Every finding on record at Guthrie Home Care

The following statement of deficiencies represents the results of a partial extended re-certification survey of Guthrie Home Health Certified Home Health Agency conducted on 08/07/2023 through 08/16/2023. A standard re-certification survey was initiated on 08/07/2023. Deficient practices were identified within Level 1 standards in Condition 484.60 (Care planning, coordination of services, and quality of care), resulting in a partial extended survey. The survey consisted of a review of 17 clinical records, including 5 discharge records, 10 personnel records, and 7 observational home visits. The survey also included a review of pertinent policies and procedures, Quality Improvement meeting minutes for the past 12 months, the agency Admission Packet, the Emergency Preparedness Plan, and the Complaint log. The agency had no contracts. Pre-survey activities consisted of a review on 08/04/23 of the agency’s Health Commerce System account, Internet Quality Improvement and Evaluation System (iQIES) reports for the period 11/01/22 through 04/28/23, and the agency’s compliance with report submission for the 2021 statistical report. The Director of Patient Services, Clinical Manager, and nursing staff were interviewed. Findings were reviewed at the exit conference on 08/16/2023. The following deficiencies were identified as a result of the survey: Federal: G 514 RN performs assessment; G 528 Health, psychosocial, functional, cognition; 536 A review of all current medications; G 574 Plan of care must include the following; G 590 Promptly alert relevant physician of changes; G 606 Integration of all services; G 646 Program activities; and G 682 Infection prevention. State: J 1140, J 1156, and J 1260 Governing authority; R 504 and R 702 Criminal history record check; and W 610 Responsibilities of home care service entities.

RN performs assessment CFR(s): 484.55(a)(1) A registered nurse must conduct an initial assessment visit to determine the immediate care and support needs of the patient; and, for Medicare patients, to determine eligibility for the Medicare home health benefit, including homebound status. The initial assessment visit must be held either within 48 hours of referral, or within 48 hours of the patient's return home, or on the physician or allowed practitioner - ordered start of care date. This ELEMENT is not met as evidenced by: Based on clinical record review, observational home visits, and interviews with the Director of Patient Services (DPS) and Clinical Manager (CM), the agency failed to ensure the registered nurse (RN) conducted an initial assessment of the patient within forty-eight (48) hours of referral, the patient's return home, or on the physician-ordered start of care date in 3 of 17 patients (patients #3, 16, and 17). Evidence as follows: Home Visit (HV) Patient # 3 was admitted to the agency on 03/07/23 with diagnoses of hydronephrosis, left nephrostomy tube, history of urinary tract infections, cardiomyopathy, prostate cancer, and chronic kidney disease. An 02/20/23 urology visit note included the patient was to continue nephrostomy tube changes. On 02/24/23 the agency received a referral from the primary care provider. The referral included the patient required skilled nursing for a care of the nephrostomy tube. The patient was not admitted to the agency until 03/07/23. There was no explanation in the record for why there was a delay or documentation the physician was aware of and approved of the delay. On 03/07/23 the SN visited the patient for the initial assessment and documented the nephrostomy tube was draining clear yellow urine. The SN documented the patient was unable to flush the tube due to not being able to reach it. The dressing was located on the patient's left flank and the patient could not perform that procedure either. The SN documented a friend was able to help out but there was no documentation the friend's ability to perform care was verified during the visit. On 08/10/23 at 11:00 a.m. the surveyor conducted an observational home visit with the SN. The SN performed irrigation of the urostomy tube and dressing change to the site. Following the visit, the surveyor interviewed the patient who stated there was a wait for the nurse to visit and then a nurse had to come out and do a survey of the home. The patient stated care was not done to the nephrostomy site or flushing of the tube while waiting for admission. When asked about a friend assisting with care, the patient did not identify anyone who was doing this. The patient stated family was in the area, however, did not assist in care. On 08/11/23 at 1 p.m. the record was reviewed with the DPS and Clinical Manager. They acknowledged the findings and provided no additional information. Patient #16 was admitted to the agency on 01/05/23 with diagnoses that included pneumonia, cellulitis, type 2 diabetes, atrial fibrillation, acute kidney failure, obesity, and pressure ulcers to both buttocks. The agency failed to admit the patient within 48 hours of the patient's return home. A note written by an intake staff on 12/29/22 indicated the patient was to be discharged/referred to home with home health services and included skilled nursing, physical and occupational therapy. The 01/05/23 start of care note indicated the patient admitted to services after hospitalization from 12/13/22 through 12/29/22 The patient was not admitted to the agency until 01/05/23, 1 week after discharge. There was no explanation in the record for why there was a delay or documentation that the physician was aware of and approved of the delay. On 8/15/23, the surveyor reviewed the record with the DPS and clinical manager. They acknowledged the findings, and no additional information was provided. Failure to conduct the initial assessment within the required time frame has the potential to result in unmet patient needs and negative patient outcomes. Patient # 17 was admitted to the agency on 03/02/23 with diagnoses of type 2 diabetes, acute osteomyelitis of left ankle and foot, ulcer of left heel and midfoot, stage 2 pressure ulcer of sacral region, atrial fibrillation, and congestive heart failure. On 02/22/23 the agency received a referral for the patient to receive home care services to continue rehabilitation, and was discharged from a skilled nursing facility on 02/24/23. The discharge information included the patient’s skin was intact. On 03/02/22 the SN visited the patient for the initial assessment. The SN documented the patient had developed a stage 2 pressure ulcer to their coccyx and the area was bleeding due to friction caused by incontinence brief. The wound measured 2.5 cm x 3 cm x 0.2 cm. The patient was not admitted to the agency until 6 days after discharge from the skilled nursing facility. There was no documentation in the record for why there was a delay or evidence the physician was aware of and approved the delay. On 8/15/23 at 9:55 am, the surveyor reviewed the record with the DPS and clinical manager. They acknowledged the findings, and no additional information was provided.

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 review of clinical records, observational home visits, policies and procedures, and interviews with the Director of Patient Services (DPS), Clinical Manager, and clinical staff, it was determined in 4 of 17 patients (patients #5, 9, 15, and 17) the agency failed to ensure comprehensive assessments were of sufficient scope to identify all patient needs. Evidence as follows: Patient # 5 was admitted to the agency on 07/24/23 with diagnosis of necrotizing fasciitis with abdominal wound care. The Skilled Nurse (SN) failed to perform a complete and/or accurate assessment of the patient’s needs. Home Visit Wound The 07/24/23 Plan of Care (POC) ordered SN 3 times a week for abdominal wound care via (Vacuum -assisted closer) VAC Pressure to be at 125 mmHg continuous pressure to be changed at each visit. Agency Wound Vac Policy dated 02/16/23 states wound measurements weekly, including (length x width x depth) exudate (amount and appearance), wound bed, peri-skin appearance and any tunneling or undermining. On 07/24/23 the SN documented in the initial assessment the following wound measurements: 9.5x9.4 cm with moderate serosanguinous drainage, clean granulated beefy red wound bed, detached wound edges with tunneling at 5 o’clock and 7 o’clock. On 07/28/23 SN documented wound measurements 9.5x9.3cm moderate serosanguinous drainage, clean granulated red wound bed with detached wound edges. 08/11/23 (14 days later) SN documented wound measurements 8.5x8 cm, depth 1.2cm small serosanguinous drainage with clean moist beefy red wound bed with detached wound edges. SN failed to: Measure the wound weekly Measure the depth of wound on the start of care and weekly. Provide evidence that the tunneling had resolved. Pain The 07/24/23 POC included acetaminophen 325mg oral tablet take 2 tablets every 6 hours. Lorazepam 0.5mg oral tablet, take one tablet daily as needed; may take prior to wound vac changes if needed Maximum Daily Dose (MMD) 0.5mg. Oxycodone 10mg oral take one tablet every 4 hours as needed maximum daily dose (MDD) 60mg. Oxycodone 5mg oral take one tablet every 4 hours as needed MDD 30mg. On 08/09/23 the surveyor conducted an observational visit with SN and documented the patient had constant abdominal pain with intensity of 9/10 on 0-10 pain rating scale. The SN failed to perform a complete pain assessment to include: -frequency/amount/time last dose routine/PRN medication taken -non-medication measures used for pain relief Gastrointestinal The 07/24/23 POC included Senna 8.6 mg oral tablet take 1 tablet 2 times a day routinely for constipation. During the home visit on 08/09/23 the SN documented patient had a large bowel movement. The SN failed to: - Assess for changes in patterns or frequency of output. - Assess taking ordered medication. - Assess diet and fluid consumption. - Assess bowel sounds in all 4 quadrants. Following the SN visit the surveyor interviewed the patient that stated senna is not being taken as ordered. On 08/11/23 at 1 p.m. the record was reviewed with the DPS and Clinical Manager. They acknowledged the findings and provided no additional information. Patient # 15 was admitted to the agency on 11/30/22 with diagnoses of lung cancer, abnormalities of gait and mobility, type 2 diabetes, chronic obstructive lung, and kidney disease. The SN failed to ensure comprehensive assessments met the needs of the patient. Diabetes The 11/30/22 Plan of Care (POC) Included the following: - Humalog junior pen inject 6 units 3 times a day before meals. - Glargine 45 units Subcutaneous (SQ) once a day in the morning. Monitor Blood Glucose (BG) at each meal and notify physician if below 60 or greater than 250. On 11/30/22 the Physical Therapist (PT) documented in the initial assessment the patient tests BG and had a BG of 94 at the visit. The note included the patient was unable to administer injectable medications independently. The PT failed to assess the frequency of BG testing, person responsible for assisting the patient with monitoring and administration of insulin. Between the dates of 12/02/22-12/16/22 there was no evidence the PT assessed the frequency of testing and BG ranges including the person responsible for BG testing and insulin administration. On 12/16/22 PT obtained a verbal order for Skilled Nurse (SN) to assess and teach medication management. On 12/19/22 the SN visited the patient for an initial visit had documented BG ranges 134-271 and the patient was monitoring BG every other day. SN failed to: - Assess ranges and what time of day the readings were elevated. - Assess and teach the patient on BG monitoring and when to notify the physician with unacceptable ranges. - Assess if the patient is able to administer injectable medications. On 12/29/22 (10 days later) the Licensed Practical Nurse (LPN) visited the patient and documented BG ranges 130 – 300 and the patient was monitoring BG every other day. There is no evidence that the LPN reported the patient was not testing BG at the correct frequency per the plan of care and BG readings were not within ordered parameters to the registered nurse or the physician. Implanted Port Device On 12/19/22 the SN documented the patient had an Implanted Venous Access Device (IVAD) in the right chest and was receiving weekly chemotherapy treatments. The SN failed to assess the site and determine if a dressing was required, and coordinate care with who was managing the IVAD. On 08/11/23 at 1 p.m. the record was reviewed with the DPS and Clinical Manager. They acknowledged the findings and provided no additional information. Patient #9 was admitted to the agency on 07/13/23 with diagnoses that included knee prosthesis osteomyelitis, hypertension, asthma, paroxysmal atrial fibrillation, and bilateral shoulder replacements. The SN failed to ensure the comprehensive assessment met all of the patient's needs. On The Home Health Care Certification and Plan of Care included medication orders for: - Lovenox 40 mg /0.4 ml injectable solution; inject 40 mg subcutaneously once a day for 7 days, anticoagulant, inject into abdominal adipose tissue, start 07/13/23 and complete 07/19/23 - albuterol inhaler 90 mcg/inh; inhale 2 puffs every 4 hours as needed. COPD. On 07/13/23, the SN performed the initial assessment and identified the patient was ordered an injectable anticoagulant medication and was unable to take injectable medication unless administered by another person. The SN failed to assess the patient and caregiver's knowledge and ability to safely administer the injectable anticoagulant and to determine if the medication was available in the home to start on 07/13/23. The patient was ordered a rescue inhaler for "COPD," and during the initial assessment, the SN documented the albuterol metered dose inhaler (MDI) for asthma had good effectiveness. The SN failed to include if the patient was able to use the MDI with the osteoarthritis, the frequency the patient needed to use it, and if it was available in the home at the patient's discharge from the hospital. On 08/11/23 at 1:00 p.m., the record was reviewed with the DPS and CM, who acknowledged the findings and offered no new information. Patient #17 was admitted to the agency on 03/02/23 with diagnoses of type 2 diabetes, acute osteomyelitis of left ankle and foot, non-pressure chronic ulcer of left heel and midfoot, stage 2 pressure ulcer of sacral region, atrial fibrillation, and congestive heart failure. The patient was selected from the internet Quality Improvement Evaluation System (iQIES) Adverse Event Listing for increase in pressure ulcers. On 03/02/23 the registered nurse (RN) documented the patient had a stage 2 pressure ulcer to their coccyx measuring 2.5cm x 3cm x .2 cm and the area was bleeding due to friction of incontinence brief. In the narrative note, the RN documented they would get wound care orders from the physician. The RN educated the caregivers and patient on skin care, need to change positions every two hours, keep skin clean and dry, and try and lay on side as much as possible. The plan for the next visit included continued teaching on skin care. There was no evidence that after the start of care an RN assessed or measured the coccyx wound. On 03/03/23 at 9:55 a.m., the RN called the primary care physician and received orders for treatment of the stage 2 pressure ulcer on the coccyx. The order was that the clinician, patient, or caregiver was to perform and the SN was to monitor at visit the coccyx. Cleanse site with soap and water, rinse and pat dry, apply Destin to ulcer and cover with border gauze using aseptic technique. Perform every other day or as needed for loose or soiled dressing. On 03/06/23, the LPN documented that the coccyx remained excoriated and the daughter had not picked up the Desitin from the store yet. The LPN documented that they performed wound care per the plan of care. The RN visited the patient on 03/09/23, 03/13/23 and 03/17/23. There is no evidence the RN assessed the wound or performed any wound care. On 03/21/23, the LPN documented that wound cleansing and dressing change were done per the plan of care. The LPN documented that the bilateral buttocks wounds have become larger and are bleeding. The LPN contacted the wound clinic and were able to get the patient an appointment for 03/27/23. In the visit documentation under “Contact(s) Made as a result of this visit”, the RN case manager is listed. There is no documentation of what was discussed. Wound Care Clinic note on 03/27/23 documented that the patient presented to the clinic with a dressing to the left heel and no dressing to the sacrum. The daughter reported that she has been helping with dressing to the heel and applying Desitin to the patients buttocks. The sacrum/coccyx wound was 2.5 cm x 1.3 cm x 0.1 cm with a small amount of drainage. On 03/31/23, the RN documented the patient’s daughter changed both dressings that morning and was able to verbalize good understanding of wound care procedure using aseptic technique. The RN documented that they taught the disease process and complications of skin breakdown and signs and symptoms of infection. They also documented teaching the patient and caregiver to only walk 100 feet per day, shoes need to be loose and the patient was to use the wheelchair to move through the house an outside. On 04/01/23 a verbal order was faxed to the agency for wound care to the ulcer on sacrum/coccyx to cleanse with normal saline, pat dry, apply silver alginate to wound bed, cover with bordered gauze. Change dressing daily and as needed for loose or soiled dressing. On 04/04/23, the LPN documented the daughter had done the dressing to the coccyx prior to the visit, and the LPN did not observe the wound. On 04/13/23, the RN documented that the patient had cancelled their last wound care appointment because they were not feeling well. The appointment was rescheduled for 04/17/23. The patient’s daughter changed the patient’s bandages prior to the visit. The daughter verbalized a good understanding of dressing change procedure using aseptic technique. On 04/19/23, the RN failed to assess the patient’s wounds. Left Heel Wound The discharge paperwork from the skilled nursing facility dated 02/24/23 documented under “Skin Issues” to see the attached skin sheet. The attached Wound Assessment Sheet was dated 02/08/23 and documented the patient had a diabetic type wound associated with neuropathy and/or arterial disease of the lower limb located on their left heel that had healed. On 03/02/23 the RN completed the initial assessment. There is no evidence that the RN assessed the left heel. According to the visit documentation for 03/06/23, 03/09/23, 03/13/23, 03/17/23 and 03/21/23 there is no evidence that the left heel was ever assessed. On 03/27/23 the patient was seen at the wound clinic. The wound clinic note included the patient came in with a dressing to the left heel. The caregiver stated she was helping with the heel dressing. The note included the heel wound was an open stage 3 measuring 1.5 cm x 1 cm x 0.3 cm, the periwound was macerated with moderate drainage. On 04/01/23 a verbal order was faxed to the agency for wound care. The order for the left heel was to cleanse with normal saline, pat dry, apply collagen to wound bed, apply silver alginate over wound, cover with bordered gauze, change every other day or as needed for loose or soiled dressing. On 03/31/23, the RN visited the patient and documented the patient’s daughter stated she changed the dressing that morning. The RN documented that the daughter was able to verbalize good understanding of wound care procedure using aseptic technique. During the 04/04/23, 04/13/23, and 04/19/23 there is no evidence that the heel wound was ever observed or assessed. On 8/15/23 at 9:55 am, the surveyor reviewed the record with the DPS and clinical manager. No additional information was provided.

A review of all current medications CFR(s): 484.55(c)(5) A review of all medications the patient is currently using in order to identify any potential adverse effects and drug reactions, including ineffective drug therapy, significant side effects, significant drug interactions, duplicate drug therapy, and noncompliance with drug therapy. This ELEMENT is not met as evidenced by: Based on a review of clinical records, observational home visits, and interviews with the Director of Patient Services (DPS) and Clinical Manager, it was determined in 7 out of 17 records (patients #1-4, 7, 14, and 17) the skilled nurse (SN) failed to perform comprehensive medication reviews. Evidence as follows: Home Visit (HV) Patient # 3 was admitted to the agency on 03/07/23 with diagnoses of hydronephrosis, left nephrostomy tube, history of urinary tract infections, cardiomyopathy, prostate cancer, and chronic kidney disease. The SN failed to ensure all medications were included and/or accurate in the plan of care. On 02/24/23 the patient was seen for a cardiology referral. The dosage of amlodipine was listed as 5 mg daily. On 03/07/23 the SN visited the patient for the initial assessment and documented the patient had an updated medication list in the home and the after-visit summary was used to reconcile medications. The SN failed to recognize the dosage for amlodipine had changed. The 03/07/23 home health certification and plan of care (POC) included amlodipine 2.5 mg per day. On 07/03/23 the SN visited the patient for recertification and documented the patient denied any medication changes since the last visit. The amlodipine dosage remained the same on the 07/05/23-09/02/23 POC. On 08/10/23 at 11:00 a.m. the surveyor conducted an observational home visit with the SN for irrigation of the urostomy tube and dressing change to the site. Following the visit, the surveyor interviewed the patient and reviewed medications. The following was revealed during the interview: The patient provided a medication list from a 02/16/23 physician visit and stated it was correct with current medications. The amlodipine order 2.5 mg was inconsistent with the medication list 5 mg per day. The 07/05/23 POC also included ferrous sulfate 325 mg every other day. The patient stated the doctor discontinued the medication because it was building up in their system. On 08/11/23 at 1 p.m. the record was reviewed with the DPS and Clinical Manager. They acknowledged the findings and provided no additional information. HV Patient # 2 was admitted to the agency on 04/27/23 with diagnoses of osteomyelitis, gangrene to toes and s/p amputation of L great toe and metatarsal. The SN failed to ensure medications were correct in the plan of care. On 08/09/23 at 10:30 a.m. the surveyor conducted an observational home visit with the SN to observe the assessment and wound vac dressing change. During the visit the SN discussed pain management with the patient. The patient stated pain occurred mostly night and was managed with Tylenol occasional Ibuprofen. The SN did not ask any further questions. The SN visit documentation included pain was managed with over the counter (OTC) pain relievers and the medication profile was reviewed with no new or changed medications. The 06/26/23-08/24/23 Home Health Certification and Plan of Care did not include Tylenol and Ibuprofen as current medications. Following the visit, the surveyor interviewed the patient who stated Tylenol 500 mg three tablets was taken once daily and Ibuprofen 200 mg three tablets was taken every 4-5 days. On 08/11/23 at 1 p.m. the record was reviewed with the DPS and Clinical Manager. They acknowledged the findings and provided no additional information. Patient #14 was admitted to the agency on 04/13/23 with diagnoses that included malignant neoplasm of the breast, bilateral radical mastectomy, concurrent breast reconstruction, hypertension, chronic obstructive pulmonary disease (COPD), and hypothyroidism. The SN failed to ensure all medications were included and accurate in the plan of care. On 04/11/23, the patient was discharged from the hospital with a new medication, cephalexin (an antibiotic) 500mg, three times daily for 10 days. On 04/13/23, the SN performed an initial assessment of the patient and documented the patient had a history of COPD and used "inhalation therapy, including albuterol, formoterol, budesonide, and ipratropium. (2 fast-acting bronchodilators and 2 steroid-type maintenance inhalers). During the assessment, the SN reconciled the patient's medication and documented that "all current patient medications were reconciled utilizing a med list from the hospital discharge found in the home and compared to meds the patient states they are currently taking. There were no discrepancies noted or reported." There was no evidence to support the SN visualized the prescription bottles or inhalers in the home but reconciled the medications "to the medications the patient states she is currently taking," The SN failed to verify if the patient had obtained the antibiotic during the 2 days since discharge. There were no inhalers on the patient's medication profile and no evidence the SN reconciled the medications with the medications in the home or called the physician to inquire about the inhalers. On 08/10/23, the agency's policy, Clinical Drug Monitoring, dated 02/16/23, included: "Medication Reconciliation is the formal process of comparing all of the prescription and non-prescription medications (including OTC, vitamins, supplements, etc.,) a patient is taking to an external list of the patient's ordered medications." On 08/14/23, the record was reviewed with the DPS and Clinical Manager. They acknowledged the findings and provided no additional information. Home Visit (HV) Patient #1 was admitted to the agency on 06/15/23 with diagnoses that included discitis, sepsis, hypertension, osteoarthritis, spondylosis, and depression. The SN failed to ensure all medications were updated and accurate in the plan of care. On 08/10/23 at 1:00 p.m., the surveyor conducted an observational home visit with the skilled nurse (SN); after the visit, the surveyor asked the patient if changes to the medication regimen had occurred since discharge from the hospital. The patient and spouse remembered one change due to the patient's blood pressure being "higher than it should be." The Home Health Certification and Plan of Care (POC) dated 06/15/23 included amlodipine benazepril 5-10 mg tablet; take 1 tab daily. The surveyor asked to see the patient's medication bottle. The patient's spouse indicated a new bottle had just arrived via mail, and both bottles did not reflect a new, higher dosage. The surveyor asked if the SN was aware of the change. The patient replied, "yes, I'm asked every time they come if there are any new medications or changes in the medications, and I told them about doubling that one." The SN failed to verify the dosage change with the physician and update the POC. On 08/11/23 at 1 p.m., the record was reviewed with the DPS and Clinical Manager. They acknowledged the findings and provided no additional information. Patient #17 was admitted to the agency on 03/02/23 with diagnoses of type 2 diabetes, acute osteomyelitis of left ankle and foot, ulcer of left heel and midfoot, stage 2 pressure ulcer of sacral region, atrial fibrillation, and congestive heart failure. The SN failed to ensure all medications were included and/or accurate in the plan of care. On 02/24/23, the patient was discharged from a skilled nursing facility with a referral for home care to continue rehab. The nurse practitioner notes from the facility on 01/18/23 23 documented that the patient was on Coumadin (anti-coagulant) and they would follow up on the labs regularly to ensure therapeutic Coumadin level. The “snapshot” of the patient that was uploaded to the facilities system on 02/22/23 had a list of medications that included Coumadin 6mg oral tab. The SN performed the start of care on 03/02/23 documented the patient was on anticoagulation therapy. The SOC nurse documented that the patient was on anticoagulant therapy. The SN documented that medications were reviewed and the patient had a medication list from the skilled nursing facility. There is no evidence to support the SN visualized the prescription bottles in the home. There were no anti-coagulants on the patient’s medication profile and no evidence the SN reconciled the medications with the medications in the home or called the physician to inquire about anti-coagulants. On 8/15/23 at 9:55 am, the surveyor reviewed the record with the DPS and clinical manager. They acknowledged the findings and no additional information was provided. Patient #7 was admitted to the agency on 07/11/23 with diagnoses of type 2 diabetes, urinary tract infection, acute kidney failure, altered mental status, and hypertension. The SN failed to ensure all medications included on the plan of care were accurate. On 07/11/23, the SN visited the patient for the initial assessment and documented that a medication reconciliation was completed with the patient’s caregiver. The 07/11/23 plan of care included sennosides-docusate sodium stool softener (Senokot S 50mg – 8.6mg). The SN noted that the patient did not have Senokot S 50mg – 8.6mg. There is no evidence the SN followed up to ensure that the patient obtained or was using the medication. The 07/11/23 plan of care included Insulin Lispro KwikPen 100 units/mL injectable solution. Inject 3 units 4 times per day; Patient to receive insulin per sliding scale -61-150: 0 units -151-200: 3 units -201-250: 5 units -251-300: 8 units -301-350: 10 units -351-400: 12 units - Over 400: 15 units and call physician On 08/08/23 at 12:30 p.m., the surveyor conducted an observational home visit with the SN. After the visit, the surveyor asked the patient’s caregiver about the patient’s medications. There was no Senokot S 50mg-8.6mg. T the caregiver explained they never picked it up because they never needed it. The caregiver also showed the surveyor the insulin sliding scale, which she said they used twice a day as instructed by the doctor. The sliding scale did not contain a baseline dose of 3 units of insulin and the caregiver stated they were only using the sliding scale twice a day because that is what the doctor ordered. The caregiver stated that the SN was aware that they were only checking the patient’s blood sugar and using the sliding scale twice a day. The SN failed to contact the physician to clarify insulin and sliding scale order and update the plan of care. On 08/11/23 at 1:00 p.m., the record was reviewed with the DPS and Clinical Manager. They acknowledged the findings and provided no additional information. Home Visit (HV) Patient #4 was admitted to the agency on 08/02/23 with diagnoses of pneumonitis due to inhalation of food/vomit, lobar pneumonia, chronic obstructive pulmonary disease, type 2 diabetes, and nicotine dependence. The SN failed to ensure all medications were accurate in the plan of care. The 08/02/23 plan of care included the -escitalopram 20mg daily, -meloxicam 7.5mg daily, -Glucerna take 1 can 2 times a day between meals -Ensure take 1 can orally 2 time a day, Breakfast and Dinner supplement -nicotine patches 7mg/24 hour extended release, apply 1 patch daily, -pantoprazole 40mg delayed release daily -prednisone 10mg: take 3 tablets on 08/02/23 - 08/05/23, take 2 tablets on 08/06/23 - 08/09/23, take 1 tablet on 08/10/23 - 08/13/23, take 0.5 tablets 08/14/23 - 08/19/23. Discontinue on 8/19/23. On 08/02/23, the SN documented the patient was not using the nicotine patch and did not have Breztri inhaler. Additionally, the patient had prednisone 10mg tablets and was unsure what to use them for. On 08/03/23, the SN contacted the physician’s office requested a prescription for Mucinex and nystatin. On 08/04/23, the SN spoke with the physician’s office nurse who stated they sent prescriptions to the pharmacy for Spiriva inhaler, Mucinex and nystatin. The prednisone was discussed and needed to be clarified with the physician. On 08/07/23, the SN obtained verbal orders for famotidine 10mg oral tablet 2 times per day; Mucinex 600mg oral tablet, extended release every 12 hours; nystatin 100,000 units/mL oral suspension; take 5 mL 4 times per day; updated the order for the prednisone tapering schedule with the discontinue date of 08/22/23. The physician also discontinued the pantoprazole. On 08/08/23 at 09:45 a.m. the surveyor conducted an observational home visit with SN for medication management and disease teaching. The SN asked to see the patient’s medications and the caregiver showed her the bottles. The patient stated that she was not taking certain medications and showed the bottles to SN. The patient and the caregiver stated they had not picked up any medication from the pharmacy and that they had not picked up any supplement drinks from the pharmacy. The patient also told the nurse that she was taking Symbicort inhaler. The nurse called the physician’s office during the visit and was told the medications that the prescriptions for Breztri inhaler, Mucinex, and Nystatin that were ordered on 08/04/23 never went through to the pharmacy and the physician’s office would re-send them to the pharmacy. The SN also requested to be called back by the physician’s office to go over the patient’s medications. Following the visit, the surveyor interviewed the patient and reviewed medications. The following was revealed during the interview: The patient was not taking: -escitalopram 20mg daily -meloxicam 7.5mg daily -nicotine 7mg/24-hour transdermal film -prednisone 10mg tablets -famotidine 10mg tablets They were using their Symbicort inhaler twice a day. They did not have Glucerna or Ensure. According to the 08/08/23 note following the observed visit, the SN received a call from the physicians office changed the prednisone to as needed when the patient feels their breathing is getting worse, they can use the Symbicort until they obtain the Breztri, and the Glucerna could be discontinued because the patient has a prescription for ensure. The note documents that the medication list was updated. The 08/02/23 plan of care still included: -escitalopram 20mg orally daily -meloxicam 7.5mg orally daily -Glucerna One dose 1 can orally 2 times a day between meals -nicotine patches 7mg/24 hour transdermal film extended release, apply 1 patch daily -pantoprazole 40mg delayed release tablet daily -prednisone 10mg taper ending on 08/19/23. It did not include Mucinex, nystatin, or the updated prednisone order. On 8/11/23 at 1:00 p.m., the surveyor reviewed the record with the DPS and clinical manager. They acknowledged the findings and no additional information was provided.

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 a review of clinical records, observational home visits, and interviews with the Director of Patient Services (DPS) and Clinical Manager, it was determined in 4 of 17 records (patients #7, 11, 16, and 17) the agency failed to develop complete and accurate plans of care that were individualized to address the total needs of the patients. Evidence as follows: Home Visit (HV) Patient # 3 was admitted to the agency on 03/07/23 with diagnoses of hydronephrosis, left nephrostomy (drainage from kidney) tube, history of urinary tract infections, cardiomyopathy, prostate cancer, and chronic kidney disease. The 02/20/23 urology visit note included the patient was to continue nephrostomy tube changes. On 02/24/23 the agency received a referral from the primary care provider. The referral included the patient required skilled nursing for caring for a nephrostomy tube. On 03/07/23 the SN visited the patient for the initial assessment and documented the nephrostomy tube was draining clear yellow urine. The SN documented speaking to the nurse practitioner in interventional radiology and who gave the order for flushing and dressing changes twice weekly. It was unclear whether the method of cleaning the site was discussed. The 03/07/23 home health certification and plan of care (POC) included care to the nephrostomy tube to include cleaning around the tube with soap and water, pat dry, apply split gauze, may windowpane edges with tape. There was no catheter size on the plan of care. The agency 04/01/2021 Nephrostomy and Dressing Changes policy and procedure included standard, aseptic and sterile precautions to be used throughout the procedure and advised cleansing the area with wound cleansing solution or normal saline. It was unclear whether there was discussion with the nurse practitioner regarding the specifics of the dressing order. Nurse visits between from 03/07/23 and 07/31/23 contained documentation of following the plan of care for cleansing the site with soap and water. On 08/03/23 the SN documented a verbal order from the primary care physician to change care to the urostomy site from the previous order as stated above to cleaning around the site with alcohol swab, apply split sponges and cover with a transparent film dressing. On 08/10/23 at 11:00 a.m. the surveyor conducted an observational home visit with the SN. The SN performed irrigation of the urostomy tube and dressing change to the site. Prior to the visit the surveyor interviewed the SN and asked why the order had changed from soap and water to alcohol swabs. The SN stated that is how they had usually done it. The nurse used swabs during the visit to clean around the site. On 08/11/23 at 1 p.m. the record was reviewed with the DPS and Clinical Manager. They acknowledged the findings and provided no additional information. Patient #16 was admitted to the agency on 01/05/23 with diagnoses that included pneumonia, cellulitis, type 2 diabetes, atrial fibrillation, acute kidney failure, obesity, and pressure ulcers on both buttocks. The SN failed to ensure that the plan of care was accurate. Diabetes The Home Health Certification and Plan of Care (POC) dated 01/05/23 ordered the skilled nurse (SN) to monitor the blood glucose at every visit, with the patient checking the glucose "3 times per day in the am, after dinner and at bedtime." On 01/19/23, the SN visited for a resumption of care and documented the patient was testing the blood sugar 3 times per day "before meals." On 1/24/23, the SN documented the patient tested the blood sugar "once daily." On 01/30 and 02/07/23, the SN also documented the patient tested the blood sugar "once daily." There was no evidence the SN notified the physician to verify the blood sugar testing orders had been changed or update the POC accordingly. On 08/15/23, the record was reviewed with the DPS and Clinical Manager. They acknowledged the findings and provided no additional information. Patient #11 was admitted to the agency on 07/19/23 with diagnoses of stage 3 pressure ulcer of the right buttock, localized edema, cellulites of the right and left lower limb, chronic kidney disease and type 2 diabetes. Daily Weights On 07/19/23 the SN documented in the start of care the patient weighed 209 lbs. The 07/19/23 – 09/16/23 Plan of Care (POC) included an order for the patient or caregiver to perform daily weights and keep a daily log. The patient, caregiver, or clinician was to call the physician for a weight gain of more than 3 lbs in 1 day or more than 5 lbs in a week. Clinicians visited on the following dates: -07/24/23 -07/25/23 -07/27/23 -07/31/23 -08/01/23 -08/03/23 -08/07/23 -08/08/23 The assessment notes from these visits failed to include documentation daily weights were performed by the clinician, caregiver or patient and logged to ensure weight was maintained within ordered parameters. Dressing Change The SN failed to follow the plan of care by not ensuring the wound dressing was changed every 3 days as ordered. On 07/19/23 the SN documented the patient had a stage 3 pressure ulcer to right buttock/right gluteal fold that measured 1 cm x 0.7 cm x .2 cm. The 07/19/23 – 09/16/23 Plan of Care (POC) included an order for wound care to the area to cleanse gently with saline, pat dry, apply Triad Hydrophyllic cream (wound treatment) to wound bed, cover with bordered gauze, and change every 3 days and as needed if loose/soiled. The SN frequency was 2 visits a week for 8 weeks, beginning the week of 07/23/23. The patient went more than 3 days without a dressing change between 07/19/23 and 07/24/23, 07/27/23 and 07/31/23 and 08/03/23 and 08/10/23. There is no evidence that the SN received an order from the physician to change the timing of the dressing change or made the physician aware when the dressing wasn’t changed at the ordered frequency. On 08/15/23 at 9:55 a.m., the surveyor reviewed the record with the DPS and clinical manager. They acknowledged the findings, and no additional information was provided. Patient #7 was admitted to the agency on 07/11/23 with diagnoses of type 2 diabetes, urinary tract infection, acute kidney failure, altered mental status, and hypertension. The SN failed to ensure that the plan of care was accurate. The 07/11/23 plan of care included the following: SN to monitor blood sugar at each visit. Caregiver to test blood sugar before meals and at bedtime and maintain a log. Caregiver to report blood sugar less than 60 or greater than 250 to the physician. On 07/19/23, the SN documented the patient’s caregiver was checking her blood sugar twice a day and the blood sugars for the past 7 days were 182-294. The SN documented the caregiver stated the physician wanted the patient to eat whatever they wanted because the physician did not want the patient to lose weight and felt the patient’s blood sugars were not overly abnormal. On 08/08/23 at 12:30 p.m., the surveyor conducted an observational home visit with the SN. The SN checked the patient’s blood sugar log and noted that their blood sugar that morning was 254. The SN did not ask if the caregiver had contacted the doctor, due to it being outside the parameter of above 250. Following the visit, the surveyor interviewed the patient and caregiver. The caregiver stated after discharge from the hospital, the patient went to the physician who told them it was ok to check the patient’s blood sugar twice a day. The caregiver stated the patient’s blood sugar usually ran in the low to mid-200’s and that they did not notify the doctor unless it was over 400, which is what was indicated on the sliding scale. The SN failed to contact the physician to determine if the POC should be updated to reflect the caregiver checks blood sugar twice a day and/or increase the blood sugar parameter for when the caregiver should call the physician. On 08/11/23 at 1:00 p.m., the surveyor reviewed the chart with the clinical manager and DPS. They acknowledged the findings, and no additional information was provided. Patient #17 was admitted to the agency on 03/02/23 with diagnoses of type 2 diabetes, acute osteomyelitis of left ankle and foot, ulcer of left heel and midfoot, stage 2 pressure ulcer of sacral region, atrial fibrillation, and congestive heart failure. The 03/02/23 plan of care was incomplete and failed to address the following: Left Heel Wound On 02/24/23 the patient was discharged from a skilled nursing facility. The discharge documentation included the patient had a healed diabetic wound on the left heel (see G 528). On 03/27/23 the patient was seen at the wound clinic. The note included the patient had an open stage 3 wound to the left heel measuring 1.5 cm x 1 cm x 0.3 cm, the periwound was macerated with moderate drainage. The note included the patient had a dressing to the left heel, and the caregiver stated she was helping with the heel dressing. The 03/02/23 plan of care failed to include a plan with orders for wound care to the left heel including: -the frequency and person responsible to perform wound care -instructions for wound cleansing/cleansing agent -type of dressing -a plan for the SN to assess/monitor the wound Diabetes According to the Plan of Care, the RN/LPN was to monitor the blood sugar at every visit and the patient was to check blood sugar levels once a day in the morning. There is no evidence that the SN was assessing whether the blood sugar was being monitored daily or monitoring the blood sugar at visits. The SN performed the start of care on 03/02/23. They documented the patient monitored their blood glucose once a day and did check it this morning but had not resumed regular blood glucose testing since return home. The SN documented that the normal blood glucose range was from 110 – 200. On 03/09/23, the SN did not document whether the patient or caregiver had been checking the blood sugar daily and what the usual range was. On 03/13/23, the patient stated that they have not been checking their blood sugar. On 03/17/23, 03/21/23, 03/31/23, 04/04/23, and 04/13/23, the SN did not document whether the patient or caregiver had been checking the blood sugar daily and what the usual range was per the plan of care. On 8/15/23 at 9:55 am, the surveyor reviewed the record with the DPS and clinical manager. They acknowledged the findings, and no additional information was provided.

Promptly alert relevant physician of changes CFR(s): 484.60(c)(1) The HHA must promptly alert the relevant physician(s) or allowed practitioner(s) to any changes in the patient's condition or needs that suggest that outcomes are not being achieved and/or that the plan of care should be altered. This ELEMENT is not met as evidenced by: Based on a review of clinical records, observational home visits, and interviews with the Director of Patient Services (DPS) and Clinical Manager, it was determined for 6 out of 17 records (patients #11, 12, and 14-17) the skilled nurse (SN) failed to notify the physician when changes in the patient's condition occurred. Evidence as follows: Patient # 15 was admitted to the agency on 11/30/22 with diagnoses of malignant neoplasm of the right lower lobe, abnormalities of gait and mobility, chronic obstructive pulmonary disease, chronic kidney disease, and type 2 diabetes mellitus. The 11/30/22 Plan of Care (POC) included the following: - Humalog junior pen inject 6 units 3 times a day before meals. - Glargine 45 units subcutaneous (SQ) once a day in the morning. - Clinician to monitor vital signs and notify the physician with unacceptable ranges. - Monitor Blood Glucose (BG) daily at each meal and notify MD if below 60 or greater than 250. On 12/16/22 the Physical Therapist (PT) who was managing the patient, obtained a verbal order for Skilled Nurse (SN) to assess and teach medication management. Diabetes On 12/19/22 the SN visited the patient for an initial visit The SN documented the patients BG had been 134-271 and that the patient is testing every other day. SN failed to: Notify the physician with BG reading over 250. Notify the physician the patient was not testing at the correct frequency. On 12/29/22 (10 days later) the Licensed Practical Nurse (LPN) visited patient for a visit had documented BG ranges 130 – 300 and that the patient is monitoring BG every other day. There is no evidence that the LPN reported findings to the registered nurse or the physician. On 08/11/23 at 1 p.m. the record was reviewed with the DPS and Clinical Manager. They acknowledged the findings and provided no additional information. Patient # 12 was admitted to the agency on 07/06/23 with diagnoses of Pneumonia, chronic respiratory failure, and urinary tract infection. The clinicians failed to coordinate with the physician to address uncontrolled pain. The 07/06/23 plan of care included the clinicians were to monitor pain at each visit and report any new, unusual, or increased pain to the physician. On 07/07/23 the Occupational Therapist (OT) completed the initial evaluation visit. The OT documented the patient’s pain was 6/10 on 0-10 pain rating scale. The OT failed to perform a complete pain assessment including the patient’s use of pain medication and coordinate with the SN and physician to determine if an update to the plan of care was needed. The Physical Therapy Assistant (PTA) visited the patient on 07/11/23, 07/13/23 and 07/20/23. At each visit, the PTA documented the patient reported moderate to severe pain ranging 7-10/10 on 0-10 pain rating scale. The PTA failed to notify the SN or the physician to coordinate a plan for effective pain management. The Physical Therapist (PT) visited the patient on 07/24/23, 07/28/23 and 08/03/23 and documented at each visit the patient had severe pain ranging 8-10/10 on 0-10 pain rating scale. There was no evidence the PT coordinated care with the SN or notified the physician of the patient’s uncontrolled pain. On 08/08/23 PT documented 8/10 pain, the PT documented “discussed other avenues of pain control to consider with her physician, including heat, and topical agents”. And patient continues with limitations secondary to server pain. The Clinicians failed to: Notify the physician with uncontrolled pain. Coordinate a plan of care with outcomes that could be achieved. Patient #16 was admitted to the agency on 01/05/23 with diagnoses that included pneumonia, cellulitis, type 2 diabetes, atrial fibrillation, acute kidney failure, obesity, and pressure ulcers to both buttocks. Diabetes The Home Health Certification and Plan of Care (POC) dated 01/05/23 included: - RN/LPN to monitor blood sugar at each skilled nursing visit. Notify MD as indicated - Patient to check blood sugar levels 3 times per day in am, after dinner and at bedtime. Patient will notify MD of blood sugar levels 250. On 01/24/23, the SN documented the readings had been between 50s and 60s since the last visit. The SN failed to either verify if the patient had notified the physician, or to notify the physician of the low, out-of-range blood sugars. Weight Monitoring The POC included "teach patient to weigh self daily at the same time every day; document; teach to report 2-3 lb weight gain/day or 5 lb gain/week to nurse or PCP." At the start of care on 01/05/23, the SN documented the patient's weight was 228 lbs. On 01/09/23, the SN documented a weight of 191 lbs., a 37 lb weight loss. On 01/19/23, at the resumption of care visit, the SN documented the Patient's weight was 206 lbs., a 15 lb weight gain. On 01/24/23, the patient had not checked the weight, and the SN documented the Patient was reminded to check the weight. On 01/30 and 02/07/23, the weights were 199 and 185 lbs., weight loss of 7 and 14 lbs. The SN failed to either verify the patient had notified the physician, or notify the physician, regarding the weight fluctuations. Oxygen The POC included: - oxygen via nasal cannula, inhale 2 liters continuously - patient to wear oxygen, 2 liters nasal cannula at night The initial nursing visit included the patient only wears the oxygen at night. The SN failed to verify oxygen orders with the physician and update the POC. On 08/15/23, the surveyor reviewed the record with the DPS and clinical manager. They acknowledged the findings, and no additional information was provided. Patient #14 was admitted to the agency on 04/13/23 with diagnoses that included malignant neoplasm of the breast, bilateral radical mastectomy, concurrent breast reconstruction, hypertension, chronic obstructive pulmonary disease (COPD), and hypothyroidism. The SN failed to notify the physician of changes in the patient's condition. The 04/13/23 Home Health Certification and Plan of Care included "oxygen saturation - perform on routine visits for patients with pulmonary diagnoses, at SOC, ROC, RECERT and PRN for respiratory distress/compromise. Call Physician if less than 92% unless otherwise ordered." On 05/01/23, the OT visited the Patient and logged the oxygen saturation at 91%. The OT failed to notify the Physician of the oxygen saturation reading out of ordered parameters. On 08/15/23, the surveyor reviewed the record with the DPS and clinical manager. They acknowledged the findings, and no additional information was provided. Patient #17 was admitted to the agency on 03/02/23 with diagnoses of type 2 diabetes, acute osteomyelitis of left ankle and foot, ulcer of left heel and midfoot, stage 2 pressure ulcer of sacral region, atrial fibrillation, and congestive heart failure. The SN failed to notify the physician of changes in the patient’s condition On 03/02/23 the SN documented in the start of care there was swelling in the patients legs and the patient had non-pitting edema in the calf, ankle and foot. The 03/02/23 – 04/30/23 Plan of Care included an order to monitor edema at visit and the clinician, caregiver, or patient was to report to the physician any new, unusual or increased edema. There is no evidence that the SN alerted the physician when there was an increase in edema. On 03/06/23, the LPN documented no pitting edema in the patient’s bilateral lower extremities. On 03/09/23, the SN documented the patient had 2+ pitting edema in their right ankle and foot and 3+ pitting edema in their left ankle and foot. There is no evidence this increase in edema was reported to the physician. On 03/13/23, 03/17/23 and 03/31/23 the SN visited the patient. At each visit, the SN documented the patient had bilateral lower extremity pitting edema ranging between 2+ - 3+. The was no evidence that the increase in edema was reported to the physician. On 08/15/23 at 9:55 a.m., the surveyor reviewed the record with the DPS and clinical manager. They acknowledged the findings, and no additional information was provided. Patient #11 was admitted to the agency on 07/19/23 with diagnoses of stage 3 pressure ulcer of the right buttock, localized edema, cellulites of the right and left lower limb, chronic kidney disease and type 2 diabetes. The SN failed to notify the physician of changes in the patient’s condition On 07/19/23 the SN documented in the start of care the patient had 2+ pitting edema in their bilateral lower extremities. The 07/19/23 – 09/16/23 Plan of Care (POC) included an order to monitor edema at visit and the clinician, caregiver, or patient was to report to the physician any new, unusual or increased edema. There is no evidence that the SN alerted the physician when there was an increase in edema. On 07/31/23, the SN documented the patient had 3+ pitting edema in their right lower extremity and 4+ pitting edema in their left lower extremity. The was no evidence that the increase in edema was reported to the physician. On 08/15/23 at 9:55 a.m., the surveyor reviewed the chart with the clinical manager and DPS. They acknowledged the findings, and no additional information was provided.

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 review of patient records, observational home visits, and interviews with the Director of Patient Services (DPS) and Clinical Managers it was determined in 4 out of 17 patients (patients #3, 11, 14, and 17) the agency staff failed to provide coordinated care to meet the needs of the patients. Evidence as follows: Home Visit (HV) Patient # 3 was admitted to the agency on 03/07/23 with diagnoses of hydronephrosis, left nephrostomy tube, history of urinary tract infections, cardiomyopathy, prostate cancer, and chronic kidney disease. The SN failed to coordinate to ensure changes following medical procedures were monitored. On 06/02/23 the SN visited the patient and documented the patient had an appointment with urology the previous day and was started on an antibiotic (Macrobid) 100 mg BID for 7 days. On 06/07/23 the patient had a follow-up visit with the urologist for a procedure. The post-procedure instructions included to leave the nephrostomy tube clamped to evaluate for possible removal. On 06/08/23 the SN documented the patient had a procedure the previous day including a cystoscopy with left retrograde pyelogram and stent exchange. The SN documented the nephrostomy dressing was changed during the visit, so there was no need to visit the patient until the next week. There was no evidence the SN was aware the patient was to clamp the tube and no discussion with the patient regarding if the tube was clamped, how it was being tolerated and review of signs and symptoms to report. On 06/12/23 the SN visited the patient and documented flushing the tube and the patient was on an antibiotic (Keflex) 500 mg four time a day for 2 days following the procedure which was finished. There was no discussion of clamping the tube, how it was tolerated and for how long. On 08/11/23 at 1 p.m. the record was reviewed with the DPS and Clinical Manager. They acknowledged the findings and provided no additional information. Patient #14 was admitted to the agency on 04/13/23 with diagnoses that included malignant neoplasm of the breast, bilateral radical mastectomy, concurrent breast reconstruction, hypertension, chronic obstructive pulmonary disease (COPD), and hypothyroidism. The SN failed to coordinate to ensure the patient received appropriate, timely post-operative services. On 04/11/23, as part of the referral, the patient's provider completed the "Hospital Home Care Referral, Documentation of Physician Face to Face Encounter" form that ordered nursing and home health aide services and indicated they were medically necessary. The document included the patient would benefit from wound care support at home and assistance with Jackson Pratt (JP) drains. The referral information provided to the agency included a History and Physical dated 03/22/23 that identified the patient had "some" family support in the area and that the patient had been living in her van before recently obtaining an apartment to complete the surgery. The SN failed to determine if the patient's living situation was stable and referred to social services. (NO MSW ON STAFF)remove? On 04/13/23 at 9:45 a.m., the SN performed an initial assessment and documented the patient's adult child was the primary caregiver; however, they were infrequently available, "less often than weekly," and only "somewhat" willing to provide care. Further SN documentation described a wound vac to the anterior chest and JP drains to the bilateral axilla area. The SN failed to assess how the patient had been independently performing the activities of daily living, including bathing, dressing, and cooking, since the 04/11/23 hospital discharge and failed to determine whether the patient's current living situation was stable or if social services should be referred. On 04/18/23, 5 days following the initial visit, the SN visited and updated the wound care orders, noting that the occlusive dressing was removed; the surgeon gave permission for showering, with bacitracin to be applied to the incisions. Abd pads were covering the incisions, held in place with a "chest type binder," and the JP drains were intact on the right and left sides. The SN failed to identify if the patient had or could shower, was able to perform the dressing change and chest binder application independently, and had the supplies on hand. On 04/20/23, the SN obtained an order for an occupational therapy evaluation and assessment to occur on 04/24/23, 9 days after hospital discharge and 1 week after the start of care. On 04/24/23, the occupational therapist (OT) visited the patient for an initial evaluation and assessment, and documented at arrival, the patient was found upset and stated to the OT, "I think my drains are leaking, my binder and shirt are covered in blood." The OT observed the JP drains were hanging down without support while the patient was walking. The OT alerted the nursing supervisor and SN. The OT determined the patient would benefit from skilled OT and home health aide services 11 days after the start of care. On 08/14/23, the surveyor interviewed the DPS regarding the home health aide referral process. The DPS stated when we get an aide referral, we explain to the referring party that we only have one aide, so we get a verbal order for OT evaluation, who would then determine the services necessary. On 08/14/23, the agency policy "Patient Referral and Admission Process" was reviewed. The policy included: - The RN Coordinates Services - The RN will coordinate the referral process to the following staff personnel according to the patient's individual needs and as directed by the physician's plan of treatment; LPN and HHA services to be coordinated by the RN, and PT, OT, ST, and MSW. On 08/11/23 at 1:00 p.m., the record was reviewed with the DPS and Clinical Manager. They acknowledged the findings and provided no additional information. Patient # 11 was admitted to the agency on 07/19/23 with diagnoses of stage 3 pressure ulcer of the right buttock, localized edema, cellulites of the right and left lower limb, chronic kidney disease and type 2 diabetes. (State the problem up front) The clinicians failed to coordinate care to ensure the patient’s personal care needs were met. On 07/19/23 The SN completed the initial assessment. The SN documented the patient lived in an Assisted Living Facility, where staff provided assistance with medications, meals and showering. The note included the patient was moving to an independent living apartment. The SN obtained a referral for the Occupational Therapist (OT) to evaluate Activities of Daily Living (ADLs) prior to moving to independent living. On 07/31/23, the SN documented the patient moved into their new home. The patient stated Meals on Wheels was starting and an evaluation for aide services with a private agency for assistance with ADLs was scheduled that day. On 07/31/23 the patient reported to the OT they received a warning letter from the housing management because they were incontinent on a piece of furniture. The patient stated they did not have anyone to help with their leg wraps. The patient stated the private aide never showed up over the weekend. The note included the patient was unable to transfer into or out of bed because they could not lift their legs into the bed and the patient stated that they would not shower without an aide helping. The OT advised the patient to call various agencies that may be able to get aide services. Although the OT documented contact was made with the SN case manager, SN supervisor and physician; there was no evidence the OT coordinated care for a plan for the agency to provide aide services or notified the physician the patient was not able to independently meet personal care needs. On 08/15/23 at 9:55 a.m., the surveyor reviewed the chart with the clinical manager and DPS. They acknowledged the findings, and no additional information was provided. Patient #17 was admitted to the agency on 03/02/23 with diagnoses of type 2 diabetes, acute osteomyelitis of left ankle and foot, ulcer of left heel and midfoot, stage 2 pressure ulcer of sacral region, atrial fibrillation, and congestive heart failure. The patient was selected from the internet Quality Improvement Evaluation System (iQIES) Adverse Event Listing for increase in pressure ulcers. Wound Care The registered nurse case manager (RNCM) and licensed practical nurse (LPN) failed to coordinate care to ensure wound changes were properly assessed, reported timely and new treatments communicated with the provider. On 03/02/23 the start of care (SOC) nurse documented in the initial assessment the patient had a stage 2 pressure ulcer to their coccyx and the area was bleeding due to friction of incontinence brief. The wound measured 2.5 cm x 3 cm x .02 cm. The SOC nurse documented they educated the patient on skin care, to change positions every 2 hours, to keep skin clean and dry and for the patient to lay on their sides as much as possible. The SOC nurse documented they would contact the physician for wound care orders. The 03/02/23 plan of care included the following wound care orders: cleanse coccyx with soap and water, rinse and pat dry, apply Destin to ulcer and cover with border gauze using aseptic technique. Perform every other day or as needed for loose or soiled dressing. On 03/06/23 the LPN visited the patient. The LPN documented the patient’s coccyx was excoriated and the caregiver stated Desitin barrier cream had not been picked up from the store. The note included the LPN performed the wound care per the plan of care. There was no evidence the LPN reported to the RNCM the caregiver had not obtained the Desitin and wound care was not performed as ordered. On 03/09/23 and 03/13/23 the RNCM visited the patient. There is no documentation in the visit note they assessed the coccyx wound or performed wound care. The RNCM documented they educated the patient and family on skin breakdown prevention, including keeping the skin clean and dry, changing positions at least every 2 hours, ensuring linens underneath the patient were clean and wrinkle free and ensuring the patient received adequate hydration and protein intake. On 03/17/23 the RNCM visited the patient. There is no documentation the wound was assessed or wound care was performed. On 03/21/23, the LPN documented that wound cleansing and dressing change were done per the plan of care. The LPN documented that the bilateral buttocks wounds have become larger and bleeding. The LPN contacted the wound clinic and scheduled an appointment for the patient 03/27/23. The visit note indicated the RNCM was contacted. There was no documentation of what information was communicated to the RNCM, including that the wound was worsening. The RNCM did not re-assess the patient until 10 days later on 03/31/23. On 03/31/23, the patient’s daughter had changed the dressing prior to the RNCM arriving and the RNCM was unable to assess the wound. The RNCM documented the patient’s daughter verbalized good understanding of wound care procedure using aseptic technique. Coumadin Monitoring On 04/04/23, the LPN documented the patient was seen at the Coumadin clinic on 04/03/23 and their INR (blood test measuring how long it takes blood to clot) was 6.4, their Coumadin was on hold, and their next home blood draw would be Wednesday. The visit note indicated the RNCM was contacted but there was no documentation of what information was communicated to the RNCM including if they were notified the patient had been taking Coumadin and it was now on hold. On 8/15/23 at 9:55 am, the surveyor reviewed the record with the DPS and clinical manager. No additional information was provided.

Program activities CFR(s): 484.65(c) Standard: Program activities. The HHA's performance improvement activities must-- This STANDARD is not met as evidenced by: Based on a review of the agency's Quality Assessment Performance Improvement (QAPI) Program, interviews with the Director of Patient Services (DPS), and Clinical Manager, it was determined that the activities of the program were inadequate to improve the deficiencies found in the data reports of agency quality of care, services, and operations. Evidence as follows: The surveyor reviewed the Professional Advisory Committee's (PAC) 01/12/22 through 06/28/23 meeting minutes, the 06/2023 agency Board of Directors meeting minutes, the 01/01/23 through 08/16/23 agency adverse events log, start of care (SOC) audits from 04/2022 through 10/2022, wound care focused audits and 07/2023 Medication Reconciliation Issues and Intake Statistics. Each monthly SOC audit provided included a compliance summary which included areas such as the following; - edema assessment - disaster triage - updated medication list - care plan complete On 08/16/23, interviews were completed with the DPS and Clinical Manager who stated SOC audits were halted after 10/2022 due to the staffing shortage and the QAPI auditor was filling in as an intake nurse. The Clinical Manager stated they had recently begun to work on medication reconciliation issues and provided the 07/2023 Medication Reconciliation Issues monthly focused audit of internally ordered medication (ordered by their own healthcare system providers). No action plans were seen for the areas that were not in compliance with the report, which reflected a lack of input from the PAC. On 08/16/23, the Clinical Manager provided the "Potentially Avoidable Event Overview" prepared for the agency by a contracted data collection entity. The report was compiled from data dated 08/01/22-07/31/23 and consisted of 13 categories, which compared the overall percentages of national and state averages, which were also complied by the data entity. The agency had negative findings in 10 of 13 categories, such as, "a substantial decline in management of oral medications: agency 2.94%, national average 0.57%, and state 0.34%." No action plans or performance improvement projects were seen to determine the cause of or implement preventive actions for any of the identified negative findings. During the entrance conference, it was noted the agency had 1 aide and no social worker on staff. Each PAC meeting minutes identified "staffing needs." - 06/28/23 1 RN, 1 per diem (PD) RN - 04/12/23 1 RN case manager, 1 LPN, and 2 PD RNs - 10/26/22 2 RN case managers, 2 PD RNs, 1 LPN, 1 PT and PD PT, OT and MSW. None of the PAC minutes included recruitment for home health aides or the continued recruitment of an MSW. The 06/2023 agency Board of Directors meeting minutes included 1 RN and 1 PD RN under staffing needs, and no need for aides or a social worker. Failure to implement action plans and performance improvement projects for identified deficiencies can result in negative outcomes and patient hospitalizations.

Infection Prevention CFR(s): 484.70(a) Standard: Infection Prevention. The HHA must follow accepted standards of practice, including the use of standard precautions, to prevent the transmission of infections and communicable diseases. This STANDARD is not met as evidenced by: Based on 7 observational home visits with clinicians, review of agency policies and procedures, and interviews with the Director of Patient Services (DPS) and Clinical Manager, it was determined during 1 of 7 visits (patient #1), the skilled nurse (SN) failed to follow accepted standards of infection control practices. Evidence as follows: Home Visit Patient #1 was admitted to the agency on 06/15/23 with diagnoses that included discitis, sepsis, hypertension, osteoarthritis, spondylosis, and depression. The Home Health Care Certification and Plan of Care dated 06/15/23 contained an order for the registered nurse to change the central line dressing weekly in compliance with the Guthrie Home Health NY Policy and Procedure, "Central Line Site Care and Dressing Changes." On 08/10/23 at 1:00 p.m., the surveyor conducted an observational home visit with the skilled nurse (SN), who drew blood from and performed a dressing change to the peripherally inserted central catheter (PICC). The SN completed the blood draw, packaged the samples for transport, and set them aside. Without changing gloves, the SN obtained the dressing change kit, donned the mask, then doffed and discarded the gloves. The SN failed to perform hand hygiene after discarding the used gloves prior to donning the next. Without performing hand hygiene, the SN removed the package of sterile gloves from the sterile kit. While donning the gloves, 1 glove tore. The SN removed a second package from the kit and donned the gloves. The SN removed and discarded the old dressing, contaminating the sterile gloves, then proceeded to cleanse the site with an antimicrobial agent, use a gauze pad to blot the area dry, and apply the new dressing with the contaminated gloves. The patient observed the procedure with an unmasked mouth and nose inches from the PICC insertion point (right basilic vein - upper arm). On 08/10/23, the surveyor reviewed the Guthrie Home Health policy "Central Line Care and Dressing Changes," dated 02/16/23. The SN failed to adhere to the following procedure directives: A. Wash hands and apply gloves B. Put on bouffant cap C. Place mask on patient if able to tolerate E. Have patient turn head away from site if unable to tolerate mask F. Remove dressing. Dispose of dressing G. Remove gloves and wash hands H. Place sterile gloves on using sterile technique, cleanse area with antimicrobial agent. Let dry completely; do not blow or blot dry. On 08/11/23 at 09:00 a.m., the surveyor conducted an interview with employee #11, who stated hand hygiene should be performed before starting and in between glove changes. The surveyor stated hand hygiene wasn't observed before or between glove changes. The surveyor also mentioned removing the old dressing and not discarding the contaminated gloves before starting the sterile part of the dressing change. Employee #11 replied, "I must've been nervous, and then my glove tore. They (PICCs) aren't sutured anymore. I try to secure the line with my left hand while cleaning with the right. It's very difficult to remove without dislodging the line." On 08/11/23, the findings were reviewed with the Director of Patient Services and Clinical Manager (CM), who acknowledged the findings. On 08/15/23, the CM provided a home visit supervision summary dated 07/12/22 completed with employee #11, which included observation of a PICC dressing change. The CM pointed to the summary, where she had previously documented, "the training associated with this was started but not finished." Failure to ensure the SN is oriented to agency policies and procedures regarding standard precautions for the prevention and transmission of infectious agents has the potential for unmet patient needs and possible negative patient outcomes.