Every finding on record at Harrison County Health Department & Harrison County Home Health

An extended survey for Medicare recertification for the home health was completed on 02/07/2024. The provider had eight current patients. Two condition level deficiencies were identified during this survey at: -§484.55 Condition of Participation: Comprehensive assessments of patients; and -§484.60 Condition of Participation: Care planning, coordination of services, and quality of care. A home health agency that is found out of compliance with any Condition of Participation evaluated as part of a standard survey may not train or competency evaluate their home health aides for a period of two (2) years following the date of this survey. A deficiency has been cited at 484.80(f) (3) - see Tag G788. The Emergency Preparedness regulations were reviewed as part of the Medicare recertification survey completed on 02/07/2024. One standard level deficiency was identified.

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 review of the provider’s rehabilitation services agreement, policy review, employee file review, and interview, the provider failed to ensure the contract PT (physical therapist) received the provider’s emergency management training in one of one contract employee file review (Contract PT). This deficient practice has the potential to adversely affect the care and services to all patients in the event of an emergency. Findings included: Review of the rehabilitation services agreement signed and dated by the provider’s administrator 07/27/2023 and signed by the contracting provider’s CEO (Chief Executive Officer) 08/11/2023 showed in part, “Orientation. Agency (provider) shall provide appropriate initial orientation to individuals supplying services under this Agreement. Thereafter, annual education will be provided.” Review of the provider’s undated policy, titled, “In Service Education”, showed in part certain in-service programs are determined by the Agency (provider) to be mandatory initially and annually for all staff. These include but are not limited to the Emergency Operations Plan. Contract PT Employee file review showed: - The contract PT had been hired in 2005 by the prior home health provider before the CHOW (change of ownership); and - There failed to be any evidence of emergency preparedness (EP) training since the CHOW of the home health provider. During an interview on 02/06/2024 at 11:30 AM, the clinical manager stated that: - He/she had all of the training from the “Named home health provider” (the prior provider before the CHOW); - The contract PT had worked for them (the provider) already; and - No EP training had been done with the contract PT since the CHOW.

Comprehensive Assessment of Patients CFR(s): 484.55 Condition of participation: Comprehensive assessment of patients. Each patient must receive, and an HHA must provide, a patient-specific, comprehensive assessment. For Medicare beneficiaries, the HHA must verify the patient's eligibility for the Medicare home health benefit including homebound status, both at the time of the initial assessment visit and at the time of the comprehensive assessment. This CONDITION is not met as evidenced by: Based on clinical record review, and interview, the home health provider failed to ensure that a complete and accurate patient specific comprehensive assessment was completed for each patient. The provider failed to: - Ensure that the registered nurse conducted the initial assessment within 48 hours of the patient’s return home (G514); - Ensure that the comprehensive assessment was completed within 5 calendar days of the start of care (G520); and - Ensure that the comprehensive assessment adequately reflected the patient's current health, psychosocial, functional, and cognitive status (G528). The cumulative effects of these deficient practices has the potential to effect all patients served by the home health provider.

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 policy review, clinical record review, and interview, the provider failed to ensure the initial assessment was completed within 48 (forty-eight) hours of the referral in two of five full records reviewed (Records/Patients #1 and #2). This deficient practice has the potential to affect the immediate needs of all the provider’s patients. Findings included: Review of the provider’s undated policy titled, “Initial/Comprehensive Assessment,” showed in part: - A RN (registered nurse), PT (physical therapist) or SLP (speech, language pathologist) must conduct the initial assessment visit within 48 hours of the referral, within 48 hours of the patient’s return home, or on the physician-ordered start of care (SOC) date; - The initial assessment visit is conducted to determine the immediate care needs of the patient; and - In the absence of a physician-specified start of care date, the initial assessment visit is conducted within 48 hours of the referral. RECORD/PATIENT #1: Review of a referral dated 01/16/2024 from an inpatient rehabilitation hospital showed HH/PT/OT/Skilled (home health/physical therapy/occupational therapy/skilled nurse). Review of the clinical record showed the patient was admitted to home health services on 01/22/2024 with a primary diagnosis of MS (multiple sclerosis- a disease in which the immune system eats away at the protective covering of nerves). Review of the SOC OASIS (Start of Care Outcome and Assessment Information Set; a standardized data collection tool) dated 01/22/2024 (six days following referral) showed: - Item M0090- Date assessment completed: 01/22/2024 - Item M1005, Inpatient discharge date 01/16/2024; and - Item M0102, Date of physician-ordered SOC marked N/A, no specific SOC date. Review of an inter-office communication note dated 01/18/2024 showed the RN called the patient and left a voicemail, the patient returned call and requested someone come on Monday (01/22/2024) so their spouse could be present. Further review of the clinical record failed to show a specific physician ordered start of care. During an interview on 02/07/2024 starting at 1:15 PM, the clinical manager stated that he/she did not see a late SOC order and would have expected the initial assessment to have been completed within forty-eight hours of referral or discharge home since there was no late SOC order. RECORD/PATIENT #2: Review of the clinical record showed: - A referral dated 01/05/2024 from an acute care hospital; and - The patient was admitted to home health services on 01/16/2024 with a primary diagnosis of a fractured sacrum (a triangular shaped bone that lies at the bottom of the spine located just above the tailbone). Review of the SOC OASIS (Start of Care Outcome and Assessment Information Set; a standardized data collection tool) dated 01/16/2024 (11 days following referral) showed: - Item M0090- Date assessment completed: 01/16/2024; - Item M1005, Inpatient discharge date 01/11/2024; and - Item M0102, Date of physician-ordered SOC marked N/A, no specific SOC date. Review of an inter-office communication note dated 01/13/2024 showed the RN called the patient to set up admission time. Due to the weather, the patient requested to wait until the roads were better and it wasn’t quite as cold out. Patient request to be called tomorrow (01/14/2024) or Monday (01/15/2024) and stated they were doing okay at home. Further review of the clinical record showed: - A physician order dated 01/17/2024 (six days after discharge from the acute hospital) that showed patient to home health on 01/16/2024 per his/her request; and - It failed to contain an order within 48 hours of the patient’s return home. During an interview starting at 1:15 PM, the clinical manager stated that he/she would expect the PCP (primary care physician) to be contacted about the late SOC; and - The staff usually did call and they may have forgot to document with the weather.

5 calendar days after start of care CFR(s): 484.55(b)(1) The comprehensive assessment must be completed in a timely manner, consistent with the patient's immediate needs, but no later than 5 calendar days after the start of care. This ELEMENT is not met as evidenced by: Based on policy review, clinical record review, and interview, the provider failed to ensure the registered nurse (RN) completed the comprehensive assessment no later than five days after the start of care in one of five full records reviewed (Patient #3). This deficient practice has the potential to affect the needs of all the provider's patients. Findings included: Review of the provider’s undated policy titled “Initial/Comprehensive Assessment,” showed in part: - A RN (registered nurse), PT (physical therapist), or SLP (speech language pathologist) must conduct the initial assessment within 48 hours of referral, within 48 hours of the patient's return home or on the physician ordered start of care date; and - Completion of the comprehensive assessment must be completed in a timely manner consistent with the patient's needs, but no later than five (5) calendar days after the start of care. Review of the provider’s policy titled, “Care Planning Process,” revised 02/08/2022, showed in part: - All disciplines involved in the patient’s care will contribute to the POC (plan of care); and - In order to assure that care provided is appropriately planned to meet each patient's specific needs and problems, the agency will utilize data/information gathered during patient assessments in the care planning process. RECORD/PATIENT #3: Review of the clinical record showed the patient was admitted with a primary diagnosis of malignant neoplasm of the larynx (cancer of the voice box). Review of the referral information, dated 11/20/2023 from an acute care hospital, showed in part, disposition: anticipate home with HH (home health) and PT (physical therapy) in AM if tolerating TF (tube feeding). Review of the updated referral information, dated 11/21/2023 from an acute care hospital, showed in part, a face to face completed and electronically signed by the patient’s inpatient physician, with disciplines requested: Skilled Nursing and physical therapy. Further review of the clinical record showed: - A SOC OASIS (Start of Care Outcome and Assessment Information Set; a standardized data collection tool) with Item M0090- Date assessment completed: 11/22/2023, and electronically signed by RN B; and - A PT evaluation completed 12/07/2023 (fifteen days after the initial assessment). During an interview on 02/07/2024, starting at 1:15 PM, the clinical manager stated that the disciplines on the referral are supposed to go within the first five days of SOC (start of care), that is the expectation.

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 policy review, record review, and interview, the home health provider failed to ensure the comprehensive assessment accurately reflected the patient’s current health status including relevant past medical history in, three of five full records reviewed (Records/Patients #3, #4, and #5). This deficient practice has the potential to affect all patients served by the provider. Findings included: Review of the provider’s undated policy titled, “Initial/Comprehensive Assessment,” showed, in part: -Each patient admitted by the agency will have appropriate initial/comprehensive assessments performed and documented; - The assessment will reflect the patient's current health status and include information to demonstrate the patient’s progress toward achievement of desired outcomes; - A RN (registered nurse), PT (physical therapist), or SLP (speech language pathologist) must conduct the initial assessment within 48 hours of referral, within 48 hours of the patient's return home or on the physician ordered start of care date; - Completion of the comprehensive assessment must be completed in a timely manner consistent with the patient's needs, but no later than five (5) calendar days after the start of care; and - The initial comprehensive assessment also includes: * Relevant diagnosis and health status * Relevant medical history * Physical assessment/review of systems and pertinent physical findings * Strengths, goals and care preferences, including information that may be used to demonstrate the patient's progress towards achievement of the goals identified by the patient and measurable outcomes identified by the agency * Drug allergies, sensitivities, past adverse drug reactions and past history of medication compliance * Laboratory results. Review of the provider’s undated policy titled, “Reassessments,” showed, in part: - The comprehensive assessment (including OASIS- Outcome and Assessment Information Set data elements) must be updated and revised as frequently as the patient's condition warrants due to a major improvement or decline in health status; - staff will additionally reassess each patient with each home visit on an ongoing basis to evaluate current problems and needs as well as to adjust the care provided; and - Staff will analyze the data from assessments and reassessments. Such analysis of data will assist staff in identifying and prioritizing patient needs and problems to direct care and services. RECORD/PATIENT #4: Review of the clinical record, showed, in part: - The patient was admitted to home health services on 01/08/2024 with a primary diagnosis of a fracture to the shaft of humerus (left upper arm) and is temporally residing with his/her daughter; and - The SOC (start of care) assessment visit was on 01/08/2024. Review of the SOC visit note dated 01/08/2024, showed, in part: - The pain section showed, “no pain,” marked (The skilled nurse failed to assess the patient’s history of pain); - The musculoskeletal section showed the patient had a fracture to left shoulder; - The functional status showed, “walker,” selected for device use prior to current illness, exacerbation, or injury (The skilled nurse failed to document functional limitations related to the patient’s recently fractured left arm); - The activities permitted section showed, no restrictions, up as tolerated, and walker listed (The skilled nurse failed to assess the patient’s ability to use a walker since recently fracturing the left arm requiring the left arm to be in a sling. During home visit observation the patient had to pull his/her arm through the sling to hold onto the walker with both hands); - The living arrangements section showed, the patient lives with other person(s) in the home, around the clock (The patient is currently staying with his/her daughter until the patient is able to return home and the daughter works); - The risk for rehospitalization section showed that the patient lives alone; and - The assessment summary section showed a comment that the patient was “alert and oriented elderly (male/female) with fractured humerus in a sling on left side” (The skilled nurse failed to document an assessment of any limitations/restrictions related to the patient’s use of a sling). Review of the Occupational Therapy evaluation visit note dated 01/10/2024, showed, in part: - The pain section had pain rated 6 out of 10 (0 being no pain and 10 being the worst pain), pain location of both knees and left shoulder, description was “shooting” pain, pain worse with movement, pain relieved with medications and rest, “impacts patient mobility and ability to perform ADL (activities of daily living) tasks” was noted in the impact on activities question, breakthrough medication needed for pain had “less than daily” selected, and the comment section had “Patient takes Tylenol 1xday (one time per day) with good pain relief” noted (The skilled nurse failed to assess the patient’s history of pain, what exacerbates pain, and interventions to relieve pain, including the use of Tylenol); - The musculoskeletal assessment section showed, “Patient is NWB (non-weightbearing) with LUE (left upper extremity) and has standard RW (rolling walker) so difficulty with balance during ambulation” (The skilled nurse failed to assess the patient’s non-weight bearing status with LUE, the use of rolling walker, and difficulty with balance during ambulation); and - The occupational therapist failed to document an assessment of the patient’s ability to use a walker while having the left upper extremity in a sling. Review of the Occupational Therapy visit note dated 01/16/2024, that began at 9:15 AM and ended at 10:30 AM, showed, in part: - The pain section had pain rated 6 out of 10, pain location of right bottom (buttocks), left shoulder and both knees listed, description was dull cramping pain, pain is worse with movement, sitting on sore (buttocks wound), and walking, pain relieved with medications and rest, frequency of pain and impact on activities had “Pt (patient) has pain daily but is typically able to work through pain to complete activities” was noted in the impact on activities, and the comment section had “majority of day, depending on activity” noted, and “Pt is using barrier cream on sore on bottom. Nurse states (he/she) will bring some cream and different dressing for it. Pt is taking 500mg Tylenol 2 tabs 2x/day for shoulder and knee pain” noted in the comments section; and - The care planning/coordination section had “spoke to SN (skilled nurse) regarding pts sore and HR” (The skilled nurse failed to assess the patient’s pain history and use of Tylenol to relieve pain. The Tylenol was discontinued by the physician on 01/10/2024 due to the risk of drug to drug interactions). Review of the SN (skilled nurse) visit note, dated 01/16/2024, that began at 10:15 AM and ended at 11:00 AM, showed, in part: - The patient had a heart rate of 100 beats/minute (beats per minute) with an irregular rhythm (The skilled nurse failed to assess for signs or symptoms related to new onset of irregular heart rhythm); - The pain assessment section showed, “no pain” (During the OT visit that began one hour prior to this visit, showed the patient’s pain was rated at a 6 out of 10. The skilled nurse failed to assess the patient’s history of pain); and - The musculoskeletal assessment section showed, “weakness” and required the use of an assistive device of a walker (The skilled nurse failed to assess the patient’s left upper extremity limitations/restrictions). Review of the Physical Therapy visit note dated 01/17/2024, showed, in part: - The visit was completed by a PTA (physical therapy assistant); - The vital signs section showed the patient’s blood pressure reading as 130/100; - The pain section showed, pain rated 3 out of 10 (0 being no pain and 10 being the worst pain), pain location of both knees and left shoulder, pain description was aching, pain relieved with medications and rest, and “Pt (patient) has pain daily but is typically able to work through pain to complete activities” was noted in the impact on activities, and the comment section had “Pt took Tylenol 500mg (milligrams), 2 tabs (tablets) at 1600 (4:00 PM)” noted; - The care planning/coordination section had the PT (physical therapist) was notified of the patient’s progress towards goals; and - The documentation failed to show if the patient’s blood pressure was reassessed by the PTA during the visit). Review of the SN visit note dated 01/19/2024, showed, in part: - The pain assessment section had “no pain” selected; - The musculoskeletal assessment section had “weakness” selected with an assistive device of a walker; and - The skilled nurse failed to assess the patient’s history of pain, left upper extremity limitations from fracture, left upper extremity sling and restrictions related to fracture. Review of the Physical Therapy visit note, dated 01/22/2024, that began at 9:00AM and ended at 9:40 AM, showed, in part: - The pain section was left blank (The PT failed to document a complete pain assessment); and - The patient’s response to skilled care provided this visit showed, “Pt participates well in therapy and is motivated to improve but continues to be limited by L (left) shoulder and B (bilateral) knee pain” noted (The PT failed to perform a complete pain assessment). Review of the SN visit note, dated 01/22/2024, that began at 9:45 AM and ended at 10:00 AM, showed, in part: - The pain assessment section showed “no pain” was selected (The skilled nurse failed to perform a complete pain assessment); and - The musculoskeletal assessment section showed “weakness” selected with an assistive device of a walker (The skilled nurse failed to assess the patient’s ability to use a walker with a fracture to the left arm requiring the use of a sling). Review of the Occupational Therapy visit note dated 01/23/2024, showed, in part: - The pain section showed pain rated 6 out of 10, pain location of bottom, both knees and left shoulder, description was dull, aching, throbbing pain, pain is worse with movement, pain relieved with medications and rest, frequency of pain and impact on activities had “daily” noted, how often breakthrough medication is needed for pain had 2-3 times/day selected, “Pt currently takes 500mg Tylenol 2 tabs 2x/day and it helps relieve pain,” noted in the comments section (The skilled nurse failed to assess the patient’s complete pain history, only documenting “no pain” during the SN visit the previous day); - The patient’s response to skilled care provided this visit showed, “pt tolerated well, although pt is not making progress towards ADL goals at this time d/t (due to) poor standing balance and limited motion to LUE” (The skilled nurse failed to document an assessment regarding the patient’s limited motion to LUE during the SN visits); and - The care planning/coordination section had care coordination with PT regarding pts progress/lack of progress towards goals. Review of the Physical Therapy visit note dated 01/30/2024, showed, in part: - The pain section showed pain rated 1 out of 10, pain location of left shoulder caused by fracture, pain description was left blank, pain relieved with repositioning, breakthrough medication “never” needed, frequency of pain and impact on activities had “daily but not constant and usually does not affect (his/her) activity which is limited for now per medical restrictions,” and “Pt does not take anything for pain and denied needing anything for pain management” was noted in the comments section (The PT failed to perform a complete pain history assessment. The OT visit notes showed that the patient had a history of pain that required the use of Tylenol); - The care planning/coordination section showed that care was coordinated with the PTA regarding the patient having an ortho (orthopedic) appointment for “shoulder” or “knee” on 02/09/2024 and discharge plan for next week (The PT failed to document the patient’s history with an orthopedic doctor and/or the patient being provided care from an orthopedic doctor). Review of the Occupational Therapy visit note dated 01/30/2024, showed, in part: - The visit was completed by the OTA (occupational therapy assistant); and - The pain section showed pain rated 5 out of 10, pain location of bottom, both knees and left shoulder, description was dull, aching, throbbing pain, pain is worse with movement, pain relieved with medications and rest, frequency of pain and impact on activities had “daily” noted, how often breakthrough medication is needed for pain had “daily” selected, “Pt has Tylenol 500mg (he/she) can take that relieves pain,” noted in the comments section (The OT assessments showed the patient’s history of pain requiring the use of Tylenol. The skilled nurse visit notes showed that the patient had “no pain” and the skilled nurse failed to perform a complete pain history assessment). Review of the SN visit note, dated 02/02/2024, showed, in part: - The pain assessment section showed “no pain” selected; - The musculoskeletal assessment section showed “weakness” selected with an assistive device of a walker; and - The skilled nurse failed to perform a complete assessment of the patient’s history of pain and left upper extremity limitations/restrictions related to fracture. RECORD/PATIENT #5: Review of the clinical record, showed, in part: - The patient was admitted to home health services on 01/06/2024 with a primary diagnosis of a UTI (urinary tract infection- an illness in any part of the urinary tract, the system of organs that makes urine) and resided in the home when a spouse and adult daughter; - The patient’s daughter was listed as the primary caregiver; and - The SOC (start of care) assessment visit was on 01/06/2024. Review of the SOC visit note dated 01/06/2024, showed, in part: - The patient was discharged from an inpatient rehabilitation hospital or facility within the past 14 days; - The patients inpatient facility diagnosis was Takotsubo syndrome (a temporary heart condition that develops in response to an intense emotional or physical experience); - Additional hospital/facility stay diagnosis, surgeries, and treatments, showed, DM (diabetes mellitus-a disease that result in too much sugar in the blood), GERD (gastroesophageal reflux disease- a chronic disease in which stomach content persistently and regularly flows up into the esophagus), HTN (hypertension- high blood pressure, is when the pressure in the blood vessels is too high), hypothyroid (a condition in which the thyroid gland doesn't produce enough thyroid hormone), rheumatoid arthritis (a chronic inflammatory disorder usually affecting small joints in the hands and feet), and total knee replacement (a surgical procedure to resurface a knee that is damaged); - Primary diagnosis and other diagnoses section showed the patient’s primary diagnosis listed as UTI with a symptom control rating of 3 (three- Symptoms poorly controlled, patient needs frequent adjustment in treatment and dose monitoring). Other diagnoses included: Enterococcus as the cause of diseases classified elsewhere with a symptom control rating of 3, non-STEMI (Non-ST-Elevation Myocardial Infarction-a type of heart attack) with a symptom control rating of 2 (two- symptoms controlled with difficulty, affecting daily functioning, patient needs ongoing monitoring), atherosclerosis (build up a plaque inside the walls of the arteries) heart disease of coronary artery (a blockage in the arteries that supply blood and oxygen to the heart) with symptom control rating of 2, hypertensive heart and chronic kidney disease without heart failure symptom control rating of 2, type 2 diabetes mellitis with diabetic chronic kidney disease symptom control rating 1 (one- symptoms well controlled with current therapy), chronic kidney disease with symptom control rating one, metabolic encephalopathy with a symptom control rating of one, rheumatoid arthritis with a symptom control rating of one, dysphagia with a symptom control rating of one, hyperlipidemia with a symptom control rating of one, hypothyroidism with a symptom control rating of one, GERD with a symptom control rating of 0 (zero- asymptomatic, no treatment needed at this time), long term (current) use of antithrombolytics/antiplatelets (no symptom control rating), acquired absence of other organs (no symptom control rating); - Pertinent medical history and reason for home care/additional diagnosis information included: 12/20/2023 non-stemi, dx (diagnosis) of Takotsubo cardiomyopathy, metabolic encephalopathy (a problem in the brain that is caused by a chemical imbalance in the blood), chronic kidney disease (long standing disease of the kidneys leading to renal failure), uncontrolled hypothyroidism and noncompliance per H&P (history and physical); - The pain assessment section showed, pain rated 5 out of 10, location of mid back, pain caused by arthritis, description of pain was sharp, dull, and cramping, movement and the time of day made pain worse, medication and relaxation relieved pain, frequency of pain and impact on activities had “occasionally” and “infrequently” noted, how often breakthrough medication needed was left blank, and “current pain control medications adequate” was selected (The nurse failed to document what medication was used and/or when/how often) - Urinary assessment section showed “frequent UTI’s” and patient voids without problems; - Urinary history question (M1600), regarding if the patient had been treated for a urinary tract infection in the past 14 days, showed “no” selected (The skilled nurse failed to document why the primary diagnosis was a UTI and history of UTI treatments); - The cardiovascular/respiratory section failed to show documentation of a cardiac assessment related to the Takotsubo cardiomyopathy; - The cardiovascular/respiratory section showed, a cardiac history of heart failure, hypertension, non-STEMI, normal heart sounds, pitting edema to right and left ankle of 3+ (Grade 1+: up to 2mm (millimeter) of depression and rebounds (returns) immediately. Grade 2+: 3-4mm of depression and rebounds in 15 seconds or less. Grade 3+: 5-6mm of depression and rebounds in 60 seconds. Grade 4+: 8mm of depression and rebounds in 2-3 minutes), pitting edema to right and left calf of 2+, lung sounds are clear, and respirations are easy/non-labored; - The musculoskeletal assessment section showed “no deficits” selected (No further documentation of assessment findings to explain how the patient has ambulation limitations without musculoskeletal deficits); - The functional limitations section showed ambulation limitations and the patient required assistance when going up/down stairs or walking long distances (No further documentation to include what type of assistance needed); and - Interventions included daily weights and notify the physician of a weight gain of 5 (five) pound in 7 (seven) days. Review of the SN visit note, dated 01/08/2024, showed, in part: - The urinary assessment section showed, “voids without problems,” selected (The documentation failed to show a history of UTI’s and/or treatment); - The cardiovascular/respiratory section showed, normal heart sounds, dependent edema to right and left feet, pitting edema to right and left ankle of 1+, lung sounds are clear, and respirations are easy/non-labored (the documentation failed to include the patient’s weight); - The musculoskeletal section showed “weakness” selected (the assessment failed to include any further assessment details regarding weakness); and - Interventions/education provided this visit showed, medication, daily weights, elevation of lower extremities to prevent fluid retention (the skilled nurse failed to include an assessment of the patient’s weight and assessment of a daily weight log). Review of the SN visit note, dated 01/12/2024, showed, in part: - The cardiovascular/respiratory section showed dependent edema to right and left feet and respirations are easy/non-labored; - Interventions/education provided this visit showed, the importance of keeping feet elevated to help with dependent edema bilaterally in (his/her) feet and ankles; and - The skilled nurse failed to assess the patient’s weight and daily weight log. Review of the SN visit note, dated 01/16/2024, showed, in part: - The cardiovascular/respiratory section showed dependent edema to right and left feet, pitting edema to right and left ankle of 3+ (the documentation failed to show daily weights being assessed and patient was having increased edema); and - Interventions/education provided this visit showed, keep feet elevated to help with swelling (No documentation of assessment regarding the patient’s knowledge of the importance of daily weight compliance to monitor for the amount of fluid retention). Review of the PT visit note, dated 01/17/2024, showed, in part: - The pain assessment section showed, “no pain,” selected; - The “patient denies pain outside of normal aches and pains and has not taken medication for pain,” (the PT failed to document what the patient’s normal aches and pain were). Review of the PT visit note, dated 01/18/2024, showed, in part: - The pain assessment section showed, “no pain,” selected; - The “Pt has occasional arthritis pain but has not taken medication for it,” was noted in the comments section (No further pain assessment details were documented); - The patients response to skilled care provided, showed, “Pt tolerated treatment fairly well but does seem to be somewhat more SOA (short of air) with activities this date. SpO2 (oxygen saturation) monitored and remained WNL” (within normal limits); and - No further documentation and/or follow up assessment for the shortness of air. Review of the SN visit note, dated 01/19/2024, showed, in part: - The cardiovascular/respiratory section showed, pitting edema to right and left ankle of 1+; - The integumentary section showed, “Pt has a bruise on top of right foot but denies any pain with palpitation” in the comment section, normal skin color, warm and dry, and wounds identified was left blank (No further assessment documentation regarding the bruise and the history of how/when the bruise developed); - Interventions/education provided this visit showed, teaching related to edema of lower extremities bilaterally (the skilled nurse failed to perform an assessment of the patient’s weight during the visit and the daily weight log). Review of the SN visit note, dated 01/22/2024, showed, in part: - The cardiovascular/respiratory section showed, pitting edema to right and left ankle of 2+, respirations are easy/non-labored; - The integumentary section showed, “Recheck of bruise on right ankle area above foot shows improvement in coloration. Pt continues to deny any pain at the site,” normal skin color, warm and dry, and “no” wounds identified (the skilled nurse failed to assess the patient’s history of the bruise); and - Interventions/education provided this visit showed, the importance of keeping legs elevated to promote drainage of edema in bilateral lower extremities (the skilled nurse failed to assess the patient’s weight and daily weight log). Review of the PT visit note, dated 01/22/2024, showed, in part: - The vital signs section showed, “vitals obtained from nursing documentation, as patient was seen by HH (home health) nurse prior to this visit,” noted (The physical therapist failed to assess the patient’s vital signs and documented vital signs that were obtained by another clinician (SN) during a previous visit); - The pain assessment section showed, “no pain,” and “pt denies pain and has not required medication for pain” (the PT failed to perform a complete pain history assessment); and - The documentation failed to show the patient’s history of SOA experienced during the previous therapy visit (on 01/18/2024) and/or if the SOA had resolved. Review of the ST (speech therapy) evaluation visit note, dated 01/22/2024, showed, in part: - The vital signs section was left blank and “vitals taken by SN shortly before ST visit. See SN note,” was noted in the comments (The ST failed to assess the patient’s vital signs); - The assessment section related to the prior level and current functional status was left blank. The comment section for attention span and memory, had “roughly within functional limits. Patient oriented x4 (times), mild memory impairment, patient able to recall 2/3 unrelated words with delay intact.” The comment section of problem solving had “mild deficit” noted (Other areas/systems to assess were left blank); - The pain assessment section showed, “patient denies pain” and pain location had “n/a (not applicable)” (The ST failed to perform a complete assessment of the patient’s pain history); - Treatment/education initiated this visit showed, “clinician educated on memory strategies including writing things down, use of alarms/reminders, rehearsal, self talk. Patient and daughter verbalized understanding,” noted; - The coordination details section showed, informed care team of ST eval only; and - The ST failed to document a complete comprehensive assessment and/or findings during the evaluation visit (The referral records showed, speech therapy treatments included, cognitive training, dysphasia therapy, speech language communication therapy. Goals for speech therapy to address cognition, expression of language, comprehensive, safety awareness and safe swallowing). Review of the SN visit note, dated 01/29/2024, showed, in part: - The cardiovascular/respiratory section showed, pitting edema to right ankle of 2+ and left ankle of 1+ (The skilled nurse failed to assess the patient’s weight and daily weight log); and - The integumentary section showed, the patient had normal skin color, skin was warm and dry, and no wounds were identified (The skilled nurse failed to document a follow-up assessment of the bruise to the top of the patient’s right foot). Review of the SN visit note, dated 02/02/2024, showed, in part: - A PRN (as needed) visit was made due to patient having a fall; - The pain assessment section showed, pain rated a 2 out of 10, location was the left flank, cause of the pain was a fall, description of pain was dull and aching, pain was worse with movement, pain relieved by ice and rest, current pain control medications adequate, and “Pt has fist sized bruising to left flank area from fall earlier in the day, denied increased pain with palpitation. Pt encouraged to place ice on site to help minimize bruising,” was noted in the comment section (The skilled nurse failed to include documentation of the pain control medications and/or history of pain medication use); - The cardiovascular/respiratory section showed, pitting edema to right ankle and left ankle of 3+ selected, “Pt has 2+ edema bilaterally to lower ext (extremities),” dyspnea with moderate exertion and cough (The skilled nurse failed to include further documentation related to the patient having dyspnea with moderate exertion and cough. These are new/not previously documented symptoms); - The integumentary section showed, the patient had normal skin color, the skin was warm and dry, and wounds identified question was left blank; - The wound documentation flowsheet chart showed, wound #1 documented, location of the wound was the left flank, the type of wound was listed as a trauma wound, the wound status showed the wound was closed, and “fist size bruise from fall earlier in the daytime” was noted (No further assessment details were documented); and - The skilled nurse failed to assess the patient’s weight, daily weight log, a follow-up assessment of the bruise to the top of the right foot (identified on 01/19/2024), and measurements of the trauma wound to the left flank. Review of the SN visit note, dated 02/03/2024, showed, in part: - A PRN visit was made due to the patient having a large blister on the right foot; - The pain assessment section showed, “no pain” selected (The skilled nurse failed to perform a complete pain history assessment. The patient had pain to the left flank the previous day due to a fall); - The cardiovascular/respiratory section showed, edema to right ankle and left ankle of 4+, lung sounds are clear, and respirations are easy/non-labored (The skilled nurse failed to assess the patient’s weight, daily weight log, and perform a follow-up assessment and/or documentation of the patient’s history of dyspnea with moderate exertion and cough that was noted during the SN visit the previous day); - The integumentary section showed, the patient had normal skin color, skin was warm and dry, and the wounds identified section was left blank; - The wound documentation flowsheet chart showed, wound #1 documented, location of left flank, the type of wound was listed as a trauma wound, the wound status showed the wound was closed, and “Pt bruising has darkened to a deep purple” (The skilled nurse failed to document the measurement of the bruise); - The wound documentation flowsheet chart showed, wound #2 documented, location of right ankle, the type of wound was listed as a venous ulcer, wound status showed closed, the length was 5 cm (centimeters) and the width was 4 cm, surrounding tissue was shiny with edema, the wound was covered with 4x4’s (gauze) and secured with coban (a cohesive elastic wrap), and “patient has a small egg sized blister on right ankle that is intact and fluid filled at this time. Applied dressing and will recheck on next visit” (The skilled nurse failed to assess the patient’s weight and daily weight log to monitor the amount of fluid retention. The patient’s edema progressed, a fluid filled blister developed, and the patient’s weight was not assessed during the skilled nurse visit); - The interventions/education provided this visit showed, “dressed right ankle/foot explaining to daughter and patient that popping the blister would just open up the wound and make it a higher risk for infection. Explained to let the blister pop on its own and keep it covered. Reminded patient/cg (patient and caregiver) to apply ice to bruising, and to keep feet elevated to decrease swelling of feet and ankles,” (The skilled nurse failed to assess the amount of fluid retention by weighing the patient); and - Plan for next visit showed, assessment for general wellness, vitals, pain, recheck bruising and blister, teaching on wound care, and treatments/procedures of lab draw (The skilled nurse failed to assess and/or document what the lab draw was for and/or related to. The clinical record failed to show orders for lab draws). During an interview on 02/07/2024 that began at 1:15 PM, the Clinical Manager stated that: - Staff should be completing full assessments of the patient’s including the patient’s compliance with physician orders and documenting any noncompliance; - The nurse should be following up with patients regarding pain and vital sign; and - The nurse does a great job but does not always document the best. RECORD/PATIENT #3: Review of the clinical record showed the patient was admitted 11/22/2023 with a primary diagnosis of malignant neoplasm of the larynx (cancer of the voice box). Review of the POC dated 11/22/2023 to 01/20/2024, showed in part, under SN endocrine (system that consists of mainly glands that create and release hormones that assist in blood sugar regulation) interventions: Assess/perform/instruct Pt/Pcg (patient/Pt’s care giver): blood glucose testing daily and importance of recording and compliance. Review of the SOC (start of care) OASIS (Outcome and Assessment Information Set; a standardized data collection tool) dated 11/22/2023, SN visit notes dated 11/23/2023, 11/27/2023, 11/30/2023, 12/04/2023, 12/07/2023, 12/11/2023, 12/14/2023, 12/19/2023, 12/21/2023, 01/03/2024, and 01/08/2024 all failed to contain any documentation of any blood sugar results. During an interview on 02/07/2024 starting at 1:15 PM, the clinical manager stated that he/she would expect blood glucose results to be documented.

Care planning, coordination, quality of care CFR(s): 484.60 Condition of participation: Care planning, coordination of services, and quality of care. Patients are accepted for treatment on the reasonable expectation that an HHA can meet the patient's medical, nursing, rehabilitative, and social needs in his or her place of residence. Each patient must receive an individualized written plan of care, including any revisions or additions. The individualized plan of care must specify the care and services necessary to meet the patient-specific needs as identified in the comprehensive assessment, including identification of the responsible discipline(s), and the measurable outcomes that the HHA anticipates will occur as a result of implementing and coordinating the plan of care. The individualized plan of care must also specify the patient and caregiver education and training. Services must be furnished in accordance with accepted standards of practice. This CONDITION is not met as evidenced by: Based on record review, home visit observation, and interview, the provider failed to: - Ensure that each patient received services that were written in the plan of care (POC) and signed by the physician, when therapy treatment plans failed to be included on the POC, and were not signed by a physician or allowed practitioner (G572); -Ensure that each patient's written individualized plan of care (POC) included safety measures to prevent against injury, functional limitations, patient-specific interventions, and all types of services required (G574); - Ensure drugs, services, and treatments were administered only as ordered by a physician (G580); - Promptly alert the relevant physician(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 (G590); - Ensure the integration of orders from all physicians or allowed practitioners involved in the plan of care (G604); - Ensure coordination of care to meet the patient’s needs (608); - Ensure that each patient and his or her caregiver received education regarding medication order changes, the reason for the order to discontinue the medication, and the risk for continuing the use of the medication against the physician’s order (G610); and - Ensure that the patient was provided a list with medication schedule/instructions, that included medications name, dose, and frequency in which medication were to be administered (616). The cumulative effect of these deficient practices has the potential to affect individualized and physician ordered care provided to all the provider's patients.

Plan of care CFR(s): 484.60(a)(1) Each patient must receive the home health services that are written in an individualized plan of care that identifies patient-specific measurable outcomes and goals, and which is established, periodically reviewed, and signed by a doctor of medicine, osteopathy, or podiatry acting within the scope of his or her state license, certification, or registration. If a physician or allowed practitioner refers a patient under a plan of care that cannot be completed until after an evaluation visit, the physician or allowed practitioner is consulted to approve additions or modifications to the original plan. This STANDARD is not met as evidenced by: Based on policy review, record review, and interview, the home health provider failed to ensure that each patient received services that were written in the plan of care (POC) and signed by the physician, when therapy treatment plans and orders/interventions, failed to be included on the POC, and were not signed by a physician or allowed practitioner in, three of five full records reviewed (Records/Patients #3, #4, and #5). This deficient practice has the potential to affect all patients served by the provider. RECORD/PATIENT #3: Review of the clinical record showed the patient was admitted 11/21/2023 with a primary diagnosis of malignant neoplasm of the larynx (cancer of the voice box). Review of the POC dated 11/22/2023 to 01/20/2024 failed to show orders for physical therapy (PT) or Speech therapy (ST). Review the physical therapy evaluation dated 12/07/2023, showed in part: - Interventions, goals, rehab potential and discharge planning; - Care coordination marked with physician contacted with assessment findings and approved orders and, discipline and frequency; and - It failed to be signed by the PCP (primary care physician). Further review of the clinical record showed: - An ambulatory referral to speech therapy order dated 11/28/2023 signed by a referring PA-C (Certified physician assistant). - A Speech/Language Pathology evaluation dated 12/05/2023, showed in part: * Interventions, goals, rehab potential and discharge planning; * Care coordination with physician contacted with assessment findings and approved orders and, discipline and frequency failed to be marked; and - It failed to be signed by the PCP (primary care physician). Findings included: Review of the provider’s undated policy titled, “Care Planning Process,” showed, in part: - In order to assure that care provided is appropriately planned to meet each patient's specific needs and problems, the agency will utilize data/information gathered during patient assessments in the care planning process; and - The patient care plan for therapy services (PT- Physical Therapy, OT- Occupational Therapy, and SLP- Speech Language Pathology) will be developed and implemented with the physician. Review of the provider’s undated policy titled, “Physicians Verbal Orders,” showed, in part: - Drugs and treatments are administered by the agency staff only as ordered by the physician; - Orders are obtained prior to the provision of any care, including changes in the plan of care; - Orders for patient care are obtained from the physician, either verbally or in writing; - When a verbal order is received, the order must be written down, read back to verify order and receive confirmation from individual who gave order. A record of this order is documented on a physician’s supplemental order form. All orders include: * The patient's name * Physicians name * Date and time the order is taken * The signature of the person taking the order * The specific order(s); and - All verbal orders must be subsequently signed by the physician. RECORD/PATIENT #4: Review of the clinical record, showed, in part: - The patient was admitted to home health services on 01/08/2024 with a primary diagnosis of a fracture to the shaft of humerus (left upper arm) and is temporally residing with his/her daughter; and - The SOC (start of care) assessment visit was on 01/08/2024. Review of the POC (plan of care), showed, in part: - Discipline showed SN (skilled nursing) with visit frequency of 2 (two) times a week for 2 weeks and 1 (one) time a week for 5 (five) weeks (No other disciplines were listed); - Intervention and goals for SN (No other interventions/goals for any other discipline); and - The POC failed to include PT and OT services. Review of the Occupational Therapy evaluation visit note dated 01/10/2024, showed, in part: - The plan of care section showed: * OT visit frequency of 1x/week (1 time for 1 week), 2x/week x3weeks (2 times a week for 3 weeks) * OT treatment plan showed, establish a home exercise program and ADL (activities of daily living) training - Care was coordinated with PT regarding the patient having difficulty using rolling walker due to LUE (left upper extremity) is NWB (non-weight-bearing); and - The clinical record failed to show a POC for OT that was signed by a physician. Review of the Physical Therapy evaluation visit note dated 01/11/2024, showed, in part: - The plan of care section showed: * PT visit frequency of 1x1 (1 time for 1 week), 2x3 (2 times a week for 3 weeks), and 1x1 * PT treatment plan showed, establish a home exercise program, therapeutic exercises, balance training, functional mobilities, and transfer training - Care was coordinated with nursing, PTA, and OT regarding the patient's plan of care; and - The clinical record failed to show a POC for PT that was signed by a physician. RECORD/PATIENT #5: Review of the clinical record, showed, in part: - The patient was admitted to home health services on 01/06/2024 with a primary diagnosis of a UTI (urinary tract infection- an illness in any part of the urinary tract, the system of organs that makes urine) and resided in the home when a spouse and adult daughter; - The patient’s daughter was listed as the primary caregiver; and - The SOC (start of care) assessment visit was on 01/06/2024. Review of the POC (plan of care), showed, in part: - Discipline showed SN (skilled nursing) with visit frequency of 2 times a week for 2 weeks and 1 time a week for 4 (four) weeks (No other disciplines were listed); - Intervention and goals for SN (No other interventions/goals for any other discipline); and - The POC failed to include PT and OT services. Review of the Physical Therapy evaluation visit note dated 01/11/2024, showed, in part: - The plan of care section showed: * PT visit frequency of 1x1 (1 time for 1 week), 2x3 (2 times a week for 3 weeks), and 1x1 * PT treatment plan showed, establish a home exercise program, therapeutic exercises, balance training, functional mobilities, and transfer training - Care was coordinated with nursing, PTA, and OT regarding the patient's plan of care; and - The clinical record failed to show a POC for PT that was signed by a physician. Review of the Occupational Therapy evaluation visit note dated 01/18/2024, showed, in part: - The plan of care section showed: * OT visit frequency of 1x/week (1 time for 1 week), 2x/week x3weeks (2 times a week for 3 weeks) * OT treatment plan showed, establish a home exercise program and ADL (activities of daily living) training - Care was coordinated with PT regarding the patient having difficulty using rolling walker due to LUE (left upper extremity) is NWB (non-weight-bearing); and - The clinical record failed to show a POC for OT that was signed by a physician. During an interview on 02/06/2024 that at 3:00 PM, the Clinical Manager stated that: - Therapy should be on the POC; - He/she has to pull the information from the therapy evaluation visits and put it on the POC; - He/she didn’t realize that the POC for these patient’s did not include therapy; and - He/she is not sure why these patient’s were missed.

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 policy review, record review, home visit observation, and interview, the home health provider failed to ensure that each patient's written individualized plan of care (POC) included safety measures to prevent against injury, functional limitations, patient-specific interventions, and all types of services required, in three of five full records reviewed (Records/Patients #1, #4, and #5). This deficient practice has the potential to affect all patients served by the provider. RECORD/PATIENT #1: Review of the clinical record showed the patient was admitted to home health services on 01/22/2024 with a primary diagnosis of MS (multiple sclerosis- a disease in which the immune system eats away at the protective covering of nerves). Review of the POC dated 01/22/2024 to 03/21/2024 showed, in part: - It failed to contain documentation of the patient having an implanted baclofen pump (a permanently implanted pump that delivers baclofen (medication given to treat muscle spasticity) to the spinal fluid; and - The safety measures portion failed to have anything documented. Observation on 02/02/2024 at 1:30 PM, during the patient’s home visit showed the patient complain of slight discomfort with palpation to abdomen. Per interview conducted during observation, the patient stated that it was just because of the implanted baclofen pump. During an interview on 02/07/2024, starting at 1:15 PM, the clinical manager stated that: - The baclofen pump and dosage should be included on the POC; and - The safety measures on the POC should not be left blank. Findings included: Review of the provider’s undated policy titled, “Care Planning Process,” showed, in part: - In order to assure that care provided is appropriately planned to meet each patient's specific needs and problems, the agency will utilize data/information gathered during patient assessments in the care planning process; - The patient care plan for therapy services (PT- Physical Therapy, OT- Occupational Therapy, and SLP- Speech Language Pathology) will be: * The Plan of Care CMS #485 (certification/recertification orders): developed and implemented with physician. Demonstrates problems in interventions through physician orders and long range goals identified * Initial Assessment: description of problems and changes. Demonstrates identified problems, interventions, and goals at time of admission * Visit Notes: documents modifications to care/service, current problems, interventions, and short term goals; individualized. Will be revised as problems are identified. Review and revision will be ongoing with each home visit and will be based on patient’s health status, environment and relevant baseline data from assessments to determine current needs, problems, interventions and goals. Will reflect goal evaluation/goal resolution * All initial and ongoing assessments will utilize relevant baseline data to determine patient problems, needs, interventions and goals - The Plan of Care for Skilled Nursing will be: * Initial care plan will be CMS #485 Plan of Care, which is developed and implemented with physician. Demonstrates problems (diagnoses), interventions (physician orders) and long range goals identified * Initial Assessment: description of problems and changes. Demonstrates identified problems, interventions, and goals at time of admission * Visit Notes: documents modifications to care/service, current problems, interventions, and short term goals; individualized. Will be revised as problems are identified. Review and revision will be ongoing with each home visit and will be based on patient’s health status, environment and relevant baseline data from assessments to determine current needs, problems, interventions and goals. Will reflect goal evaluation/goal resolution * All initial and ongoing assessments will utilize relevant baseline data to determine patient problems, needs, interventions and goals; and - Care will be coordinated initially and ongoing among staff providing care. Care planning for each patient will be individualized to include: * Problems and needs * Goals based on problems, needs, conditions, wishes and ability to respond to care or services * Specific care or services to be provided including frequency, type and duration * Implementation of actions and interventions * Review and revision as indicated. Review of the provider’s undated policy titled, “Physicians Verbal Orders,” showed, in part: - Purpose: To document verbal orders received from the patient’s physician; - Drugs and treatments are administered by the agency staff only as ordered by the physician. Only authorized staff receives and record verbal orders. Verbal orders are put in writing and signed and dated by the RN (registered nurse) or qualified therapist responsible for furnishing or supervising the care. Orders are obtained prior to the provision of any care, including changes in the plan of care; - Orders for patient care are obtained from the physician, either verbally or in writing; - Verbal orders may be taken by licensed staff according to agency policy; - All verbal orders must be subsequently signed by the physician; and - When a verbal order is received, the order must be written down, read back to verify order and receive confirmation from individual who gave order. A record of this order is documented on a physician’s supplemental order form. All orders include: * The patient's name * Physicians name * Date and time the order is taken * The signature of the person taking the order * The specific order(s). RECORD/PATIENT #4: Review of the clinical record, showed, in part: - The patient was admitted to home health services on 01/08/2024 with a primary diagnosis of a fracture to the shaft of humerus (left upper arm) and is temporally residing with his/her daughter; and - The SOC (start of care) assessment visit was on 01/08/2024. Review of the POC (plan of care), showed, in part: - The patient has a fractured humerus and wears a sling; - The patient requires a walker to ambulate; - Functional limitations showed endurance listed; - The POC failed to show interventions and/or orders for the sling to the LUE (left upper extremity) and/or mobility restrictions for the LUE; and - Cardiovascular intervention showed, “check PT/INR (PT- Prothrombin time, measures how long it takes for a clot to form in the blood sample. INR- international normalized ratio, is a type of calculation based on PT test results) weekly” and PRN (as needed) starting 01/10/2024 (The POC intervention failed to show who was to check the PT/INR, how the PT/INR was to be checked, and who to report the PT/INR results to). Review of the SOC visit note dated 01/08/2024, showed, in part: - The musculoskeletal section showed the patient had a fracture to left shoulder; - The functional status showed, “walker,” selected for device use prior to current illness, exacerbation, or injury; - The assessment summary section showed a comment that the patient was “alert and oriented elderly (male/female) with fractured humerus in a sling on left side;” and - The activities permitted section showed, no restrictions, up as tolerated, and walker listed. During home visit observation, on 02/05/2024, beginning at 1:30 PM, showed, in part: - The patient’s left arm was in a sling; - The patient reported that he/she was ordered by the doctor to limit the use of his/her left arm and he/she is not to put any weight on the left arm; - The patient reported that he/she received OT services but they (OT) discharged him/her last week because they have done all they can do until the restrictions are discontinued by the doctor; - The PT confirmed that OT discharged the patient until after the patient follows up with the physician and the plan is to begin outpatient therapy after being cleared by the doctor; - The PT confirmed that the patient has restrictions to LUE until his/her follow-up appointment with the doctor; and - The PT was unsure why the POC failed to show the restrictions to the LUE and interventions for the sling. During an interview on 02/06/2024 that at 2:45 PM, the Clinical Manager stated that: - There were no orders received for LUE restrictions and the use of a sling; - If the physician was contacted for orders or clarification, it did not get documented; and - The POC should have included the sling and any restrictions to the patient’s left arm. RECORD/PATIENT #5: Review of the clinical record, showed, in part: - The patient was admitted to home health services on 01/06/2024 and resided in the home when a spouse and adult daughter; - The patient’s primary diagnosis on the POC showed, UTI (urinary tract infection); - The POC failed to show interventions and/or orders for a UTI; - The referral record showed the patient had a PMH (past medical history) of a UTI in December that he/she was treated for (The referral failed to show the patient had a UTI at the time of the patient’s discharge home); - The patient’s daughter was listed as the primary caregiver; and - The SOC (start of care) assessment visit was on 01/06/2024. During an interview on 02/07/2024, beginning at 1:15 PM, the Clinical Manager stated that: - He/she did not know why the patient’s primary diagnosis was listed as a UTI; - Coding is done by someone else; and - He/she has no clue how the primary diagnosis coding is determined.

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 policy review, record review, and interview, the home health provider failed to ensure treatments were provided as ordered by the physician, when the staff provided treatments without physician orders in, two of five full records reviewed (Records/Patients #4 and #5). This deficient practice has the potential to affect all patients served by the provider. Findings included: Review of the provider’s policy titled, “Care Planning Process,” revised 02/08/2022, showed in part: - All disciplines involved in the patient’s care will contribute to the POC (plan of care); - The following factors should be considered during the care planning process: * Individualized patient needs. * Monitoring effectiveness of medications, as appropriate. * Pain and symptom management, as appropriate. - The POC may include, but will not be limited to: * Individualized goals and interventions. * Specific services to be provided. * Medications and treatments. - During each home visit, the clinician will monitor the patient’s response to care against the established POC; and - In the event that the patient is not achieving goals and the POC needs to be altered, the physician will be notified. Review of the provider’s undated policy titled, “Physicians Verbal Orders,” showed, in part: - Purpose: To document verbal orders received from the patient’s physician; - Drugs and treatments are administered by the agency staff only as ordered by the physician. Only authorized staff receives and record verbal orders. Verbal orders are put in writing and signed and dated by the RN (registered nurse) or qualified therapist responsible for furnishing or supervising the care. Orders are obtained prior to the provision of any care, including changes in the plan of care; - Orders for patient care are obtained from the physician, either verbally or in writing; - Verbal orders may be taken by licensed staff according to agency policy; - All verbal orders must be subsequently signed by the physician; and - When a verbal order is received, the order must be written down, read back to verify order and receive confirmation from individual who gave order. A record of this order is documented on a physician’s supplemental order form. All orders include: * The patient's name. * Physicians name. * Date and time the order is taken. * The signature of the person taking the order. * The specific order(s). RECORD/PATIENT #4: Review of the clinical record, showed in part: - The patient was admitted to home health services on 01/08/2024 with a primary diagnosis of a fracture to the shaft of humerus (bone in upper arm) left side and was temporarily residing with his/her daughter; - The referral record showed: * The patient’s history during his/her inpatient admission and the care that was provided. * An inpatient admitting diagnosis of Gastroenteritis (an intestinal infection that causes diarrhea, cramps, nausea, vomiting, and fever). * A discharge summary with discharge to home with self care. * A discharge medication list. * The discharge summary showed, in part, “will order home health and plan for close follow-up next week in clinic we will discuss (his/her) future goals of care,” noted in the hospital course section. * A Home Health Face-To-Face Encounter that showed in part: physical therapy (PT) and occupational therapy (OT) were the home health services needed for weakness, humerus fracture, and gait training. * The referral record failed to include orders for home health services. - The SOC (start of care) assessment visit was completed by a RN (registered nurse) on 01/08/2024; - The clinical record failed to include any orders, including verbal orders, received from the physician to start home health services; - The POC (plan of care) was signed by the physician on 01/16/2024 and failed to include PT and OT services; and - The clinical record failed to include any orders for PT and/or OT. Review of the OT evaluation visit note dated 01/10/2024, showed in part: - The plan of care summary section, showed in part: * Occupational therapy visit frequency of 1x/week x1 week (1 time for 1 week) and 2x/week x3 weeks (two times a week for three weeks). * OT treatment plan showed ADL (activities of daily living) training and home program established. * Care Planning/Coordination showed, care was coordinated with PT. * Coordination details showed, the patient was having difficulty using RW (rolling walker) at home due to LUE (left upper extremity) being NWB (non-weight bearing); * Plan for next visit showed, teach HEP (home exercise program); - The occupational therapist failed to notify the physician and obtain orders for OT services; and - OT did not have plan of care orders that were signed by a physician. Review of the Physical Therapy (PT) evaluation visit note dated 01/10/2024, showed, in part: - The plan of care summary section showed: * Physical therapy visit frequency of 1x1 (1 time for 1 week), 2x3 (two times a week for three weeks), and 1x1; * PT treatment plan showed establish home exercise program, therapeutic exercises, balance training, functional mobilities, and transfer training; * Care Planning/Coordination showed, care was coordinated with the nurse, the PTA (physical therapy assistant), and OT; * Coordination details showed that care was coordinated regarding the patient’s POC; - The physical therapist failed to notify the physician and obtain orders for PT services; and - PT did not have plan of care orders that were signed by a physician. RECORD/PATIENT #5: Review of the clinical record, showed in part: - The patient was admitted to home health services on 01/06/2024 with a primary diagnosis of a UTI (urinary tract infection- an illness in any part of the urinary tract, the system of organs that makes urine) and resided in the home with a spouse and adult daughter; - The referral record showed: * The referral was faxed to the provider on 01/04/2024 with a fax cover sheet that showed the patient had a targeted discharge date of 01/05/2024 and would need physical therapy (PT), occupational therapy (OT), and speech therapy (ST); * The patient’s history during his/her inpatient admission and the care that was provided; * Additional diagnoses included: Metabolic encephalopathy (a problem in the brain that is caused by a chemical imbalance in the blood), Takotsubo cardiomyopathy (a temporary heart condition that develops in response to an intense emotional or physical experience), hypothyroidism (a condition in which the thyroid gland doesn't produce enough thyroid hormone), recent non-STEMI (Non-ST-Elevation Myocardial Infarction-a type of heart attack), dysphagia, and hypertension (high blood pressure, is when the pressure in the blood vessels is too high); * An inpatient primary diagnosis of nontraumatic brain dysfunction; * A discharge order for patient to discharge to home with home health for PT, OT, and ST services to evaluate and develop a plan of care; * An inpatient progress note with active medications the patient was taking while inpatient; * The referral record failed to include any other orders, including, orders for discharge medications; and * A progress note showed active problems of coronary artery disease, recent NSTEMI, presumed Takotsubo cardiomyopathy and continue medical management with Aspirin, Plavix, Atorvastatin, and metoprolol. - The patient’s daughter was listed as the primary caregiver for the patient; - The SOC (start of care) assessment visit was completed on 01/06/2024; and - The POC (plan of care) was signed by the physician on 01/10/2024. Review of the POC showed, in part: - Skilled nursing services was the only discipline listed; and - The physician signed the POC on 01/10/2024. Review of the Physical Therapy evaluation visit note dated 01/11/2024, showed, in part: - The plan of care section showed: * PT visit frequency of 1x1 (1 time for 1 week), 2x3 (2 times a week for 3 weeks), and 1x1; * PT treatment plan showed, establish a home exercise program, therapeutic exercises, balance training, functional mobilities, and transfer training; - Care was coordinated with nursing, PTA, and OT regarding the patient's plan of care; and - The clinical record failed to show PT treatment orders and/or a POC signed by a physician. Review of the Occupational Therapy evaluation visit note dated 01/18/2024, showed, in part: - The plan of care section showed: * OT visit frequency of 1x/week (1 time for 1 week), 2x/week x3weeks (2 times a week for 3 weeks) * OT treatment plan showed, establish a home exercise program and ADL (activities of daily living) training - Care was coordinated with PT; and - The clinical record failed to show OT treatment orders and/or a POC signed by a physician. Review of the SN visit note, dated 02/03/2024, showed, in part: - A PRN visit was made due to the patient having a large blister on the right foot; - The wound documentation flowsheet chart showed, wound #1 documented, location of left flank, the type of wound was listed as a trauma wound, the wound status showed the wound was closed, and “Pt bruising has darkened to a deep purple” (The skilled nurse failed to document the measurement of the bruise); - The wound documentation flowsheet chart showed, wound #2 documented, location of right ankle, the type of wound was listed as a venous ulcer, wound status showed closed, the length was 5 cm (centimeters) and the width was 4 cm, surrounding tissue was shiny with edema, the wound was covered with 4x4’s (gauze) and secured with coban (a cohesive elastic wrap), and “patient has a small egg sized blister on right ankle that is intact and fluid filled at this time. Applied dressing and will recheck on next visit” (The skilled nurse failed to assess the patient’s weight and daily weight log to monitor the amount of fluid retention. The patient’s edema progressed, a fluid filled blister developed, and the patient’s weight was not assessed during the skilled nurse visit); - The interventions/education provided this visit showed, “dressed right ankle/foot explaining to daughter and patient that popping the blister would just open up the wound and make it a higher risk for infection. Explained to let the blister pop on its own and keep it covered. Reminded patient/cg (patient and caregiver) to apply ice to bruising, and to keep feet elevated to decrease swelling of feet and ankles”; and - The skilled nurse provided wound care treatment and educated the patient and caregiver to apply ice without obtaining orders from the physician. During an interview on 02/06/2024 that began at 2:45 PM, RN A stated that: - He/she did not obtain orders from the physician prior to providing treatment; - He/she just puts the orders in and faxes them to the physician for signature; and - No orders were received for the patient to apply ice. During an interview on 02/07/2024 that began at 10:20 AM, the Clinical Manager stated that: - There were no orders received with the referral; - Staff look at the patients discharge papers that the patient was sent home with to see what the discharge orders are; - Staff are supposed to call the PCP (primary care provider) and get verbal orders but staff forget to do that; - An RN always completes the SOC visits and if the patient has a nursing need the SN obtains verbal orders for nursing; - No verbal orders were received for the RN to do the SOC visits; - The SN is the only discipline on the POC and signed by the physician; and - PT and OT should be on there with the SN and they are not; - PT and OT do not have a POC signed by a physician; and - No PT or OT verbal orders for treatment have been received and entered into the patients records.

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 policy review, record review, and interview, the home health provider failed to promptly alert the physician to changes in the patient's condition or needs, to clarify orders and/or receive orders, in four of five full records reviewed (Records/Patients #2, #3, #4, and #5). This deficient practice has the potential to affect all patients served by the agency. RECORD/PATIENT #2: Review of the clinical record showed the patient was admitted to home health services on 01/16/2024 with a primary diagnosis of a fractured sacrum (a triangular shaped bone that lies at the bottom of the spine located just above the tailbone). Review of the POC dated 01/16/2024 to 03/15/2024 failed to include Tylenol documented as a medication the patient was to be taking. Review of the PT (physical therapy) evaluation, dated 01/18/2024, showed under the care coordination section, in part: - Conferenced with SN (skilled nursing); and - Regarding PT POC, SN: Patient states he/she takes Tylenol. This needs reconciled on med sheet. Review of an Inter-Office Communication Note, dated 01/18/2024, documented by the PT, showed: - The patient takes Tylenol; and - This (patient taking Tylenol) needs reconciled in medication sheet. Further review of the clinical record failed to show any communication with the physician documented regarding the patient taking Tylenol which failed to be included in the POC. During an interview on 02/07/2024 starting at 1:15 PM, the clinical manager stated that the process generally was: - PT generally would put a note in the Inter-Office Communication, and called or texted and the nurse followed up; and - The nurse should have taken care of this. RECORD/PATIENT #3: Review of the clinical record showed the patient was admitted with a primary diagnosis of malignant neoplasm of the larynx (cancer of the voice box). Review of the POC dated 11/22/2023 to 01/20/2024 showed in part, under the nutritional requirements: Diet NPO (nothing by mouth). Review of a ST evaluation dated 12/05/2023, showed in part, the following documentation: - Patient noncompliant with prescribed diet of NPO; - Patient admitted to eating soft/pureed foods; - Patient educated on risks of aspiration pneumonia (occurs when food or liquid is breathed into the airways or lungs, instead of being swallowed) and importance of compliance with prescribed diet; and - It failed to show any communication with the physician documented regarding the patient’s noncompliance with their prescribed NPO diet. Review of a ST visit note dated 12/22/2023, showed in part, the following documentation under the subjective portion of the visit note: - Upon arrival to the patient’s home, the patient was at the kitchen sink rinsing their mouth after they had finished a piece of toast for breakfast; - Patient reports he/she took quarter sized bites; - Patient reported he/she had been eating hotdogs, chips, and sausage- Patient assured the ST that they were small bites that were adequately masticated (chewed) prior to swallowing; - While eating chips he/she admitted occasionally finding food particles around tracheostomy (a surgical opening in the airway in the windpipe to facilitate breathing) dressing; and - Patient stated he/she “feels stuff build up in his/her lungs” but speculated this had to do with their COPD (Chronic Obstructive Pulmonary Disease- a group of lung diseases that block airflow and make it difficult to breathe) and patient has a follow up visit with their doctor this afternoon; and - It failed to show any communication with the physician documented regarding the patient’s noncompliance with their prescribed NPO diet. Review of a ST visit note dated 01/04/2024, showed in part, the following documentation under the subjective portion of the visit note: - Patient reported he/she was eating solid foods one to two times a day; - This includes cereal, sausage, hotdogs, brats, mashed potatoes, et cetera; - He/she stated that they avoided stringy foods, specifically green beans, due to a previous experience with the bean of a green bean getting stuck in their tracheostomy; - The ST asked the patient who cleared them for food PO (by mouth) the patient stated that they believed they were able to tolerate solid foods, but admitted they were not cleared by a physician; - The patient reported that they were finding food particles in their tracheostomy dressing less frequently than reported at the last visit; and - It failed to show any communication with the physician documented regarding the patient’s noncompliance with their prescribed NPO diet. During an interview on 02/07/2024 starting at 1:15 PM, the clinical manager stated that: - He/she would expect the diet noncompliance to be communicated to the PCP; and - He/she was sure the PCP was notified. Findings included: Review of the provider’s undated policy titled, “Coordination of Patient Care,” showed, in part: - Agency staff members regularly communicate and document to ensure that their efforts are coordinated effectively and ultimately support the objectives outlined in the plan of care; - The Agency must: * Assure communication with all physicians involved in the plan of care * Integrate orders from all physicians involved in the plan of care to assure the coordination of all services and interventions provided to the patient * Coordinate care delivery to meet the patient’s needs, and involve the patient, representative (if any), and caregiver(s), as appropriate, in the coordination of care activities - Staff provides the physician with patient information on an ongoing basis; and - The clinical manager provides oversight of all patient care services, including coordinating patient care. RECORD/PATIENT #4: Review of the clinical record, showed, in part: - The patient was admitted to home health services on 01/08/2024 with a primary diagnosis of a fracture to the shaft of humerus (left upper arm) and is temporally residing with his/her daughter; - The referral record showed: * The patient’s history during his/her inpatient admission and the care that was provided * An inpatient admitting diagnosis of Gastroenteritis (an intestinal infection that causes diarrhea, cramps, nausea, vomiting, and fever) * A discharge summary with discharge to home with self care * A discharge medication list * The discharge summary showed, in part, “will order home health and plan for close follow-up next week in clinic we will discuss (his/her) future goals of care,” noted in the hospital course section * A Home Health Face-To-Face Encounter that showed, in part, physical therapy and occupational therapy were the home health services needed for weakness, humerus fracture, and gait training * The referral record failed to include orders for home health services - The SOC (start of care) assessment visit was completed by a RN (registered nurse) on 01/08/2024; - The clinical record failed to include any orders, including verbal orders, received by the physician to start home health services; and - The POC (plan of care) was signed by the physician on 01/16/2024. Review of the SOC visit note dated 01/08/2024, showed, in part: - The drug regimen review showed issues were identified and the physician was notified of the medication issues (The skilled nurse failed to include documentation of what the issues identified were and the Prescribed/recommended actions included); - The musculoskeletal section showed the patient had a fracture to left shoulder; - The activities permitted section showed, no restrictions, up as tolerated, and walker listed (The skilled nurse failed to notify the physician to confirm/clarify if the patient had any activity restrictions related to the left arm fracture); and - The assessment summary section showed a comment that the patient was “alert and oriented elderly (male/female) with fractured humerus in a sling on left side” noted (The skilled nurse failed to notify the physician to receive orders for the sling to the left arm). Review of a Medication Issue Communication/Order document, dated 01/10/2024, showed, in part: - A drug interactions report showing the patient’s drug to drug interactions; - Stop medication(s) showed, acetaminophen was written (Also known as Tylenol, which is an analgesic medication that is used to treat minor aches and pains, and reduce fever); - The physician signed and dated it on 01/10/2024; and - It was faxed to the home health agency on 01/10/2024 at 2:41 PM. Review of the Occupational Therapy (OT) evaluation visit note dated 01/10/2024, showed, in part: - The musculoskeletal assessment section showed, “Patient is NWB (non-weightbearing) with LUE (left upper extremity) and has standard RW (rolling walker) so difficulty with balance during ambulation,” noted; - The patient’s LUE was in a sling due to a fractured humerus; - Activities permitted showed NWB LUE; - The assessment summary section showed, “patient with significant decline in ADL (activities of daily living) status due to multiple hospitalizations and patient is NWB on LUE and wearing a sling. Patient had appointment with orthopedic doctor for L (left) shoulder on 1/12/24 but this has been cancelled due to the weather;” - The plan of care summary section showed: * Occupational therapy visit frequency of 1x/week x1 week (1 time for 1 week) and 2x/week x3 weeks (two times a week for three weeks) * OT treatment plan showed ADL training and home program established * Care Planning/Coordination showed, care was coordinated with PT (physical therapy) * Coordination details showed, the patient is having difficulty using RW at home due to LUE is NWB * Plan for next visit showed, teach HEP (home exercise program); and - The occupational therapist failed to notify the physician and receive orders for the plan of care. Review of the Physical Therapy (PT) evaluation visit note dated 01/10/2024, showed, in part: - The patient had difficulty walking related to LUE fracture; - The patient had 2+ edema to BLE (bilateral lower extremities); - Activities permitted showed NWB LUE; - The plan of care summary section showed: * Physical therapy visit frequency of 1x1 (1 time for 1 week), 2x3 (two times a week for three weeks), and 1x1; * PT treatment plan showed establish home exercise program, therapeutic exercises, balance training, functional mobilities, and transfer training * Care Planning/Coordination showed, care was coordinated with the nurse, the PTA (physical therapy assistant), and OT * Coordination details showed that care was coordinated regarding the patient’s POC; and - The physical therapist failed to notify the physician regarding the evaluation, the patient’s edema, and receive orders for the plan of care. Review of the Occupational Therapy visit note dated 01/16/2024, that began at 9:15 AM and ended at 10:30 AM, showed, in part: - The pain section had pain rated 6 out of 10, pain location of right bottom (buttocks), left shoulder and both knees listed, description was dull cramping pain, pain is worse with movement, sitting on sore (buttocks wound), and walking, pain relieved with medications and rest, frequency of pain and impact on activities had “Pt (patient) has pain daily but is typically able to work through pain to complete activities” was noted in the impact on activities, and the comment section had “majority of day, depending on activity” noted, and “Pt is using barrier cream on sore on bottom. Nurse states (he/she) will bring some cream and different dressing for it. Pt is taking 500mg Tylenol 2 tabs 2x/day for shoulder and knee pain” noted in the comments section; and - The OT failed to notify the physician regarding the patient’s pain, the patient’s continued use of Tylenol for pain, and the need for OT POC orders. Review of the SN (skilled nurse) visit note, dated 01/16/2024, that began at 10:15 AM and ended at 11:00 AM, showed, in part: - The patient had a heart rate of 100 beats/minute (beats per minute) with an irregular rhythm; and - The skilled nurse failed to notify the physician regarding the new onset of an irregular heart rhythm. Review of the Physical Therapy visit note dated 01/17/2024, showed, in part: - The visit was completed by a PTA (physical therapy assistant); - The vital signs section showed the patient’s blood pressure reading as 130/100; - The pain section showed, pain rated 3 out of 10 (0 being no pain and 10 being the worst pain), pain location of both knees and left shoulder, pain description was aching, pain relieved with medications and rest, and “Pt (patient) has pain daily but is typically able to work through pain to complete activities” was noted in the impact on activities, and the comment section had “Pt took Tylenol 500mg (milligrams), 2 tabs (tablets) at 1600 (4:00 PM)” noted; - The care planning/coordination section showed, care was coordinated with the PT (physical therapist) regarding the patient’s progress towards goals (The documentation failed to show that care was coordinated with the physician); and - The PTA failed to notify the physician of the patient’s abnormal blood pressure reading and the patient’s continued use of Tylenol. Review of the Occupational Therapy visit note dated 01/23/2024, showed, in part: - The pain section showed pain rated 6 out of 10, pain location of bottom, both knees and left shoulder, description was dull, aching, throbbing pain, pain is worse with movement, pain relieved with medications and rest, frequency of pain and impact on activities had “daily” noted, how often breakthrough medication is needed for pain had 2-3 times/day selected, “Pt currently takes 500mg Tylenol 2 tabs 2x/day and it helps relieve pain,” noted in the comments section (The skilled nurse failed to assess the patient’s complete pain history, only documenting “no pain” during the SN visit the previous day); - The patient’s response to skilled care provided this visit showed, “pt tolerated well, although pt is not making progress towards ADL goals at this time d/t (due to) poor standing balance and limited motion to LUE;” and - The OT failed to notify the physician regarding the patient’s pain, the continued use of Tylenol, the need for OT POC orders, and the patient’s lack of progress towards goals. Review of the Occupational Therapy visit note dated 01/30/2024, showed, in part: - The visit was completed by the OTA (occupational therapy assistant); - The pain section showed pain rated 5 out of 10, pain location of bottom, both knees and left shoulder, description was dull, aching, throbbing pain, pain is worse with movement, pain relieved with medications and rest, frequency of pain and impact on activities had “daily” noted, how often breakthrough medication is needed for pain had “daily” selected, “Pt has Tylenol 500mg (he/she) can take that relieves pain,” noted in the comments section; and - The OTA failed to notify the physician regarding the continued use of Tylenol. During an interview on 02/07/2024 that began at 10:20 AM, the Clinical Manager stated that: - There were no orders received with the referral; - Staff look at the patients discharge papers that the patient was sent home with to see what the discharge orders are; - Staff are supposed to call the PCP (primary care provider) and get verbal orders but staff forget to do that; - An RN always completes the SOC visits and if the patient has a nursing need the SN obtains verbal orders for nursing; - No verbal orders were received for the RN to do the SOC visit; - The staff should document any non-compliance and report it to the physician; and - The physician should have been notified of the patient’s continued use of Tylenol. RECORD/PATIENT #5: Review of the clinical record, showed, in part: - The patient was admitted to home health services on 01/06/2024 with a primary diagnosis of a UTI (urinary tract infection- an illness in any part of the urinary tract, the system of organs that makes urine) and resided in the home when a spouse and adult daughter; - The referral record showed: * The referral was faxed to the provider on 01/04/2024 with a fax cover sheet that showed the patient had a targeted discharge dare of 01/05/2024 and would need PT, OT, and ST * The patient’s history during his/her inpatient admission and the care that was provided * Additional diagnoses included: Metabolic encephalopathy (a problem in the brain that is caused by a chemical imbalance in the blood), Takotsubo cardiomyopathy (a temporary heart condition that develops in response to an intense emotional or physical experience), hypothyroidism (a condition in which the thyroid gland doesn't produce enough thyroid hormone), recent non-STEMI (Non-ST-Elevation Myocardial Infarction-a type of heart attack), dysphagia, and hypertension (high blood pressure, is when the pressure in the blood vessels is too high) * An inpatient primary diagnosis of nontraumatic brain dysfunction * A discharge order for patient to discharge to home with home health for PT, OT, and ST services to evaluate and develop a plan of care * An inpatient progress note with active medications the patient was taking while inpatient * The referral record failed to include any other orders, including, orders for discharge medications * A progress note showed active problems of coronary artery disease, recent NSTEMI, presumed Takotsubo cardiomyopathy and continue medical management with Aspirin, Plavix, Atorvastatin, and metoprolol - The patient’s daughter was listed as the primary caregiver for the patient; - The SOC (start of care) assessment visit was completed on 01/06/2024; and - The POC (plan of care) was signed by the physician on 01/10/2024. Review of the SOC visit note dated 01/06/2024, showed, in part: - The SOC visit was conducted by a RN (The clinical record failed to show an order for a skilled nurse to evaluate and develop a plan of care); - The drug regimen review showed issues were identified and the physician was notified of the medication issues (The skilled nurse failed to include documentation of what the issues identified were and the Prescribed/recommended actions included); and - The cardiovascular/respiratory section showed, a cardiac history of heart failure, hypertension, non-STEMI, normal heart sounds, pitting edema to right and left ankle of 3+ (Grade 1+: up to 2mm (millimeter) of depression and rebounds (returns) immediately. Grade 2+: 3-4mm of depression and rebounds in 15 seconds or less. Grade 3+: 5-6mm of depression and rebounds in 60 seconds. Grade 4+: 8mm of depression and rebounds in 2-3 minutes), pitting edema to right and left calf of 2+ (The SN failed to notify the physician regarding the edema). Review of the medication profile, showed, in part: - Aspirin (used to reduce the risk of heart attack) and Atorvastatin (treats high cholesterol and triglyceride levels which may reduce the risk of stroke, heart attack, and heart and blood vessel problems) was not listed on the medication profile (The were in the referral record for medications the patient was taking); and - The skilled nurse failed to document the physician was notified to clarify the medication discrepancies and obtain medication orders. Review of the SN visit note, dated 01/08/2024, showed, in part: - The cardiovascular/respiratory section showed, dependent edema to right and left feet, pitting edema to right and left ankle of 1+ (The SN failed to notify the physician regarding the patient’s edema); and - The skilled nurse failed to notify the physician regarding the edema. Review of the Physical Therapy evaluation visit note dated 01/11/2024, showed, in part: - The plan of care summary section showed: * Physical therapy visit frequency of 1x1, 2x3, and 1x1; * PT treatment plan showed, establish home exercise program, therapeutic exercises, balance training, functional mobilities, and transfer training * Care Planning/Coordination showed, care was coordinated with the nurse and the PTA regarding the patient’s POC; and - The physical therapist failed to notify the physician regarding the evaluation and receive orders for the plan of care. Review of the SN visit note, dated 01/12/2024, showed, in part: - The cardiovascular/respiratory section showed dependent edema to right and left feet; and - The skilled nurse failed to notify the physician regarding the edema. Review of the SN visit note, dated 01/16/2024, showed, in part: - The cardiovascular/respiratory section showed dependent edema to right and left feet, pitting edema to right and left ankle of 3+; and - The SN failed to notify the physician of the edema. Review of the PT visit note, dated 01/18/2024, showed, in part: - The visit was completed by a PTA; - The patient’s response to skilled care provided this visit, showed, “Pt tolerated treatment fairly well but does seem to be somewhat more SOA (short of air) with activities this date. SpO2 (oxygen saturation) monitored and remained WNL” (within normal limits); and - The PTA failed to notify the physician of the increased SOA. Review of the Occupational Therapy evaluation visit note dated 01/18/2024, showed, in part: - The patient would benefit from UB (upper body) general strengthening/endurance on an outpatient basis - OT provided UE (upper extremity) general strengthening exercises; - the patient was able to complete all exercises with verbal cueing and verbalized understanding of HEP (home exercise program) at this time; - The care planning/coordination of care section showed that physical therapy was informed of this was an evaluation only (no further OT needed) and UE HEP program was established; and - The occupational therapist failed to notify the physician regarding the evaluation visit and the recommendations of the patient benefitting from OT on an outpatient basis. Review of the SN visit note, dated 01/19/2024, showed, in part: - The cardiovascular/respiratory section showed, pitting edema to right and left ankle of 1+; - The integumentary section showed, “Pt has a bruise on top of right foot but denies any pain with palpitation” in the comment section, normal skin color, warm and dry, and wounds identified was left blank; and - The SN failed no notify the physician of the edema and bruise to the patient’s right foot. Review of the SN visit note, dated 01/22/2024, showed, in part: - The cardiovascular/respiratory section showed, pitting edema to right and left ankle of 2+; - The integumentary section showed, “Recheck of bruise on right ankle area above foot shows improvement in coloration. Pt continues to deny any pain at the site” was noted; - The SN failed to notify the physician regarding the edema and right ankle bruise. Review of the SN visit note, dated 01/29/2024, showed, in part: - The cardiovascular/respiratory section showed, pitting edema to right ankle of 2+ and left ankle of 1+; and - The SN failed to notify the physician of the edema. Review of the SN visit note, dated 02/02/2024, showed, in part: - A PRN (as needed) visit was made due to patient having a fall; - The pain assessment section showed, pain rated a 2 out of 10, location was the left flank, cause of the pain was a fall, description of pain was dull and aching, pain was worse with movement, pain relieved by ice and rest, current pain control medications adequate, and “Pt has fist sized bruising to left flank area from fall earlier in the day, denied increased pain with palpitation. Pt encouraged to place ice on site to help minimize bruising,” was noted in the comment section; - The cardiovascular/respiratory section showed, pitting edema to right ankle and left ankle of 3+ selected, “Pt has 2+ edema bilaterally to lower ext (extremities),” dyspnea with moderate exertion and cough; - The wound documentation flowsheet chart showed, wound #1 documented, location of the wound was the left flank, the type of wound was listed as a trauma wound, the wound status showed the wound was closed, and “fist size bruise from fall earlier in the daytime” was noted; - The primary care provider was notified of the fall; and - The skilled nurse failed to notify the physician of the patient’s edema, dyspnea with moderate exertion, cough, and pain from the fall. Review of a communication note, received from the primary providers office, dated 02/02/2024, showed, in part: - The home health nurse contacted the provider to report the patient had a fall and bumped his/her left flank; - There was a softball size lump on his/her left flank that was non-tender; - The patient does not have any pain in the area and vitals are normal (The patient did have pain in the area); - If additional tenderness develops in the area, an ultrasound will be done; and - The SN failed to inform the physician that the patient had edema to bilateral lower extremities, dyspnea with moderate exertion, cough, and pain to left flank. Review of the SN visit note, dated 02/03/2024, showed, in part: - A PRN visit was made due to the patient having a large blister on the right foot; - The cardiovascular/respiratory section showed, edema to right ankle and left ankle of 4+; - The wound documentation flowsheet chart showed, wound #1 documented, location of left flank, the type of wound was listed as a trauma wound, the wound status showed the wound was closed, and “Pt bruising has darkened to a deep purple” (The skilled nurse failed to document the measurement of the bruise); - The wound documentation flowsheet chart showed, wound #2 documented, location of right ankle, the type of wound was listed as a venous ulcer, wound status showed closed, the length was 5 cm (centimeters) and the width was 4 cm, surrounding tissue was shiny with edema, the wound was covered with 4x4’s (gauze) and secured with coban (a cohesive elastic wrap), and “patient has a small egg sized blister on right ankle that is intact and fluid filled at this time. Applied dressing and will recheck on next visit” (The skilled nurse failed to assess the patient’s weight and daily weight log to monitor the amount of fluid retention. The patient’s edema progressed, a fluid filled blister developed, and the patient’s weight was not assessed during the skilled nurse visit); - The interventions/education provided this visit showed, “dressed right ankle/foot explaining to daughter and patient that popping the blister would just open up the wound and make it a higher risk for infection. Explained to let the blister pop on its own and keep it covered. Reminded patient/cg (patient and caregiver) to apply ice to bruising, and to keep feet elevated to decrease swelling of feet and ankles;” and - The skilled nurse failed to notify the physician to report the edema and fluid filled blister. The SN failed to receives physician orders to cover the blister with 4x4 gauze and coban and orders for the patient to apply ice to bruising. Review of a communication note, received from the primary providers office, dated 02/06/2024, showed, in part: - The home health nurse contacted the provider to report the patient’s critical AST (Aspartate Aminotransferase Test- is a blood test that looks for liver damage) lab value of 144 (The lab results showed the normal range was 15-46 units per liter); - The physician ordered the patient to stop taking his/her Atorvastatin; and - The SN failed to inform the physician that the medication was not on the medication profile (The referral showed the patient was taking Atorvastatin but the medication profile failed to include it at the SOC. The SN failed to clarify medication discrepancies with the provider on admission). During an interview on 02/06/2024 that began at 3:10 PM, RN A stated that: - He/she did not notify the physician of the patient’s edema; - Only the fall was reported to the physician; - The pain was not reported to the physician because the patient has chronic pain and uses a heating pad (his/her) back when sitting down; and - No orders were received for the patient to apply ice or heat. During an interview on 02/07/2024 that began at 1:15 PM, the Clinical Manager stated that: - The PCP should be called after the initial evaluation visits to confirm the plan of care and to clarify and discrepancies; - The medications are reviewed on the SOC and discrepancies should be clarified with the physician and documented; and - The physician should always be notified when a patient has a change in condition or an abnormal assessment finding.

Integrate all orders CFR(s): 484.60(d)(2) Integrate orders from all physicians or allowed practitioners involved in the plan of care to assure the coordination of all services and interventions provided to the patient. This ELEMENT is not met as evidenced by: Based on policy review, record review, and interview, the provider failed to integrate orders from all physicians involved in the plan of care (POC), to assure that coordination of all services and interventions were provided to the patient in, one of five full records reviewed (Record/Patient #3). This deficient practice has the potential to affect all patients served by the provider. Findings included: Review of the provider’s undated policy titled, “Coordination of Patient Care,” showed, in part: - Agency staff members regularly communicate and document to ensure that their efforts are coordinated effectively and ultimately support the objectives outlined in the plan of care; - The Agency (provider) must: * Assure communication with all physicians involved in the plan of care * Integrate orders from all physicians involved in the POC to assure the coordination of all services and interventions provided to the patient * Coordinate care delivery to meet the patient’s needs, and involve the patient, representative (if any), and caregiver(s), as appropriate, in the coordination of care activities - Staff provides the physician with patient information on an ongoing basis; and - The clinical manager provides oversight of all patient care services. Oversight includes: * Coordinating patient care; * Coordinating referrals; * Ensuring that patient needs are continually assessed; and * Ensuring the development, implementation and updates of the individualized plan of care. RECORD/PATIENT #3: Review of the clinical record showed the patient was admitted 11/21/2023 with a primary diagnosis of malignant neoplasm of the larynx (cancer of the voice box). Review of the referral information, dated 11/20/2023 from an acute care hospital, showed in part, disposition: anticipate home with HH (home health) and PT (physical therapy) in AM if tolerating TF (tube feeding). Review of the updated referral information, dated 11/21/2023 from an acute care hospital, showed in part, a face to face completed and electronically signed by the patient’s inpatient physician, with disciplines requested: Skilled Nursing (SN) and physical therapy. Review of the POC dated 11/22/2023 to 01/20/2024 showed: - SN two times a week for four weeks; and - The POC failed to include orders for physical therapy. Review of the physical therapy evaluation dated 12/07/2023, showed in part: - Interventions, goals, rehab potential and discharge planning; - The CARE COORDINATION section of the visit was marked with: physician contacted with assessment findings and approved orders, discipline and frequency; and - The evaluation failed to be signed by the PCP (primary care physician). Further review of the clinical record showed: - An ambulatory referral/order for speech therapy, dated 11/28/2023, signed by a referring PA-C (Certified physician assistant). - A Speech/Language Pathology evaluation dated 12/05/2023, showed in part: * Interventions, goals, rehab potential and discharge planning; * The CARE COORDINATION section of the visit note failed to include coordination with the physician for assessment findings, approval of orders, discipline and frequency of orders; and - The evaluation visit failed to be signed by the PCP. During an interview on 02/07/2024 starting at 1:15 PM, the clinical manager stated that: - There was an ambulatory referral order for ST, and provided a copy of the order; - He/She did not see where the ambulatory referral order for ST was communicated with the PCP and approval obtained; and - He/she would expect the PCP to be notified of the order received for ST.

Coordinate care delivery CFR(s): 484.60(d)(4) Coordinate care delivery to meet the patient's needs, and involve the patient, representative (if any), and caregiver(s), as appropriate, in the coordination of care activities. This ELEMENT is not met as evidenced by: Based on policy review, record review, and interview, the home health provider failed to coordinate care delivery to meet the patient’s needs, between all individuals involved in the patient’s care, as well as the patient and/or caregiver(s) in, three of five full records reviewed (Records/Patients #2, #4, and #5). This deficient practice has the potential to affect all patients served by the agency. RECORD/PATIENT #2: Review of the clinical record showed the patient was admitted to home health services on 01/16/2024 with a primary diagnosis of a fractured sacrum (a triangular shaped bone that lies at the bottom of the spine located just above the tailbone). Review of the POC dated 01/16/2024 to 03/15/2024 failed to include Tylenol documented as a medication the patient was to be taking. Review of the PT (physical therapy) evaluation, dated 01/18/2024, showed under the care coordination section, in part: - Conferenced with SN (skilled nursing); and - Regarding PT POC, SN: Patient states he/she takes Tylenol, this needs reconciled on med sheet. Review of an Inter-Office Communication Note, dated 01/18/2024, documented by the PT, showed: - The patient takes Tylenol; and - This (patient taking Tylenol) needs reconciled in medication sheet. Further review of the clinical record failed to show any follow up documentation with the PCP regarding the patient taking Tylenol which failed to be included in the POC. During an interview on 02/07/2024 starting at 1:15 PM, the clinical manager stated that the process generally was: - PT generally would put a note in the Inter-Office Communication, and called or texted and the nurse followed up; and - The nurse should have taken care of this. Findings included: Review of the provider’s undated policy titled, “Coordination of Patient Care,” showed, in part: - Agency staff members regularly communicate and document to ensure that their efforts are coordinated effectively and ultimately support the objectives outlined in the plan of care; - The Agency must: * Assure communication with all physicians involved in the plan of care * Integrate orders from all physicians involved in the plan of care to assure the coordination of all services and interventions provided to the patient * Coordinate care delivery to meet the patient’s needs, and involve the patient, representative (if any), and caregiver(s), as appropriate, in the coordination of care activities - Staff provides the physician with patient information on an ongoing basis; and - The clinical manager provides oversight of all patient care services, including coordinating patient care. Review of the provider’s undated policy titled, “Care Planning Process,” showed, in part: - In order to assure that care provided is appropriately planned to meet each patient's specific needs and problems, the agency will utilize data/information gathered during patient assessments in the care planning process; - All initial and ongoing assessments will utilize relevant baseline data to determine patient problems, needs, interventions and goals; - Care will be coordinated initially and ongoing among staff providing care; and - Care planning for each patient will be individualized to include: * Problems and needs * Goals based on problems, needs, conditions, wishes and ability to respond to care or services * Specific care or services to be provided including frequency, type and duration * Implementation of actions and interventions * Review and revision as indicated. RECORD/PATIENT #4: Review of the clinical record, showed, in part: - The patient was admitted to home health services on 01/08/2024 with a primary diagnosis of a fracture to the shaft of humerus (left upper arm) and is temporally residing with his/her daughter; and - The SOC (start of care) assessment visit was on 01/08/2024. Review of the SOC visit note dated 01/08/2024, showed, in part: - The drug regimen review showed issues were identified and the physician was notified of the medication issues; - The skilled nurse failed to include documentation of what the issues identified were and the prescribed/recommended actions included; and - The SN failed to document coordination of care with the physician, PT, and/or OT, regarding the SOC assessment findings. Review of a Medication Issue Communication/Order document, dated 01/10/2024, showed, in part: - A drug interactions report showing the patient’s drug to drug interactions; - Stop medication(s) showed, acetaminophen was written (Also known as Tylenol, which is an analgesic medication that is used to treat minor aches and pains, and reduce fever); - The physician signed and dated it on 01/10/2024; and - It was faxed to the home health agency on 01/10/2024 at 2:41 PM. Review of the medication profile showed, Acetaminophen listed, with a discontinued date of 01/10/2024. Review of the Occupational Therapy evaluation visit note dated 01/10/2024, showed, in part: - The pain section had pain rated 6 out of 10 (0 being no pain and 10 being the worst pain), pain location of both knees and left shoulder, description was “shooting” pain, pain worse with movement, pain relieved with medications and rest, “impacts patient mobility and ability to perform ADL (activities of daily living) tasks” was noted in the impact on activities question, breakthrough medication needed for pain had “less than daily” selected, and the comment section had “Patient takes Tylenol 1xday (one time per day) with good pain relief” noted (The skilled nurse failed to assess the patient’s history of pain, what exacerbates pain, and interventions to relieve pain, including the use of Tylenol); - The musculoskeletal assessment section showed, “Patient is NWB (non-weightbearing) with LUE (left upper extremity) and has standard RW (rolling walker) so difficulty with balance during ambulation” (The clinical record failed to show coordination of care with the skilled nurse and/or PT regarding the patient being NWB to the LUE and/or where the OT obtained the information from); and - The occupational therapist failed to inform the SN of the patient’s pain and continued use of Tylenol. Review of the Occupational Therapy visit note dated 01/16/2024, that began at 9:15 AM and ended at 10:30 AM, showed, in part: - The pain section had pain rated 6 out of 10, pain location of right bottom (buttocks), left shoulder and both knees listed, description was dull cramping pain, pain is worse with movement, sitting on sore (buttocks wound), and walking, pain relieved with medications and rest, frequency of pain and impact on activities had “Pt (patient) has pain daily but is typically able to work through pain to complete activities” was noted in the impact on activities, and the comment section had “majority of day, depending on activity” noted, and “Pt is using barrier cream on sore on bottom. Nurse states (he/she) will bring some cream and different dressing for it. Pt is taking 500mg Tylenol 2 tabs 2x/day for shoulder and knee pain” noted in the comments section; and - The care planning/coordination section had “spoke to SN (skilled nurse) regarding pts sore and HR;” and - The OT failed to inform the SN that the patient had pain and the continued use ofTylenol. Review of the Physical Therapy visit note dated 01/17/2024, showed, in part: - The visit was completed by a PTA (physical therapy assistant); - The vital signs section showed the patient’s blood pressure reading as 130/100; - The pain section showed, pain rated 3 out of 10 (0 being no pain and 10 being the worst pain), pain location of both knees and left shoulder, pain description was aching, pain relieved with medications and rest, and “Pt (patient) has pain daily but is typically able to work through pain to complete activities” was noted in the impact on activities, and the comment section had “Pt took Tylenol 500mg (milligrams), 2 tabs (tablets) at 1600 (4:00 PM)” noted; - The care planning/coordination section had the PT (physical therapist) was notified of the patient’s progress towards goals; and - The PTA failed to coordinate care with the patient’s SN regarding the high blood pressure, pain, and continued use of Tylenol. Review of the Occupational Therapy visit note dated 01/23/2024, showed, in part: - The pain section showed pain rated 6 out of 10, pain location of bottom, both knees and left shoulder, description was dull, aching, throbbing pain, pain is worse with movement, pain relieved with medications and rest, frequency of pain and impact on activities had “daily” noted, how often breakthrough medication is needed for pain had 2-3 times/day selected, “Pt currently takes 500mg Tylenol 2 tabs 2x/day and it helps relieve pain,” noted in the comments section; - The patient’s response to skilled care provided this visit showed, “pt tolerated well, although pt is not making progress towards ADL goals at this time d/t (due to) poor standing balance and limited motion to LUE;” - The care planning/coordination section had care coordination with PT regarding pts progress/lack of progress towards goals; and - The OT failed to coordinate care with the SN regarding the patient’s continued pain, Tylenol use, and lack of progress towards goals. Review of the Physical Therapy visit note dated 01/30/2024, showed, in part: - The care planning/coordination section showed that care was coordinated with the PTA regarding the patient having an ortho (orthopedic) appointment for “shoulder” or “knee” on 02/09/2024 and discharge plan for next week; and - The PT failed to coordinate care with the SN regarding the patient’s doctors appointment and the plan to discharge the patient from PT services. Review of the Occupational Therapy visit note dated 01/30/2024, showed, in part: - The visit was completed by the OTA (occupational therapy assistant); - The pain section showed pain rated 5 out of 10, pain location of bottom, both knees and left shoulder, description was dull, aching, throbbing pain, pain is worse with movement, pain relieved with medications and rest, frequency of pain and impact on activities had “daily” noted, how often breakthrough medication is needed for pain had “daily” selected, “Pt has Tylenol 500mg (he/she) can take that relieves pain,” noted in the comments section; - The discharge planning section showed, OT to d/c or place pt (patient) on hold next visit; and - The OTA failed to inform the SN of the patient’s pain, Tylenol use, and plan to discharge the patient from OT services. During home visit observation on 02/05/2024, beginning at 1:30 PM, showed, in part: - The patient reported that he/she received OT services but they (OT) discharged him/her last week because they have done all they can do until the restrictions are discontinued by the doctor; - The PT confirmed that the patient has restrictions to LUE until his/her follow-up appointment with the doctor; and - The PT confirmed that OT discharged the patient until after the patient follows up with the physician and the plan is to begin outpatient therapy after being cleared by the doctor. During an interview on 02/06/2024 that at 2:15 PM, RN A stated that: - PT and OT never contacted him/her regarding the patients continued use of Tylenol; - He/she was unaware that the patient had been discharged from OT services; and - He/she was never notified by PT or OT regarding the patient having pain. During an interview on 02/06/2024 that at 2:45 PM, the Clinical Manager stated that: - He/she was unaware that OT discharged the patient; - He/she was unable to find any record of OT coordinating care regarding discharge plans to anyone; and - Sometimes coordination is done by secured text messaging and staff do not always document it in the patient’s chart. RECORD/PATIENT #5: Review of the clinical record, showed, in part: - The patient was admitted to home health services on 01/06/2024 with a primary diagnosis of a UTI (urinary tract infection- an illness in any part of the urinary tract, the system of organs that makes urine) and resided in the home when a spouse and adult daughter; - The patient’s daughter was listed as the primary caregiver; and - The SOC (start of care) assessment visit was completed by a RN on 01/06/2024. Review of the PT visit note, dated 01/18/2024, showed, in part: - The patients response to skilled care provided, showed, “Pt tolerated treatment fairly well but does seem to be somewhat more SOA (short of air) with activities this date. SpO2 (oxygen saturation) monitored and remained WNL” (within normal limits); and - The PT failed to inform the SN regarding the patient having SOA. During an interview on 02/07/2024 that began at 1:15 PM, the Clinical Manager stated that: - Therapy should be coordinating any change in condition to the SN; and - The SN will make a visit to assess the patient’s status and report changes in condition to the physician.

Patients receive education and training CFR(s): 484.60(d)(5) Ensure that each patient, and his or her caregiver(s) where applicable, receive ongoing education and training provided by the HHA, as appropriate, regarding the care and services identified in the plan of care. The HHA must provide training, as necessary, to ensure a timely discharge. This ELEMENT is not met as evidenced by: Based on policy review, record review, and interview, the home health provider failed to ensure that each patient and his or her caregiver(s), received education regarding the physician order to discontinue the use of Tylenol due to drug to drug medication interaction, and the risks for continued use, in one of five full records reviewed (Record/Patient #4). This deficient practice has the potential to affect all patients served by the agency. Findings included: Review of the provider’s undated policy titled, “Coordination of Patient Care,” showed, in part: - The agency must coordinate care delivery to meet the patient’s needs, and involve the patient, representative (if any), and caregiver(s), as appropriate, in the coordination of care activities; and - Ensure that each patient, and his or her caregiver(s), where applicable, receives ongoing education and training provided by the agency, as appropriate, regarding the care and services identified in the plan of care. Review of the provider’s undated policy titled, “Nursing Services,” showed, in part: - Professional nursing services will be provided by a registered nurse and include: * Counseling and educating the patient and family regarding the disease process, self-care techniques and prevention strategies * Coordination of services * Informing the physician and other staff of changes in the patient's needs; and - Nursing care will be provided in accordance with the patient’s plan of care, under the supervision of a registered nurse. RECORD/PATIENT #4: - The patient was admitted to home health services on 01/08/2024 with a primary diagnosis of a fracture to the shaft of humerus (left upper arm) and is temporarily residing with his/her daughter; and - The SOC (start of care) assessment visit was on 01/08/2024. Review of the SOC visit note dated 01/08/2024, showed, in part: - The drug regimen review showed issues were identified and the physician was notified of the medication issues (The skilled nurse failed to include documentation of what the issues identified were and the prescribed/recommended actions included); and - The patient was education on medication side effects and information. Review of a Medication Issue Communication/Order document, dated 01/10/2024, showed, in part: - A drug interactions report showing the patient’s drug to drug interactions; - Stop medication(s) showed, acetaminophen was written (Also known as Tylenol, which is an analgesic medication that is used to treat minor aches and pains, and reduce fever); - The physician signed and dated it on 01/10/2024; and - It was faxed to the home health agency on 01/10/2024 at 2:41 PM. Review of the Occupational Therapy visit note dated 01/16/2024, that began at 9:15 AM and ended at 10:30 AM, showed, in part: - The pain section showed pain rated 6 out of 10, pain location of right bottom (buttocks), left shoulder and both knees listed, description was dull cramping pain, pain is worse with movement, sitting on sore (buttocks wound), and walking, pain relieved with medications and rest, frequency of pain and impact on activities had “Pt (patient) has pain daily but is typically able to work through pain to complete activities” was noted in the impact on activities, and the comment section had “majority of day, depending on activity” noted, and “Pt is using barrier cream on sore on bottom. Nurse states (he/she) will bring some cream and different dressing for it. Pt is taking 500mg Tylenol (analgesic medication to treat pain) 2 tabs 2x/day for shoulder and knee pain” noted in the comments section; and - The care planning/coordination section had “spoke to SN (skilled nurse) regarding pts sore and HR.” The clinical record failed to show education provided to the patient regarding the physician’s order to stop taking Tylenol due to the risk of drug-to-drug interaction with Coumadin (blood thinner). - A drug interactions report showing the patient’s drug to drug interactions; - Stop medication(s) showed, acetaminophen was written (Also known as Tylenol, which is an analgesic medication that is used to treat minor aches and pains, and reduce fever); - The physician signed and dated it on 01/10/2024; and - It was faxed to the home health agency on 01/10/2024 at 2:41 PM. During an interview on 02/07/2024 that began at 1:15 PM, the Clinical Manager stated that: - The medications are reviewed on the SOC and discrepancies should be clarified with the physician and documented; and - The patient should have been informed that the physician ordered him/her to stop taking Tylenol.

Patient medication schedule/instructions CFR(s): 484.60(e)(2) Patient medication schedule/instructions, including: medication name, dosage and frequency and which medications will be administered by HHA personnel and personnel acting on behalf of the HHA. This ELEMENT is not met as evidenced by: Based on policy review, home visit observation, and interview, the provider failed to provide the patient/caregiver with a copy of written instructions outlining the patient’s medication schedule/instructions in, but not limited to, one of three home visit observations, (Record/Patient #1). This deficient practice has the potential to adversely affect the medication administration of all patients served by the provider. Findings included: Review of the provider’s undated policy titled, “Coordination of Patient Care,” showed, in part, the agency (provider) will coordinate care with the patient by providing a copy of written instructions outlining patient medication schedule/instructions, including: medication name, dosage, route and frequency and which medications will be administered by agency personnel acting on behalf of the agency. RECORD/PATIENT #1: Review of the clinical record showed the patient was admitted to home health services on 01/22/2024 with a primary diagnosis of MS (multiple sclerosis- a disease in which the immune system attacks the protective covering of nerves). Observation on 02/02/2024 at 1:30 PM, during the patient’s home visit, the admission folder was reviewed and failed to contain a copy of the written POC or a current written medication list. Per interview conducted during observation, RN B stated that he/she: - Did not leave a written medication list; and - Probably should. During an interview on 02/07/2024, starting at 1:15 PM, the clinical manager stated that: - The medication list is on the POC; and - The POC should have been in the home with the written medication list on it; and - This was the first skilled nurse visit since the patient was admitted.

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: Based on policy review, clinical record review, and interview, the provider failed to provide SN (skilled nursing) and PT (physical therapy) services at the frequency ordered in one of five full records reviewed (Record/Patient #3). This deficient practice has the potential to adversely affect all patients served by the provider. Findings included: Review of the provider’s undated policy titled, “Care Planning Process,” showed, in part: - In order to assure that care provided is appropriately planned to meet each patient's specific needs and problems, the agency will utilize data/information gathered during patient assessments in the care planning process; - The patient care plan for skilled nursing will be: * Initial care plan will be CMS #485 Plan of Care, which is developed and implemented with the physician; and * Demonstrates problems (diagnoses), interventions (physician orders) and long-range goals. Review of the provider’s undated policy titled, “Physicians Verbal Orders,” showed, in part: - Drugs and treatments are administered by the agency staff only as ordered by the physician; - Orders are obtained prior to the provision of any care, including changes in the plan of care; - Orders for patient care are obtained from the physician, either verbally or in writing; - When a verbal order is received, the order must be written down, read back to verify order and receive confirmation from individual who gave order. A record of this order is documented on a physician’s supplemental order form. Review of the provider’s undated policy titled, “Coordination of Patient Care,” showed, in part: - Agency staff members regularly communicate and document to ensure that their efforts are coordinated effectively and ultimately support the objectives outlined in the plan of care; - The Agency must: * Assure communication with all physicians involved in the plan of care * Integrate orders from all physicians involved in the plan of care to assure the coordination of all services and interventions provided to the patient; and * Coordinate care delivery to meet the patient’s needs, and involve the patient, representative (if any), and caregiver(s), as appropriate, in the coordination of care activities. - Staff provides the physician with patient information on an ongoing basis; and - The clinical manager provides oversight of all patient care services, including coordinating patient care. RECORD/PATIENT #3: Review of the clinical record showed the patient was admitted with a primary diagnosis of malignant neoplasm of the larynx (cancer of the voice box). Review of a physician order dated 12/22/2023, showed: - Date order received: 12/21/2023; - Effective date: 12/21/2023; and - Visit Frequency: RN/LVN (registered nurse/licensed vocational nurse- (SN)) one time a week for three weeks starting 12/21/2023. Further review of the clinical record showed: - There failed to be a SN visit the following week (12/24/2023 to 12/30/2023; and - There failed to be any communication by the SN with the physician regarding the failure to follow the visit frequency the week of 12/24/2023 to 12/30/2023). Review of the PT evaluation visit dated 12/07/2023 showed: Frequency/Duration of physical therapy visits 1x1, 2x3, 1x1 (one time a week for one week, two times a week for three weeks and one time a week for one week. Further review of the clinical record showed: - PT visits at a frequency of 1x1, 2x2 and failed to show any visits the following week (12/24/2023 to 12/30/2023); and - There failed to be any communication by the PT with the physician regarding the failure to follow the visit frequency the week of 12/24/2023 to 12/30/2023. During an interview on 02/07/2024 starting at 1:15 PM, the clinical manager stated that: - He/she would expect the POC to be followed; and - The PCP should have been notified of the missed visits.

Participate in HHA-sponsored in-service CFR(s): 484.75(b)(9) Participation in HHA-sponsored in-service training. This ELEMENT is not met as evidenced by: Based on review of the rehabilitation services agreement, employee file review, and interview, the provider failed to ensure contract staff were provided annual agency In-service training in one of one contract employee file reviewed (Contract Physical Therapist-PT). This deficient practice has the potential to affect all patients of the provider served by contract employees. Findings included: Review of the rehabilitation services agreement signed and dated by the provider’s administrator on 07/27/2023 and signed by the contracting provider’s CEO (Chief Executive Officer) 08/11/2023, showed, in part, “Orientation. Agency shall provide appropriate initial orientation to individuals supplying services under this Agreement. Thereafter, annual education will be provided.” Contract PT Employee file review showed: - The contract PT had been hired in 2005 by the prior home health agency before the CHOW (change of ownership); and - The file failed to contain evidence of agency in-service from 06/2022 through the date of the survey exit, 02/07/2024. During an interview on 02/06/2024 at 11:30 AM with the clinical manager, he/she stated that: - I have all of the training from “Named home health provider” (the prior provider before the CHOW); - This contract PT worked for them already; - No training has been done with this contract PT since the CHOW; - I only did home health agency In-service training with our staff here; and - We were approved to start taking home health patients in June of 2022, but we were not made aware and did not start taking patients until January of 2023.

Org. had partial/extended survey CFR(s): 484.80(f)(3) Was subjected to an extended (or partially extended) survey as a result of having been found to have furnished substandard care (or for other reasons as determined by CMS or the state); or This ELEMENT is not met as evidenced by: Based on the results of this extended level survey, resulting in noncompliance with two Conditions of Participation: 484.55 Comprehensive assessment of patients, and 484.60 Care planning, Coordination of Services and Quality of Care, the provider may not train or competency evaluate their home health aides for a period of two (2) years following the date of this survey. The restriction ends 02/07/2026.

The Emergency Preparedness regulations were reviewed as part of the Medicare certification survey completed on 05/19/2021. During the survey it was determined Home Health of Harrison County Hospital is in compliance with the requirements of 42 CFR 418.102 Condition of Participation: Emergency Preparedness for Home Health Agencies.

A partial extended survey for Medicare certification for Home Health of Harrison County Hospital was completed on 05/19/2021. The agency had 8 current patients. A COVID-19 Focused Infection Control Survey was completed in conjunction with the survey and no deficiencies were identified related to the Focused Infection Control Survey.

Written notice of patient's rights CFR(s): 484.50(a)(1)(i) (i) Written notice of the patient's rights and responsibilities under this rule, and the HHA's transfer and discharge policies as set forth in paragraph (d) of this section. Written notice must be understandable to persons who have limited English proficiency and accessible to individuals with disabilities; This ELEMENT is not met as evidenced by: Based on agency policy review, review of the agency's current patient rights information, admission packet review, and interview, the agency failed to ensure staff provided the written notice of patient rights, to meet the requirements of the new federal home health regulations effective 01/13/2018, to include a completed and signed copy of the agency's Condition of Patient Rights form which included rights and responsibilities in a manner that the patient/representative understands, in two (Record/Patient #2, and #4) of three home visit observations. This deficient practice has the potential to affect the knowledge and comprehension of the rights and responsibilities for all patients/representatives served by the agency. Findings included: Review of the agency's policy titled, "Patient Rights," revised November, 2020 showed: - The patient and representative (if any) have the right to be informed of the patients' rights in a language and manner the individual understands. The home health agency must protect and promote the exercise of these rights; - During the initial evaluation visit and in advance of furnishing care to the patient, the agency will provide to the patient and legal representative (if any), orally and written, understandable to those who have limited English proficiency, and accessible individuals with disabilities, the patient rights information; - Obtain a signature confirming the patient or representative received a copy of the notice of rights and responsibilities; - No later than the second visit from a skilled professional, verbal notice of rights and responsibilities will be provided. It will be in the patient's primary/preferred language and in a manner they understand, free of charge, with the use of a competent interpreter if necessary; and - A patient or selected representative (if any) will receive the above information within four business days of the initial evaluation visit. Review of the agency's undated current patient rights information sheet showed: - 484.50 COP-Patient Rights- The patient/representative have the right to be informed of his/her rights in a language and manner the individual understands. The agency must protect and promote the exercise of these rights. RECORD/PATIENT #2: Review of the plan of care (POC) dated 04/29/2021 through 06/27/2021 showed: - Start of care date: 04/29/2021; - Skilled nurse (SN) visit frequency: 1 time per week for 3 weeks (1w3); - Physical therapist (PT)/physical therapy assistant (PTA) 1w1 and 2w1; - Occupational therapist (OT)/certified occupational therapy assistant (COTA) 1w1; and - Speech therapist (ST) 2w2. Review of the clinical record showed: - A SN start of care (SOC) visit note dated 04/29/2021; - An OT evaluation and discharge note dated 05/03/2021; - A ST evaluation note dated 05/03/2021; and - A PT evaluation note dated 05//12/2021. A home visit observation on 05/17/2021 at 12:45 PM showed: - As of this date, 05/17/2021, during PTA A's therapy visit, the agency staff had not returned the patient's admission copy of the agency's Condition of Participation: Patient Rights signed by the patient, 17 days after the SN SOC visit date. During an interview on 05/17/2021 at 12:45 PM, PTA A stated he/she did not deal with the admission packet and was unsure of the packet contents. RECORD/PATIENT #4: Review of the POC dated 05/11/2021 through 07/09/2021 showed: - Start of care date: 05/11/2021; - SN visit frequency: 1w4; and - PT/PTA visit frequency: 2w4. Review of the clinical record showed a SN SOC date of 05/11/2021 and a PT/PTA evaluation note dated 05/12/2021. A home visit observation on 05/18/2021 at 9:30 AM showed: - As of 05/18/2021, during SN B's nursing visit, agency staff had not returned the patient's admission copy of the agency's Condition of Participation: Patient Rights signed by the patient, 7 days after the SN SOC visit date. During an interview on 05/18/2021 at 10:30 AM, the director of home health stated: - Patients sign the consent for treatment and financial liability which included the Condition of Participation: Patient Rights when the nurse admits the patient to service; - The forms are brought back to the agency and are scanned into the computer; and - The nurse should take the forms back to the patient's home and place in the admission folder on the next visit, but sometimes staff forget to take the forms back to the patient to place in the folder.

HHA administrator contact information CFR(s): 484.50(a)(1)(ii) (ii) Contact information for the HHA administrator, including the administrator's name, business address, and business phone number in order to receive complaints. This ELEMENT is not met as evidenced by: Based on review of the agency's policy, the agency's current patient rights information sheet, home visit observation, and interview, the agency failed to ensure staff provided the written notice of patient rights to meet the requirements of the new federal home health regulations effective 01/13/2018 to include the rights of the patient and representative (if any) regarding contact information for the home health agency administrator to receive complaints which affected one (Record/Patient #2) of three home visit observations. This deficient practice has the potential to affect the knowledge and comprehension of the rights and responsibilities for all patients/representatives served by the agency. Findings included: Review of the agency's policy titled, "Patient Rights," revised November, 2020 showed: - The patient and representative (if any) have the right to be informed of the patients' rights in a language and manner the individual understands. The home health agency must protect and promote the exercise of these rights; - During the initial evaluation visit and in advance of furnishing care to the patient, the agency will provide to the patient and legal representative (if any), orally and written, understandable to those who have limited English proficiency, and accessible individuals with disabilities, the patient rights information; - Contact information for the agency's administrator, including name, business address, and business phone number; - Obtain a signature confirming the patient or representative received a copy of the notice of rights and responsibilities; and - No later than the second visit from a skilled professional, verbal notice of rights and responsibilities will be provided. It will be in the patient's primary/preferred language and in a manner they understand, free of charge, with the use of a competent interpreter if necessary; and - A patient or selected representative (if any) will receive the above information within four business days of the initial evaluation visit. Review of the agency's undated current patient rights information sheet showed: - -485.50 COP-Patient Rights- Contact information, name, business address and phone number for the administrator to receive complaints. RECORD/PATIENT 2: Review of the plan of care (POC) dated 04/29/2021 through 06/27/2021 showed: - Start of care date: 04/29/2021; - Skilled nurse (SN) visit frequency: 1 time per week for 3 (1w3) weeks; - Physical therapist (PT)/physical therapy assistant (PTA) 1w1 and 2w2; - Occupational therapist (OT)/certified occupational therapy assistant (COTA) 1w1; and - Speech therapist (ST) 2w2. Review of the clinical record showed: - A SN start of care (SOC) visit note dated 04/29/2021; - An OT evaluation and discharge note dated 05/03/2021; - A PT evaluation note dated 05//12/2021; and - A ST discharge visit note dated 05/13/2021. A home visit observation on 05/17/2021 at 12:45 PM showed: - As of this date, 05/17/2021, during the PTA A's therapy visit, the patient's admission folder did not contain a copy of the agency's Condition of Participation: Patient Rights signed by the patient, 17 days after the SN SOC visit date to include the name, business address and business phone number of the administrator to receive complaints. During an interview on 05/17/2021 at 12:45 PM, physical therapy assistant (PTA) A stated he/she did not deal with the admission packet and was unsure of the packet contents. During an interview on 05/18/2021 at 10:30 AM, the director of home health stated: - Patients sign the consent for treatment and financial liability which included the Condition of Participation: Patient Rights when the nurse admits the patient to service; - The forms are brought back to the agency and are scanned into the computer; - The nurse should take the forms back to the patient's home and place in the admission folder on the next visit, but sometimes staff forget to take the forms back to the patient to place in the folder.

Payment from federally funded programs CFR(s): 484.50(c)(7)(i, ii, iii, iv) Be advised, orally and in writing, of- (i) The extent to which payment for HHA services may be expected from Medicare, Medicaid, or any other federally-funded or federal aid program known to the HHA, (ii) The charges for services that may not be covered by Medicare, Medicaid, or any other federally-funded or federal aid program known to the HHA, (iii) The charges the individual may have to pay before care is initiated; and (iv) Any changes in the information provided in accordance with paragraph (c)(7) of this section when they occur. The HHA must advise the patient and representative (if any), of these changes as soon as possible, in advance of the next home health visit. The HHA must comply with the patient notice requirements at 42 CFR 411.408(d)(2) and 42 CFR 411.408(f). This ELEMENT is not met as evidenced by: Based on review the agency's policy, the agency's current patient rights information sheet, home visit observation, and interview, the agency failed to ensure staff provided the written notice of patient rights to meet the requirements of the new federal home health regulations effective 01/13/2018 to include; the patient and representative (if any) have the right to be advised orally and in writing of, the extent to which payment for services may be expected from Medicare/Medicaid or any other federally funded or federal aid program known to the agency; the charges for services that may not be covered by Medicare/Medicaid or any other federally funded aid program known to the agency; the charges the individual may have to pay before care is initiated; and the agency must advise the patient/representative of any changes as soon as possible, in advance of the next home health visit, which affected two (Record/Patient #2 and #4) of three home visit observations. This deficient practice has the potential to affect the knowledge and comprehension of the rights and responsibilities for all patients/representatives served by the agency. Findings included: Review of the agency's policy titled, "Patient Rights," revised November, 2020 showed: - The patient and representative (if any) have the right to be informed of the patients' rights in a language and manner the individual understands. The home health agency must protect and promote the exercise of these rights; - During the initial evaluation visit and in advance of furnishing care to the patient, the agency will provide to the patient and legal representative (if any), orally and written, understandable to those who have limited English proficiency, and accessible individuals with disabilities, the patient rights information; - Obtain a signature confirming the patient or representative received a copy of the notice of rights and responsibilities; and - No later than the second visit from a skilled professional, verbal notice of rights and responsibilities will be provided. It will be in the patient's primary/preferred language and in a manner they understand, free of charge, with the use of a competent interpreter if necessary; - A patient or selected representative (if any) will receive the above information within four business days of the initial evaluation visit and - Did not include the right to be advised orally and in writing of the extent to which payment for services may be expected from Medicare/Medicaid or any other federally funded or federal aid program known to the agency; the charges for services that may not be covered by Medicare/Medicaid or any other federally funded aid program known to the agency; the charges the individual may have to pay before care is initiated; and the agency must advise the patient/representative of these changes as soon as possible, in advance of the next home health visit. Review of the agency's undated current patient rights information sheet showed: - -485.50 COP-Patient Rights- The right to be advised orally and in writing of the extent to which payment for services may be expected from Medicare/Medicaid or any other federally funded or federal aid program known to the agency; the charges for services that may not be covered by Medicare/Medicaid or any other federally funded aid program known to the agency; the charges the individual may have to pay before care is initiated; and the agency must advise the patient/representative of these changes as soon as possible, in advance of the next home health visit. RECORD/PATIENT 2: Review of the plan of care (POC) dated 04/29/2021 through 06/27/2021 showed: - Start of care date: 04/29/2021; - Skilled nurse (SN) visit frequency: 1 time per week for 3 (1w3) weeks; - Physical therapist (PT)/physical therapy assistant (PTA) 1w1 and 2w2; - Occupational therapist (OT)/certified occupational therapy assistant (COTA) 1w1; and - Speech therapist (ST) 2w2. Review of the clinical record showed: - A SN start of care (SOC) visit note dated 04/29/2021; - An OT evaluation and discharge note dated 05/03/2021; - A PT evaluation note dated 05//12/2021; and - A ST discharge visit note dated 05/13/2021. A home visit observation on 05/17/2021 at 12:45 PM showed: - As of this date, 05/17/2021, during the PTA A's therapy visit, the patient's admission folder did not contain a copy of the agency's Condition of Participation: Patient Rights signed by the patient, 17 days after the SN SOC visit date to include the extent to which payment for services may be expected from Medicare/Medicaid or any other federally funded or federal aid program known to the agency; the charges for services that may not be covered by Medicare/Medicaid or any other federally funded aid program known to the agency; the charges the individual may have to pay before care is initiated; and the agency must advise the patient/representative of these changes as soon as possible, in advance of the next home health visit. During an interview on 05/17/2021 at 12:45 PM, physical therapy assistant (PTA) A stated he/she did not deal with the admission packet and was unsure of the packet contents. RECORD/PATIENT #4: Review of the POC dated 05/11/2021 through 07/09/2021 showed: - Start of care date: 05/11/2021; - SN visit frequency: 1w4; and - PT/PTA visit frequency: 2w4. Review of the clinical record showed a SN SOC date of 05/11/2021 and a PT/PTA evaluation note dated 05/12/2021 A home visit observation on 05/18/2021 at 9:30 AM showed: - As of 05/18/2021, during SN B's nursing visit, agency staff had not returned the patient's admission copy of the agency's Condition of Participation: Patient Rights signed by the patient, 7 days after the SN SOC visit date to include the extent to which payment for services may be expected from Medicare/Medicaid or any other federally funded or federal aid program known to the agency; the charges for services that may not be covered by Medicare/Medicaid or any other federally funded aid program known to the agency; the charges the individual may have to pay before care is initiated; and the agency must advise the patient/representative of these changes as soon as possible, in advance of the next home health visit. During an interview on 05/18/2021 at 10:30 AM, the director of home health stated: - Patients sign the consent for treatment and financial liability which included the Condition of Participation: Patient Rights when the nurse admits the patient to service; - The forms are brought back to the agency and are scanned into the computer; - The nurse should take the forms back to the patient's home and place in the admission folder on the next visit, but sometimes staff forget to take the forms back to the patient to place in the folder.

State toll free HH telephone hotline CFR(s): 484.50(c)(9) Be advised of the state toll free home health telephone hot line, its contact information, its hours of operation, and that its purpose is to receive complaints or questions about local HHAs. This ELEMENT is not met as evidenced by: Based on agency policy review, review of the agency's current patient rights information, admission packet review, and interview, the agency failed to ensure staff provided the written notice of patient rights to meet the requirements of the new federal home health regulations effective 01/13/2018 to include a completed and signed copy of the agency's Condition of Patient Rights form which included the Missouri state toll free home health telephone hotline, its contact information, its hours of operation and that its purpose is to receive complaints of or questions about local agencies, 1-800-392-0210 available 7:00 AM to 12:00 midnight, seven days a week, was given and placed in the admission folder of two (Record/Patient #2, and #4) of three home visit observations. This deficient practice has the potential to affect the knowledge and comprehension of the rights and responsibilities for all patients/representatives served by the agency. Findings included: Review of the agency's policy titled, "Patient Rights," revised November, 2020 showed: - The patient and representative (if any) have the right to be informed of the patients' rights in a language and manner the individual understands. The home health agency must protect and promote the exercise of these rights; - During the initial evaluation visit and in advance of furnishing care to the patient, the agency will provide to the patient and legal representative (if any), orally and written, understandable to those who have limited English proficiency, and accessible individuals with disabilities, the patient rights information; - Obtain a signature confirming the patient or representative received a copy of the notice of rights and responsibilities; - No later than the second visit from a skilled professional, verbal notice of rights and responsibilities will be provided. It will be in the patient's primary/preferred language and in a manner they understand, free of charge, with the use of a competent interpreter if necessary; - A patient or selected representative (if any) will receive the above information within four business days of the initial evaluation visit; and - Failed to include the required Missouri hotline number with correct hours of operation. Review of the agency's undated current patient rights information sheet showed: - 484.50 COP-Patient Rights- The patient/representative have the right to be advised of the state toll free home health telephone hotline, its contact information, its hours of operation and that its purpose is to receive complaints of or questions about local agencies, 1-800-392-0210 available 7:00 AM to 12:00 midnight, seven days a week. RECORD/PATIENT 2: Review of the plan of care (POC) dated 04/29/2021 through 06/27/2021 showed: - Start of care date: 04/29/2021; - Skilled nurse (SN) visit frequency: 1 time per week for 3 (1w3) weeks; - Physical therapist (PT)/physical therapy assistant (PTA) 1w1 and 2w2; - Occupational therapist (OT)/certified occupational therapy assistant (COTA) 1w1; and - Speech therapist (ST) 2w2. Review of the clinical record showed: - A SN start of care (SOC) visit note dated 04/29/2021; - An OT evaluation and discharge note dated 05/03/2021; - A PT evaluation note dated 05//12/2021; and - A ST discharge visit note dated 05/13/2021. A home visit observation on 05/17/2021 at 12:45 PM showed: - As of this date, 05/17/2021, during the PTA A's therapy visit, the patient's admission folder did not contain a copy of the agency's Condition of Participation: Patient Rights signed by the patient, 17 days after the SN SOC visit date to include the state toll free home health telephone hotline, its contact information, its hours of operation and that its purpose is to receive complaints of or questions about local agencies, 1-800-392-0210 available 7:00 AM to 12:00 midnight, seven days a week. During an interview on 05/17/2021 at 12:45 PM, physical therapy assistant (PTA) A stated he/she did not deal with the admission packet and was unsure of the packet contents. RECORD/PATIENT #4: Review of the POC dated 05/11/2021 through 07/09/2021 showed: - Start of care date: 05/11/2021; - SN visit frequency: 1w4; and - PT/PTA visit frequency: 2w4. Review of the clinical record showed a SN SOC date of 05/11/2021 and a PT/PTA evaluation note dated 05/12/2021 A home visit observation on 05/18/2021 at 9:30 AM showed: - As of 05/18/2021, during SN B's nursing visit, agency staff had not returned the patient's admission copy of the agency's Condition of Participation: Patient Rights signed by the patient, 7 days after the SN SOC visit date to include the state toll free home health telephone hotline, its contact information, its hours of operation and that its purpose is to receive complaints of or questions about local agencies, 1-800-392-0210 available 7:00 AM to 12:00 midnight, seven days a week. During an interview on 05/18/2021 at 10:30 AM, the director of home health stated: - Patients sign the consent for treatment and financial liability which included the Condition of Participation: Patient Rights when the nurse admits the patient to service; - The forms are brought back to the agency and are scanned into the computer; - The nurse should take the forms back to the patient's home and place in the admission folder on the next visit, but sometimes staff forget to take the forms back to the patient to place in the folder.

Transfer and discharge CFR(s): 484.50(d) Standard: Transfer and discharge. The patient and representative (if any), have a right to be informed of the HHA's policies for transfer and discharge. The HHA may only transfer or discharge the patient from the HHA if: This STANDARD is not met as evidenced by: Based on agency policy review, review of the agency's current patient rights information, admission packet review, and interview, the agency failed to ensure staff provided the written notice of patient rights to meet the requirements of the new federal home health regulations effective 01/13/2018 to include a completed and signed copy of the agency's Condition of Patient Rights form which included the written notice of the agency's transfer/discharge policies to the patient or representative (if any) within four business days of the initial evaluation was given and placed in the admission folder of two (Record/Patient #2, and #4) of three home visit observations. This deficient practice has the potential to affect the knowledge and comprehension of the rights and responsibilities for all patients/representatives served by the agency. Findings included: Review of the agency's policy titled, "Patient Rights," revised November, 2020 showed: - The patient and representative (if any) have the right to be informed of the patients' rights in a language and manner the individual understands. The home health agency must protect and promote the exercise of these rights; - During the initial evaluation visit and in advance of furnishing care to the patient, the agency will provide to the patient and legal representative (if any), orally and written, understandable to those who have limited English proficiency, and accessible individuals with disabilities, the patient rights information; - To include a written notice of the agency's transfer/discharge policies to the patient or representative (if any) within four business days of the initial evaluation - Obtain a signature confirming the patient or representative received a copy of the notice of rights and responsibilities; - No later than the second visit from a skilled professional, verbal notice of rights and responsibilities will be provided. It will be in the patient's primary/preferred language and in a manner they understand, free of charge, with the use of a competent interpreter if necessary; and - A patient or selected representative (if any) will receive the above information within four business days of the initial evaluation visit. Review of the agency's undated current patient rights information sheet showed: - 484.50 COP-Patient Rights- To include a written notice of the agency's transfer/discharge policies to the patient or representative (if any) within four business days of the initial evaluation. RECORD/PATIENT #2: Review of the plan of care (POC) dated 04/29/2021 through 06/27/2021 showed: - Start of care (SOC) date: 04/29/2021; - Skilled nurse (SN) visit frequency: 1 time per week for 3 weeks (1w3); - Physical therapist (PT)/physical therapy assistant (PTA) 1w1 and 2w1; - Occupational therapist (OT)/certified occupational therapy assistant (COTA) 1w1; and - Speech therapist (ST) 2w2. Review of the clinical record showed: - A SN start of care (SOC) visit note dated 04/29/2021; - An OT evaluation and discharge note dated 05/03/2021; - A ST evaluation note dated 05/03/2021; and - A PT evaluation note dated 05//12/202. A home visit observation on 05/17/2021 at 12:45 PM during the PTA A's therapy visit, showed: - As of this date, 17 days after the initial SOC, the patient admission packet did not include a written notice of the agency's transfer/discharge policies. During an interview on 05/17/2021 at 12:45 PM, PTA A stated he/she did not deal with the admission packet and was unsure of the packet contents. RECORD/PATIENT #4: Review of the POC dated 05/11/2021 through 07/09/2021 showed: - Start of care date: 05/11/2021; - SN visit frequency: 1w4; and - PT/PTA visit frequency: 2w4. Review of the clinical record showed a SN SOC date of 05/11/2021 and a PT/PTA evaluation note dated 05/12/2021 A home visit observation on 05/18/2021 at 9:30 AM during SN B's nursing visit, showed: - As of this date, eight days after the SOC, the patient admission packet did not include a written notice of the agency's transfer/discharge policies. During an interview on 05/18/2021 at 10:30 AM, the director of home health stated: - He/she did not realize the polices should be place in the information packet for the patients.

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 review of agency policy, clinical record review, and interview, the agency failed to complete the initial assessment of the patient within 48 hours of the referral to home care, or 48 hours after the patient returned home, or on the physician ordered start of care date to determine the immediate care and support needs of the patient and to determine eligibility and homebound status in one (Record/Patient #1) of five full records reviewed. This deficient practice has the potential to affect the immediate needs of all patients served by the agency. Findings included: Review of the agency's policy titled, "Initial Assessments/Comprehensive Assessments," revised February, 2018 showed: - Policy: Each patient admitted by the agency will have appropriate initial assessments performed and documented; - Initial assessment and time frame: A registered nurse (RN), physical therapist (PT), or speech therapist (SP) must conduct the initial assessment visit within 48 hours of referral, within 48 hours of the patient's return home or on physician ordered start of care date; - The initial assessment visit is conducted to determine the immediate care and support needs of the patient; - In the absence of a physician specified start of care date, the initial assessment visit is conducted within 48 hours of the referral; and - If the physician specified a start of care date, this supersedes the 48 hour time frame. RECORD/PATIENT #1: Review of the hospital discharge summary dated 05/06/2021 showed: - Discharge date: 05/07/2021. Review of the plan of care (POC) dated 5/10/2021 through 07/08/2021 showed: - Diagnoses include but not limited to: Merkel cell carcinoma of the face, lymphedema (chronic swelling of the lower extremities), and type two diabetes mellitus (uncontrolled blood sugar levels). Review of the OASIS Nursing Services Start of Care dated 05/10/2021 showed: - Start of care date: 05/10/2021. three days after the patient's discharge from the hospital; and - Failed to show a reason for the delay in the start of care. During an interview on 05/19/2021 at 8:30 AM, the findings were reviewed with the director of home health who stated: - The family requested the late SOC /admission; and - If the agency got an order it would have been in the email chat communication with the physician. An order was not provided to the survey staff by the end of the survey.

A review of all current medications CFR(s): 484.55(c)(5) A review of all medications the patient is currently using in order to identify any potential adverse effects and drug reactions, including ineffective drug therapy, significant side effects, significant drug interactions, duplicate drug therapy, and noncompliance with drug therapy. This ELEMENT is not met as evidenced by: Based on agency policy review, clinical record review, home visit observation, and interview, the agency failed to ensure staff reviewed all of the medications the patients were currently using in order to identify any potential adverse effects and drug interactions in three (Record/Patient #1, #3 and #6) of three home visit observations. This deficient practice has the potential to affect all patients served by the agency. Findings included: Review of the agency's policy titled, "Drug Regimen Review," revised May, 2020 showed: - Policy: To ensure that patients are following the correct prescribed medication regimen. Provides a means by which all personnel responsible for providing care have an accurate record of medications; - The drug regimen review is completed at the time of admission. The comprehensive assessment will include a review of all medications the patient is currently using, including over the counter drugs, 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; - The registered nurse (RN) shall take all verbal orders for medications. The nurse receiving the order will be responsible for updating/changing the drug regimen review; - All medications are reviewed using the DeVero online interactions tab for proper dosage, allergies, side effects, duplicate drug therapy, contraindications, and adverse reactions. All major interactions are faxed to the primary care physician (PCP) when identified; - High risk drugs are anticoagulants (blood thinners), hypoglycemic (diabetic medications to lower blood sugar levels), insulin, and narcotics (pain relievers); and - On admissions completed by therapies and/or if therapy is notified of a medication change, they will notify an RN. The RN will do a medication review, educate the patient/caregiver, and update the medication profile in the clinical record. The therapies will update the medication profile in the patient's home. All communication will be documented in the clinical record. RECORD/PATIENT #1: Review of the plan of care (POC) dated 05/10/2021 through 07/08/2021 showed: - Diagnoses include but not limited to: Type 2 diabetes mellitus (an impairment in the way the body regulates and uses sugar (glucose) as a fuel) and this long-term (chronic) condition results in too much sugar circulating in the bloodstream; - Insulin Detemir (a long-acting, man-made version of human insulin) 10 units every night at bedtime; - Safety measures: Diabetic precautions; - Interventions: Notify physician if blood glucose is greater than 400 milligrams (mg)/deciliter (dl) or less than 70 mg/dl, fasting or random; - Assess/instruct in hypoglycemia (a condition in which your blood sugar (glucose) level is lower than normal, glucose is your body's main energy source, needs to be treated immediately) and hyperglycemia (high levels of sugar, or glucose, in the blood and it occurs when the body does not produce or use enough insulin, which is a hormone that absorbs glucose into cells for use as energy) and appropriate actions to take; and - Assess/perform/instruct patient in blood glucose testing and importance of recording and compliance. Review of the comprehensive assessment dated 05/10/2021 showed: - Patient supposed to do sliding scale insulin with meals, but does not always eat three meals per day; - He/she checked his/her blood glucose a couple of times per day, dependent upon when he/she ate. A home visit on 05/17/2021 at 3:56 PM showed: - The patient did not allow the surveyor to see a home medication list; and - The agency medication profile did not show a sliding scale for insulin. During a home visit observation on 05/17/2021 at 3:56 PM, the RN stated: - He/she knew about the sliding scale insulin, but forgot to put it on the medication profile; - He/she then asked the patient what the dose was and looked at the patient's home list for the doses of sliding scale insulin; and - The patient stated he/she used the sliding scale "yesterday" (05/16/2021) but declined to give more information on how often he/she had to take the sliding scale doses. During a home visit observation on 05/17/2021 at 3:56 PM, the patient stated: - He/she took Insulin Detemir 11 units at bedtime, not 10 units as ordered; - Refused to allow the registered nurse (RN) to look at recorded blood glucose levels or show glucometer (machine to check blood glucose levels) to the RN; and - Did not want to answer questions about using sliding scale (changes in insulin dosages according to blood glucose readings) insulin to control blood glucose levels. Review of the clinical record did not show the RN notified the physician of the patient's use of a sliding scale dosage for a sliding scale dose/range for medications used by the patient on 05/16/2021 or of non-compliance with diabetic management by the patient. RECORD/PATIENT #3: Review of the POC dated 04/22/2021 through 06/20/2021 showed: - Diagnoses included: Type 2 diabetes mellitus, hypertension, chronic kidney disease, hypothyroidism (thyroid gland does not make enough thyroid hormone which controls how your body's cells use energy from food, a process called metabolism), and other long term drug therapy; - Warfarin (a blood thinner) 5 mg daily except Wednesday PM starting 04/22/2021; and - Warfarin 5 mg weekly on Wednesday PM starting 04/22/2021. Review of the medication profile dated 04/23/2021 showed: - Warfarin (a blood thinner) 5 mg daily except Wednesday PM starting 04/22/2021; and - Warfarin 5 mg weekly on Wednesday PM starting 04/22/2021. During an interview on 05/18/2021 at 11:45 AM, the RN stated that: - "It's a typo, it should say 5 mg, ½ tablet weekly on Wednesday PM, start 04/22/2021". RECORD/PATIENT #6: Review of the POC dated 01/15/2021 through 03/15/2021 showed: - Diagnoses included but not limited to: Hypertensive heart disease (heart problems that occur because of high blood pressure that is present over a long time), acute diastolic heart failure (congestive heart failure, buildup of fluid around the heart), acute respiratory failure with hypoxia (low blood level of oxygen), chronic obstructive pulmonary disease (chronic inflammatory lung disease that causes obstructed airflow from the lungs), and dependence on supplemental oxygen; and - Medications: Oxygen flow rate, delivery system (nasal cannula, mask), and duration not listed on the POC. Review of the medication profile dated 01/15/2021 did not include oxygen flow rate, delivery system (nasal cannula, mask), and duration. During an interview on 05/18/2021 at 11:40 AM, the director of home health stated that oxygen should be listed on the medication profile and interventions and goals should be on the POC.

Plan of care must include the following CFR(s): 484.60(a)(2)(i-xvi) The individualized plan of care must include the following: (i) All pertinent diagnoses; (ii) The patient's mental, psychosocial, and cognitive status; (iii) The types of services, supplies, and equipment required; (iv) The frequency and duration of visits to be made; (v) Prognosis; (vi) Rehabilitation potential; (vii) Functional limitations; (viii) Activities permitted; (ix) Nutritional requirements; (x) All medications and treatments; (xi) Safety measures to protect against injury; (xii) A description of the patient's risk for emergency department visits and hospital re-admission, and all necessary interventions to address the underlying risk factors. (xiii) Patient and caregiver education and training to facilitate timely discharge; (xiv) Patient-specific interventions and education; measurable outcomes and goals identified by the HHA and the patient; (xv) Information related to any advanced directives; and (xvi) Any additional items the HHA or physician or allowed practitioner may choose to include. This ELEMENT is not met as evidenced by: Based on policy review, clinical record review, and interview, the agency failed to ensure that each patient's written individualized plan of care (POC) included all the required elements in two (Record/Patient #1, and #3) of five full records reviewed. This deficient practice has the potential to impact the care provided to all patients served by the agency. Findings included: Review of the agency's policy titled, "Care Planning Process," revised February, 2018, showed: - Policy: In order to assure that care provided is appropriately planned to meet each patient's needs and problems, the agency will utilize data/information gathered during patient assessments in care planning process; - The POC for skilled nursing (SN) will be developed and implemented with the physician; will demonstrate problems (diagnoses), interventions (physician orders), and long range goals; - The initial assessment will give the description of problems and changes and identifies problems, interventions, and goals at the time of admission; - Visit notes: Include documentation of modifications to care/service, current problems, interventions, and short term goals; individualized. Will be revised as problems are identified; review and revision will be ongoing with each home visit and will be based on the patient's health status, environment, and relevant baseline data from assessments to determine current needs problems, interventions, and goals; and will reflect goal evaluation/goal resolution; - Care will be coordinated initially and ongoing among staff providing care; and - Care planning will be individualized and include problems/needs, goals based on problems, needs, conditions, wishes and ability to respond to care/services, specific care/services to be provided including frequency, type, and duration, implementation of actions and interventions, and review and revision as indicated. RECORD/PATIENT #1: Review of the OASIS Nursing Services Start of Care (SOC) (a federally mandated assessment tool) dated 05/10/2021 showed: - Patient recently had shingles to left hand and arm; continued to have numbness in hand and arm. Review of the plan of care (POC) dated 05/10/2021 showed: - Start of care date: 05/10/2021; - Diagnoses included but not limited to: Type two diabetes mellitus (an impairment in the way the body regulates and uses sugar (glucose) as a fuel. This long-term (chronic) condition results in too much sugar circulating in the bloodstream); - Durable Medical Equipment/Supplies (DME): Diabetic supplies; and - Did not address Shingles to the left hand and arm and numbness to left hand and arm. RECORD/PATIENT #3: Review of the POC dated 04/22/2021 through 06/20/2021 showed: - Warfarin sodium (a blood thinning agent) 5 milligrams (mg), one tablet daily except Wednesday, start 04/22/2021; - Warfarin sodium 5 mg, one tablet, weekly on Wednesday, start 04/22/2021; - Did not address the need for Prothrombin times to be drawn, when or how often, to assess the dosages needed for physician ordered blood thinning medication. Review of the OASIS dated 04/22/2021 showed: - Did not address need for Prothrombin (Protime, a test used to help diagnose bleeding or clotting disorders) times to be drawn, when or how often, to assess dosages needed for physician ordered blood thinning medication. During an interview on 05/18/20212 at 11:45 AM, the registered nurse (RN) stated: - The patient goes to outpatient clinic to have Protimes drawn; and - The Warfarin sodium dosages were "typo errors." During an interview on 05/19/2021 at 8:30 AM, the above findings were reviewed with the director of home health and no additional information/documentation was provided.

All orders recorded in plan of care CFR(s): 484.60(a)(3) All patient care orders, including verbal orders, must be recorded in the plan of care. This ELEMENT is not met as evidenced by: Based on policy review, clinical record review, and interview, the agency failed to ensure all patient care orders were recorded in plan of care (POC) in one (Record/Patient #6) of five full record reviews. This deficient practice has the potential to affect all patients served by the agency. Findings included: Review of the agency's policy titled, "Physicians Verbal Orders," revised February, 2018 showed: - Policy: Drugs and treatments are administered by the agency staff only as ordered by the physician. Only authorized staff receives and records verbal orders. Verbal orders are put in writing and signed and dated by the registered nurse (RN) or qualified therapists responsible for furnishing or supervising the care. Orders are obtained prior to the provision of any care, including changes in the POC; - When a verbal order is received, the order must be written down, read back to verify and receive confirmation from the individual who gave the order. A record of this order is documented on a physician's supplemental order form and should include patient name, physician name, date and time of the person taking the order, the specific order; and - The original order is documented and authenticated by licensed staff and submitted to the agency within three business days after receipt. The original order is faxed/emailed, or taken to the physician for signature and authentication; a copy will remain in the patient's record until the signed order is returned, then will be attached to the copy in the EMR (electronic medical record); faxed signatures are acceptable, however the agency is responsible for obtaining an original signature if verification is required; and no stamped signatures are permitted. RECORD/PATENT #6: Review of the POC dated 01/15/2021 through 03/15/2021 showed: - Diagnoses included but not limited to: Hypertensive heart disease (heart problems that occur because of high blood pressure that is present over a long time), acute diastolic heart failure (congestive heart failure, buildup of fluid around the heart), acute respiratory failure with hypoxia (low blood level of oxygen), chronic obstructive pulmonary disease (chronic inflammatory lung disease that causes obstructed airflow from the lungs), and dependence on supplemental oxygen. - Medications: Oxygen (flow rate, delivery system (nasal cannula, mask), and duration were not listed on the POC). Review of the medication profile dated 01/15/2021 did not include oxygen flow rate, delivery system (nasal cannula, mask), and duration. Review of an email communication dated 01/28/2021 written by the registered nurse (RN) showed: - Patient admitted on January 15, 2021; was sent home on oxygen and told he/she only needed to wear the oxygen with exertion; O2 saturation (amount of oxygen in the blood stream) was 91% (normal 95 - 100%) sitting during SN visit, told the patient to use for the next few days. Could the physician give a titrate (amount of oxygen to be delivered) order to put on his/her chart?; - No order for titration or use of oxygen was written by the RN as of 02/01/2021 when the patient was transferred to the hospital. During an interview on 05/19/2021 at 8:30 AM. the director of home health stated: - Some communication may be on emails and would show the collaboration with the doctors; - He/she said it would be on the individual clinician's login and they would have to access the emails for that physician; and - Staff had issues with actually writing the orders from the email communications and sending to the physician for signature.

Communication with all physicians CFR(s): 484.60(d)(1) Assure communication with all physicians or allowed practitioners involved in the plan of care. This ELEMENT is not met as evidenced by: Based on policy review, and clinical record review, the agency failed to ensure communication with all physicians involved in the plan of care (POC) in two (Record/Patient #2 and #3) of five full records reviewed. This deficient practice has the potential to affect the quality of care provided to all patients served by the agency. Findings included: Review of the agency's policy titled, "Coordination of Patient Care," revised May, 2020 showed: - Policy: Agency staff members regularly communicate and document to ensure their efforts are coordinated effectively and ultimately support the objectives outlined in the plan of care; - The agency must assure communication with all physicians involved in the POC; - Integrate orders from all physicians involved in the POC to assure the coordination of all services and interventions provided to the patient; and - The clinical manager and/or nursing supervisor communicates with staff daily to discuss changes in the physician's order. RECORD/PATIENT #2: Review of the POC dated 04/29/2021 through 06/27/2021 showed: - Diagnoses included: Other sequelae (chronic or residual conditions that are complications of an initial acute disease, illness or injury, the most common sequela is pain), of cerebral infarct (stroke), facial weakness following cerebral infarct. Review of a skilled nurse visit sheet dated 05/06/2021 showed: - The RN assessed shingles rash and associated pain; - Patient and caregiver report cleansing the rash in the mornings, wearing loose white t-shirt over rash; - RN offered to cleanse areas and apply non-adherent dressing but patient refused, did not feel it was necessary; - Supplies and instructions left with patient and caregiver; - Noted on left side of trunk unilateral shingles rash with soft vesicles over an erythematous base; - Educated to keep area clean and wear loose clothing, put on clean clothes daily, avoid rubbing or scratching the skin, can apply cool cloth for itching or pain relief until lesions have dried and crust forms; - Educated in importance of antiviral medication compliance and to take pain medications as needed for pain relief; - Ongoing skill need: Continue to assess new shingles rash and pain related to this new diagnoses; continue to assess caregiver for medication management and treatment of shingles pain, and continue to monitor and assess for ophthalmic complications of herpes zoster shingles infection; - Coordination with the SN and patient and caregiver; - Care team updated with patient care plan and new diagnosis of shingles; and - No coordination of care recorded with the physician. Review of bottles of home medications during a home visit on 05/17/2021 at 12:45 PM showed started on Valtrex (a medication to treat herpes simplex or shingles)1 gram, one tablet, BID (twice daily). During an interview on 05/18/2021 at 11:00 AM, the director of home health stated: No documentation or communication with the physician about shingles found. RECORD/PATIENT #3: Review of the POC dated 04/22/0221 through 06/20/2021 showed: - The POC failed to include a diagnosis of blood blister to the bottom of the third right toe. Review of the OASIS Nursing Services Start of Care (SOC) (a federally mandated assessment tool) dated 04/22/2021 showed: - The SOC documentation failed to include an assessment of the blood blister to the bottom of the third right toe. Review of a skilled nurse visit note dated 04/29/2021 showed: - The patient had a blood blister on the bottom side of the third right toe; - Band aid in place and family will take care of this and changing it; and - Care coordination did not include the physician. During an interview on 05/19/2021 at 8:30 AM, the above findings were reviewed with the director of home health and no additional information/documentation was provided.

Visit schedule CFR(s): 484.60(e)(1) Visit schedule, including frequency of visits by HHA personnel and personnel acting on behalf of the HHA. This ELEMENT is not met as evidenced by: Based on agency policy review, review of the agency's current patient rights information, admission packet review, home visit observation, and interview, the agency failed to ensure the staff provided a written visit schedule to patients that included what discipline was visiting and the frequency of visits in three (Record/Patient #1, #2, and #4) of three home visit observations. This deficient practice has the potential to affect the knowledge and comprehension of the rights and responsibilities for all patients/representatives served by the agency. Findings included: Review of the agency's policy titled, "Patient Rights," revised November, 2020 showed: - The agency must provide the patient/caregiver with a copy of written instructions outlining the visit schedule, including frequency of all personnel; Review of the agency's undated current patient rights information sheet showed: - 484.50 COP-Patient Rights- The patient/representative have the right to participate in and be informed about and consent or refuse care in advance of and during treatment, where appropriate, with respect to frequency of visits. RECORD/PATIENT #1: Review of the plan of care (POC) dated 05/10/2021 through 07/08/2021 showed: - Start of care date: 05/10/2021; - Skilled Nurse (SN) visit frequency: 1 time per week for 1 week (1w1) and 2w3; and - Physical therapist (PT)/physical therapy assistant (PTA) 2w4. Review of the clinical record showed: - A SN start of care (SOC) note dated 05/10/2021; - A PT evaluation note dated 05/11/2021; and - A SN visit note for 05/17//2021. A home visit observation on 05/17/2021 at 3:56 PM showed: - As of this date, 05/17/2021, during SN C's visit, agency staff did not provide the patient/caregiver with a copy of written instructions outlining the visit schedule, including frequency of all personnel. RECORD/PATIENT #2: Review of the POC dated 04/29/2021 through 06/27/2021 showed: - Start of care date: 04/29/2021; - SN visit frequency: 1w3; - PT/PTA 1w1 and 2w1; - Occupational therapist (OT)/certified occupational therapy assistant (COTA) 1w1; and - Speech therapist (ST) 2w2. Review of the clinical record showed: - A SN start of care (SOC) visit note dated 04/29/2021; - An OT evaluation and discharge note dated 05/03/2021; - A ST evaluation note dated 05/03/2021; and - A PT evaluation note dated 05//12/2021. A home visit observation on 05/17/2021 at 12:45 PM showed: - As of this date, 05/17/2021, during PTA A's therapy visit, agency staff did not provide the patient/caregiver with a copy of written instructions outlining the visit schedule, including frequency of all personnel. RECORD/PATIENT #4: Review of the POC dated 05/11/2021 through 07/09/2021 showed: - Start of care date: 05/11/2021; - SN visit frequency: 1w4; and - PT/PTA visit frequency: 2w4. Review of the clinical record showed a SN SOC date of 05/11/2021 and a PT/PTA evaluation note dated 05/12/2021 A home visit observation on 05/18/2021 at 9:30 AM showed: - As of 05/18/2021, during SN B's nursing visit, agency staff did not provide the patient/caregiver with a copy of written instructions outlining the visit schedule, including frequency of all personnel. During an interview on 05/18/2021 at 10:30 AM, the director of home health stated: - Staff should leave a schedule of visits in the home either on the agency's printed calendar or wherever the patient wanted the visits recorded.

Patient medication schedule/instructions CFR(s): 484.60(e)(2) Patient medication schedule/instructions, including: medication name, dosage and frequency and which medications will be administered by HHA personnel and personnel acting on behalf of the HHA. This ELEMENT is not met as evidenced by: Based on home visit observation, and interview, the agency failed to ensure staff provided the patient or caregiver (if any) with a copy of written instructions outlining the patient's medication schedule/instruction, including the medication dosage which affected one (Record/Patient #2) of three home visit observations. This deficient practice has the potential to affect the knowledge of self-care and agency expectations in all patients served by the agency. Findings included: RECORD/PATIENT #2: During a home visit observation on 05/17/2021 at 12:45 PM, with physical therapy assistant (PTA) A, the surveyor observed the patient's home folder. The agency failed to provide dosages for medications listed on the home medication profile list for the patient. During an interview on 05/18/2021 at 1:15 PM, the findings were reviewed with the director of home health who acknowledged the above findings and no additional documentation/information was provided.

Treatments and therapy services CFR(s): 484.60(e)(3) Any treatments to be administered by HHA personnel and personnel acting on behalf of the HHA, including therapy services. This ELEMENT is not met as evidenced by: Based on policy review, home visit observation, and interview, the agency failed to ensure staff provided the patient or caregiver (if any) with a copy of instructions of any treatments being administered by the agency in three (Record/Patient #1, #2, and #4) of three home visit observations. This deficient practice has the potential to affect the knowledge and comprehension of the rights and responsibilities for all patients/representatives served by the agency. Findings included: Review of the agency's policy titled, "Patient Rights," revised November, 2020, showed: - The agency must provide the patient/caregiver (if any) with a copy of written instructions outlining any treatment to be administered by agency personnel, including therapy service. RECORD/PATIENT #1: During a home visit on 05/17/2021 at 3:56 PM with skilled nurse (SN) C, the surveyor observed the patient's home folder. The agency failed to provide written instructions for any specific treatments for skilled nursing or physical therapy. RECORD/PATIENT #2: During a home visit on 05/17/2021 at 12:45 PM with the physical therapy assistant (PTA) A, the surveyor observed the patient's home folder. The agency failed to provide written instructions/information for diabetic management for pre-diabetes (when your blood sugar level is higher than it should be but not high enough for your doctor to diagnose diabetes), blood sugar level changes and parameters, and the effects of blood sugar changes, and instructions for the care and treatment of shingles (is a common viral infection, and causes a large, painful rash with blisters). RECORD/PATIENT #4: During a home visit on 05/18/2021 at 9:30 AM with SN B, the surveyor observed the patient's home folder. The agency failed to provide written physical therapy exercises for the patient. On 05/18/2021 at 1:00 PM, the director of home health stated instructions for treatments including therapy should be left in the home.

Name/contact information of clinical manager CFR(s): 484.60(e)(5) Name and contact information of the HHA clinical manager. This ELEMENT is not met as evidenced by: Based on agency policy review, admission packet review, home visit observation, and interview, the agency failed to ensure staff provided the information of the name and contact number of the clinical manager in the admission packet during the initial assessment which affected three (Record/Patient #1, #2, and #4) of three home visit observations. This deficient practice has the potential to affect the knowledge and comprehension of the rights and responsibilities for all patients/representatives served by the agency. Findings included: Review of the agency's policy titled, "Patient Rights," revised November, 2020 showed: - The agency must provide the patient/caregiver (if any) with a copy of written instructions outlining the following; the name/contact information for the agency clinical manager. RECORD/PATIENT #1: During a home visit observation on 05/17/2021 at 3:56 PM with skilled nurse (SN) C, the surveyor observed the patient's home folder. The agency failed to provide written information related to the clinical manager's name and contact number. RECORD/PATIENT #2: During a home visit observation on 05/17/2021 at 12:45 PM with physical therapy assistant (PTA) A, the surveyor observed the patient's home folder. The agency failed to provide written information related to the clinical manager's name and contact number. RECORD/PATIENT #4: During a home visit observation on 05/18/2021 at 9:30 AM with SN B, the surveyor observed the patient's home folder. The agency failed to provide written information related to the clinical manager's name and contact number. During an interview on 05/18/2021 at 10:30 AM, the director of home health stated the name and contact number should be written in the patient's home folder.

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 policy review, record review, home visit observation, and interview, the agency failed to ensure staff followed infection control standards of practice in two (Record/Patient #1 and #2) of three home visits observations. This deficient practice has the potential to affect all patients served by the agency. Findings included: Review of the agency's policy titled, "Personal Protective Equipment," revised April, 2017 showed: - Policy: To protect personnel from the possibility of contracting and/or spreading an infectious disease; to comply with requirements set forth by OSHA (Occupational Safety and Health Administration), as clarified by those CDC (Centers for Disease Control) guidelines to healthcare worker safety and health; - Personal protective equipment (PPE) shall be provided to all personnel and are indicated in which the employee is at risk of exposure to a blood borne pathogen; - Gloves should be used when touching excretions, secretions, blood, body fluids, mucous membranes, or non-intact skin; - Handling potentially contaminated items; - It is likely that hands will come in contact with blood, body fluids, or other potentially infectious material; - Wash hands after removing gloves; gloves do not replace hand hygiene. Review of the agency's policy titled, "Handwashing," revised June, 2016 showed: - Policy: To provide guidelines for effective hand hygiene in order to prevent the transmission of bacteria, germs and infections. It is important for all staff members to practice good hand hygiene in order to prevent infecting patients and to ensure their own personal health; - The CDC has recommended guidelines when to use non anti-microbial soap and water, anti-microbial soap and water, or an alcohol based hand rub. When hands are visibly soiled with blood or body fluids, wash with an anti-microbial soap and water; - Hands should be cleansed when hands are soiled, after coming in contact with a patient's intact skin; and - After coming in contact with a contaminated body site and then moving to a clean body site on the same patient. Review of the agency's policy titled, "Exposure Control Plan: OSHA Regulations," revised February, 2018 showed: - Nursing Bag Technique: Upon entering the home, place the bag on a clean surface; paper towels or plastic bag may be used to create a clean area if indicated; - Remove all items which will be needed for the visit; - Place items on one of the paper towels; - Clean any visibly soiled items which will be returned to the bag; and - Methods of disinfection: Thermometers will be wiped with an alcohol pad after each use; stethoscopes, pulse oximeters (measures oxygen in the blood stream), and blood pressure cuffs will be cleaned with an agency approved disinfectant after each use. RECORD/PATIENT #1: Review of the plan of care (POC) dated 05/10/2021 through 07/08/2021 showed: - Diagnoses include, but not limited to: Merkel cell carcinoma of the face and history of irradiation of carcinoma to the face; and - Skin integrity interventions: Apply silver sulfadiazine (a wound healing medication) to left side of face daily and cover with non-adherent dressing. During a home visit observation on 05/17/2021 at 3:56 PM, skilled nurse (SN) C provided wound care to the patient's face and did not wash hands or use hand sanitizer between glove changes during the wound care. On 05/18/2021 at 1:00 PM, the above findings were reviewed with the home health director who acknowledged the findings and he/she agreed that SN C should have cleansed his/her hands between glove changes. RECORD/PATIENT #2: A home visit observation on 05/17/2021 at 12:45 PM with physical therapy assistant (PTA) A showed: - Placed a clean barrier on a chair, removed from the nursing bag a plastic bag that contained the blood pressure cuff, thermometer, and pulse oximeter and placed them on the clean barrier; - Used the items on the patient, and placed each item back onto the clean field; - Then cleaned each piece of equipment, and laid the cleaned items back onto the now contaminated field; - Picked up each item and placed the items into a plastic bag, sanitized the bag and placed the bag into the nursing bag; and - Stated he/she cleaned the equipment and then wiped down the plastic bag before placing the bag into the nursing bag. On 05/18/2021 at 10:30 AM, the above findings were reviewed with the home health director who acknowledged the findings and he/she agreed that PTA A should have used a second clean field to place the equipment on after he/she cleaned the equipment and before returning them to the plastic bag and nursing bag.

Services by skilled professionals CFR(s): 484.75(a) Standard: Provision of services by skilled professionals. Skilled professional services are authorized, delivered, and supervised only by health care professionals who meet the appropriate qualifications specified under §484.115 and who practice according to the HHA's policies and procedures. This STANDARD is not met as evidenced by: Based on review of agency policy, standards of care review, clinical record review, and interview, the agency failed to provide the skilled professional services of the registered nurse (RN) when the RN failed to provide services according to standards of practice and the agency's policy and procedures in two (Records/Patients #1 and #3) of five full records reviewed. This deficient practice has the potential to adversely affect the nursing needs of all patients served by the agency. Findings included: Review of the agency's policy titled, "Nursing Services," revised February, 2018 showed: - Policy: Patients receiving nursing services will have appropriate assessments, reassessments, and care planning and established outcomes performed; - Nursing care will be provided in accordance with the patient's care plan; and - Professional nursing service will be provided by a registered nurse and includes providing services and/or treatments requiring substantial and specialized nursing care. Review of the article by Karen S. Clay, RN, BSN, CWCN Copyright 2008 titled, "Evidence-Based Pressure Ulcer Prevention: A Study Guide for Nurses," showed the following: "The standard of practice requires at least weekly measurement of the wound. In addition, every time you change the dressing, assess peri-wound skin, wound margins, wound tissue, drainage, odor, pain, and any other relevant issues. On a weekly basis, assess those macroscopic (i.e., visible to the naked eye) indices, measure the wound, assess the effectiveness of the treatment, and determine any treatment plan changes." (http://www.hcpro.com/content/76944.pdf Chapter 9-Wound Healing-Page 95) RECORD/PATIENT #1: Review of the Home Health Face to Face Encounter sheet dated 05/05/2021 showed: - The following are medically necessary for home health services: *Skilled nursing (SN) for assessment/skilled observation, wound care to face and leg wraps; - Patient meets homebound status due to extreme weakness; and - Signed by the physician. Review of a physician order dated 05/05/2021 showed: - Cleanse left facial wound with normal saline, pat dry, apply Xeroform (a non-adherent petrolatum dressing is made up of a petrolatum blend on fine mesh gauze) dressing and cover with a bordered gauze one time daily. Review of the OASIS Nursing Services Start of Care dated 05/10/2021 showed: - Surgical wound left side of face, surgical removal of Merkel cell carcinoma of left side of face, scabbing down the left side of face, down left side of neck and down into the chest; most is scarring but does have an area in front of left ear that turned into a radiation burn; - Wound care performed; - No wound measurements were recorded; and - Shingles (a viral infection that causes a painful rash) in left hand and up the arm with continued numbness to hand and arm. Review of the plan of care (POC) dated 05/10/2021 showed: - Diagnoses included but not limited to: Merkel cell carcinoma of the face, lymphedema (excess fluid collection in tissues causing swelling (edema) of the lower extremities); - Durable Medical Equipment/Supplies (DME): Ace wrap, lymphedema wraps (compression bandage to treat the long-term condition where excess fluid collects in tissues causing swelling (edema) of the lower extremities), non-adherent dressing, non-sterile gloves, Silver Sulfadiazine (a silver healing agent for wounds), tape, and Unna boot (a compression dressing made by wrapping layers of gauze around the leg and foot. It is often used to protect an ulcer or open wound. The compression of the dressing helps improve blood flow in your lower leg. Compression also helps decrease swelling and pain), and - Shingles to the left hand and arm and numbness to left hand and arm failed to be addressed on the POC. A home visit observation and interview on 05/17/2021 at 4:56 PM, showed: - The RN did not perform wound measurements of face during dressing change on this visit, and stated wound measurements are done on the last visit of the week and will be done on the next visit; - The RN stated the patient/family is able to do the dressing changes to face; - The RN had not seen the patient's legs because the family changed the Unna boot to the legs and he/she had not visualized the legs since the start of care; - The family and patient reported there were no open wounds to the leg; - The family was to change the Unna boot two to three times per week and they changed the Unna boot today before the SN visit; and - The patient declined to allow the nurse to look at his/her legs. During an interview on 05/19/2021 at 8:30 AM, the findings were reviewed with the director of home health who stated that: - Wound measurements and assessments are expected to be completed weekly; and - The RN should have visualized the patient's legs for a complete skin assessment. RECORD/PATIENT #3: Review of the POC dated 04/22/2021 through 06/20/2021 showed: - Start of care: 04/22/2021; - Diagnoses included but not limited to: Diabetes mellitus; - The POC failed to include diagnosis of wound to left great toe or diagnosis for Warfarin administration (a blood thinner medication-that requires lab work on a routine basis for dosing) ; - Medication list showed Warfarin daily; - Interventions showed: *Notify the physician if blood glucose is greater than 400 milligrams (mg)/deciliter (dl) or less than 70 mg/dl fasting or randomly; *Blood glucose testing daily and importance of recording and compliance; *Wound care to the left great toe; *Blood sugar will be within physician established parameters throughout certification period; *Cleanse with normal saline, apply triple antibiotic ointment to wound, cover with non-stick dressing and wrap with Kling (a gauze wrap) secure with tape every SN visit; *Patient/caregiver to perform wound care once competence demonstrated; and *Wound will be measured weekly; - Failed to address Prothrombin times (Protime a test used to help diagnose bleeding or clotting disorders and determine the dosage of blood thinning medication to be administered) when, how often, or who was to draw the lab work. Review of the OASIS dated 04/22/2021 showed: - Left toe diabetic ulcer; - No wound measurements recorded; - Blood glucose checks daily and PRN (as needed); - No blood glucose levels recorded; and - Did not address protime lab draws. During an interview on 05/18/2021 at 11:45 AM, the RN stated: - The patient gets the protimes drawn as an outpatient at a physician's office; - It was hard to get a measurement of the wound to the toe; it was like it was scraped where the toenail was, like the toenail had been removed; - There were no weekly wound measurements documented on the OASIS, the POC, or on subsequent nursing visits; and - There was no documentation of blood glucose levels on any nurse's note or the OASIS.

Discharge and transfer summaries CFR(s): 484.110(a)(6)(i-iii) (i) A completed discharge summary that is sent to the primary care practitioner or other health care professional who will be responsible for providing care and services to the patient after discharge from the HHA (if any) within 5 business days of the patient's discharge; or (ii) A completed transfer summary that is sent within 2 business days of a planned transfer, if the patient's care will be immediately continued in a health care facility; or (iii) A completed transfer summary that is sent within 2 business days of becoming aware of an unplanned transfer, if the patient is still receiving care in a health care facility at the time when the HHA becomes aware of the transfer. This ELEMENT is not met as evidenced by: Based on policy review, record review, and interview, the agency failed to ensure a comprehensive transfer summary was sent within two business days of a transfer if the patient's care will be immediately continued in a health care facility in one (Record/Patient #6) of three discharge records reviewed. This deficient practice has the potential to affect all patients served by the agency. Findings included: Review of the agency's policy titled, "Transfer, Discharge, or Termination of Services," revised May, 2020 showed: - The policy failed to include- comprehensive transfer summary is sent within two business days of a planned transfer, or within 2 business days of becoming aware of an unplanned transfer, if the patient's care will be continued in a health care facility. RECORD/PATIENT #6: Review of the plan of care (POC) dated 01/15/2021 through 03/15/2021 showed: - Diagnoses included but not limited to: Hypertensive heart disease with heart failure, chronic obstructive pulmonary disease (asthma, emphysema), atrial fibrillation (rapid hear beat that can be life threatening) and anxiety disorder. Review of the OASIS (a federally mandated assessment tool to be completed by agency staff) Transfer form dated 02/01/2021 showed: - The patient was seen as an outpatient and needed admission to the hospital; - The summary was sent to the physician on 02/03/2021; and - No record of date of transfer summary sent to the admitting hospital. During an interview on 05/18/2021 at 11:40 AM, the director of home health stated: - The agency did not send the transfer summary to the hospital; and - He/she did not know this needed to be done.