Every finding on record at Health Quest Home Care, Inc. (Certified)

The following statement of deficiencies represents the results of a partial extended recertification survey of Health Quest Home Care Certified Home Health Agency conducted on 04/19/2021 through 4/26/2021. A standard recertification survey was initiated on 04/19/2021. Deficient practices were identified with high priority standards in Plan Of Care resulting in a partial extended survey. The survey consisted of a review of eighteen (18) clinical records. Seven active patient records identified as Patients: #7,#8,#12,#15, #16,#17,and #18; Six (6) active patients with observational home visits identified as Patients: #1, # 6, #, #9, #10, # 11, and # 13; Five (5) discharge records identified as Patients: #1, #2,#3,#4, and #5; Seven (7) personnel records for professional and paraprofessional personnel: identified as Employees #1, #2, #3, #4,#5, #6 and #7; One (1) contract; Review of pertinent policies and procedures; Quality Improvement meeting minutes for the past 12 months; agency's admission packet; Potentially avoidable events; the Emergency Preparedness Plan; and Complaint Log. Pre-survey activities consisted of reviews on 04/16/2021 of the agency's Health Commerce System account, Home Care Registry, IQIES ( Internet Qualiy Improvement and Evaluation System)Event Outcome Report for the period 01/2020 to 12/2020, and the agency's compliance with report submission for the 2019 statistical report and the Emergency drill conducted 6/11/19 through 11/13/2019. The Administrator and the Director of Patient Services were interviewed. Findings were reviewed at the exit conference on 04/26/2021. The following deficiencies are identified as a result of the survey: G- 0536- A Review Of All Current Medications G- 0574 - Plan Of Care Must Include The Following G- 0578 - Conformance With Physicians Orders G- 0580 - Only as ordered By A Physician G- 0590 - Promptly Alert Relevant Physician Of Changes G- 0984 - In Accordance With Current Clinical Practices J- 1140 - Governing Authority J- 1156 - Governing Authority J- 1168 - Governing Authority J - 1260 - Governing Authority J- 1440 - Personnel L- 001 - Unacceptable Infection Control Procedure

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: 3. Patient #6 has a start of care date of 3/31/21 with diagnoses of Diabetes Mellitus Type Two, Atrial Fibrillation, Congestive Heart Failure and Chronic Obstructive Pulmonary Disease as documented on the" Home Health Certification and Plan of Care" for the certification period of 3/31/21/to 5/29/21. "The Home Health Certification and Plan of Care" for the certification period of 3/31/21 through 5/29/21 documents: "Skilled Nursing"SN for assessment and evaluation". A home visit was conducted at the home on 4/22/21 and the Patient's medications were reviewed. The Patient had an Albuterol Sulfate inhaler in the home that was in with the other medications that was not on the Plan of Care. During an interview with the Registered Nurse (RN) on 4/22/21 at 11:00 AM , the RN stated that she was not aware the Patient had that inhaler. 4. Patient #9 has a start of care date of 2/6/21 with diagnoses of Multiple Myeloma, Cardiac Disease, Respiratory Failure, Chronic Kidney Disease and Congestive Heart Disease as documented on the "Home Health Certification and Plan of Care" for the certification period of 2/4/21 to 4/6/21 and 4/7/21 to 6/5/21. The "Home Health Certification and Plan of Care" for the certification period of 2/4/21 to 4/6/21 and 4/7/21 to 6/5/21 documents: "Skilled Nurse (SN) for assessment and evaluation". A home visit was made to the home on 4/22/21 and the Patient's medications were reviewed. The medication Atovaquone 750 mg oral suspension was in the home, the bottle documents a date of dispension is 2/27/21 and the Patient stated "I take this with food"; the pill bottle for Amiodarone 200 mg documents one (1) tablet every other day and has a dispension date of 3/28/21. There is no documented evidence the medications reviewed and reconciled. During an interview with the RN on 4/22/21 at 2:00 PM, the RN did not provide an explanation for the above findings.5. Patient # 13 has a start of care date of 4/2/2021 with diagnosis that include Sternal Surgical after care following surgery on the circulatory system, Atherosclerosis Heart Disease of native Coronary Artery with Unstable Angina Pectoris, Essential hypertension and type II Diabetes Mellitus as documented on the "Home Health Certification and Plan of Care" for the certification period of of 4/2/2021 to 5/31/2021. The Plan of Care for the certification period of 4/2/2021 to 5/31/1 documents: "Lasix 20 mg 1 tab orally daily discontinued 4/7/2021; Potassium Chloride Extended Release 20 MEQ 1 tab 2 times daily discontinued 4/16/2021" On 4/21/2021 during a home visit with the agency RN and supervisor, the medication review identify Lasix and Potassium tablets among the active medication; the patient and spouse could not remember if the patient is still taking the Potassium Chloride. There is no documented evidence the medications were reviewed and reconciled. On 4/23/21 at 11:00 AM, the Director of Patient Services was interviewed and did not provide an explanation for the above findings. 6. Patient #14 has a start of care date of 3/3/2021 with diagnosis that include Unspecified Open Wound, Right Lower Leg, initial Encounter, Acute post Hemorrhagic Anemia, Pressure Ulcer of left Buttocks, Stage II, and Unspecified Atrial Fibrillation documented on the "Home Health Certification and Plan of Care" for the certification period of 3/3/2021 to 5/1/2021. The "Home Health Certification and Plan of Care" for the certification period of 3/3/2021 to 5/1/2021 documents: the medication "Acetaminophen 325 mg capsule 2 capsules as needed every 6 hours" . During the home visit conducted on 4/21/2021 the patient states she has been taking Tylenol Extra Strength since discharge from the hospital more than a month ago" There is no documented evidence of the above medication Tylenol Extra strength orders. There is no documented evidence the medications were reviewed and reconciled. On 4/23/21 at 11:00 AM, the Director of Patient Services was interviewed and did not provide an explanation for the above findings. Based on record reviews and staff interview the agency failed to review all medications the Patient is currently using in order to reconcile all medications for duplicate therapy or missing medication orders . This was evident for six (6) of eighteen (18) patient care records reviewed.(Patients #6, # 9, #10, #11, # 12, and #13). Failure to review all medications the patient is currently using in order to reconcile all medications for duplicate or missing medication orders have the potential for negative patient outcomes. The findings are: 1. Patient #10 has a start of care date of 3/23/21 with diagnosis that include Unspecified dementia Without behavioral Disturbances, Major depressive Disorder, Hemiplegia Following Cerebral Infarction Affecting Left Non Dominant Side as documented on the " Home Health Certification and Plan of Care" for the certification period of 3/23/21 to 5/21/21. The " Home Health Certification and Plan of Care" for the certification period of 3/23/21 to 5/21/21 document: " Medications: Acetaminophen 325 mg tablet two tablets every six hours for 1-3 pain, Amlodipine 10 mg tablet one tablet daily oral (PO), Aspirin 81 mg chewable tablet one tablet daily PO, Atorvastatin 40 mg one tablet PO at bedtime( HS), Clopidogrel 75 mg tablet one tablet PO daily, Fluoxetine 10 mg capsule one capsule PO daily, Metformin 500 mg tablet one tablet twice a day PO, Metropolol Tartrate 50 mg one tablet every 12 hours PO, Mirtazapine 15 mg tablet .5 tablet daily PO, Pantoprazole 20 mg tablet delayed release, one tablet daily PO, Vitamin B12 500 ( micrograms) mcg folic Acid 400 mcg one tablet PO daily. Frequency/ Duration of Visits: Physical Therapy ( PT) once a week for one week, twice a week for six weeks, Occupational Therapy (OT) once a week for one week, twice a week for four weeks, Speech Therapy (ST) once a week for one week, Medical Social Worker (MSW) once a week for one week On 4/22/21 at 10:45 AM, during an observational home visit, a review of the medications in the home identified the following discrepancies: A bottle labeled Fluoxetine with a date filled 4/12/21 document Fluoxetine 40 mg every day PO, A bottle labeled Mirtazapine with a date filled on 4/12/21 document Mirtazapine 15 mg PO at bedtime. The last documented nursing visit was on 4/19/21. There is no documented evidence the medications were reviewed and reconciled. On 4/23/21, at 11:00 AM, the Director of Patient Services was interviewed and did not provide an explanation for the above findings. 2. Patient #11 has a start of care date of 3/14/21 with diagnosis that include Atherosclerotic Heart disease Of Native Coronary Artery without Angina Pectoris, Ischemic Cardiomyopathy, Acute Respiratory failure with Hypoxia, Paroxysmal atrial Fibrillation, Unspecified Atrial Flutter as documented on the " Home Health Certification and Plan of Care " for the certification period of 3/14/21 to 5/12/21. The " Home Health certification and Plan of Care " for the certification period of 3/14/21 to 5/12/21 document: " Allopurinol 100 mg one tablet oral (PO) daily, Amiodarone 200 mg PO daily, Atorvastatin 20 mg tablet one tablet PO daily, Eliquis 2.5 mg one tablet PO twice a day, Furosemide 80 mg tablet one tablet daily PO, Metropolol Succinate ER 25 mg tablet extended release 24 one tablet PO daily, Potassium Chloride ER 10 meq capsule extended release oral PO daily, Preservision Areds-2 250 mg-90 mg-40 mg one capsule PO daily. The " Visit Note Report" dated 3/30/21 document: " Vital signs stable, lungs are clear BLL, Patient was instructed to double dose of furosemide from 40mg to 80 mg for three days , Friday, Saturday and Sunday. Patient is back on regular dose of 40 mg a day. Follow up with Physician tomorrow, weights within normal limits, ankle and calf circumference within normal limits. There is no documented evidence of the above medications orders in the Plan of Care. There is no documented evidence the medications were reviewed and reconciled. On 3/23/21 at 11:00 AM, the Director of Patient Services was interviewed and did not provide an explanation for the above findings.

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 may choose to include. This ELEMENT is not met as evidenced by: 2. Patient #1 has a start of care date of 12/17/20 and a discharge date of 12/24/20 with diagnoses of Myocardial Infarction, Hypertension, Diabetes Mellitus Type Two and Chronic Kidney Disease as documented on the "Home Health Certification and Plan of Care" for the certification period of 12/17/2 to 2/14/21.. The "Home Health Certification and Plan of Care" for the certification period of 12/17/20 to 2/14/21 documents: SN (Skilled Nursing) two times a week for two weeks, one time a week for one week, two times a week for one week for assessment and evaluation; Glipizide 10 mg two times a day (antidiabetic); Metformin 500 mg two times a day (antidiabetic); Carvedilol 25 mg two times a day (antihypertensive); Isosorbide Monitrate ER 30 mg daily (antihypertensive); Losartan 50 mg daily (antihypertensive); Ibuprofen 200 mg three (3) tablets every six (6) hours as needed for neurotic pain; Loperamide 2 mg daily PRN (as needed)". There is no documented evidence in the Plan of Care of the times and frequency (the number of loose bowel movements) for taking the Loperamide. The initial nursing assessment dated 12/17/20 documents: Patient monitors blood glucose two times a day and is on fluid restrictions. The note does not document the amount of fluids allowed. The nursing visit dated 12/19/20 documents "Patient knows when to hold blood pressure medications". A coordination note dated 12/19/20 documents a call was received through the service "Patient reports his Neuropathy pain in bilateral lower extremities is bothering him today. Patient reports he hasn't had any relief from Tylenol and would like to try Ibuprofen. Placed call to V.A. (Hospital); no answer and closed until Monday. Writer informed RN CM (Registered Nurse Case Manager) to follow up on Monday". There is no documented evidence of Tylenol on the Plan of Care. There is no documented evidence in the Plan of Care of the following: Blood Glucose monitoring and Blood Pressure parameters for physician notification; The amount of fluid allowed for fluid restrictions; 3. Patient #3 has a start of care date of 7/22/20 and a discharge date of 8/21/20 with diagnoses of Breast Cancer, Alzheimer's Disease, Dementia, Hypertension Congestive Heart Failure and Atrial Fibrillation as documented in the "Home Health Certification and Plan of Care" for the certification period of 7/22/21 to 9/19/21. The "Home Health Certification and Plan of Care" for the certification period of 7/22/20 to 9/19/21 documents: "Skilled Nurse (SN) visits for assessment and evaluation; Home Health Aide (hha) one hour a day two times a week for one (1) week then three (3) times a week for seven (7) weeks; Advil 200 mg two (2) tablets every 12 hours as needed for pain; Oxycodone - Acetaminophen 5 mg/325 mg every six (6) hours as needed pain 3 - 10/10". There is no documented evidence in the Plan of Care of the following: Whether the Advil and Oxycodone/Acetaminophen can be taken together; A stop date for the Oxycodone or pain parameters for physician notification; The maximum dosage for the medications over a twenty-four period. There is no documented evidence the Plan of Care is complete. 4. Patient #6 has a start of care date of 3/31/21 with diagnoses of Diabetes Mellitus Type Two, Atrial Fibrillation, Congestive Heart Failure and Chronic Obstructive Pulmonary Disease as documented on the "Home Health Certification and Plan of Care" for the certification period of 3/31/21 5/29/21. The "Home Health Certification and Plan of Care" for the certification period of 3/31/21 to 5/29/21 documents: " Skilled Nurse (SN )for assessment and evaluation; Physical Therapy (PT) one time a week for one week then two times a week for four weeks; notify physician if weight is less than 179 or greater than 189; Glimepiride 1 mg two times a day (antidiabetic); Furosemide 40 mg two times a day (diuretic); Metformin ER 750 mg daily (antidiabetic). The initial nursing visit dated 3/31/21 documents the Patient is hard of hearing, and is monitoring the blood glucose two times a day. The Plan of Care does not document the functional limitation of hearing and does not document the frequency for the blood glucose monitoring. The PT note dated 4/3/21 documents the Patient weights self daily and documents the weights. Daily weights are not on the Plan of Care. 5. Patient #8 has a start of care date of 2/24/21 with diagnoses of Heel Ulcer, Diabetes Mellitus and Atrial Fibrillation as documented on the Home Health Certification and Plan of Care for the certification period of 2/24/21 to 4/23/21. The Home Health Certification and Plan of Care for the certification period of 2/24/21 to 4/23/21 documents: "Skilled Nurse (SN) for assessment and evaluation; notify physician for weight less than 232 or greater than 237. The Plan of care does not document the frequency weights are to be done. The initial SN visit dated 2/4/21 documents the Patient is monitoring blood glucose daily. The SN visit dated 3/17/21 documents the Patient is on fluid restrictions. The Plan of Care does not document the frequency for blood glucose testing and fluid restrictions. 6. Patient #9 has a start of care date of 2/6/21 with diagnoses of Multiple Myeloma, Cardiac Disease, Respiratory Failure, Chronic Kidney Disease and Congestive Heart Disease as documented on the "Home Health Certification and Plan of Care" for the certification period of 2/6/21 to 4/5/21. The Home Health Certification and Plan of Care for the certification period of 2/6/21 to 4/5/21 documents: " Skilled Nurse (SN )for assessment and evaluation; Tramadol 50 mg every 12 hours as needed for severe pain of 7 to 10; Gabapentin 100 mg three times a day (neuropathy). The Plan of Care does not document pain parameters for physician notification. The initial SN note documents the Patient is hard of hearing. This is not on the Plan of Care. The SN note dated 2/11/21 documents the Patient is on 36 ounces of fluid restrictions a day. 7. Patient #15 has a start of care date of 2/15/21 with diagnoses of Lower Extremity Ulcer, Osteoarthritis to the Knees, Hypertension and Atrial Fibrillation as documented on the "Home Health Certification and Plan of Care" for the certification period of 2/15/21 to 4/16/21. The "Home Health Certification and Plan of Care" for the certification period of 2/15/21 to 4/16/21 documents: "SN for assessment and evaluation". The initial nursing assessment dated 2/15/21 documents the Patient has vision impairment and hard of hearing. These functional limitations are not documented on the Plan of Care. During an interview with the Director of Patient Services (DPS) on 4/1/21 at 1:00 PM, the DPS did not provide explanations for the above findingsBased on clinical record reviews and interview, the agency failed to develop/revise complete and comprehensive Plans of Care. This was evident for ten (10) of eighteen (18) clinical records reviewed. (Patients #1, #3, #6, #8, #9, #10, #14, #15, #17 and #18) Failure to develop complete and comprehensive Plans has the potential for negative patient outcomes. The findings are: 1. Patient # 10 has a start of care date of 3/23/21 with diagnosis that include Hemiplegia, Type 2 Diabetes, Peripheral Angiopathy, Hypertension, Dysphagia, Hyperlipidemia as documented on the " Home Health Certification and Plan of Care" for the certification period of 3/23/21 to 5/21/21. The " Home health Certification and Plan of Care" for the certification period of 3/23/21 to 5/21/21 document:" Frequency/ duration of visits: Physical Therapy( PT) once a week for one week, twice a week for six weeks, Occupational Therapy(OT) once a week for one week, twice a week for four weeks, Speech Therapy(ST) once a week for one week, Medical Social worker (MSW) once a week for one week. Orders of Discipline and treatments: PT to evaluate / assess and develop PT plan of care to be signed by the physician. PT to provide monitoring for the presence of skin lesions on the lower extremities and teaching/ reinforcement regarding proper diabetic foot care The PT " Visit Note Report" dated 4/5/21 document: " Patient with round red area on right buttock with dry skin around it. No drainage noted at time of visit but aide applied plenty of moisture barrier. Will request nursing evaluation. The " Visit Note Report" dated 4/7/21 document: " Registered Nurse (RN) notified by PT patient has new skin breakdown on coccyx area., RN assessed new breakdown noted to be Stage 1 with two areas with potential to become Stage 2 not open at this time. Call placed to physician office, spoke with office who confirms MD wants the zinc oxide cream and foam pad. Notified Physician office nursing can monitor breakdown, per office physician will agree to skilled nursing service twice a week for two weeks and once a week for two weeks. Patient is diabetic who does not check her sugars states physician does A1C. Husband supports this and they have been doing this for years". On 4/14/21 the "Visit Note Report" document: " patient is diabetic, on Metformin, the doctor checks her sugar at appointment and per patient readings are good". There is no documented evidence of blood sugar being checked by the physician in the Plan Of Care . There is no documented evidence of verbal/ interim orders. There is no documented evidence of frequency of the nursing visits in the Plan Of Care. There is no documented evidence the Plan of Care is complete. On 4/23/21 at 11 AM, the Director Of Patient Services was interviewed and did not provide an explanation for the above findings. 8. Patient #14 has a start of care date of 3/3/2021 with diagnosis that include Unspecified Open Wound, Right Lower Leg, initial Encounter, Acute post Hemorrhagic Anemia, Pressure Ulcer of left Buttocks, Stage II, and Unspecified Atrial Fibrillation documented on the "Home Health Certification and Plan of Care" dated 3/3/2021 to 5/1/2021. The "Home Health Certification and Plan of Care" for the certification period of 3/3/2021 to 5/1/2021 documents the medication "Acetaminophen 325 mg capsule 2 capsules as needed every 6 hours for pain 3 out of 10" During the home visit conducted on 4/21/2021 the patient states that "pain is a 6 (on the pain scale of 0 to 10), and is taking Tylenol Extra Strength since discharge from the hospital more than a month ago" The "Home Health Certification and Plan of Care" lack documented evidence of Extra strength Tylenol ;treatment for pain greater than 3 on the pain scale and when to notify the physician. 9. Patient #17 has a start of care date of 1/23/2021 with diagnosis that include Encounter for change or removal of surgical wound dressing; Encounter for surgical after following surgery on the Digestive System Peritoneal Abscess and Essential Primary Hypertension documented on the Home Health Certification and Plan of Care for the certification period of 3/24/2021 to 5/22/2021. The Home Health Certification and Plan of Care for the certification period of 3/24/2021 to 5/22/2021 documents: "Hydrocodone 5 mg/acetaminophen 325 mg take 1 tab by mouth every 6 hours as needed for severe pain" The Plan of Care lack documented evidence of definition or explanation for "severe pain", and treatment for pain levels other than severe; how to monitor hydrocodone 5/325 mg effectiveness and when to notify physician. 10. Patient #18 has a start of care date of 10/15/19 with diagnosis that include Diabetes Type II, Chronic Ulcer left foot, Chronic Ulcer right foot, Chronic Ulcer right heel and Midfoot documented on the Home Health Certification and Plan of Care dated 4/7/2021 to 6/5/2021. The Home Health Certification and Plan of Care dated 4/7/2021 to 6/5/2021 documents "Novolog flexpen U-100 Insulin Aspart 100 unit/ml (3 ML) Subcutaneous- inject 3 units standing order before meals if blood sugar 351-400 inject 4 units before meal" The Plan of Care lack documented evidence of when to notify physician. On 4/23/21 at 11:00 AM, the Director Of Patient Services was interviewed and did not provide an explanation for the above findings.

Conformance with physician orders CFR(s): 484.60(b) Standard: Conformance with physician orders. This STANDARD is not met as evidenced by: 1. Patient #8 has a start of care date of 2/24/21 with diagnoses of Heel Ulcer, Diabetes Mellitus and Atrial Fibrillation as per the "Home Health Certification and Plan of Care" for the certification period of 2/24/21 to 4/23/21. The "Home Health Certification and Plan of Care" for the certification period of 2/24/21 to 4/23/21 documents: "Skilled Nurse (SN) three times a week for two weeks, two times a week for two weeks, for assessment and evaluation; parameters for ankle circumference measurements for physician notification are less than 26.6 or greater than 29.5 (there is no frequency as to when the ankles are to be measured)". The initial nursing assessment dated 2/24/21 lacks documented evidence the Patient's ankles were measured. The SN notes dated 2/26/21, 3/17/21, 3/22/21, 3/24/21 lack documented evidence the Patient's ankles were measured. 2. Patient #9 has a start of care date of 2/6/21 with diagnoses of Multiple Myeloma, Cardiac Disease, Respiratory Failure, Chronic Kidney Disease and Congestive Heart Disease as documented on the "Home Health Certification and Plan of Care" for the certification period of 2/6/21 to 4/5/21 and 4/7/21 to 6/5/21. The "Home Health Certification and Plans of Care" for the certification period of 2/6/21 through 4/6/21 and 4/7/21 through 6/5/21 documents: " Skilled Nurse(SN) visits one time a week for one week then two times a week for eight weeks, SN for assessment and evaluation, wound care- cleanse with Normal Saline and pack with Aquacell or Silver Alginate and cover with two layers of gel fiber two times a week". The SN notes dated 2/11/21, 2/16/21, 2/18/21, 2/23/21, 4/10/21, 4/13/21 and 4/17/21 do not consistently document the wound care treatment provided. During an interview with the Director of Patient Services (DPS) on 4/23/21 at 1:00 PM, the DPS did not provide an explanation for the above findings. Based on observations, record reviews and interviews, the agency failed to ensure that services are provided in accordance with the Plans of Care (POC). This was evident for two (2) of eighteen (18) clinical records reviewed. (Patients # 8 and #9). Failure to ensure that patient care is provided in accordance with the Plans of Care has the potential for patients to receive poor care and health care needs to go unmet. The findings are:

Only as ordered by a physician CFR(s): 484.60(b)(1) Drugs, services, and treatments are administered only as ordered by a physician. This ELEMENT is not met as evidenced by: Based on record review and staff interview, the agency failed to ensure that drugs are administered only as ordered by a physician. This was evident for one (1) of eighteen (18) clinical records reviewed. (Patient #11). Failure to ensure that drugs are administered only as ordered by a physician have the potential for negative patient outcomes. The findings are: Patient # 11 has a start of care date of 3/14/21 with diagnosis that include Atherosclerotic Heart disease Of Native Coronary Artery without Angina Pectoris, Ischemic Cardiomyopathy, Acute Respiratory failure with Hypoxia, Paroxysmal atrial Fibrillation, Unspecified Atrial Flutter as documented on the " Home Health Certification and Plan of Care " for the certification period of 3/14/21 to 5/12/21. The " Home Health certification and Plan of Care " for the certification period of 3/14/21 to 5/12/21 document: " Allopurinol 100 mg one tablet oral (PO) daily, Amiodarone 200 mg PO daily, Atorvastatin 20 mg tablet one tablet PO daily, Eliquis 2.5 mg one tablet PO twice a day, Furosemide 80 mg tablet one tablet daily PO, Metropolol Succinate ER 25 mg tablet extended release 24 one tablet PO daily, Potassium Cloride ER 10 meq capsule extended release oral PO daily, Preservision Areds-2 250mg-90mg-40mg one capsule PO daily. The " Visit Note Report" dated 3/30/21 document: " Vital signs stable, lungs are clear BLL, Patient was instructed to double dose of furosemide from 40mg to 80 mg for three days , Friday, Saturday and Sunday. Patient is back on regular dose of 40 mg a day. Follow up with Dr. Jha tomorrow, weights within normal limits, ankle and calf circumference within normal limits. There is no documented evidence of a specific interim physisian order for Furosemide on 3/30/21. There is no documented evidence of communication with a physician on the new order for furosemide. On 4/23/21 at 11 AM, the Director of Patient Services was interviewed and did not provide an explanation for the above findings.

Promptly alert relevant physician of changes CFR(s): 484.60(c)(1) The HHA must 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. This ELEMENT is not met as evidenced by: 3. Patient #1 has a start of care date of 12/17/20 and a discharge date of 12/24/20 with diagnoses of Myocardial Infarction, Hypertension, Diabetes Mellitus Type Two and Chronic Kidney Disease as documented "the Home Health Certification and Plan of Care" for the certification period of 12/17/20 to 2/14/21. The "Home Health Certification and Plan of Care" for the certification period of 12/17/20 2/14/21 documents: "SN (Skilled Nursing) for assessment and evaluation; Glipizide 10 mg two times a day (antidiabetic); Metformin 500 mg two times a day (antidiabetic); Carvedilol 25 mg two times a day (antihypertensive); Isosorbide Montitrate ER 30 mg daily (antihypertensive); Losartan 50 mg daily (antihypertensive); Ibuprofen 200 mg three (3) tablets every six (6) hours as needed for neurotic pain; Loperamide 2 mg daily PRN (as needed) for Diarrhea. A coordination note dated 12/19/20 documents a call was received through the service "Patient reports his Neuropathy pain in bilateral lower extremities is bothering him today. Patient reports he hasn't had any relief from Tylenol and would like to try Ibuprofen. Placed call to V.A. (Hospital); no answer and closed until Monday. Writer informed RN CM (Registered Nurse Case Manager) to follow up on Monday". The SN note dated 12/17/20 documents the Patient is on fluid restrictions and the Patient monitors blood glucose two times a day. The SN note dated 12/19/20 documents the Patient has pitting edema of plus one to the left and right lower extremities, Patient is monitoring blood glucose twice weekly. The note does not document whether the Patient is taking the Ibuprofen, and if so, the amount/ frequency and effectiveness. The SN note dated 12/21/20 documents: "the Patient is complaining of loose stools this AM, instructed on BRAT diet, verbalized understanding, will continue to monitor, Patient denies current pain, has Ibuprofen 600 mg PRN in home, Patient states he has been taking all along to help with Neuropathy; is monitoring blood glucose three (3) to four (4) times a week. A SN note dated 12/24/20 documents the Patient's pulse was 52, confused and the SN obtained the Patient's blood glucose and it was 40 and Patient was transferred to the hospital. There is no documentation the physician was notified of the transfer to the hospital. The note does not document the number of loose bowel movements the Patient has had, whether the Patient is taking the Loperamide, and if so, how often; the note does not document the Patient's past history of pain and rating amount/frequency of Ibuprofen is being taken; the frequency the Patient is monitoring the blood glucose. There is no documented evidence of communication with the physician regarding the coordination note regarding pain and the Patient's loose bowel movements and BRAT diet. 4. Patient #8 has a start of care date of 2/24/21 with diagnoses of Heel Ulcer, Diabetes Mellitus and Atrial Fibrillation as per the Home Health Certification and Plan of Care " for the certification period of 2/24/21 to 4/23/21. The Home Health Certification and Plan of Care for the certification period of 2/24/21 to 4/23/21 documents: " Skilled Nurse (SN) for assessment and evaluation; notify physician for weight less than 232 or greater than 237; Levimir 16 units daily; Humalog Insulin sliding scale 0-199 = o units, 200 - 250= 2 units, 251 - 300 = 4 units, 301 - 350 = 6 units, 351 -400 = 8 units; wound care to the heel two times a week; the Patient's weight is to be assessed (as per the parameters)". The SN notes dated between 2/26/21 through 4/9/21 do not document the Patient's weight. The SN note dated 3/22/21 documents the Patient refused to be weighted and "claims to have scale". The note does not verify whether the nurse checked to see if the Patient had a scale. The SN note dated 3/17/21 documents the Patient is on fluid restrictions. The SN note dated 3/26/21 documents "encouraged fluids". The SN note dated 3/5/21 documents the Patient is a high nutritional risk. The SN note dated 3/17/21 documents "not following ADA (diabetic) diet, Patient stated it's hard". The initial SN visit dated 2/24/21 documents the Patient is monitoring the blood glucose daily. The SN note dated 2/26/21 documents the Patient is monitoring the blood glucose two (2) times a day. The SN note dated 3/1/21 documents blood glucose readings are 191, 305 and 413; the Patient complained of being dizzy and throat was dry; physician called regarding the nursing assessment and the Patient's concerns. The record lacks documented evidence of follow up with the physician regarding the issues. The record documents the Patient was admitted to the hospital on 3/3/21 for cardiac issues. The SN note dated 3/1/21 documents there was no Iodine in the home and the Patient refused to have to dressing changed. The SN notes between 3/22/21 through 4/7/21 documents the wound to the heel is necrotic. The SN notes document the following: 3/17/21 - documents the Patient is monitoring the blood glucose three (3) times a day and the Patient would not give the RN the blood glucose readings. The SN note dated 3/24/21 documents the Patient is complaining of being dizzy, is monitoring the blood glucose four (4) times a day and the readings are 190, 212, 240. The SN note dated 3/29/21 documents the Patient is monitoring the blood glucose five (5) times a day and the readings are 179 and 250. 4/5/21 blood glucose readings are 150 to 380.4/7/21 blood glucose 180 to 350. On 4/9/21, the SN note documents the Patient was transferred to the hospital for possible DVT( Deep Vein Thrombosis). The resumption of care "Home Health Certification and Plan of Care" dated 4/19/21 documents: SN for assessment and evaluation; notify physician for weight less than 232 or greater than 237; Levimir 16 units daily; Humalog Insulin sliding scale 0-199 = o units, 200 - 250= 2 units, 251 - 300 = 4 units, 301 - 350 = 6 units, 351 -400 = 8 units; wound care to the heel two times a week; the Patient's weight is to be assessed (as per the parameters); clinical summary documentis Patient has a chronic non-stageable pressure ulcer of left lateral heel (covered with black eschar) wound. There is no documented evidence of communication with the physician regarding the status of the wound, whether Patient is on fluid restrictions, and if so, the amount, frequencies the Patient is monitoring blood glucose, non-compliance with diabetic diet and the Patient's high nutritional risk for possible revision to the Plan of Care. 5. Patient #15 has a start of care date of 2/15/21 with diagnoses of Lower Extremity Ulcer, Osteoarthritis to the Knees, Hypertension and Atrial Fibrillation as per the "Home Health Certification and Plan of Care" for the certification period of 2/15/21 to 4/16/21 and 4/16/21 to 6/14/21. The "Home Health Certification and Plans of Care" for the certification period of dated 2/15/21 4/16/21 and 4/16/21 6/14/21 documents:" Skilled Nurse ( SN) for assessment and evaluation and Acetaminophen (Tylenol) 500 mg every eight (8) hours as needed for pain." The SN visit dated 3/25/21 documents the Patient told the nurse that the physician told her not to take Tylenol and the physician was called. The record lacks documented evidence the nurse communicated with the physician regarding the Tylenol and for a possible alternative for pain medication. During an interview with the Director of Patient Services (DPS) on 4/21/21 at 1:00 PM, the DPS did not provide explanations for the above. Based on observation, clinical record reviews and interview, the agency failed to promptly notify the physician of changes in patients' status which may require alteration in Plans of Care. This was evident for five (5) of eighteen (18) clinical records reviewed. (Patients #1, #8, # 11, #12 and #15). Failure to notify the physician of the patient's status has the potential for patients to not receive interventions which may result in negative outcomes. The findings are: 1. Patient # 11 has a start of care date of 3/14/21 with diagnosis that include Atherosclerotic Heart disease Of Native Coronary Artery without Angina Pectoris, Ischemic Cardiomyopathy, Acute Respiratory failure with Hypoxia, Paroxysmal atrial Fibrillation, Unspecified Atrial Flutter as documented on the " Home Health Certification and Plan Of Care " for the certification period of 3/14/21 to 5/12/21. The " Home Health certification and Plan Of Care " for the certification period of 3/14/21 to 5/12/21 document: " Allopurinol 100 mg one tablet oral (PO) daily, Amiodarone 200 mg PO daily, Atorvastatin 20 mg tablet one tablet PO daily, Eliquis 2.5 mg one tablet PO twice a day, Furosemide 80 mg tablet one tablet daily PO, Metropolol Succinate ER 25 mg tablet extended release 24 one tablet PO daily, Potassium Cloride ER 10 meq capsule extended release oral PO daily, Preservision Areds-2 250mg-90 mg-40mg one capsule PO daily. The "Visit Note Report" dated 3/30/21 document: "Vital signs stable, lungs are clear BLL, Patient was instructed to double dose of furosemide from 40mg to 80 mg for three days , Friday, Saturday and Sunday. Patient is back on regular dose of 40 mg a day. Follow up with the Physician tomorrow, weights within normal limits, ankle and calf circumference within normal limits. There is no documented evidence of an interim/ verbal order for furosemide from 40 mg -80 mg for three days. On 4/23/21, the Director Of Patient Services was interviewed and did not provide an explanation for the above findings. 2. Patient #12 has a start of care of 2/24 21 with diagnosis that include Pressure Ulcer Stage 3, Pressure Ulcer Stage 2, Essential Hypertension, Dementia without Behavioral Disturbances Encounter for change or removal of Non Surgical Wound Dressing as documented on the "Home Health Certification and Plan Of Care" for the certification period of 2/24/21 to 4/24/21. The "Home Health Certification and Plan Of Care" document:" Frequency/ duration of visits SN ( Skilled Nurse) twice a week for two weeks, three times a week for seven weeks. Orders of discipline and treatments: Skilled Nurse to perform/ teach pressure ulcer care to left heel stage 3, cleanse with normal saline, apply Santyl, cover with 2 x 2, place mepilex to anterior ankle, wrap loosely with kling, using clean aseptic technique. Change dressing every Monday, Wednesday and Friday and as needed. Stage 2 pressure ulcer right foot medial, cleanse with normal saline Aquacel AG to wound bed, cover with Gelling fiber, wrap with kling. Change every 3-4 days. Skilled nurse for observation, assessment of pain, effectiveness of pain management regimen and skilled teaching related to pain management. Nurse to intervene to minimize complications if pain level increases. Medications: Atorvastin40 mg one tablet oral (PO) daily, Levothyroxine100mg tablet PO daily, Metropolol SuccinateER 50 mg tablet extended release 24 PO daily, Renal Caps 1 mg capsule PO daily, Centrum Silver Ultra men's 300 mcg-600 mcg -300 mcg one tablet PO daily, Santyl 250 unit/gram topical ointment, apply to left heel stage 2 ulcer Monday, Wednesday and Friday, Tamsulosin 0.4 mg capsule one capsule PO daily, Vitamin C 500 mg tablet one tablet PO daily". The "Oasis Admission" Start of Care document: "Neurologic Client Mental Status Alert, oriented to person forgetful, confused. Cognitive/ Behavioral: Totally dependent due to disturbances such as constant disorientation. memory deficit: failure to recognize persons, places". The " Client Episode Coordination Notes Report" document the following: 2/26/21 " Patient is having pain in left heel with cleaning, better after". 3/1/21 " Wound care performed to left heel and right dorsum, left heel sensitive to touch". 3/4/21 " Wound care provided to left heel and right medial foot patient is able to tolerate with minor grimacing during procedure. No complaint of pain after procedure. As per caregiver, patient is able to make needs and discomfort known". 3/8/21" Wound care performed, left heel dressing difficult to remove without soaking heel. F/U with Physician on 3/9. Patient tolerated well. Because of soaking refused Tylenol". 4/14/21 " Patient states his pain is worse when standing to use commode or get into bed , but relieved once sitting". 4/16/21 " Wound care provided per order. patient screams upon touch of left heel relieved when wound care complete. Physician office notified. Daughter aware and advise she will contact primary care provider regarding pain medication or topical medication to use with dressing change". 4/19/21 " Patient unable to verbalize pain level, but does yells and pulls away during wound care. Once complete and repositioned pain appears comfortable. Daughter and MD aware. Will discuss in Case Management (CM )meeting and follow". 4/21/21 " Patient appears comfortable at rest, but yells and resist when changed and wound care provided. Physician made aware of decline and wound assessment". A review of the " Vital signs report" from 2/24/21 to 4/21/21 document: pain rating of 1 on 3/4/21 and 2 on 4/14/21. There is no documented evidence of pain rating from 2/24/21 to 4/21/21 besides the pain rating mentioned above. There is no documented evidence of an order of analgesic for pain management. There is no documented evidence of communication with a physician. On 3/24/21 at 1:30PM, the Director Of patient Services was interviewed and did not provide an explanation for the above findings.

In accordance with current clinical practice CFR(s): 484.105(f)(2) All HHA services must be provided in accordance with current clinical practice guidelines and accepted professional standards of practice. This ELEMENT is not met as evidenced by: Based on review of clinical records, agency policy and interviews with agency staff, the agency failed to ensure the developed policy meets current and acceptable professionals standards of practice, with regards to Pain Assessments for all patients This was evident for one (1) of two (2) patients diagnosed with cognition impairments. (Patient #3) Failure to ensure the developed policy meets current and acceptable professionals standards of practice, with regards to Pain Assessments for all patients, has the potential for negative patient outcomes. The finding is: The agency's policy titled "Pain Assessment and Reassessment" has a revision date of January 2020 and documents: "each patient receiving skilled nursing services will have pain assessed initially and on an ongoing basis using established criteria that are consistent with the patient's age, condition and ability to understand, which may include: location, intensity (using pain rating scale), duration, frequency, character, e.g. dull, throbbing, aching, sharp, etc, current pain therapy and treatment, effectiveness of current therapy, how the pain affects the patient's function; each patient receiving therapy services will have pain assessed and reassessed... and will use the same established criteria for assessing/reassessing pain." The National Center for Biotechnology Information- Patient Safety and Quality: An Evidence-Based Handbook for Nurses- Chapter 17- Improving the Quality of Care Through Pain Assessment and Management April 2008 documents: "Because choice of intervention, including type of analgesic and dosing, is made based upon intensity, every pain assessment should include this type of measure. Numerous pain intensity measures have been developed and validated. Several tools provide a numeric rating of pain intensity (e.g., visual analogue scale, numeric rating scale (NRS)). Simpler tools such as the verbal rating scale, which classifies pain as mild, moderate or severe, also are commonly used. For patients with limited cognitive ability, scales with drawings or pictures are available (e.g., the Wong-Baker FACES scale). Patients with advanced dementia require behavioral observation to determine the presence of pain; tools such as the PAIN-AD are available for this patient population". The agency's pain policy does not document what is to be done should the patient not have the "ability to understand" when completing the pain assessment. The policy lacks pain scales developed for patients with impaired cognition and and not able to provide verbal descriptions of the pain. Patient #3 has a start of care date of 7/22/20 and a discharge date of 8/21/20 with diagnoses of Breast Cancer, Alzheimer's Disease, Dementia, Hypertension Congestive Heart Failure and Atrial Fibrillation as per the Home Health Certification and Plan of Care dated 7/22/20. The Home Health Certification and Plan of Care (POC) dated 7/22/20 documents: Skilled Nurse (SN) visits for assessment and evaluation; Physical Therapy (PT) one time a week for one week then two times a week for five weeks; Advil 200 mg two (2) tablets every 12 hours as needed for pain; Oxycodone - Acetaminophen 5 mg/325 mg every six (6) hours as needed pain 3 - 10/10, metal status is forgetful and disoriented. The initial SN note dated 7/22/20 documents the Patient is confused; the upper arm is documented as having a worst pain of a 5 on a scale of 0 to 10, and the Patient is taking Advil. The SN note dated 7/23/20 documents the arm pain is a 2. The SN note dated 8/4/20 documents pain to the spine and upper arm and the pain is rated a 4. The SN notes do not document the manner in which the pain ratings were obtained due to the Patient's diagnosis of Dementia and observation of confusion. The PT notes document the following: 7/23/20 - unable to rate pain due to Dementia; 7/29/20 - pain is a 3, Patient is guarding and rocking back and forth; 8/5/20 - pain of a 5 Patient is grimacing; 8/14/20 - pain is a 3 and Patient is grimacing, sad, guarded, rocking back and forth and is withdrawn; 8/19/20 - unable to rate pain using scale of 0 to 10. During a interview with the Director of Patient Services (DPS) on 4/23/21 at 1:00 PM, the DPS did not provide an explanation for the above.