Every finding on record at Hands of Wellness, Inc

The Emergency Preparedness requirements were evaluated, in conjunction with the recertification survey, on 3/21/24. Standard level deficiencies cited. Abbreviations: Pts. = Patients PM = afternoon/evening

EP Training Program CFR(s): 484.102(d)(1) §403.748(d)(1), §416.54(d)(1), §418.113(d)(1), §441.184(d)(1), §460.84(d)(1), §482.15(d)(1), §483.73(d)(1), §483.475(d)(1), §484.102(d)(1), §485.68(d)(1), §485.542(d)(1), §485.625(d)(1), §485.727(d)(1), §485.920(d)(1), §486.360(d)(1), §491.12(d)(1). *[For RNCHIs at §403.748, ASCs at §416.54, Hospitals at §482.15, ICF/IIDs at §483.475, HHAs at §484.102, REHs at §485.542, "Organizations" under §485.727, OPOs at §486.360, RHC/FQHCs at §491.12:] (1) Training program. The [facility] must do all of the following: (i) Initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles. (ii) Provide emergency preparedness training at least every 2 years. (iii) Maintain documentation of all emergency preparedness training. (iv) Demonstrate staff knowledge of emergency procedures. (v) If the emergency preparedness policies and procedures are significantly updated, the [facility] must conduct training on the updated policies and procedures. *[For Hospices at §418.113(d):] (1) Training. The hospice must do all of the following: (i) Initial training in emergency preparedness policies and procedures to all new and existing hospice employees, and individuals providing services under arrangement, consistent with their expected roles. (ii) Demonstrate staff knowledge of emergency procedures. (iii) Provide emergency preparedness training at least every 2 years. (iv) Periodically review and rehearse its emergency preparedness plan with hospice employees (including nonemployee staff), with special emphasis placed on carrying out the procedures necessary to protect patients and others. (v) Maintain documentation of all emergency preparedness training. (vi) If the emergency preparedness policies and procedures are significantly updated, the hospice must conduct training on the updated policies and procedures. *[For PRTFs at §441.184(d):] (1) Training program. The PRTF must do all of the following: (i) Initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles. (ii) After initial training, provide emergency preparedness training every 2 years. (iii) Demonstrate staff knowledge of emergency procedures. (iv) Maintain documentation of all emergency preparedness training. (v) If the emergency preparedness policies and procedures are significantly updated, the PRTF must conduct training on the updated policies and procedures. *[For PACE at §460.84(d):] (1) The PACE organization must do all of the following: (i) Initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing on-site services under arrangement, contractors, participants, and volunteers, consistent with their expected roles. (ii) Provide emergency preparedness training at least every 2 years. (iii) Demonstrate staff knowledge of emergency procedures, including informing participants of what to do, where to go, and whom to contact in case of an emergency. (iv) Maintain documentation of all training. (v) If the emergency preparedness policies and procedures are significantly updated, the PACE must conduct training on the updated policies and procedures. *[For LTC Facilities at §483.73(d):] (1) Training Program. The LTC facility must do all of the following: (i) Initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected role. (ii) Provide emergency preparedness training at least annually. (iii) Maintain documentation of all emergency preparedness training. (iv) Demonstrate staff knowledge of emergency procedures. *[For CORFs at §485.68(d):](1) Training. The CORF must do all of the following: (i) Provide initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles. (ii) Provide emergency preparedness training at least every 2 years. (iii) Maintain documentation of the training. (iv) Demonstrate staff knowledge of emergency procedures. All new personnel must be oriented and assigned specific responsibilities regarding the CORF's emergency plan within 2 weeks of their first workday. The training program must include instruction in the location and use of alarm systems and signals and firefighting equipment. (v) If the emergency preparedness policies and procedures are significantly updated, the CORF must conduct training on the updated policies and procedures. *[For CAHs at §485.625(d):] (1) Training program. The CAH must do all of the following: (i) Initial training in emergency preparedness policies and procedures, including prompt reporting and extinguishing of fires, protection, and where necessary, evacuation of patients, personnel, and guests, fire prevention, and cooperation with firefighting and disaster authorities, to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles. (ii) Provide emergency preparedness training at least every 2 years. (iii) Maintain documentation of the training. (iv) Demonstrate staff knowledge of emergency procedures. (v) If the emergency preparedness policies and procedures are significantly updated, the CAH must conduct training on the updated policies and procedures. *[For CMHCs at §485.920(d):] (1) Training. The CMHC must provide initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles, and maintain documentation of the training. The CMHC must demonstrate staff knowledge of emergency procedures. Thereafter, the CMHC must provide emergency preparedness training at least every 2 years. This STANDARD is not met as evidenced by: Based on a review of the Agency's Emergency Preparedness plan and staff interview, it was determined the Agency failed to conduct staff training, relative to the Agency's Emergency Preparedness plan. This has the potential to affect all Pts. who receive services from the Agency. Findings include: 1. The Emergency Preparedness plan was reviewed on 3/20/24. The Agency lacked documentation that staff received any training in 2022 and 2023, pertaining to the Agency's Emergency Preparedness plan. 2. During an interview with the Administrator and Director of Nursing on 3/20/24 at 3:35 PM, the Administrator confirmed the Agency failed to provide staff training relative to the Agency's Emergency Preparedness plan after 2021.

A recertification survey was conducted in conjunction with the evaluation of Emergency Preparedness requirements on 3/21/24. Standard level deficiencies cited. Abbreviations: - = to = number lbs = pounds x = times/by AM = morning > = greater than w/wk/WK = week MG = Milligrams SN = Skilled Nurse POC = Plan of care SOC = Start of care PsOC = Plans of Care BP = Blood Pressure MD = Medical Doctor RN = Registered Nurse PM = afternoon/evening s/s = signs and symptoms PCG = Primary Caregiver pt/Pt./ Pts. = Patient/Patients ST = Speech Therapy/Therapist PT = Physical Therapy/Therapist OASIS = Outcome and Assessment Information Set LPN/LVN = Licensed Practical Nurse/Licensed Vocational Nurse

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 interviews during a home visit, clinical records review, policy review and staff interviews, it was determined that for 3 of 7 (Pts. #2, #5 and #6) clinical records review, the Agency failed to ensure the PsOC included all the requirements. 2. Pt. #5 was admitted for Home Health Services on 1/20/24 with the diagnoses of Stage 4 Pressure Ulcer of Left Buttock and Stage 3 Pressure Ulcer of Left Hip. The clinical record was reviewed on 3/19/24. The record contained the POC for the certification period of 1/20/24 to 3/19/24 that required, "SN Frequency: 2-3x9w...SN perform wound care...every other day". The SN provided services 2 to 4 times a week from 1/21/24 to 3/12/24". The POC effective 1/20/24 lacked an accurate SN frequency to provide services. The POC effective 1/20/24 included: "Home Health Aide to provide assistance with personal care..." The POC lacked a frequency and duration for the Home Health Aide services. 3. Pt. #6 was admitted for Home Health Services on 3/2/23 with the diagnosis of Acute Respiratory Failure with Hypoxia. The closed clinical record was reviewed on 3/19/24. The record contained the OASIS-E Resumption of Care completed by the RN and dated 4/30/23, and the LPN visit notes for 1 to 2 times a week from 5/5/23 to 6/28/23, both included documentation the Pt. had a gastrostomy tube for nutrition/ feeding. The POC for the certification period for 5/1/23 to 6/29/23 lacked instructions for gastrostomy tube feedings; including the type of feeding, feeding schedule, care and maintenance of the gastrostomy tube. 4. During interviews with the Administrator and Director of Nursing on 3/19/24 at 10:45 AM and 11:50 AM, both confirmed the Agency failed to ensure the PsOC included all the requirements. Findings include: 1. Pt. #2 was admitted for Home Health Services on 10/26/23 with the diagnosis of Acute and Chronic Respiratory Failure with Hypoxia. During a home visit conducted with the PT on 3/18/24, the caregiver stated that Home Health Aide services have been provided 2 times a week since February 2024. The clinical record was reviewed on 3/19/24. The POC for the certification period of 2/23/24 to 4/22/24 lacked frequency and duration for Home Health Aide services.

Conformance with physician orders CFR(s): 484.60(b) Standard: Conformance with physician or allowed practitioner orders. This STANDARD is not met as evidenced by: Based on clinical record review and staff interview, it was determined in 2 of 7 (Pts. #5 and 6) clinical records reviewed, the Agency failed to ensure staff provide service, as ordered by the Physician and indicated in the POC. Findings include: 1. Pt. #5 was admitted for Home Health Services on 1/20/24 with the diagnoses of Stage 4 Pressure Ulcer of Left Buttock and Stage 3 Pressure Ulcer of Left Hip. The clinical record was reviewed on 3/19/24. The record contained the POC for the certification period of 1/20/24 to 3/19/24 that required: "SN to perform wound care to coccyx, right hip, and back. Cleanse with wound cleanser, apply Medi honey and Mepilex every other day." The LPN visit notes for 1 to 4 times a week from 1/21/24 to 3/12/24, included documentation the LPN provided wound care to 1 wound, the coccyx only. The record lacked documentation the LPN provided wound care to the right hip and back wounds from 1/20/24 to 3/19/24. The POC effective 1/20/24 required the SN, "Notify Physician of vital sign parameters out of range: Heart Rate: Greater Than (>) 100 Less Than () 160 Less Than () 90 Less Than (Pt. #6 was admitted for Home Health Services on 3/2/23 with the diagnosis of Acute Respiratory Failure with Hypoxia. The closed clinical record was reviewed on 3/19/24. The record contained the POC for the certification period of 5/1/23 to 6/29/23 that required, "SN Frequency: 2-3x9w". The record lacked documentation the SN provided a second visit during the week of 5/1/23 to 5/7/23, and a second visit during the week of 6/19/23 to 6/25/23. The POC effective 5/1/23 required the SN, "Notify Physician of vital sign parameters out of range... BP: Greater Than (>) 160 Less Than ( The PT evaluation/care plan dated 5/2/23 and signed by the Physician, required the PT to provide service "2WK2, 1WK5". The record lacked documentation the PT provided service during the week of 6/5/23 to 6/11/23. The Physician order dated 6/13/23 and signed by the Physician contained, "Continue PT 1wk2 effective week of 6-19-23 for gait training, transfer training....coordination exercises." The record lacked documentation the PT provided any service during the weeks of 6/19/23 to 6/25/23 and 6/26/23 an 6/29/23. The ST Evaluation/Care Plan dated 5/5/23 and signed by the Physician, required the ST to provide service "1 wk 8". The record lacked documentation the ST provided service during the week of 6/5/23 to 6/11/23. 3. During an interview with the Administrator and Director of Nursing on 3/19/24 at 11:50 AM, both confirmed the staff failed to comply with Physician orders.

Only as ordered by a physician CFR(s): 484.60(b)(1) Drugs, services, and treatments are administered only as ordered by a physician or allowed practitioner. This ELEMENT is not met as evidenced by: Based on clinical record reviews, Agency policy review and staff interview, it was determined in 2 of 7 (Pts. # 5 and 7) clinical records reviewed, wherein the Pt. received wound care, the Agency failed to ensure staff obtained Physician orders for all services and/or treatments. Findings include: 1. Pt. #5 was admitted for Home Health Services on 1/20/24 with the diagnoses of Stage 4 Pressure Ulcer of Left Buttock and Stage 3 Pressure Ulcer of Left Hip. The clinical record was reviewed on 3/19/24. The record contained the "Nursing Order" completed and signed by the Physician on 2/15/24 and included, "Home Health Order Sacral: SN to perform and instruct patient/PCG on wound care as follows: Cleanse wound with wound cleanser pat dry with sterile 4x4 gauze, apply Fibracol and then Xerofoarm, and cover with foam border dressing, 3x/week until healed..." The LPN visit notes dated for 1 to 4 times a week from 2/17/24 to 3/12/24 contained documentation the LPN "Cleanse with wound cleanser, apply Medi honey and mepilex every other day". The record lacked documentation the LPN provided the wound care order signed by the Physician on 2/15/24. The LPN visit notes dated 1/21/24 to 3/12/24 included documentation the SN and/or caregiver monitored and/or assessed the patient's blood sugar every visit. The POC for the certification period of 1/20/24 to 3/19/24 lacked interventions for blood sugar monitoring. 2. Pt. #7 was admitted for Home Health Services on 2/7/23 with the diagnosis of Unspecified Dementia, Severe, with Agitation. The closed clinical record was reviewed on 3/19/24. The record contained the SN visit notes dated 3/10/23 and 3/13/23 that included documentation that Pt. #7 had developed a Stage 1 pressure ulcer to the left buttock with an onset date of 3/9/23, "SN cleansed/ irrigate wound (blister) and reddened areas with Skin Integrity Wound Cleanser, patted wound dry with clean 2 x 2 gauze pad, applied Duoderm using aseptic technique". The record lacked documentation the SN obtained a Physician order for the wound care provided on 3/10/23 and 3/13/12. 3. The Agency's policy titled, "Wound Care" was reviewed on 3/20/24. The policy required: "...the plan of care must contain the specific instructions for the treatment of the wound..." 4. During an interview with the Administrator and Director of Nursing on 3/20/24 at 11:50 AM, both confirmed the Agency failed to ensure staff obtained Physician orders for all services and/or treatments.

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, Agency policy review and staff interview, it was determined in 1 of 5 (Pt. #5) clinical records reviewed, wherein the Pt. received multiple disciplines, the Agency failed to ensure there was care coordination between care providers to ensure Pt. needs are met. Findings include: 1. Pt. #5 was admitted for Home Health Services on 1/20/24 with the diagnoses of Stage 4 Pressure Ulcer of Left Buttock and Stage 3 Pressure Ulcer of Left Hip. The clinical record was reviewed on 3/19/24. The record contained the POC for the certification period of 1/20/24 to 3/19/24 that included, "...Goals... Patient will attain optimal effectiveness of pain management regimen by the end of the episode..." The PT evaluation dated 1/29/24 and PT visit notes for 2 times a week from 1/29/24 to 3/13/24 contained documentation the Pt. experienced pain 10 out of 10 (Pain severity scale: 0 equal no pain to 10 that equal severe pain), prior to therapy and after therapy. The PT evaluation also included Pt. #5 was "non-weight bearing" and had contractures to both/all shoulders, elbows, fingers, wrists, hips, knees, ankles, trunk and limited neck motions. The record lacked documentation the PT coordinated care by notifying the RN case manager or Director of Nursing, and the Physician to address the patient's pain. 2. The Agency policy titled, "Monitoring Patient Care/Coordination of Care" was reviewed on 3/20/24. The policy required: "...1. The Agency will monitor, evaluate, and report to the patient's/client's physician and/or non-physician practitioner regarding the patient's /client's progress toward achieving goals established on the plan of care...C. Integrate services, whether services are provided directly or under arrangement, to assure the identification of patient/client needs and factors that could affect patient/client safety and treatment effectiveness and the coordination of care provided by all disciplines...iii. Agency staff are expected to contact the Agency to report patient/client needs... This will be documented on a communication note and will serve as coordination of care..." 3. During an interview with the Administrator and Director of Nursing on 3/20/24 at 11:50 AM, both confirmed the Agency failed to ensure that care coordination between care providers occurred to meet the patient's needs.

Nursing services supervised by RN CFR(s): 484.75(c)(1) Nursing services are provided under the supervision of a registered nurse that meets the requirements of §484.115(k). This ELEMENT is not met as evidenced by: Based on clinical record review, Agency policy review and staff interview, it was determined in 3 of 3 (Pts. #3, 4 and 6) clinical records reviewed wherein the LPN services were provided for more than 60 days, the Agency failed to ensure the RN supervised the LPN. Findings include: 1. Pt. #3 was admitted for Home Health Services on 4/5/23 with the diagnosis of Hemiplegia following Cerebral Infarction Affecting Left Nondominant Side. The clinical record was reviewed on 3/19/24. The record contained LPN visit notes from 10/3/23 to 11/27/23, 12/1/23 to 1/29/24 at 1 to 2 times a week. The record lacked documentation the RN supervised the LPN from 10/3/23 to 1/29/24. 2. Pt. #4 was admitted for Home Health Services on 9/1/22 with the diagnosis of Type 2 Diabetes Mellitus with Hypoglycemia without Coma. The clinical record was reviewed on 3/20/24. The record contained LPN visit notes from 11/1/23 to 2/20/23 and 12/27/23 to 2/21/24 at 1 to 2 times a week. The record lacked documentation the RN supervised the LPN from 11/1/23 to 2/21/24. 3. Pt. #6 was admitted for Home Health Services on 3/2/23 with the diagnosis of Acute Respiratory Failure with Hypoxia. The closed clinical record was reviewed on 3/19/24. The record contained LPN visit notes from 3/3/23 to 4/3/23 and 5/5/23 to 6/28/23 at 1 to 2 times a week. The record lacked documentation the RN supervised the LPN from 3/3/23 to 6/28/24. 4. The Agency's policy titled, "Employee Supervision" was reviewed on 3/19/24. The policy required: "...D. Nursing Services...2. A qualified RN will supervise the licensed professional/vocational (LPN/LVN) at least every 60 days..." 5. During interviews with the Administrator and Director of Nursing on 3/19/24 at 10:45 AM and 11:50 AM, both confirmed the Agency failed to ensure the RN supervised the LPN.

Home health aide assignments and duties CFR(s): 484.80(g)(1) Standard: Home health aide assignments and duties. Home health aides are assigned to a specific patient by a registered nurse or other appropriate skilled professional, with written patient care instructions for a home health aide prepared by that registered nurse or other appropriate skilled professional (that is, physical therapist, speech-language pathologist, or occupational therapist). This STANDARD is not met as evidenced by: Based on a review of clinical records and staff interview, it was determined in 1 of 4 (Pt. #2) clinical records reviewed wherein the Pt. received Home Health Aide services, the Agency failed to ensure that written Pt. care instructions were provided to the Home Health Aide based on Pt. care needs. Findings include: 1. Pt. #2 was admitted for Home Health Services on 10/26/23 with the diagnosis of Acute and Chronic Respiratory Failure with Hypoxia. The clinical record was reviewed on 3/19/24. The record contained a “Home Health Aide Care Plan – Not Started." The record lacked documentation of a Home Health Aide Care Plan. 2. During an interview with the Administrator, Director of Nursing on 3/20/24 at 11:00 AM, the Administrator stated the PT was assigned the task but has not completed it. During the same interview, the above finding was confirmed.

Services provided by HH aide CFR(s): 484.80(g)(2) A home health aide provides services that are: (i) Ordered by the physician or allowed practitioner; (ii) Included in the plan of care; (iii) Permitted to be performed under state law; and (iv) Consistent with the home health aide training. This ELEMENT is not met as evidenced by: Based on clinical record review, observation and interviews during a home visit and staff interview, it was determined for 1 of 4 (Pt. #3) clinical records reviewed, wherein the Pt. received Home Health Aide services, the Agency failed to ensure the Home Health Aide followed the directions on the Home Health Aide Care Plan. Findings include: 1. Pt. #3 was admitted for Home Health Services on 4/5/23 with the diagnosis of Hemiplegia following Cerebral Infarction affecting left non-dominant side. The clinical record was reviewed on 3/19/24. The record contained the "Home Health Aide Care Plan" completed by the RN and dated 1/29/24. The Plan required the Home Health Aide to provide the following personal care every visit: “Shower, Shower with Chair.” During the home visit conducted with Employee #2 (Home Health Aide) on 3/19/24, Pt. #3 refused to have a shower and a bed bath was provided instead. During the home visit, Employee #2 did not notify the RN prior to providing a bed bath. Employee #2 failed to follow the Aide Plan of Care or notify the RN. 2. During an interview with the Administrator and Director of Nursing on 3/20/24 at 11:00 AM, the above finding was confirmed.

Required items in clinical record CFR(s): 484.110(a)(1) The patient's current comprehensive assessment, including all of the assessments from the most recent home health admission, clinical notes, plans of care, and physician or allowed practitioner orders; This ELEMENT is not met as evidenced by: Based on clinical record review, observation and interview during home visits, Agency Policy review and staff interview, it was determined in 5 of 7 (Pts. #2, 3, 4, 1 and 5) clinical records reviewed, the Agency failed to ensure the information contained in the clinical records were complete and accurate. 4. Pt. #1 was admitted for Home Health Services on 3/2/23 with the diagnosis of Hypertensive Heart and Chronic Kidney Disease with Heart Failure and Stage 1-4 Unspecified Chronic Kidney. The closed clinical record was reviewed on 3/19/24. The record contained the SN visit notes at 1 to 2 times a week from 1/17/24 to 3/11/24 that included: "...Patient requires skilled intervention of physical therapy for exercises to increase strength and endurance..." A home visit was conducted with Employee #1 on 3/18/24. During the home visit, an interview was conducted with Employee #1 and Pt. #1, both stated the Pt. no longer required PT services. The clinical record was reviewed on 3/19/24 and contained the PT discharge summary dated 7/12/23 that included "maximum potential reached". The SN visit notes from 1/17/24 to 3/11/24 lacked accurate interventions. 5. Pt. #5 was admitted for Home Health Services on 1/20/24 with the diagnoses of Stage 4 Pressure Ulcer of Left Buttock and Stage 3 Pressure Ulcer of Left Hip. The clinical record was reviewed on 3/19/24. The record contained the form titled, "OASIS-E Start of Care" assessment completed by the RN and dated 1/20/24. The form contained multiple choice questions regarding the patient's present functional status. Under the section titled, "Activity", the RN placed a checkmark under "Walks with help". Under the section titled, "Mobility", the RN placed a checkmark under "Slightly impaired". In the same assessment the RN documented Pt. #5 is bedbound and dependent for all care. The PT Evaluation dated 1/24/24 included, "The patient is dependent in all bed mobility activities he requires a Hoyer lift for all transfers". During an interview with the Administrator and Director of Nursing on 3/20/24 at 11:50 AM, the Director of Nursing stated Pt. #5 is totally dependent for all care, have multiple contractions and is unable to walk. The OASIS-E Start of Care assessment contained conflicting and inaccurate documentation regarding Pt. #5's functional status. The Agency's SN visit note require the SN to assess the Pt. for pain. The section titled "Pain Profile" on the SN visit note completed by the LPN and dated 2/29/24 was left blank. The LPN visit notes for 1 to 4 times a week from 1/21/24 to 2/18/24 and 3/12/24 included Pt. #5 weighed of 136 pounds. The SN visit notes dated 1/21/24 to 3/12/24 contained SN "instruct pt/cg to weigh patient and report weight gain or loss of 5lbs in 7 days. The record contained documentation that Pt. #5 is bedbound and unable to be weighed. During an interview with the Administrator and Director of Nursing on 3/20/24 at 11:50 AM, the Director of Nursing stated the patient's hospital bed do not have the ability to weigh the Pt. The record contained inaccurate documentation. The LPN visit notes for 1 to 4 times a week from 1/21/24 to 2/18/24 and 3/12/24 included the Pt. had an "indwelling/Foley catheter... Catheter changes managed by Home Health Agency". During an interview with the Administrator and Director of Nursing on 3/20/24 at 11:50 AM, both stated Pt. #5 do not have a Indwelling/Foley catheter. The record contained inaccurate documentation. 6. The Agency policy titled, "Documentation and Standards" was reviewed on 3/20/24. The policy required: "...Use complete and accurate documentation, and reflect the care actually given at each visit... Write clinical notes so they can stand alone..." 7. During interviews with the Administrator and Director of Nursing on 3/20/24 at 10:45 AM and 11:50 AM, both confirmed the Agency failed to ensure the information contained in the clinical records were complete and accurate. Findings include: 1.Pt. #2 was admitted for Home Health Services on 10/26/23 with the diagnosis of Acute and Chronic Respiratory Failure with Hypoxia. The clinical record was reviewed on 3/19/24. During a home visit conducted with the Employee #9 on 3/18/24, the caregiver stated that Home Health Aide services have been provided 2 times a week since February 2024. As of 3/20/24, the record lacked Home Health Aide visit notes for the weeks of 2/25/24 to 3/2/24, 3/3/24 to 3/9/24 and 3/10/24 to 3/16/24. The record also included a POC for the certification period of 2/23/24 to 4/22/24. The POC included documentation of the medication “Baclofen 5 MG oral tablet one tablet every 8 hours” and “Glipizide 5 MG oral tablet 1 tablet daily by mouth.” The caregiver stated that “Baclofen” has been discontinued since December 2023 and the “Glipizide” has been discontinued for at least a year. The medications listed on the POC were inaccurate. 2. Pt. #3 was admitted for Home Health Services on 4/5/23 with the diagnosis of Hemiplegia following Cerebral Infarction affecting left non-dominant side. During a home visit conducted with Employee #2 on 3/19/24, it was stated by the caregiver that Home Health Aide visits are being provided 2 times a week. Employee #2 also stated that the visit notes are to be submitted weekly. As of the clinical record review of 3/20/24, the record lacked Home Health Aide visit notes for the weeks of 3/3/24 to 3/9/24 and 3/10/24 to 3/16/24. 3. Pt. #4 was admitted for Home Health Services on 9/1/22 with the diagnosis of Type 2 Diabetes Mellitus with hypoglycemia. The clinical record was reviewed on 3/19/24. The LVN/LPN Visit notes included the following documentation under the section “Visit Narrative: Vitals checked and blood sugar also discussed with daughter s/s of hypoglycemia discussed diet and fall prevention received in bed daughter noted with concerns that her dad wants to lay around a lot and does not move as much discussed aging process and safety measures also encouraged to make MD appointment to get blood work done for anemia and B12 she agreed.” The same verbiage was found on the LVN/LPN notes dated 2/7/24, 2/14/24, 2/21/24, 2/28/24 and 3/6/24. During an interview with the Administrator on 3/20/24 at 11:00 AM, it was stated that the documentation was inaccurate.

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 4/6//21 at 3:00 PM. The Plan did not include the use of volunteers. 2. During an interview with the Administrator on 4/7//21 at 11:05 AM, the Administrator confirmed the Agency's Emergency Preparedness plan lacked volunteers.

Names and Contact Information CFR(s): 484.102(c)(1) [(c) The [facility must develop and maintain an emergency preparedness communication plan that complies with Federal, State and local laws and must be reviewed and updated at least every 2 years (annually for LTC).] The communication plan must include all of the following:] (1) Names and contact information for the following: (i) Staff. (ii) Entities providing services under arrangement. (iii) Patients' physicians (iv) Other [facilities]. (v) Volunteers. *[For Hospitals at §482.15(c) and CAHs at §485.625(c)] The communication plan must include all of the following: (1) Names and contact information for the following: (i) Staff. (ii) Entities providing services under arrangement. (iii) Patients' physicians (iv) Other [hospitals and CAHs]. (v) Volunteers. *[For RNHCIs at §403.748(c):] The communication plan must include all of the following: (1) Names and contact information for the following: (i) Staff. (ii) Entities providing services under arrangement. (iii) Next of kin, guardian, or custodian. (iv) Other RNHCIs. (v) Volunteers. *[For ASCs at §416.45(c):] The communication plan must include all of the following: (1) Names and contact information for the following: (i) Staff. (ii) Entities providing services under arrangement. (iii) Patients' physicians. (iv) Volunteers. *[For Hospices at §418.113(c):] The communication plan must include all of the following: (1) Names and contact information for the following: (i) Hospice employees. (ii) Entities providing services under arrangement. (iii) Patients' physicians. (iv) Other hospices. *[For HHAs at §484.102(c):] The communication plan must include all of the following: (1) Names and contact information for the following: (i) Staff. (ii) Entities providing services under arrangement. (iii) Patients' physicians. (iv) Volunteers. *[For OPOs at §486.360(c):] The communication plan must include all of the following: (2) Names and contact information for the following: (i) Staff. (ii) Entities providing services under arrangement. (iii) Volunteers. (iv) Other OPOs. (v) Transplant and donor hospitals in the OPO's Donation Service Area (DSA). This STANDARD is not met as evidenced by: . A. Based on the review of the Agency's Emergency Preparedness Plan and staff interview, it was determined that the Agency failed to have a communication plan that included the required names and contact information. This has the potential to affect all Pts. who receive services from the Agency. Findings include: 1. The Agency's Emergency Preparedness Plan was reviewed on 4/6//21 at 3:00 PM. The plan lacked a communication plan that meets the following requirements: Names and contact information for staff members, entities providing service under arrangement, Patients' Physicians, and Volunteers. The Emergency Preparedness Plan contained a section titled "Emergency Preparedness and Response Guide." The guide required: "...The Agency will maintain a current list of staff, contract staff, Patients'/Clients' Physicians, volunteers...for use as a communication/disaster calling tree..." 3. During an interview with the Administrator on 4/7/21 at 11:05 AM, the Administrator confirmed the Agency's Emergency Preparedness plan did not include the required names and contact information.

Recertification survey was conducted. Standard level deficiencies cited. Focused Infection Control Survey was conducted. Standard level deficiencies cited. Abbreviations: Pt./ Pts. = Patient/Patients AM = Morning PM = Afternoon/Evening SN = Skilled Nurse RN= Registered Nurse HHA= Home Health Aide PT= Physical Therapy/Physical Therapist OT= Occupational Therapy/Occupational Therapist PTA = Physical Therapy Assistant SOC = Start of care POC = Plan of care WK= Week B/L = Bilateral QV = Every visit COVID-19 = Coronavirus 2019

Conformance with physician orders CFR(s): 484.60(b) Standard: Conformance with physician or allowed practitioner orders. This STANDARD is not met as evidenced by: . A. Based on clinical record review, Agency policy, and staff interview, it was determined the Agency failed to provide HHA services as ordered by the Physician. This was found in 1 of 2 (Pt. #6) records reviewed, wherein the HHA provided service. Findings include: 1. Pt. #6. SOC 2/12/20. Primary Diagnosis: Chronic Obstructive Pulmonary Disease, Unspecified. The clinical record was reviewed on 4/6/21 at 11:55 AM. The record included the POC effective 4/12/20, which contained the Physician's order "HHA Frequency: 2wk9." The record lacked documentation the HHA provided twice weekly service for the weeks of: 4/19/20 through 4/25/20, 4/26/20 through 5/2/20, 5/3/20 through 5/9/20, 5/10/20 through 5/16/20, and 5/24/20 through 5/30/20. The record lacked communication notes as to the reason for the missed HHA visits, as well as Physician notification of the missed visits. 2. The Agency policy titled "Implementing Care and Treatment" was reviewed on 4/8/21 at 10:15 AM. The policy required: "...If the Agency misses visits or services as required by the plan of care, it must notify the responsible Physician..." 3. During an interview with the Administrator on 4/7/21 at 11:05 AM, the Administrator confirmed the above findings, and stated missed visits should be documented on a communication note in the Patient's medical record. If the missed visit cannot be made up during the current treatment week, the Physician should be notified.

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: . A. Based on clinical record review and staff interview, it was determined that the Agency failed to ensure staff screen Pts. for COVID-19, prior to providing Pt. care and service. This was found in 3 of 7 (Pts. #1, 6, and 7) clinical records reviewed. Findings include: 1. Pt. #1. SOC 1/5/21. Primary Diagnosis: Hypertensive Heart and Chronic Kidney Disease with Heart Failure. The clinical record was reviewed on 4/6/21 at 10:40 AM. The record contained documentation the HHA provided service on 2/9/21, 2/11/21, 2/24/21, 2/25/21, 3/2/21, 3/4/21, 3/9/21, 3/11/21, 3/16/21, 3/18/21, 3/23/21, 3/25/21, 3/30/21, and 4/1/21. The HHA visit notes lacked documentation the HHA screened the Pt./Caregiver for COVID-19 symptoms prior to providing service. The record also included documentation the SN provided service on 2/22/21 and 3/4/21; however, the SN notes lacked documentation the SN screened the Pt./Caregiver for COVID-19 symptoms prior to providing service. 2. Pt. #6. SOC 2/12/20. Primary Diagnosis: Chronic Obstructive Pulmonary Disease, Unspecified. The clinical record was reviewed on 4/6/21 at 11:55 AM. The record contained documentation the HHA provided service on 4/15/20, 4/17/20, 5/19/20, 5/21/20, 6/3/20, and 6/5/20. The HHA visit notes lacked documentation the HHA screened the Pt./Caregiver for COVID-19 symptoms prior to providing service. The record also included documentation the SN provided service on 4/11/20; however, this SN note lacked documentation the SN screened the Pt./Caregiver for COVID-19 symptoms prior to providing service. 3. Pt. #7. SOC 8/18/20. Primary Diagnosis: Essential (Primary) Hypertension. The clinical record was reviewed on 4/6/21 at 2:00 PM. The record contained documentation the PT/PTA provided service on 11/25/20, 11/27/20, 11/30/20, 12/2/20, 12/7/20, 12/11/20, and 12/15/20. The PT/PTA notes lacked documentation the PT/PTA screened the Pt./Caregiver for COVID-19 symptoms prior to providing service. The record also included documentation the SN provided service on 10/20/20 and 12/15/20; however, these SN notes lacked documentation the SN screened the Pt./Caregiver for COVID-19 symptoms prior to providing service. 4. During an interview with the Administrator on 4/7/21 at 11:05 AM, the Administrator confirmed the above findings. The Administrator stated all clinicians must screen Pts./Caregivers for signs and symptoms of COVID-19 prior to or immediately upon entering the Patient's home and document these screenings in the Patient's medical record.

Provide services in the plan of care CFR(s): 484.75(b)(3) Providing services that are ordered by the physician or allowed practitioner as indicated in the plan of care; This ELEMENT is not met as evidenced by: . A. Based on clinical record review, Agency policy, and staff interview, it was determined the Agency failed to provide services/provide services in a timely manner as ordered in the POC. This was found in 2 of 7 (Pt. #1 and 7) clinical records reviewed. Findings include: 1. Pt. #1. SOC 1/5/21. Primary Diagnosis: Hypertensive Heart and Chronic Kidney Disease with Heart Failure. The clinical record was reviewed on 4/6/21 at 10:40 AM. The record included the POC effective 1/5/21, which contained the Physician's order "OT Frequency: Evaluation/treat." The record lacked an OT evaluation, as well as a Physician's order to cancel the OT evaluation. This POC also included the Physician's order PT Frequency: Evaluation/treat." The record also contained a PT evaluation, completed 1/18/21, which was 13 days after the Physician's order. 2. Pt. #7. SOC 8/18/20. Primary Diagnosis: Essential (Primary) Hypertension. The clinical record was reviewed on 4/6/21 at 2:00 PM. The record included the Physician's order dated 10/13/20 "...Can benefit from Physical Therapist R/T falls and pain in B/L lower extremities, having difficulty walking." The record also contained a PT evaluation, completed 11/20/20, which was 38 days after the Physician's order. 3. The Agency policy titled "Patient/Client Assessment Guidelines" was reviewed on 4/8/21 at 9:15 AM. The policy required: "...An assessment performed due to an Intra-Agency referral will be completed as follows: Physical Therapy and Occupational Therapy--Services have up to 5 days of the received order to perform the assessment, unless otherwise specified..." 4. During an interview with the Administrator on 4/7/21 at 11:05 AM, the Administrator confirmed the above findings, and stated OT and PT evaluations should be performed within 5 days of the Physician's order.

Services provided by HH aide CFR(s): 484.80(g)(2) A home health aide provides services that are: (i) Ordered by the physician or allowed practitioner; (ii) Included in the plan of care; (iii) Permitted to be performed under state law; and (iv) Consistent with the home health aide training. This ELEMENT is not met as evidenced by: . A. Based on clinical record review, Agency policy, and staff interview, it was determined the Agency failed to ensure the HHA provided services, as per the HHA care plan. This was found in 1 of 2 (Pt. #6) clinical records reviewed, wherein the HHA provided service. Findings include: 1. Pt. #6. SOC 2/12/20. Primary Diagnosis: Chronic Obstructive Pulmonary Disease, Unspecified. The clinical record was reviewed on 4/6/21 at 11:55 AM. The record included the HHA Care Plan, dated 4/11/20. This HHA care plan included the tasks: "Assist with Chair Bath QV, Hair Care/Comb Hair QV, Oral Care QV, Skin Care QV, Pericare QV, Nail Care QV, Assist with Dressing QV, Medication Reminder QV, Incontinence Care QV, Dangle on Side of Bed QV; and Assist with Ambulation QV." The record contained documentation the HHA provided service on 4/15/20, 4/17/20, 5/19/20, 5/21/20, 6/3/20, and 6/5/20. These notes indicate the Pt. refused the following: Bathing on 4/17/20; Hair Care/Comb Hair on 4/17/20 and 6/3/20; Oral Care on 4/15/20, 4/17/20, 5/19/20, 6/3/20, and 6/5/20; Skin Care on 4/17/20 and 5/21/20; Pericare on 4/15/20, 4/17/20, 5/19/20, 5/21/20, 6/3/20, and 6/5/20; Nail Care on 4/17/20, 5/19/20, 5/21/20, 6/3/20, and 6/5/20; Assist with Dressing on 4/17/20; Medication Reminder on 4/17/20; Incontinence Care on 4/17/20; Dangle on Side of Bed 4/17/20; and Assist with Ambulation on 4/15/20. There was no documentation the HHA informed the RN of Pt. #6's refusal of these tasks. 2. The Agency policy titled "Implementing Care and Treatment" was reviewed on 4/8/21 at 10:15 AM. The policy required: "...The Aide will be provided with written Patient/Client care instructions prepared by the RN and/or Therapist...The Home Health Aide provides services that are ordered by the Physician and/or non-Physician practitioner, included in the plan of care...The duties of the Home Health Aide include but are not limited to: Reporting changes in the Patient's/Client's condition or needs to a Registered Nurse or other appropriate skilled professional..." 3. During an interview with the Administrator on 4/7/21 at 11:05 AM, the Administrator confirmed the above findings, and stated if a Pt. refuses tasks assigned on the HHA Care Plan, the HHA should inform the RN, and the HHA care plan would then be amended by the RN, accordingly.