurance Clinical Coordinator on 9/18/24 at 2:15 PM, the Director of Nursing stated that the MSW documented concerns on their assessment note, but it was not coordinated with the RN. In the same interview, the above findings were confirmed. Findings include: 1. Pt. #5 was admitted for home health services on 05/30/24 with the diagnosis of Type 2 Diabetes Mellitus with hyperglycemia. The clinical record was reviewed on 09/18/24. The record contained the following PT notes: 07/24/24 - blood pressure: 114/40, 07/31/24 – blood pressure: 118/42, 08/07/24 – blood pressure: 112/42 and 08/14/24 – blood pressure:120/42; The SN notes from the weeks of 07/21/24 through 09/08/24, included that Pt. #5’s diastolic blood pressure results were always within the prescribed parameters. The record lacked PT communications to the SN and RN that during the PT treatments Pt.#5’s diastolic blood pressure results were not within the parameters prescribed on the POC. During an interview with the QA staff and Director of Nursing on 09/16/24, it was stated that the PT should coordinate with the SN, or the office/Director of Nursing regarding vital sign that are out of the parameters so that the Pt. could be also monitored by the SN.

Coordinate referrals; CFR(s): 484.105(c)(3) Coordinating referrals, This ELEMENT is not met as evidenced by: Based on the clinical record review, contract review and staff interview, it was determined in 3 of 7 records (Pts. #3, 4 and 7) with therapy orders, the Agency failed /delayed to coordinate the therapy services. Findings include: 1. Pt. #3 was admitted to the home health services on 05/09/24 with the diagnosis of: Unspecified Atrial Fibrillation. The clinical record was reviewed on 09/18/24. The clinical record contained recertification PsOC dated 07/08/24 and 09/06/24, that required the OT and PT evaluations. As of 09/18/24, the OT and PT referrals were not coordinated. 2. Pt. #4 was admitted to the home health services on 07/24/24 with the diagnosis of: Alcoholic Cirrhosis of Liver without Ascites. The clinical record was reviewed on 09/18/24. The clinical record contained a POC dated 07/24/24, that required and PT evaluations. The PT referrals were not coordinated until 07/30/24. 3. Pt. #7 was admitted to the home health services on 01/16/24 with the diagnoses of: Chronic Atrial Fibrillation Unspecified and Type 2 Diabetes Mellitus with Diabetic Polyneuropathy. The clinical record was reviewed on 09/18/24. The clinical record contained a POC dated 01/16/24, that required and PT, ST and OT evaluations. The PT referrals were not coordinated until 01/24/24 (week #2). The ST referral was not coordinated until 01/28/24 (week #3). The OT referral was not coordinated until 02/27/24 (week #7). On 09/18/24 at 2:00 PM, during the interview with the Director of Nursing, it was stated therapy referrals should be coordinated within 48 hours of the referral-orders. 4. On 09/19/24 at 10:10 AM, the Agency’s contract was reviewed. The contract required “….vi. Staffing Company agrees to provide Client, upon request… within 48 hours of receipt of such request…” 5.The findings were confirmed, during the interview with the Office Manager, Director of Nursing and QA staff on 09/19/24 at 10:15 AM.

Plan Based on All Hazards Risk Assessment CFR(s): 484.102(a)(1)-(2) [(a) Emergency Plan. The [facility] must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least every 2 years. The plan must do the following:] (1) Be based on and include a documented, facility-based and community-based risk assessment, utilizing an all-hazards approach.* (2) Include strategies for addressing emergency events identified by the risk assessment. *[For LTC facilities at §483.73(a)(1):] Emergency Plan. The LTC facility must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least annually. The plan must do the following: (1) Be based on and include a documented, facility-based and community-based risk assessment, utilizing an all-hazards approach, including missing residents. (2) Include strategies for addressing emergency events identified by the risk assessment. *[For ICF/IIDs at §483.475(a)(1):] Emergency Plan. The ICF/IID must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least every 2 years. The plan must do the following: (1) Be based on and include a documented, facility-based and community-based risk assessment, utilizing an all-hazards approach, including missing clients. (2) Include strategies for addressing emergency events identified by the risk assessment. * [For Hospices at §418.113(a)(2):] Emergency Plan. The Hospice must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least every 2 years. The plan must do the following: (1) Be based on and include a documented, facility-based and community-based risk assessment, utilizing an all-hazards approach. (2) Include strategies for addressing emergency events identified by the risk assessment, including the management of the consequences of power failures, natural disasters, and other emergencies that would affect the hospice's ability to provide care. This STANDARD is not met as evidenced by: . A. Based on review of the Agency's Emergency Preparedness Plan and staff interview, it was determined the Agency failed to ensure the Emergency Preparedness Plan was based on a facility and community risk assessment, utilizing an all hazards approach. This has the potential to affect all Pts. served by the Agency. Findings include: 1. The Agency's Emergency Preparedness Plan was reviewed on 8/3/21 at 3:00 PM. The plan lacked a facility and community-based risk assessment, using an all hazards approach. 2. During an interview with the DON on 8/3/21 at 4:30 PM, the DON confirmed the above finding.

Policies/Procedures-Volunteers and Staffing CFR(s): 484.102(b)(5) [(b) Policies and procedures. The [facilities] must develop and implement emergency preparedness policies and procedures, based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, and the communication plan at paragraph (c) of this section. The policies and procedures must be reviewed and updated at least every 2 years (annually for LTC).] At a minimum, the policies and procedures must address the following:] (6) [or (4), (5), or (7) as noted above] The use of volunteers in an emergency or other emergency staffing strategies, including the process and role for integration of State and Federally designated health care professionals to address surge needs during an emergency. *[For RNHCIs at §403.748(b):] Policies and procedures. (6) The use of volunteers in an emergency and other emergency staffing strategies to address surge needs during an emergency. *[For Hospice at §418.113(b):] Policies and procedures. (4) The use of hospice employees in an emergency and other emergency staffing strategies, including the process and role for integration of State and Federally designated health care professionals to address surge needs during an emergency. This STANDARD is not met as evidenced by: . A. Based on review of the Agency's Emergency Preparedness Plan and staff interview, it was determined the Agency failed to ensure the Emergency Plan included volunteers. This has the potential to affect all Pts. receiving services from the Agency. Findings include: 1. The Agency's Emergency Preparedness Plan was reviewed on 8/3/21 at 3:00 PM. The Plan did not include the use of volunteers. 2. During an interview with the DON on 8/3/21 at 4:30 PM, the DON confirmed the above finding.

EP Testing Requirements CFR(s): 484.102(d)(2) *[For RNCHI at §403.748, ASCs at §416.54, HHAs at §484.102, CORFs at §485.68, OPO, "Organizations" under §485.727, CMHC at §485.920, RHC/FQHC at §491.12, ESRD Facilities at §494.62]: (2) Testing. The [facility] must conduct exercises to test the emergency plan annually. The [facility] must do all of the following: (i) Participate in a full-scale exercise that is community-based every 2 years; or (A) When a community-based exercise is not accessible, conduct a facility-based functional exercise every 2 years; or (B) If the [facility] experiences an actual natural or man-made emergency that requires activation of the emergency plan, the [facility] is exempt from engaging in its next required community-based or individual, facility-based functional exercise following the onset of the actual event. (ii) Conduct an additional exercise at least every 2 years, opposite the year the full-scale or functional exercise under paragraph (d)(2)(i) of this section is conducted, that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or individual, facility-based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the [facility's] response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the [facility's] emergency plan, as needed. *[For Hospices at 418.113(d):] (2) Testing for hospices that provide care in the patient's home. The hospice must conduct exercises to test the emergency plan at least annually. The hospice must do the following: (i) Participate in a full-scale exercise that is community based every 2 years; or (A) When a community based exercise is not accessible, conduct an individual facility based functional exercise every 2 years; or (B) If the hospice experiences a natural or man-made emergency that requires activation of the emergency plan, the hospital is exempt from engaging in its next required full scale community-based exercise or individual facility- based functional exercise following the onset of the emergency event. (ii) Conduct an additional exercise every 2 years, opposite the year the full-scale or functional exercise under paragraph (d) (2)(i) of this section is conducted, that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or a facility based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (3) Testing for hospices that provide inpatient care directly. The hospice must conduct exercises to test the emergency plan twice per year. The hospice must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual facility-based functional exercise; or (B) If the hospice experiences a natural or man-made emergency that requires activation of the emergency plan, the hospice is exempt from engaging in its next required full-scale community based or facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional annual exercise that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or a facility based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop led by a facilitator that includes a group discussion using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the hospice's response to and maintain documentation of all drills, tabletop exercises, and emergency events and revise the hospice's emergency plan, as needed. *[For PRFTs at §441.184(d), Hospitals at §482.15(d), CAHs at §485.625(d):] (2) Testing. The [PRTF, Hospital, CAH] must conduct exercises to test the emergency plan twice per year. The [PRTF, Hospital, CAH] must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise; or (B) If the [PRTF, Hospital, CAH] experiences an actual natural or man-made emergency that requires activation of the emergency plan, the [facility] is exempt from engaging in its next required full-scale community based or individual, facility-based functional exercise following the onset of the emergency event. (ii) Conduct an [additional] annual exercise or and that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or individual, a facility-based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the [facility's] response to and maintain documentation of all drills, tabletop exercises, and emergency events and revise the [facility's] emergency plan, as needed. *[For LTC Facilities at §483.73(d):] (2) The [LTC facility] must conduct exercises to test the emergency plan at least twice per year, including unannounced staff drills using the emergency procedures. The [LTC facility, ICF/IID] must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise. (B) If the [LTC facility] facility experiences an actual natural or man-made emergency that requires activation of the emergency plan, the LTC facility is exempt from engaging its next required a full-scale community-based or individual, facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional annual exercise that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or an individual, facility based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the [LTC facility] facility's response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the [LTC facility] facility's emergency plan, as needed. *[For ICF/IIDs at §483.475(d)]: (2) Testing. The ICF/IID must conduct exercises to test the emergency plan at least twice per year. The ICF/IID must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise; or. (B) If the ICF/IID experiences an actual natural or man-made emergency that requires activation of the emergency plan, the ICF/IID is exempt from engaging in its next required full-scale community-based or individual, facility- based functional exercise following the onset of the emergency event. (ii) Conduct an additional annual exercise that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or an individual, facility-based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the ICF/IID's response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the ICF/IID's emergency plan, as needed. *[For OPOs at §486.360] (d)(2) Testing. The OPO must conduct exercises to test the emergency plan. The OPO must do the following: (i) Conduct a paper-based, tabletop exercise or workshop at least annually. A tabletop exercise is led by a facilitator and includes a group discussion, using a narrated, clinically relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. If the OPO experiences an actual natural or man-made emergency that requires activation of the emergency plan, the OPO is exempt from engaging in its next required testing exercise following the onset of the emergency event. (ii) Analyze the OPO's response to and maintain documentation of all tabletop exercises, and emergency events, and revise the [RNHCI's and OPO's] emergency plan, as needed. This STANDARD is not met as evidenced by: . A. Based on a review of the Agency's Emergency Preparedness Program and Plan, and staff interview, it was determined the Agency failed to ensure the Agency had conducted Agency tabletop exercises as required, to ensure the effectiveness of the Agency's Emergency Preparedness Plan. This has the potential to affect all Pts. receiving services. Findings Include: 1. The Agency's Emergency Preparedness Plan was reviewed on 8/3/21 at 3:00 PM. The plan lacked documentation of another community based or table-top exercise for 2019. 2. An interview was conducted with the DON on 8/3/21 at 4:30 PM. The DON stated the Agency activated the Emergency Preparedness Plan for COVID-19 on 3/20/20, and confirmed the Agency did not have any other actual emergencies activated or tabletop exercises conducted after 2018.

. Recertification survey completed. Standard level deficiencies cited. A focused Infection Control Survey (FIC) was conducted on 8/5/21. Standard level deficiencies written. Abbreviations: # = number WK = week lbs. = pounds AM = morning PO = by mouth mg = milligrams cm = centimeters SN = Skilled Nurse POC = Plan of care SOC = Start of care PsOC = Plans of Care MD = Medical Doctor RN = Registered Nurse QA = Quality Assurance PM = afternoon/evening PCR = Pre-Claim Review Pt./ Pts. = Patient/Patients DON = Director of Nursing PT = Physical Therapy/Therapist COVID-19 = Coronavirus disease 2019 COTA = Certified Occupational Therapy Assistant

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: . A. Based on a review of clinical records and staff interview, it was determined the Agency failed to ensure staff provide service/treatment as ordered by the Physician, and indicated in the POC. This was found in 6 of 10 (Pts. #5, 7, 9, 1, 8 and 10) clinical records reviewed. Findings include: 1. Pt. #5. SOC 3/9/21. Principal Diagnosis: Acute Diastolic (Congestive) Heart Failure. The clinical record was reviewed on 8/3/21 at 3:15 PM. The record included the POC effective 7/9/21 requiring, "SN to assess and evaluate patient's ...weight every SN visit ...and to notify MD of significant changes in patient's condition especially fluid retention and weight gain of greater than 2 lbs. in 24 hours or greater than 5 lbs. in one week..." The record lacked documentation of Pt. #5's weight. The same POC also required, "SN to assess skin around stoma for any signs/symptoms of irritation or infection." The record lacked documentation of assessment for Pt.#5's tracheostomy site. 2. Pt. #7. SOC 6/18/21. Principal Diagnosis: Type 2 Diabetes Mellitus Without Complication. The clinical record was reviewed on 8/3/21 at 1:50 PM. The record included a POC effective 6/18/21 requiring, "SN to do Blood Glucose monitoring via fingerstick every visit ..." The SN notes lacked documentation of blood glucose results during the following visits: 6/23/21, 7/6/21, 7/20/21 and 7/22/21. 3. Pt. #9. SOC 5/19/21. Principal Diagnosis: Chronic Atrophic Gastritis Without Bleeding. The closed clinical record was reviewed on 8/3/21 at 1:30 PM. The record included a POC for the certification period of 5/19/21 to 7/7/21 requiring, "SN Frequency: 1 WK 9." The record lacked documentation of SN visits for the weeks of 5/23/21 to 5/29/21, 6/6/21 to 6/12/21 and 6/13/21 to 6/19/21. The record lacked documentation as to why the skilled visits were missed and Physician notification of these missed visits. . 4. Pt. #1. SOC 3/5/21. Primary Diagnosis: Atherosclerotic Heart Disease of Native Coronary Artery without Angina Pectoris. The record contained the PsOC for the certification period of 5/4/21 to 7/2/21 and effective 7/4/21 requiring: "SN to Notify MD of... Weight Gain/Loss (lbs/Week) Greater Than 5." The weekly SN visit notes from 6/9/21 to 6/23/21, recertification comprehensive assessment dated 7/2/21, and the weekly SN visit notes from 7/6/21 to 7/26/21 lacked documentation the SN assessed the Pt. weekly for a weight gain/loss. 5. Pt. #6. SOC 6/20/21. Diagnoses: Unspecified Polyosteoarthritis, Type 2 Diabetes Mellitus with Diabetic Polyneuropathy and Hyperglycemia. The clinical record was reviewed on 8/4/21 at 12:45 PM. The record contained the POC effective 6/20/21 requiring: "SN to notify MD of...Weight Gain/Loss (lbs/Week) Greater Than 5." The SN visit note dated 6/24/21 and weekly SN visit notes from 7/7/21 to 7/27/21 lacked documentation the SN assessed the Pt. weekly for a weight gain/loss. The POC effective 6/20/21 required: "SN to notify MD of... Fasting Blood Sugar Greater Than 200 or Less Than 80. Random Blood Sugar Greater Than 250 Or Less Than 80. The weekly SN visit notes from 7/7/21 to 7/27/21 lacked documentation the SN assessed the Pt. for blood sugars outside the parameters indicated in the POC. 6. Pt. #10. SOC 1/8/21. Diagnoses: Unspecified Chronic Obstructive Pulmonary Disease and Chronic Diastolic (Congestive) Heart Failure. The closed clinical record was reviewed on 8/4/21 at 2:35 PM. The record contained the POC for the certification period of 3/9/21 to 5/7/21 requiring: "SN to notify MD of...Weight Gain/Loss (lbs/Week) Greater Than 5." The weekly SN visit notes from 3/9/21 to 4/29/21, and the recertification comprehensive assessment dated 5/4/21 lacked documentation the SN assessed the Pt. weekly for a weight gain/loss. 7. During an interview with the Assistant Administrator, DON, RN/QA Supervisor and Quality Assurance Staff/PCR on 8/5/21 at 9:40 AM, all the administrative staff identified above confirmed services/treatment were not provided, as ordered by the Physician and indicated in 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: . A. Based on a review of clinical records and staff interview, it was determined the Agency failed to ensure the POC contained all disciplines providing Pt. care/service. This was found in 1 of 3 (Pt. #6) clinical records reviewed, wherein Home Health Aide services were provided. Findings include: 1. Pt. #6. SOC 6/20/21. Diagnoses: Unspecified Polyosteoarthritis, Type 2 Diabetes Mellitus with Diabetic Polyneuropathy and Hyperglycemia. The clinical record was reviewed on 8/4/21 at 12:45 PM. The record contained the weekly Home Health Aide visit notes from 6/26/21 to 7/31/21, indicating the Aide provided Pt. care. The POC effective 6/20/21 does not require the service of a Home Health Aide. As of 8/4/21, the record lacked any modifications to the POC requiring Home Health Aide service. 2. During an interview with the Assistant Administrator, DON, RN/QA Supervisor and Quality Assurance Staff/PCR on 8/5/21 at 9:40 AM, the DON and RN/QA Supervisor confirmed the above findings.

Promptly alert relevant physician of changes CFR(s): 484.60(c)(1) The HHA must promptly alert the relevant physician(s) or allowed practitioner(s) to any changes in the patient's condition or needs that suggest that outcomes are not being achieved and/or that the plan of care should be altered. This ELEMENT is not met as evidenced by: . A. Based on a review of clinical records, staff interview and Agency Policy review, the Agency failed to ensure that the physician was notified regarding changes in condition. This was found in 3 of 10 (Pt. #2, #5 and #9) clinical records reviewed. Findings include: 1. Pt. #2. SOC 7/1/21. Principal Diagnosis: Type 2 Diabetes Mellitus With Diabetic Neuropathy, Unspecified. The clinical record was reviewed on 8/3/21 at 11:53 AM. The record included a COTA note dated 7/30/21 which included documentation: "Upon COTA arrival Pt. had set off emergency button and Pt's. son-in-law had just arrived. Per report, Pt. had a fall on Monday, hit head and has bruising and cuts on his chin, cheek, forehead and under eye. Pt.'s son-in-law took Pt. to hospital to get a full check-up ..." The record lacked documentation the physician was notified of the fall. An interview was conducted with the DON and RN/QA Supervisor on 8/4/21 at 11:30 AM. The DON and RN/QA Supervisor stated that staff reports incidents and changes of condition to the RN in the office and they are responsible for reporting it to the physician. As of 8/4/21 at 11:30 AM, Pt. #2's fall incident with injuries was not reported to the Physician. 2. Pt. #5. SOC 7/9/21. Primary Diagnosis: Acute Diastolic (Congestive) Heart Failure. The clinical record was reviewed on 8/3/21 at 3:15 PM. The record included the SN note dated 7/21/21 that included: "Wound Care Flowsheet: Wound 1: Location: Left groin, Wound Type: Pressure Ulcer ...Stage II, Measurement ...1 cm x 1 cm ... Wound 2: Location: Right Lower Leg, Wound Type: Pressure Ulcer ... Stage II, Measurement 2 cm x 1.4 cm ..." The record also included a SN note dated 7/28/21 that included: "Wound Care Flow Sheet: Wound 1: Location: Left groin, Wound Type: Pressure Ulcer ...Stage II, Measurement ...0.3 cm x 0.2 cm ... Wound 2: Location: Right Lower Leg, Wound Type: Pressure Ulcer ... Stage II, Measurement 1.4 cm x 1 cm ..." As of 8/4/21 at 11:30 AM, the record lacked documentation the Physician was notified of the new onset of pressure injury identified on 7/21/21. 3. Pt. #9. SOC 5/19/21. Principal Diagnosis: Chronic Atrophic Gastritis Without Bleeding. The clinical record was reviewed on 8/3/21 at 1:30 PM. The record included a POC for the certification period of 5/19/21 to 7/7/21 requiring, "SN Frequency: 1 WK 9." The record lacked documentation of SN visits for the weeks of 5/23/21 to 5/29/21, 6/6/21 to 6/12/21 and 6/13/21 to 6/19/21. The record lacked documentation as to why the skilled visits were missed and Physician notification of these missed visits. The same record also included documentation of missed visits on 6/2/21 and 6/23/21 but lacked documentation that these documented missed visits were reported to the Physician. 4. The Agency Policy "Clinical Record and Documentation" was reviewed on 8/4/21 at 1:40 PM. The policy required, "...H. Missed Visits are documented on the Missed Visit form with reasons for missed visit and Follow-up as required. The physician will be notified of the Missed Visit and the date and time of notification will be documented..." 5. The Agency Policy "Physician Communication and Receiving Orders" was reviewed on 8/4/21 at 2:30 PM. The policy required, " All communication with the physician shall be documented in the medical record. Communication with a patient's physician is required in the following cases: A change in the patient's condition occurs ..." 6. During an interview with the Assistant Administrator, DON, RN/QA Supervisor and Quality Assurance Staff/PCR on 8/4/21 at 11:30 AM, the above findings were confirmed. The DON stated that missed visits, incidents and changes in Pt.'s condition should be reported to the Physician.

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: 2. Pt. #1. SOC 3/5/21. Primary Diagnosis: Atherosclerotic Heart Disease of Native Coronary Artery without Angina Pectoris. A home visit was conducted on 8/2/21 at 2:30 PM with the RN/QA Supervisor. During the home visit, an interview was conducted with the Pt. and the patient's medications were observed: Magnesium 250 mg tablets - Pt stated she take "1 tablet everyday since 7/1/21, it was ordered by her Internist"; Citracal with Vitamin D - the Pt. stated she take "one-half tablet every evening with dinner for many years"; Metoprolol Succinate oral tablet - the Pt. stated she take "1 tablet daily, not 1 1/2 tablets, the doctor dropped the other 1/2 tablet about 6 months ago"; Centrum Silver multivitamin - the Pt. stated "I've taken one tablet everyday for at least 12 years". An inquiry was made regarding the Minoxidil, the Pt. stated "Minoxidil was started in May or June this year, but I only took it a few days, then the doctor stopped this medicine". During the home visit, the Pt. stated the nurse was aware of the medications identified above. The clinical record of Pt. #1 was reviewed on 8/4/21 at 10:30 AM. The record included the "Medication Profile" form completed by the RN and effective 7/3/21 which lacked Magnesium, Citracal with Vitamin D and Centrum Silver. The form included Metoprolol Succinate 50 MG Oral Tablet, Extended Release 1 1/2 tablets daily By mouth", an inaccurate dose of this medication; and contained Minoxidil 2.5 MG Oral Tablet 2 pills daily By mouth (PO) which was discontinued. The Medication Profile form was inaccurate 3. Pt. #3. SOC 7/9/21. Diagnoses: Essential (Primary) Hypertension and Presence of Automatic (Implantable) Cardiac Defibrillator. The clinical record was reviewed on 8/3/21 at 11:50 AM. A home visit was conducted on 8/2/21 at 2:30 PM with Employee #9. During the home visit, the patient's primary caregiver was present who gives the Pt. his medications. The caregiver stated, "He takes either the Plavix or Aspirin, the doctor said either one, but not both... So I give him the Plavix, he hasn't had any Aspirin in over a year". The caregiver stated, "I told the nurse he doesn't take Aspirin anymore". The clinical record of Pt. #3 was reviewed on 8/4/21 at 11:50 AM. The record included the "Medication Profile" form, completed by the RN and dated 7/9/21 which included: "Aspirin 81 MG Oral Tablet Chewable 1 Daily By Mouth". The Medication Profile form was inaccurate. 4. The Agency policy titled, "Medication Worksheet & Schedule" was reviewed on 8/4/21 at 1:10 PM. The policy required: "...All patients receiving nursing services will have a current and accurate Medication Sheet... 1. Medication Sheets are established at the time of admission and updated as the physician alters the patient's medication regimen..." 5. During an interview with the Assistant Administrator, DON, RN/QA Supervisor and Quality Assurance Staff/PCR on 8/4/21 at 11:30 AM and 8/5/21 at 9:40 AM, the DON and RN/QA Supervisor confirmed the SN/RN failed to ensure medications listed in the clinical record were complete and accurate. . A. Based on observations and interviews during home visits, a review of clinical records, Agency policy and staff interview, it was determined the Agency failed to ensure the medications listed in the clinical record were complete and accurate. This was found in 3 of 10 (Pts. #4, 1 and 3) clinical records reviewed. Findings include: 1. Pt. #4. SOC 5/6/21. Primary Diagnosis: Incontinence Without Sensory Awareness. A home visit was conducted on 8/3/21 at 9:00 AM with Employee #1. During the home visit, an interview was conducted with the Pt. and the patient's medications were observed. The following medications were found in the patient's home: Ferrous Sulfate 325 mg 1 tablet oral twice daily and Baclofen 5 mg ½ tablet oral twice daily. Pt. #4 stated, "I take 1/2 tablet of the Baclofen twice daily and the iron tablet, I take two times a day..." The clinical record was reviewed on 8/3/21 at 11:00 AM. The record contained a "Medication Profile" form completed by the RN and dated 7/5/21 to 9/2/21. The record's "Medication Profile" listed the following: Baclofen 5 mg oral tablet 1 tablet 2 times a day by mouth (PO) and Ferrous Sulfate Oral 325 (65 Iron Elemental Iron) oral 1 tablet daily by mouth (PO). The Medication Profile was not accurate.

Authentication CFR(s): 484.110(b) Standard: Authentication. All entries must be legible, clear, complete, and appropriately authenticated, dated, and timed. Authentication must include a signature and a title (occupation), or a secured computer entry by a unique identifier, of a primary author who has reviewed and approved the entry. This STANDARD is not met as evidenced by: 4. Pt. #1. SOC 3/5/21. Primary Diagnosis: Atherosclerotic Heart Disease of Native Coronary Artery without Angina Pectoris. The clinical record was reviewed on 8/4/21 at 10:30 AM. The record contained a "Notice of Medicare Non-Coverage" form. The form included the patient's printed name and signature. The form required staff to enter a checkmark indicating the services the Pt. received, effective date the services would end, and the date the Pt. signed the form, these sections were left blank. 5. Pt. #3. SOC 7/9/21. Diagnoses: Essential (Primary) Hypertension and Presence of Automatic (Implantable) Cardiac Defibrillator. The clinical record was reviewed on 8/3/21 at 11:50 AM. The record contained a "Notice of Medicare Non-Coverage" form. The form included the patient's printed name and the services the Pt. received (SN and PT). The form had the first page only (1 of 2 pages). Page 1 lacked the effective date that SN and PT services would end, this section was left blank. 6. Pt. #6. SOC 6/20/21. Diagnoses: Unspecified Polyosteoarthritis, Type 2 Diabetes Mellitus with Diabetic Polyneuropathy and Hyperglycemia. The clinical record was reviewed on 8/4/21 at 12:45 PM. The record contained a "Notice of Medicare Non-Coverage" form which included the patient's printed name and signature. The form lacked a checkmark indicating the type of services that would end, effective date the services would end, and the date the Pt. signed the form, these sections were left blank. 7. Pt. #8. SOC 5/21/21. Primary Diagnosis: Aftercare Following Joint Replacement Surgery. The closed clinical record was reviewed on 8/4/21 at 1:40 PM. The record contained a "Notice of Medicare Non-Coverage" form which included the patient's printed name and signature. The form lacked a checkmark indicating the type of services that ended and effective date the services ended, these sections were left blank. 8. During an interview with the Assistant Administrator, DON, RN/QA Supervisor and Quality Assurance Staff/PCR on 8/5/21 at 9:40 AM, all the administrative staff identified above confirmed, the Agency failed to ensure forms were complete and accurate. . A. Based on a review of clinical records, Agency policy, and staff interview, it was determined the Agency failed to ensure forms were complete and accurate. This was found in 7 of 10 (Pts. #4, 5, 7, 1, 3, 6 and 8) clinical record reviewed. Findings include: 1. Pt. #4. SOC 5/6/21. Primary Diagnosis: Incontinence Without Sensory Awareness. The clinical record was reviewed on 8/3/21 at 11:00 AM. The record contained a "Notice of Medicare Non-Coverage" document. The effective date of coverage of the patient's current home health services would end was left blank. This document was signed by the Pt., but not dated. 2. Pt. #5. SOC 7/9/21. Primary Diagnosis: Acute Diastolic (Congestive) Heart Failure. The clinical record was reviewed on 8/3/21 at 3:15 PM. The record contained a "Notice of Medicare Non-Coverage" document. The effective date of coverage of the patient's current home health services would end was left blank. This document was signed by the Pt., but not dated. 3. Pt. #7. SOC 6/18/21. Primary Diagnosis: Type 2 Diabetes Mellitus Without Complication. The clinical record was reviewed on 8/3/21 at 1:50 PM. The record contained a "Notice of Medicare Non-Coverage" document. The effective date of coverage of the patient's current home health services would end was left blank. This document was signed by the Pt., but not dated.