Every finding on record at Healthview Home Health & Hospice

An unannounced on-site recertification survey was conducted 03/30/26-04/01/26. No deficiencies to the Medicare Conditions of Participation for Emergency Preparedness were identified.

An unannounced on-site recertification survey was conducted 03/30/26-04/01/26. Standard level deficiencies to the Medicare Conditions of Participation were identified.

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 agency policy, clinical record review, and staff interviews, the agency failed to complete the initial comprehensive physical therapy assessment within 5 days of the admission for 1 of 4 discharged patients (#2). Findings included: Patient #2 was admitted on 11/06/25 with a diagnosis of stage 5 kidney disease. The plan of care for 11/06/25-1/4/26 included orders for skilled nurse visits 1 time a week for 1 week, 1 time a week for 8 weeks with 3 PRN (as needed), and physical therapy (PT) to evaluate and treat. Review of the clinical record revealed that the PT evaluation was not conducted until 12/1/25. An interview conducted on 3/30/26 at 11:20 AM with the administrator revealed that the initial PT comprehensive assessment physician should have been completed within 5 days of admission or a new order for a delayed assessment should have been obtained from the physician.

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 agency policy, clinical record review, and staff interviews, the agency failed to include bleeding precautions in the plan of care for 5 of 11 patients with orders for anti-platelet and/or anticoagulant medications (used to prevent blood clots) (patient #’s 5, 6, 10, 11, & 13). Findings included: A policy, Plan of Care- CMS# 485 and Physician Orders (revised 3/2018) received on 3/31/26 at 9:33 AM from the Executive Director stated, “The individualized plan of care must include the following: … Safety measures to protect against injury…” 1. Patient #5 was admitted on 2/21/26 with diagnoses of encounter for attention to colostomy and acute embolism (blood clot that travels) and thrombosis (blood clots in veins) of deep veins. The plan of care (POC) for 2/21/26-4/21/26 included orders for skilled nurse visits 1 time a week for 1 week, 1 time a week for 4 weeks, and 2 PRN (as needed), and “Apixaban [oral blood thinner to prevent clots] 5mg take 1 tablet by mouth twice daily for blood clots.” A review of the clinical record revealed that there were no bleeding precautions included in the POC. 2. Patient #6 was admitted on 2/4/26 with diagnoses of encounter for attn (attention) to oth (other) artif (artificial) openings (opening in abdominal wall for urine drainage) and long term (current) use of aspirin (antiplatelet to prevent blood clots). The plan of care for (POC) 2/4/26-4/4/26 included orders for skilled nurse visits 1 time a week for 1 week, 1 time a week for 8 weeks, with 3 PRN (as needed) and, “Aspirin EC (enteric coated) 81 mg every day by mouth HTN [high blood pressure].” A review of the clinical record revealed that there were no bleeding precautions included in the POC. 3. Patient #10 was admitted on 6/5/25 with diagnoses of pressure ulcer of sacral region, stage 4 (full thickness wound at base of spine) and long term (current) use of aspirin (antiplatelet to prevent blood clots). The plan of care for (POC) for 1/31/26-3/31/26 included orders for skilled nurse visits 1 time a week for 8 weeks and “Aspirin (anti-platelet) 81mg take 1 tablet by mouth daily for heart health.” A review of the clinical record revealed that there were no bleeding precautions included in the POC. 4. Patient #11 was admitted on 2/7/26 with diagnoses of encounter for change or removal of surgical dressing and long term (current) use of aspirin (antiplatelet to prevent blood clots). The plan of care (POC) for 2/7/26-4/7/26 included orders for skilled nurse visits 1 time a week for 1 week, 1 time a week for 5 weeks, 3 PRN (as needed), and “Aspirin Adult Low Strength 81mg take 1 tablet by mouth daily for heart health.” A review of the clinical record revealed that there were no bleeding precautions included in the POC. 5. Patient #13 was admitted on 2/21/26 with diagnoses of other sequelae of cerebral infarction (long term neurological or physical deficits after a blockage of blood flow to the brain), long term (current) use of aspirin (antiplatelet to prevent blood clots), and long term (current) use of antithrombotic (medications to prevent blood clots). The plan of care (POC) for 2/21/26-4/21/26 included orders for skilled nurse visits 1 time a week for 1 week, 1 time a week for 8 weeks, 3 PRN (as needed), “Aspirin 81 mg oral tb [tablet] take 1 tab daily-blood thinner,” and “Clopidogrel [anti-platelet] 75 mg TAB. 1 TAB daily for HDL [high cholesterol].” A review of the clinical record revealed that there were no bleeding precautions included in the POC. An interview conducted on 4/1/26 at 8:59 AM with the Executive Director revealed that patients #6, 10, 11, and 13 should have had bleeding precautions documented under safety precautions. The Executive Director stated, “She’s [patient #5] a cash patient that specifically asked for ostomy education.” The interview revealed that the agency does not normally add precautions or additional care plans for privately paid patients.

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 agency policy, clinical record review, and staff interviews, the agency failed to include an order for wound care for an insertion site for a suprapubic catheter (device inserted through an abdominal incision into the bladder to drain urine) for 1 of 1 patient with a suprapubic catheter, (patient # 6). Findings included: Findings included: A policy, Plan of Care-CMS #485 and Physician Orders (revised 3/18) received on 3/31/26 at 9:33 AM from the Executive Director stated, “The individualized plan of care must include the following: … All medications and treatments… All patient care orders…” Patient #6 was admitted on 2/4/26 with diagnoses of encounter for attn (attention) to oth (other) artif (artificial) openings (opening in abdominal wall for urine drainage). The plan of care for 2/4/26-4/4/26 included orders for skilled nurse visits 1 time a week for 1 week, 1 time a week for 8 weeks, with 3 PRN (as needed). A review of the clinical record revealed that on 2/4/26 registered nurse (RN) #11 documented, “Red around insertion site, has not been cleaned since surgery, tubing dry and crusty, cleansed with alcohol wipes…” Further review revealed that there was no physician’s order for insertion site care. During an interview conducted on 4/1/26 at 9:30 AM RN #11 stated, “I do not see that [an order to cleanse with alcohol.” During an interview conducted on 4/1/26 at 9:50 AM the Executive Director stated, “They [nurses] should have an order.”

Preparing clinical notes CFR(s): 484.75(b)(6) Preparing clinical notes; This ELEMENT is not met as evidenced by: Based on agency policy, clinical record review, and staff interviews, the agency inaccurately documented pressure injury stages (classification based on tissue damage) for 1 of 4 patients with pressure injuries, (patient #10). Findings included: A policy, Assessment/Staging of Pressure Ulcers (not dated) received on 04/01/26 at 10:02 AM from the agency administrator stated, “Stage 2: Partial thickness loss of dermis [middle layer of skin] presenting as a shallow ulcer with red pink wound bed without slough… Stage 3 : Full thickness skin loss… May include undermining [destruction of tissue under the edges of a wound] or tunneling [destruction of the facia (connective tissue) in any direction, creating passages, appearing in stage 3 or greater wounds.] … Pressure ulcers heal to a progressively shallower depth; they do not replace lost muscle, subcutaneous fat or dermis… Reverse staging does not accurately characterize what is physically occurring…” Patient #10 was admitted on 06/05/2025 with a diagnosis of pressure ulcer of sacral region (area at the base of the spine), stage 4 (full thickness loss-with exposed bone). The plan of care for 01/31/2026 included orders for skilled nurse (SN) visits 1 time a week for 8 weeks with 4 PRN (as needed) and “SN to clean sacrum with soap and water. Pat Dry, apply [name brand wound cleanser] damp gauze into undermining [erosion of wound] of wound bed, place [name brand dressing] into wound bed, cover with border foam dressing…” Review of the clinical record revealed the following documentation: On 2/5/26 licensed practical nurse (LPN) #10 documented, “Stage 2, Sacrum 4.5cm x 5.1 cm x 1 cm with 3cm tunneling. On 2/10/26 register nurse (RN) #7 documented, “Stage 2, 4.5cm x 4.3 cm x 1.3 cm undermining 3.3 cm…” On 2/26/26 RN #7 documented, “Stage 2, with tunneling.” LPN #10 was not available for an interview. RN #7 was not available for an interview. An interview conducted on 3/31/26 at 8:53 AM with the Executive Director revealed that undermining and/or tunneling cannot be present in a Stage 2 wound and if initially staged as stage 4 the wound should always be documented as stage 4.

Communication with physicians CFR(s): 484.75(b)(7) Communication with all physicians involved in the plan of care and other health care practitioners (as appropriate) related to the current plan of care; This ELEMENT is not met as evidenced by: Based on agency policy, clinical, record review, and staff interview, the agency failed to notify the physician of a delay in a physical therapy evaluation for 1 of 9 (#2) patient with an order for physical therapy; and failed to provide an update to the physician for 1 of 1 patient with a request to contact the physician (#2); and failed to notify the physician of missed skilled nurse visits for 1 of 2 patients with missed skilled nurse visits (#6); and failed to notify the physician of a possible wound infection for 1 of 1 patient with symptoms of an infected wound (#7); and failed to document that a physician was notified of a patient fall for 1 of 2 patients with documented falls (#15). Findings included: A policy, Coordination of Patient Care (revised 03/2018) received on 3/31/26 at 9:33AM from the Executive Director stated, “The agency must: Assure communication with all physicians involved in the plan of care.” A policy Plan of Care-CMS #485 and Physician Orders (revised 03/2018) received on 3/31/26 at 9:33 AM from the Executive Director stared, “The agency alerts the physician to any changes that suggest a need to alter the plan of care. If the agency provides fewer visits than the physician’s orders, it has altered the plan of care, and the physician must be notified…” 1. Patient #2 was admitted on 11/06/25 with a diagnosis of stage 5 kidney disease. The plan of care for 11/06/25-1/4/26 included orders for skilled nurse visits 1 time a week for 1 week, 1 time a week for 8 weeks with 3 PRN (as needed), and physical therapy (PT) to evaluate and treat. Review of the clinical record revealed that the PT evaluation was not conducted until 12/1/25. Further review revealed that there was no documentation of the physician being notified of the delay. An interview conducted on 3/30/26 at 11:20 AM with the administrator revealed that the physician should have been notified if the evaluation could not be completed within 5 days of the admission and documented. Review of the clinical record revealed that during the registered nurse (RN) visit from 12/01/25 RN #7 documented, “pt [patient] has mucus in foley cath [indwelling urinary catheter] line tubing at this visit, per dtr [daughter] UTLOGIST wants a report this afternoon on pt status.” Further review revealed that there was no documentation of the urologist being given a report. RN #7 was not available for an interview. An interview conducted with the agency administrator of 4/1/26 at approximately 9:15 AM revealed that the nurse should have contacted the physician and documented the conversation. 2. Patient #6 was admitted on 2/21/26 with a diagnosis of encounter for attention to colostomy (artificial opening in the abdomen to divert stool into an external pouch). The plan of care for 2/21/26-4/21/26 included orders for skilled nurse (SN) visits 1 time a week for 1 week, 1 time a week for 4 weeks with 2 PRN (as needed) and “SN may perform colostomy appliance change and stoma care at each visit.” Review of the clinical record revealed that the SN visits of 2/28/26, 3/5/26, 3/12/26 and 3/19/26 were documented as missed visits. Further review revealed that there was no documentation that the physician was notified. An interview conducted on 4/1/26 at approximately 9:00AM with the administrator revealed that the physician should have been notified after each missed visit. 3. Patient #7 was admitted on 11/10/2025 with a diagnosis of stage 3 pressure injury of the sacrum (wound with full thickness skin loss at the base of the spine). The plan of care for 03/10/26-5/8/26 included orders for skilled nurse visits 1 time a week for 9 weeks with 3 PRN (as needed) and “Wound care orders to sacrum. Remove old dressing, clean wound with normal saline or wound cleanser, pat dry, apply moisturizer to intact skin, apply calcium alginate [absorbent dressing] into wound bed. Cover with border foam dressing or ABD [absorbent pad] and tape. Dressing to be changed daily…” Review of the clinical record revealed that on 3/11/26 RN #9 documented, “Drainage: Small<25% of DRSG [sic] is Purulent [thick, cloudy, pus-like fluid indication an infected wound].” Further review revealed that there was no documentation of the physician being notified. During an interview conducted on 4/1/26 at 9:14AM RN #9 stated, “No, I did not [call the physician] but I will.” During an interview conducted on 4/1/26 at 9:16 AM the administrator stated, “She [RN} should have call that day.” 4. Patient #15 was admitted on 3/4/26 with a diagnosis of hypertensive heart disease 9high blood pressure) with heart failure (reduced ability to pump blood). The plan of care for 3/4/26-5/2/26 included order for occupational therapy (OT) visits 1 time to evaluate and treat and 1 time a week for 8 weeks. Review of the clinical record revealed that during the OT visit on 3/19/26 OT #6 documented that the patient had a fall. Further review revealed that there was no documentation of the physician being notified. During an interview conducted on 4/1/26 at approximately 10:30 AM OT #6 stated that the physician was notified and confirmed that the notification was not documented. An interview conducted on 4/1/26 at approximately 10:35 AM with the administrator revealed that all communication with the physicians should be documented.

An unannounced, on-site recertification survey was conducted 4/10/23-4/12/23. Standard level deficiencies were identified to the Emergency Preparedness Plan.

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 policy review, personnel record reviews and staff interview, the agency failed to provide emergency preparedness training upon hire and at least every two years for 2 of 3 personnel files reviewed (RN #1 and Physical therapy assistant #6). Findings included: A policy, “Employee Orientation’ (reviewed/revised 3/2018) was provided by the agency director on 4/12/23 at 10:37 a.m. The policy stated, “Orientation for each employee will minimally include…Emergency Plan…” A policy, “Inservice Education” (reviewed/revised 3/2018), was provided by the agency director on 4/12/23 at 4:16 p.m. The policy stated, “Certain inservice programs are determined to by the agency to be mandatory initially and annually for all staff…Emergency Operations Plan.” 1. RN #1 had a hire date of 11/7/22. There was no evidence of emergency preparedness training upon hire. An interview with human resources on 4/12/23 at 11:24 a.m. there was no evidence of emergency preparedness training. 2. Physical therapy assistant #6 had a hire date of 2/14/22. There was no evidence of emergency preparedness training upon hire. An interview with human resources on 4/12/23 at 11:24 a.m. there was no evidence of emergency preparedness training.

EP Testing Requirements CFR(s): 484.102(d)(2) §416.54(d)(2), §418.113(d)(2), §441.184(d)(2), §460.84(d)(2), §482.15(d)(2), §483.73(d)(2), §483.475(d)(2), §484.102(d)(2), §485.68(d)(2), §485.542(d)(2), §485.625(d)(2), §485.727(d)(2), §485.920(d)(2), §491.12(d)(2), §494.62(d)(2). *[For ASCs at §416.54, CORFs at §485.68, REHs at §485.542, OPO, "Organizations" under §485.727, CMHCs at §485.920, RHCs/FQHCs at §491.12, and ESRD Facilities at §494.62]: (2) Testing. The [facility] must conduct exercises to test the emergency plan annually. The [facility] must do all of the following: (i) Participate in a full-scale exercise that is community-based every 2 years; or (A) When a community-based exercise is not accessible, conduct a facility-based functional exercise every 2 years; or (B) If the [facility] experiences an actual natural or man-made emergency that requires activation of the emergency plan, the [facility] is exempt from engaging in its next required community-based or individual, facility-based functional exercise following the onset of the actual event. (ii) Conduct an additional exercise at least every 2 years, opposite the year the full-scale or functional exercise under paragraph (d)(2)(i) of this section is conducted, that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or individual, facility-based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the [facility's] response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the [facility's] emergency plan, as needed. *[For Hospices at 418.113(d):] (2) Testing for hospices that provide care in the patient's home. The hospice must conduct exercises to test the emergency plan at least annually. The hospice must do the following: (i) Participate in a full-scale exercise that is community based every 2 years; or (A) When a community based exercise is not accessible, conduct an individual facility based functional exercise every 2 years; or (B) If the hospice experiences a natural or man-made emergency that requires activation of the emergency plan, the hospital is exempt from engaging in its next required full scale community-based exercise or individual facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional exercise every 2 years, opposite the year the full-scale or functional exercise under paragraph (d)(2)(i) of this section is conducted, that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or a facility based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (3) Testing for hospices that provide inpatient care directly. The hospice must conduct exercises to test the emergency plan twice per year. The hospice must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual facility-based functional exercise; or (B) If the hospice experiences a natural or man-made emergency that requires activation of the emergency plan, the hospice is exempt from engaging in its next required full-scale community based or facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional annual exercise that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or a facility based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop led by a facilitator that includes a group discussion using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the hospice's response to and maintain documentation of all drills, tabletop exercises, and emergency events and revise the hospice's emergency plan, as needed. *[For PRFTs at §441.184(d), Hospitals at §482.15(d), CAHs at §485.625(d):] (2) Testing. The [PRTF, Hospital, CAH] must conduct exercises to test the emergency plan twice per year. The [PRTF, Hospital, CAH] must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise; or (B) If the [PRTF, Hospital, CAH] experiences an actual natural or man-made emergency that requires activation of the emergency plan, the [facility] is exempt from engaging in its next required full-scale community based or individual, facility-based functional exercise following the onset of the emergency event. (ii) Conduct an [additional] annual exercise or and that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or individual, a facility-based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the [facility's] response to and maintain documentation of all drills, tabletop exercises, and emergency events and revise the [facility's] emergency plan, as needed. *[For PACE at §460.84(d):] (2) Testing. The PACE organization must conduct exercises to test the emergency plan at least annually. The PACE organization must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise; or (B) If the PACE experiences an actual natural or man-made emergency that requires activation of the emergency plan, the PACE is exempt from engaging in its next required full-scale community based or individual, facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional exercise every 2 years opposite the year the full-scale or functional exercise under paragraph (d)(2)(i) of this section is conducted that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or individual, a facility based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the PACE's response to and maintain documentation of all drills, tabletop exercises, and emergency events and revise the PACE's emergency plan, as needed. *[For LTC Facilities at §483.73(d):] (2) The [LTC facility] must conduct exercises to test the emergency plan at least twice per year, including unannounced staff drills using the emergency procedures. The [LTC facility, ICF/IID] must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise. (B) If the [LTC facility] facility experiences an actual natural or man-made emergency that requires activation of the emergency plan, the LTC facility is exempt from engaging its next required a full-scale community-based or individual, facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional annual exercise that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or an individual, facility based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the [LTC facility] facility's response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the [LTC facility] facility's emergency plan, as needed. *[For ICF/IIDs at §483.475(d)]: (2) Testing. The ICF/IID must conduct exercises to test the emergency plan at least twice per year. The ICF/IID must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise; or. (B) If the ICF/IID experiences an actual natural or man-made emergency that requires activation of the emergency plan, the ICF/IID is exempt from engaging in its next required full-scale community-based or individual, facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional annual exercise that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or an individual, facility-based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the ICF/IID's response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the ICF/IID's emergency plan, as needed. *[For HHAs at §484.102] (d)(2) Testing. The HHA must conduct exercises to test the emergency plan at least annually. The HHA must do the following: (i) Participate in a full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise every 2 years; or. (B) If the HHA experiences an actual natural or man-made emergency that requires activation of the emergency plan, the HHA is exempt from engaging in its next required full-scale community-based or individual, facility based functional exercise following the onset of the emergency event. (ii) Conduct an additional exercise every 2 years, opposite the year the full-scale or functional exercise under paragraph (d)(2)(i) of this section is conducted, that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or an individual, facility-based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the HHA's response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the HHA's emergency plan, as needed. *[For OPOs at §486.360] (d)(2) Testing. The OPO must conduct exercises to test the emergency plan. The OPO must do the following: (i) Conduct a paper-based, tabletop exercise or workshop at least annually. A tabletop exercise is led by a facilitator and includes a group discussion, using a narrated, clinically relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. If the OPO experiences an actual natural or man-made emergency that requires activation of the emergency plan, the OPO is exempt from engaging in its next required testing exercise following the onset of the emergency event. (ii) Analyze the OPO's response to and maintain documentation of all tabletop exercises, and emergency events, and revise the [RNHCI's and OPO's] emergency plan, as needed. *[ RNCHIs at §403.748]: (d)(2) Testing. The RNHCI must conduct exercises to test the emergency plan. The RNHCI must do the following: (i) Conduct a paper-based, tabletop exercise at least annually. A tabletop exercise is a group discussion led by a facilitator, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (ii) Analyze the RNHCI's response to and maintain documentation of all tabletop exercises, and emergency events, and revise the RNHCI's emergency plan, as needed. This STANDARD is not met as evidenced by: Based on agency policy, agency emails and staff interviews the agency failed to analyze the effectiveness of the emergency plan placed into effect related to a weather emergency event . The findings included: The policy, Emergency Preparedness Program and Plan, was provided by the office manager on 4/12/23 at approximately 4:30 pm. The policy stated, "______ [name of agency] will periodically train and exercise its emergency preparedness response to test and ensure that the agency that effective planning and response to emergencies [sic] are established and appropriate for the agency...Documentation of each exercise/drill will be maintained which will normally include...An after-action report..." A series of agency wide emails dated 9/25/22-9/29/22 related to preparation for Tropical Storm Ian were provided by the agency director on 4/12/23. The director was unable to provide any type of documentation related to the effectiveness of the emergency plan which was outlined in the agency wide emails.

An onsite recertification survey was conducted 4/10/23-4/12/23. Standard level deficiencies to the Medicare CoP were identified.

Accuracy of encoded OASIS data CFR(s): 484.45(b) Standard: The encoded OASIS data must accurately reflect the patient's status at the time of assessment. This STANDARD is not met as evidenced by: Based on policy review, clinical record review, and staff interview, the agency failed to accurately assess patients’ status on the OASIS (Outcome and Assessment Information Set—standardized assessment) for 4 of 13 active patients (#1, 3, 10, 4). Findings included: 4. Patient # 4 had a Start of Care [SOC] date of 3/13/23 and admitting diagnoses of infection/inflammatory reaction due reaction due to cardiac and vascular devices, type 1 diabetes mellitus with hyperglycemia [high blood sugar] and type 1 diabetes mellitus with diabetic chronic kidney disease [diabetes damages small vessels throughout the body, affecting the kidneys]. Review of the Plan of Care [POC] for the certification period 3/13/23 to 5/11/23 revealed the patient was ordered Tradjenta [used to treat diabetes] 5 mg daily. Review of the OASIS [The Outcome and Assessment Information Set-comprehensive assessment completed at SOC], completed on 3/30/23, revealed question NO415 was answered “No-patient is not on hypoglycemic medication”. During an interview with the agency director on 3/12/23 at approximately 2:30 pm, the director confirmed the OASIS question was answered incorrectly. A policy, “Initial Assessment/Comprehensive Assessments” (reviewed/revised 3/2018), was provided by the office manager on 4/11/23 at 12:26 p.m. The policy stated, “The initial comprehensive assessment will also incorporate the current version of the Outcome and Assessment Information Set (OASIS) items…The OASIS date items…must include…Medications.” 1. Patient #1 was admitted on 3/16/23 with diagnoses of cirrhosis of the liver and type 2 diabetes. The initial assessment was conducted by PT #3 on 3/16/23. The patient was not identified as taking hypoglycemic medications (medication to lower blood sugar) in the OASIS (Outcome and Assessment Information Set—standardized assessment). The Plan of Care for 3/16/23-5/14/23 included Metformin 850 mg daily (used to treat diabetes) and Semaglutide 7 mg daily (used to treat diabetes). An interview with the administrator on 4/12/23 at 2:32 p.m. confirmed the patient was prescribed anti-diabetic medications. 2. Patient #3 was admitted on 3/20/23 with diagnoses of psoas muscle (muscle that connects vertebrae to femur) abscess, right above the knee amputation, paraplegia (paralysis of lower part of body), type 2 diabetes, and embolism and thrombosis (blood clot) of iliac artery (artery that blood to the legs and pelvic region). The initial assessment was conducted by RN #1 on 3/20/23. The patient was not identified as taking anticoagulant medications (medication that decreases clotting time) in the OASIS (Outcome and Assessment Information Set—standardized assessment). The Plan of Care (POC) for 3/20/23-5/18/23 included Apixaban (anticoagulant) 5 mg twice daily. 3. Patient #10 was admitted on 3/14/23 with diagnoses of incomplete quadriplegia (weakness but not total paralysis in arms and legs) and type 2 diabetes. The initial assessment was conducted by PT #10 on 3/14/23. The patient was not identified as taking an opioid medication (a type of pain medication) in the OASIS (Outcome and Assessment Information Set—standardized assessment). The Plan of Care (POC) for 3/14/23-5/12/23 included Hydrocodone 5 mg/325 mg three times daily as needed for pain.

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 staff interviews, the agency failed to conduct the initial assessment within 48 hours of referral or on the physician ordered start of care date for 10 of 18 patients (#3, 5, 10, 11, 12, 2, 6, 8, 14 and 15). Findings included: 6. Patient # 2 had a Start of Care [SOC] date of 3/27/23 and admitting diagnoses of hemiplegia [paralysis of one side of the body] following cerebral infarction [stroke], acute kidney failure [kidneys lose the ability to remove waste and balance fluids] and type 2 diabetes mellitus with chronic kidney disease. Review of the agency referral indicated a referral for physical therapy [PT] with a date of 3/22/23, with a planned SOC date of 3/24/23. Review of the clinical record revealed PT did not initiate the SOC until 3/27/23. An interview was conducted with the agency director on 4/12/23 at approximately 2:30 pm During the interview, the director confirmed the SOC was not initiated within the required timeframe. 7. Patient # 6 had a Start of Care [SOC] date of 3/30/23 and admitting diagnoses of pressure ulcer of sacral region [triangular bone at the base of the spine], stage 2 [intact blister or shallow ulcer] and type 2 diabetes with diabetic peripheral angiopathy [narrowing of the arteries]. Review of the referral information revealed the SOC referral date was 3/27/23, the planned SOC date was 3/29/23. The SOC was not completed until 3/30/23. Review of the clinical record revealed no order from the physician for an admission outside the 48-hour requirement. During an interview with the agency director on 4/12/23 at 3 pm, the director confirmed the SOC was not completed within the required time frame. 8. Patient # 8 had a Start of Care [SOC] date of 3/2/23 and an admitting diagnosis of hemorrhage due to vascular prosthesis device/graft [implanted device intended to repair or replace sections of native or artificial vessels]. Review of the referral information revealed a referral SOC date of 2/28/23, Planned SOC date 3/2/23 [outside the required timeframe]. There was no physician’s order for the admission to be completed outside the 48-hour requirement. During an interview with the agency director on 4/12/23 at 2:30 pm, the director confirmed the SOC was noted completed within the required timeframe. 9. Patient # 14 had a Start of Care [SOC] date of 11/2/22 and an admitting diagnosis of atrial fibrillation [an abnormal heart rhythm]. Review of the referral information revealed the SOC referral date 10/27/22, the planned SOC date was 10/29/22. The SOC was not completed until 11/1/22. Review of the clinical record revealed no physician’s order for admission outside the required 48 hours. During an interview with the agency director on 4/12/23 at approximately 2:30 pm, the director confirmed the SOC was not completed within the required timeframe. 10. Patient # 15 had a Start of Care [SOC] date of 2/1/22 with an admitting diagnosis of sepsis [infection of the blood stream]. Review of the referral information received revealed the referral date was 1/24/22 with a planned SOC date of 1/24/22. Further review of the referral information revealed the patient was to receive SN [skilled nursing], PT [physical therapy] and OT [occupational therapy]. Review of the clinical record revealed the SOC assessment was not initiated until 2/1/22. There was no evidence of a physician’s order to admit outside the required 48 hours after the referral. During an interview with the agency director on 4/12/23 at approximately 3:30 pm, the director confirmed the admission was not initiated within the 48-hour timeframe. A policy, “Initial Assessment/Comprehensive Assessments” (reviewed/revised 3/2018), was provided by the office manager on 4/11/23 at 12:26 p.m. The policy stated, “A RN, PT or SLP [registered nurse, physical therapist, or speech language pathologist] must conduct the initial assessment visit within 48 hours of referral, within 48 hours of the patient’s return home or on the physical ordered start of care date…In the absence of a physician-specified start of care date, the initial assessment visit is conducted within 48 hours of the referral…” 1. Patient #3 was admitted on 3/20/23 with diagnoses of psoas muscle (muscle that connects vertebrae to femur) abscess, right above the knee amputation, paraplegia (paralysis of lower part of body), type 2 diabetes, and embolism and thrombosis (blood clot) of iliac artery (artery that blood to the legs and pelvic region). The referral on 3/17/23 requested skilled nursing for wound care. There was no evidence of a physician ordered start of care date outside of the 48-hour time frame. An interview with the agency director on 4/12/23 at 2:40 p.m. revealed there was no documentation of why the initial assessment was not completed within 48 hours. 2. Patient #5 was admitted on 3/13/23 with diagnoses of gastrointestinal hemorrhage, Fournier gangrene (a form of necrotizing fasciitis or gangrene affecting the external genitalia or perineum), and malignant neoplasm of the rectum. The referral on 3/8/23 requested skilled nursing for wound care, physical therapy evaluation, and occupational therapy evaluation. There was no evidence of a physician ordered start of care date outside of the 48-hour time frame. An interview with the agency director on 4/12/23 at 2:50 p.m. revealed there was no documentation of why the initial assessment was not completed within 48 hours. 3. Patient #10 was admitted on 3/14/23 with diagnoses of incomplete quadriplegia (weakness but not total paralysis in arms and legs) and type 2 diabetes. The referral on 3/7/23 requested physical therapy. There was no evidence of a physician ordered start of care date outside of the 48-hour time frame. An interview with the agency director on 4/12/23 at 2:59 p.m. revealed there was no documentation of why the initial assessment was not completed within 48 hours. 4. Patient #11 was admitted on 4/1/23 with diagnoses of melena (blood in the stool), acute gastrointestinal ulcer without hemorrhage, and type 2 diabetes. The referral from 3/29/23 requested skill nursing, physical therapy (PT), and occupational therapy (OT). There was no evidence of a physician ordered start of care date outside of the 48-hour time frame. An interview with the agency director on 4/12/23 at 3:05 p.m. revealed there was no documentation of why the initial assessment was not completed within 48 hours. 5. Patient #12 was admitted to the agency on 3/1/23 with diagnoses of acute cystitis (inflammation or infection of the urinary bladder) without hematuria (blood in urine), type 2 diabetes, hepatic (liver) failure, and hypertensive heart disease with heart failure. The referral from 2/21/23 did not list ordered disciplines. There was no evidence of a physician ordered start of care date outside of the 48-hour time frame. An interview with the agency director on 4/12/23 at 3:12 p.m. revealed there was no documentation of why the initial assessment was not completed within 48 hours.

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 staff interview, the agency failed to conduct evaluations per the referral within five days for 8 of 12 patients with therapy ordered on the referral (#5, 9, 11, 12, 6, 8, 14, and 17). Findings included: 5. Patient # 6 had a Start of Care [SOC] date of 3/30/23 and admitting diagnoses of pressure ulcer of sacral region [triangular bone at the base of the spine], stage 2 [intact blister or shallow ulcer] and type 2 diabetes with diabetic peripheral angiopathy [narrowing of the arteries]. Review of the referral information dated 3/27/23 revealed the following information “PT [physical therapy] to access [sic], eval [evaluate], and treat x 1 per MD orders…OT [occupational therapy] to access [sic], eval, and treat x 1 per MD orders…” The PT evaluation was conducted on 4/4/23 [outside the 5-day window]. Further review of the clinical record revealed the OT evaluation had not been completed as of 4/12/23. During an interview with the director on 4/12/23 at approximately 2 pm, the director confirmed the PT evaluation was completed outside the required timeframe and the OT evaluation was not completed. 6. Patient # 8 had a Start of Care [SOC] date of 3/2/23 and an admitting diagnosis of hemorrhage due to vascular prosthesis device/graft [implanted device intended to repair or replace sections of native or artificial vessels]. Review of the referral information revealed a referral SOC date of 2/28/23, Planned SOC date 3/2/23 [outside the required timeframe]. The referral listed the following disciplines…” PT [physical therapy] to assess, evaluate and treat x 1 per MD orders. OT [occupational therapy] to assess, evaluate and treat x 1 per MD orders…” Review of the clinical record revealed the PT and OT evaluations were completed on 3/23/23. During an interview with the agency director on 4/12/23 at 2:30 pm, the director confirmed the PT/OT evaluations were not completed within the required time frame. 7. Patient # 14 had a Start of Care date of 11/2/22 and an admitting diagnosis of atrial fibrillation [an abnormal heart rhythm]. The Plan of Care dated 11/1/22-12/30/22 revealed “ambulation” was listed under Functional Limitation. Review of the hospital referral dated 10/27/22 revealed an order for PT [physical therapy] to evaluate and treat. Review of the clinical record revealed no PT evaluation was completed. The patient was discharged on 12/29/22 without a PT evaluation. During an interview with the agency director on 4/12/23 at approximately 3 pm, the director stated, “We should have done a PT evaluation, I don’t know how it was missed.” 8. Patient # 17 had a Start of Care of 11/17/22 and admitting diagnoses of cellulitis [infection of skin] of right lower limb, osteomyelitis [infection of bone] of lower leg and encounter for adjustment and management of vascular access device [device that allows repeated and long-term access to the blood stream for frequent or repeated administration of medications. Review of the Plan of Care for the certification period 11/17/22 to 1/15/22 included orders for “PT [physical therapy] to evaluate and OT [occupational therapy] 1 visit to eval [evaluate] and treat”. Review of the clinical record revealed the physical therapy evaluation was conducted on 11/23/22 [outside the required timeframe]. The OT evaluation was not completed before the patient was discharged. During an interview with the agency director on 4/12/23 at approximately 2:30 pm, the director confirmed the PT evaluation was conducted outside the required timeframe and the OT evaluation was not conducted. A policy, “Assessment and Reassessment Guidelines” (reviewed/revised 3/2018), was provided by the office manager on 4/11/23 at 12:26 p.m. The policy stated, “…the Comprehensive Assessment…Must be completed in a timely manner consistent with the patient’s needs, but no later than five (5) days after the start of the care.” 1. Patient #5 was admitted on 3/13/23 with a diagnosis of gastrointestinal hemorrhage. The referral from 3/8/23 requested skilled nursing, physical therapy (PT), and occupation therapy (OT). There was no evidence OT attempted to conduct the evaluation visit until 3/22/23. There was no evidence of a PT evaluation until 3/23/23. An interview with the agency director on 4/12/23 at 2:50 p.m. confirmed the evaluation visits should have been conducted within five days of the initial assessment. The interview also revealed there was reason documented why the assessments were conducted later than five days. 2. Patient #9 was admitted on 3/8/23 with a diagnosis of hemiplegia (paralysis on one side of the body) following a cerebral infarction (stroke). The referral from 3/6/23 requested skilled nursing, physical therapy (PT), and medical social work. There was no evidence of a PT evaluation until 3/14/23. An interview with the agency director on 4/12/23 at 2:57 p.m. confirmed the evaluation visit should have been conducted within five days of the initial assessment. The interview also revealed there was reason documented why the assessments were conducted later than five days. 3. Patient #11 was admitted on 4/1/23 with diagnoses of melena (blood in the stool), acute gastrointestinal ulcer without hemorrhage, and type 2 diabetes. The referral from 3/29/23 requested skill nursing, physical therapy (PT), and occupational therapy (OT). There was evidence of an OT evaluation until 4/11/23. An interview with the agency director on 4/12/23 at 3:05 p.m. confirmed the evaluation visit should have been conducted within five days of the initial assessment. The interview also revealed there was reason documented why the assessments were conducted later than five days. 4. Patient #12 was admitted to the agency on 3/1/23 with diagnoses of acute cystitis (inflammation or infection of the urinary bladder) without hematuria (blood in urine), type 2 diabetes, hepatic (liver) failure, and hypertensive heart disease with heart failure. The referral from 2/21/23 did not list ordered disciplines. The Plan of Care for 3/1/23-4/29/23 included orders for skilled nursing weekly for nine weeks; physical therapy (PT) evaluate and treat; and occupational therapy (OT) evaluate and treat. The PT conducted the evaluation visit on 3/14/23. The OT conducted the evaluation visit on 3/16/23. An interview with the agency director on 4/12/23 at 3:12 p.m. confirmed the evaluation visit should have been conducted within five days of the initial assessment. The interview also revealed there was reason documented why the assessments were conducted later than five days.

Last 5 days of every 60 days unless: CFR(s): 484.55(d)(1)(i,ii,iii) The last 5 days of every 60 days beginning with the start-of-care date, unless there is a- (i) Beneficiary elected transfer; (ii) Significant change in condition; or (iii) Discharge and return to the same HHA during the 60-day episode. This ELEMENT is not met as evidenced by: Based on policy review, clinical record review and staff interview, the agency failed to complete the OASIS every 60 days for 1 of 5 discharged patients (#16). Findings include: A policy, “Plan of Care—CMS #485 and Physician Orders” (reviewed/revised 3/2018), was provided by the office manager on 4/11/23 at 12:26 p.m. The policy stated, “Recertification of the Plan of Care is required at least every 60 days…” Patient #16 was admitted on 5/26/22 with diagnoses of pressure ulcer stage 3 (an open wound from pressure that has broken through the top two layers of skin into the fatty tissue), type 2 diabetes, and non-pressure chronic ulcer to the right foot. The Plan of Care for 5/26/22-7/24/22 included orders skilled nursing twice weekly for eight weeks. On 7/26/22, a recertification assessment was conducted by RN #9, two days after the certification ended. An interview with RN #9 on 4/12/23 at 2:24 p.m. revealed there was an oversight, and the recertification assessment was conducted when the RN realized it was missed.

Within 48 hours of the patient's return CFR(s): 484.55(d)(2) Within 48 hours of the patient's return to the home from a hospital admission of 24 hours or more for any reason other than diagnostic tests, or on physician or allowed practitioner - ordered resumption date; This ELEMENT is not met as evidenced by: Based on clinical record review and staff interviews the agency failed to complete the resumption of care [ROC-comprehensive assessment completed after the patient has an inpatient admission] within 48 hours after the patient returned home for 1 of 5 discharged patients [#13]. The findings included: Patient # 13 had a Start of Care date of 12/13/22 and an admitting diagnosis of type 2 diabetes mellitus with hyperglycemia [high blood sugar]. Review of the Plan of Care for the certification period 12/13/22 to 2/10/22 included orders for SN [skilled nursing] 1 time a week for 9 weeks. Review of the clinical record revealed the patient was transferred to _____ [name of hospital] on 12/27/22. The patient was discharged from ___ [name of the hospital] on 1/1/23. Review of the clinical record revealed the agency was informed on 1/1/23 patient # 13 had been discharged home. Further review of the clinical record revealed the ROC [resumption of care-comprehensive assessment completed after the patient is admitted to an inpatient facility and then discharged home] was not completed until 1/4/23. An interview was conducted with the agency director on 4/12/23 at approximately 3 pm. During the interview the director confirmed the ROC was not completed within 48 hours.

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, observations, clinical record review, and staff interview, the agency failed to include current medications on the Plan of Care for 10 of 18 patients (#3, 9, 10, 11, 16, 4, 6, 7, 8, and 17); and to include PICC line (peripherally inserted central line) and lab orders on the Plan of Care for 1 of 2 patients with a PICC line (#16). Findings included: 6. Patient # 4 had a Start of Care [SOC] date of 3/13/23 and admitting diagnoses of infection/inflammatory reaction due reaction due to cardiac and vascular devices, type 1 diabetes mellitus with hyperglycemia [high blood sugar] and type 1 diabetes mellitus with diabetic chronic kidney disease [diabetes damages small vessels throughout the body, affecting the kidneys]. Review of the Plan of Care [POC] for the certification period 3/13/23 to 5/11/23 included orders for SN [skilled nursing] 3 times a week for 8 weeks, 2 times a week for 1 week. Review of the clinical record revealed LPN # 7 conducted a routine visit on 4/20/23 and documented the following information, “Pain information provided by the patient. Throbbing pain in top of right arm with a severity of 06…pain alleviated by med; Tylenol [over the counter pain medication]; helps some but not enough…” Further review of the POC revealed Tylenol was not listed as a current medication. LPN # 7 was not available for interview. The agency director was interviewed on 4/12/23 at approximately 2:30 pm. During the interview, the director confirmed the POC was not updated to include Tylenol. 7. Patient # 6 had a Start of Care [SOC] date of 3/30/23 and admitting diagnoses of pressure ulcer of sacral region [triangular bone at the base of the spine], stage 2 [intact blister or shallow ulcer] and type 2 diabetes with diabetic peripheral angiopathy [narrowing of the arteries]. Review of the Plan of Care for the certification period 3/30/23 to 5/28/23 included orders for SN [skilled nursing] 1 time a week for 1 week, 2 times a week for 2 weeks, 1 time a week for 6 weeks. On 4/11/23 at approximately 10 am, a joint visit was made with RN # 1. During the visit, a medication review was conducted using a medication profile provided by the agency. The patient was using supplement oxygen via nasal cannula during the visit. During an interview with the caregiver, the caregiver reported the patient used oxygen at 3 liters continuously since before coming home from the skilled nursing facility. The oxygen was not included on the plan of care. During an interview with RN # 1 on 4/12/23 at approximately 1:20 pm, the RN confirmed oxygen should have been listed on the POC. 8. Patient # 7 had a Start of Care date of 3/28/23 and an admitting diagnosis of sepsis [infection of the bloodstream]. Review of the Plan of Care [POC] for the certification period 3/28/23 to 5/26/23 included orders for PT [physical therapy 1 time a week for 1 week, 2 times a week for 2 weeks. A joint visit was conducted on 4/11/23 at approximately 1 pm with PTA [physical therapy assistant] # 4. During the visit a medication review was conducted using a medication profile provided by the agency. The medication profile provided by the agency included the following medications: Alirocumab [used to treat high cholesterol] 150 mg every week; Ondansetron [nausea] 4 mg take 1 tablet every 8 hours a needed; Xarelto [blood thinner] 10 mg. Take 1 tablet daily; Losartan [blood pressure] 1 tablet [no dosage] daily; Medroxyprogesterone [hormone medication] 10 mg every day for 10 days; Aspirin 81 mg take 1 tablet each day. During an interview with the caregiver at the time of the joint visit, the caregiver reported the patient was not taking these medications since being admitted to the agency. “She was taking those medications before she was admitted to the hospital this last time but has not been on them since coming home from the hospital and being readmitted to home health.” During an interview with PTA # 4 on 4/12/23 at approximately 1:25 pm, the PTA confirmed the POC included medications the patient was not taking any longer. 9. Patient # 8 had a Start of Care date pf 3/2/23 and an admitting diagnosis of hemorrhage due to vascular prosthesis device/graft [implanted device intended to repair or replace sections of native or artificial vessels]. Review of the Plan of Care for the certification period of 3/2/23 to 4/30/23 [medication section] included Acetaminophen [over the counter pain relief] 325 mg 2 tablets every 4-6 hours as needed. The entry did not include indications for the use of the medication. During an interview with the agency director on 4/12/23 at approximately 2:30 pm, the director confirmed the medications should have included indications for their use. 10. Patient # 17 had a Start of Care of 11/17/22 and admitting diagnoses of cellulitis [infection of skin] of right lower limb, osteomyelitis [infection of bone] of lower leg and encounter for adjustment and management of vascular access device [device that allows repeated and long-term access to the blood stream for frequent or repeated administration of medications]. Review of the Plan of Care [POC] for the certification period 11/17/22 to 1/15/23 included orders for SN [skilled nursing] 2 times a week for 4 weeks, 1 time a week for 5 weeks. Review of the medication section of the POC revealed the following medications were entered twice -Amiodarone [used to treat cardiac dysrhythmias] 200 mg every day by mouth, Gabapentin [anticonvulsant medication] 600 mg three times a day and Vancomycin [antibiotic] 1.5 mg daily. During an interview with the agency director on 4/12/23 at approximately 2:30 pm, the director confirmed the medications should not have been listed twice on the POC. A policy, “Plan of Care—CMS #485 and Physician Orders” (reviewed/revised 3/2018), was provided by the office manager on 4/11/23 at 12:26 p.m. The policy stated, “The individualized plan of care must include…All medications and treatments…” A policy, “Medication Reconciliation” (reviewed/revised 3/2018), was provided by the office manager on 4/11/23 at 12:26 p.m. The policy stated, “At time of admission, the admitting RN, PT, or SLP [registered nurse, physical therapist, or speech language pathologist] will create and document a complete list of medications that patient is taking at home, including dose, strength, route, and frequency.” A policy, “Medication Profile” (reviewed/revised 3/2018), was provided by the office manager on 4/11/23 at 12:26 p.m. The policy stated, “The comprehensive assessment (OASIS) performed at the time of the admission includes a review all medications that the patient is currently using…All prescribed medications, over-the-counter (OTC) medications and home remedies will be documented on the medication profile as well as…Dose, strength, frequency, and route.” 1. Patient #3 was admitted on 3/20/23 with diagnoses of psoas muscle (muscle that connects vertebrae to femur) abscess, right above the knee amputation, paraplegia (paralysis of lower part of body), and type 2 diabetes. The Plan of Care (POC) for 3/20/23-5/18/23 included orders for skilled nursing three times per week for eight weeks, and three as needed visits. The referral information included Lantus (type of insulin) and Humalog (type of insulin). The initial assessment identified the patient was on a hypoglycemic medication (medication used to lower blood sugar. The POC omitted insulins. In an interview with RN #1 on 4/12/23 at 1:25 p.m., the RN stated, “I think he was on it [insulin]” at the start of care. The RN revealed she did not have access to the referral information when in the patient’s home for the initial assessment. 2. Patient #9 was admitted on 3/8/23 with a diagnosis of hemiplegia (paralysis on one side of the body) following a cerebral infarction (stroke) and type 2 diabetes. The Plan of Care (POC) for 3/8/23-5/6/23 included orders for skilled nursing visits weekly for nine weeks; and physical therapy visits twice weekly for eight weeks. The POC included orders for Metformin 750 mg twice daily (used to treat diabetes). A home visit was conducted on 4/12/23 at approximately 12:45 p.m. with RN #9. A review of the patient’s home medications revealed the patient was taking Metformin daily. An interview with RN #9, during the home visit, confirmed the patient was taking Metformin daily. 3. Patient #10 was admitted on 3/14/23 with diagnoses of incomplete quadriplegia (weakness but not total paralysis in arms and legs) and type 2 diabetes. The Plan of Care (POC) for 3/14/23-5/12/23 included orders for physical therapy twice weekly for nine weeks. A home visit was conducted on 4/11/23 at 10:45 a.m. with physical therapy assistant (PTA) #6. During the visit, the patient indicated that he had a “cream” for his back. There was no topical medication on the POC. An interview with the PTA on 4/12/23 at 2:10 p.m. revealed the patient was using Voltaren gel (anti-inflammatory medication) and confirmed it was not on the POC. 4. Patient #11 was admitted on 4/1/23 with diagnoses of melena (blood in the stool), acute gastrointestinal ulcer without hemorrhage, and type 2 diabetes. The Plan of Care (POC) for 4/1/23-5/30/23 included orders for skilled nursing once for one week, twice weekly for two weeks, then weekly for seven weeks; physical therapy once for one week, then twice weekly for four weeks; and occupational therapy to evaluate. A home visit was conducted with Occupational Therapist (OT) #16 on 4/11/23 at 11:45 a.m. A review of the medications revealed the patient was taking Omeprazole (used to treat excess stomach acid) 20 mg twice daily. The prescription bottle was dated 3/29/23. An interview with the OT during the home visit confirmed Omeprazole was omitted from the POC. 5A. Patient #16 was admitted on 5/26/22 with diagnoses of pressure ulcer stage 3 (an open wound from pressure that has broken through the top two layers of skin into the fatty tissue), type 2 diabetes, and non-pressure chronic ulcer to the right foot. The Plan of Care (POC) for 7/25/2-9/22/22 included orders for skilled nursing twice weekly for nine weeks. The recertification assessment conducted on 7/26/22 revealed the patient managed pain with ibuprofen [anti-inflammatory medication]. The POC did not include ibuprofen. An interview with RN #9 on 4/12/23 at 2:24 p.m. confirmed ibuprofen should have been on the POC. 5B. Patient #16 was admitted on 5/26/22 with diagnoses of pressure ulcer stage 3 (an open wound from pressure that has broken through the top two layers of skin into the fatty tissue), type 2 diabetes, and non-pressure chronic ulcer to the right foot. The Plan of Care (POC) for 7/25/2-9/22/22 included orders for skilled nursing twice weekly for nine weeks. The POC also included for Vancomycin (antibiotic) 1 gm every 24 hours via PICC line (peripherally inserted central catheter). There were no PICC line management orders or labs ordered on the POC. The recertification assessment on 7/26/22 revealed RN #9 changed the PICC line dressing and obtained blood via venipuncture. A PICC line dressing change and venipuncture was also performed on 8/2/22. An interview with RN #9 on 4/12/23 at 2:24 p.m. revealed the omitted PICC management orders and lab orders were an oversight.

Conformance with physician orders CFR(s): 484.60(b) Standard: Conformance with physician or allowed practitioner orders. This STANDARD is not met as evidenced by: Based on agency policy, clinical record review and staff interviews the agency failed to provide home health aide services to 1 of 1 patients with aide services ordered on the Plan of Care [POC] [#15]. The findings included: The policy, CMS # 485 and Physician Orders [3/2018], was provided by the office manager on 4/11/23 at 12:26 pm. The policy stated, “Skilled nursing and other home health services will be in accordance with a Plan of Care…” Patient # 15 had a Start of Care date of 2/1/22 with an admitting diagnosis of sepsis [infection of the blood stream]. Review of the Plan of Care [POC] for the certification period 4/2/22 to 5/31/22 listed pressure ulcer of sacral [area at the base of the spine] area, stage 2 [intact blister of shallow crater] as the primary diagnosis. The POC included orders for SN [skilled nurse] 1 time a week for 4 weeks; HHA [home health aide] 2 times a week for 3 weeks starting 4/3/22. Review of the clinical record revealed no HHA visits were made until 5/3/22 when a supplemental order was written for HHA visits 2 times a week for 4 weeks then 1 time a week for 1 week. During an interview with the agency director on 4/12/23 at approximately 3 pm, during the interview the director confirmed the patient did not receive aide services in accordance with the POC.

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, clinical record review and staff interview, the agency failed to notify the physician of changes in patients’ condition for 4 of 18 patients reviewed (#1, 3, 12, and 15); failed to notify the physician for orders related to a wrist fracture for 1 of 1 patient admitted with a wrist fracture [#5]; and failed to notify the physician of visits not made in accordance with the Plan of Care for 5 of 18 patients (#1, 12, 5, 9, and 13); failed to notify physician of blood sugars outside the given parameters for 1 of 5 discharged patients #(13). Findings included: 6A. Patient # 13 had a Start of Care [SOC] date of 12/13/22 and an admitting diagnosis of type 2 diabetes mellitus with hyperglycemia [high blood sugar]. Review of the Plan of Care for the certification period 12/13/22 to 2/10/22 included orders for SN [skilled nursing] 1 time a week for 9 weeks and “Physical parameters for notifying physician…blood sugar greater than 60 less than 100…” Review of the clinical record revealed RN # 1 conducted the SOC visit on 12/13/22. RN # 1 documented the following information,” …She has not yet checked FSBS [finger stick blood sugar] today or eaten but did take her medication. Checked FSBS-56…” Further review of the clinical record revealed no evidence the physician was notified of the blood sugar reading being outside the given parameter. During an interview with RN # 1 on 4/12/23 at approximately 1:15 pm the RN stated, “No, I don’t think I did notify the physician.” 6B. Patient # 13 had a Start of Care [SOC] date of 12/13/22 and an admitting diagnosis of type 2 diabetes mellitus with hyperglycemia [high blood sugar]. Review of the Plan of Care for the certification period 12/13/22 to 2/10/22 included orders for SN [skilled nursing] 1 time a week for 9 weeks. Review of the clinical record reveal RN # 1 entered a missed visit note for 12/23/22. During an interview with RN # 1 on 4/12/23 at approximately 1:25 pm, RN # 1 stated, “I don’t know if I informed the physician of the missed visit or not.” An interview was conducted with the agency director on 4/12/23 at approximately 2:30 pm, during the interview the director stated, “I do not see where the physician was notified of the missed nursing visit for that week.” 7A. Patient # 15 had a Start of Care date of 2/1/22 with an admitting diagnosis of sepsis [infection of the blood stream]. Review of the Plan of Care [POC] for the certification period 2/1/22 to 4/1/22 included orders for SN [skilled nursing] 2 times a week for 3 weeks then 1 time a week for 4 weeks. Review of the clinical record revealed RN # 13 conducted a visit on 4/1/22 and documented the following information, “…patient [sic] has small skin tear below sacrum [area below the spine] on right upper cheek…this sn [sic] will obtain orders for wound care to this site…” Further review of the clinical record revealed no evidence the RN notified the physician for orders for wound care. RN # 13 was not available for interview. The agency director was interviewed on 4/12/23 at approximately 3:00 pm, and confirmed the physician was not notified of the new skin tear. 7B. Patient # 15 had a Start of Care date of 2/1/22 with an admitting diagnosis of sepsis [infection of the blood stream]. Review of the Plan of Care [POC] for the certification period 2/1/22 to 4/1/22 included orders for SN [skilled nursing] 2 times a week for 3 weeks then 1 time a week for 4 weeks. Review of the clinical record revealed LPN # 12 conducted a routine visit on 4/6/22 and documented the following information, “…SN will also noticed a new wound on patients [sic] right knee that has not been noticed be SN. Patient states it recently came up and that it came from him holding pillow between his legs…SN applied Meda [sic] honey and 4x4 gauze and tape…” Further review of the clinical record revealed no evidence the physician was notified of the new wound. LPN # 12 was not available for interview. The agency director was interviewed on 4/12/23 at approximately 3:00 pm. During the interview the director confirmed the physician was not notified of the new wound. 7C. Patient # 15 had a Start of Care date of 2/1/22 with an admitting diagnosis of sepsis [infection of the blood stream]. Review of the Plan of Care [POC] for the certification period 2/1/22 to 4/1/22 included orders for SN [skilled nursing] 2 times a week for 3 weeks then 1 time a week for 4 weeks. Review of the clinical record revealed LPN # 12 conducted a routine visit on 4/21/22. LPN # 12 documented the following information, “SN will was informed that during an outing with brother pushing wheelchair patients [sic] feet fell off footrest and toes were scraped up on his right foot…SN washed toes with soap and water and applied meda [sic] honey and cover with gauzed [sic] and taped [sic].” Further review of the clinical record revealed LPN # 12 conducted a visit on 5/17/22 and documented the following information related to the toes, “Patient is bleeding from around his toenails…Patient had previously injured his toes…SN cleaned with soap and water and applied medi honey and 4x4s…” Review of the clinical record revealed no evidence LPN # 12 notified the physician of the new wound. LPN # 12 was not available for interview. The agency director was interviewed on 4/12/23 at approximately 3:00 pm. During the interview the director confirmed the physician was not notified of the new wound. 7D. Patient # 15 had a Start of Care date of 2/1/22 with an admitting diagnosis of sepsis [infection of the blood stream]. Review of the Plan of Care [POC] for the certification period 2/1/22 to 4/1/22 included orders for SN [skilled nursing] 2 times a week for 3 weeks then 1 time a week for 4 weeks. Review of the clinical record revealed LPN # 12 conducted routine visits on 4/14/22, 4/21/22 and 5/3/21. The LPN documented the patient had a “stage II [intact blister or shallow crater] located at midline sacrum [area below the spine].” On 4/14/22 LPN # 12 documented the wound measurements as 1 cm x 0.5 cm x 0 cm; On 4/21/22 LPN # 12 documented the following measurements 3 cm x 1.5 cm x 0 cm; On 5/3/22 the LPN documented the following measurements 5 cm x 3.6 cm x 0 cm. Review of the clinical record revealed no evidence the physician was notified of the increase in size of the wound. LPN # 12 was not available for interview. The agency director was interviewed on 4/12/23 at approximately 3:00 pm. During the interview the director confirmed the physician was not notified of the increase in size of the wound. A policy, “Coordination of Patient Care” (reviewed/revised 3/2018), was provided by the agency director on 4/11/23 at 4:10 p.m. The policy stated, “The agency must assure communication with all physicians involved in the plan of care…Staff provides the physician with patient information on an ongoing basis regarding…Current condition and changes in condition…outcomes of care and service…” 1A. Patient #1 was admitted on 3/16/23 with diagnoses of cirrhosis of the liver and type 2 diabetes. The Plan of Care for 3/24/23 and 3/16/23-5/14/23 included orders for physical therapy weekly for five weeks. The physical therapist assistant (PTA) notes for 3/31/23 stated, “Pt. [Patient] open [sic] the order and had increased confusion and swelling in BLE [bilateral lower extremities]. I talked with the husband and stated she needed to go to the ER [emergency room]. he [sic] stated he did not know what to do and refused ER. I called ____ [physical therapist] to infomr [sic] her. She stated she will call the pt. husband to try to help.” An interview with the Physical Therapist (PT) #3 was conducted on 4/12/23 at 2:28 p.m. The PT revealed the patient had an appointment scheduled for the following week to have fluid removed from abdomen. The PT stated that the patient had 2 liters of fluid removed. The PT attributed the confusion and swelling to the build up of fluid. During the interview, the PT confirmed the physician was not notified of the increased confusion and swelling of the bilateral lower extremities the PTA identified. 1B. Patient #1 was admitted on 3/16/23 with diagnoses of cirrhosis of the liver and type 2 diabetes. The Plan of Care (POC) for 3/24/23 and 3/16/23-5/14/23 included orders for physical therapy weekly for five weeks. The physical therapist assistant (PTA) visit for 4/6/23 was not made because the patient was unavailable. There was no evidence the physician was notified visits were not made in accordance with the POC. An interview with PTA #6 on 4/12/23 at 2:04 p.m. revealed the missed visit note did not have evidence the physician was notified. The PTA stated, “I did call the doctor.” 2. Patient #3 was admitted on 3/20/23 with diagnoses of psoas muscle (muscle that connects vertebrae to femur) abscess, right above the knee amputation, stage 4 pressure ulcers (full thickness tissue loss that may expose muscles, tendon, or bone) of the sacrum (area at the base of the spine), right buttock, and left buttock, and paraplegia (paralysis of lower part of body). The Plan of Care (POC) for 3/20/23-5/18/23 included orders for skilled nursing three times per week for eight weeks, and three as needed visits. The POC included orders for wound care daily (caregiver to perform on days when nurse does not visit) to sacrum and right and left buttock. On the initial assessment, the nurse documented the wounds “have joined.” The wound measured 33 cm x 13.3 cm x 5 cm. On 3/27/23, the measurement was 29 cm x 29 cm x 4.5 cm with tunneling of 4.5 cm, 4 cm, and 2 cm. There was no further documentation related to the tunneling. There was no evidence the physician was notified of the increase in wound size. An interview with RN #1 on 4/12/23 at 1:25 p.m. confirmed the physician was not notified of the increase in wound size because the decline was caused by patient non-compliance. 3A. Patient #12 was admitted to the agency on 3/1/23 with diagnoses of acute cystitis (inflammation or infection of the urinary bladder) without hematuria (blood in urine), type 2 diabetes, hepatic (liver) failure, and hypertensive heart disease with heart failure. The Plan of Care for 3/1/23-4/29/23 included orders for skilled nursing weekly for nine weeks. LPN #7 conducted a visit on 3/7/23. The visit note revealed an oxygen saturation level of 64%. There was no evidence of the physician was notified of the low oxygen saturation. An interview with the agency director on 4/12/23 at 3:12 p.m. confirmed there was no evidence the physician was notified of the oxygen saturation. 3B. Patient #12 was admitted to the agency on 3/1/23 with diagnoses of acute cystitis (inflammation or infection of the urinary bladder) without hematuria (blood in urine), type 2 diabetes, hepatic (liver) failure, and hypertensive heart disease with heart failure. The Plan of Care for 3/1/23-4/29/23 included orders for skilled nursing weekly for nine weeks; physical therapy (PT) evaluate and treat; and occupational therapy (OT) evaluate and treat. On 3/31/23 and 4/3/23, the physical therapy assistant completed missed visit notes for patient refusal. There was no evidence the physician was notified. An interview with the agency director on 4/12/23 at 3:12 p.m. confirmed there was no evidence the physician was notified of the missed visits. 4. Patient #5 was admitted on 3/13/23 with diagnoses of gastrointestinal hemorrhage, Fournier gangrene (a form of necrotizing fasciitis or gangrene affecting the external genitalia or perineum), and malignant neoplasm of the rectum. The referral included orders for nursing, physical therapy (PT), and occupational therapy (OT). The Plan of Care for 3/13/23-5/11/23 included orders for nursing weekly for eight weeks. An interim order beginning on 3/23/23 included PT once for one week, twice weekly for four weeks, then weekly for three weeks. On 3/22/23, OT completed documentation for a missed visit. There was no evidence the physician was notified of the missed visit. On 4/5/23, the nurse documented a missed visit. There was no evidence the physician was notified of the missed visit. An interview with the agency director on 4/12/23 at 2:50 p.m. confirmed there was no evidence the physician was notified of the missed visits 5. Patient #9 was admitted on 3/8/23 with a diagnosis of hemiplegia (paralysis on one side of the body) following a cerebral infarction (stroke). The Plan of Care (POC) for 3/8/23-5/6/23 included orders for skilled nursing visits weekly for nine weeks; and physical therapy visits twice weekly for eight weeks. The physical therapy assistant (PTA) completed a missed visit note for 3/30/23. There was no evidence the physician was notified of the missed visit. An interview with the agency director on 4/12/23 at 2:50 p.m. confirmed there was no evidence the physician was notified of the missed visits

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 Centers for Disease Control and Prevention [CDC] Hand Hygiene guidance, direct observation and staff interviews the RN failed to use proper hand hygiene/or change gloves appropriately for 1 of 6 patients who received a home visit [#6]. The findings included: The Centers of Disease Control and Prevention Hand Hygiene guidance stated, “… Healthcare personnel should use an alcohol-based hand rub or wash with soap and water for the following clinical indications: Immediately before touching a patient…Before moving from work on a soiled body site to a clean body site on the same patient…After touching a patient or the patient’s immediate environment…After contact with blood, body fluids, or contaminated surfaces… Immediately after removing gloves…” Patient # 6 had a Start of Care [SOC] date of 3/30/23 and admitting diagnoses of pressure ulcer of sacral region [triangular bone at the base of the spine], stage 2 [intact blister or shallow ulcer] and type 2 diabetes with diabetic peripheral angiopathy [narrowing of the arteries]. Review of the Plan of Care for the certification period 3/30/23 to 5/28/23 included orders for SN [skilled nursing] 1 time a week for 1 week, 2 times a week for 2 weeks, 1 time a week for 6 weeks and “wound are to stage II sacrum: cleanse with soap/water, NS [normal saline] or wound cleanser, pat dry, apply Calmoseptine [moisture barrier ointment] BID [two times a day] and PRN [as needed] soiling…” A joint visit was made on 4/11/23 at approximately 10 am with RN # 1. During the visit the RN completed wound care to the sacral pressure ulcer. RN # 1 did not do hand hygiene prior to applying gloves for wound care. RN # 1 applied gloves. The patient had been incontinent of stool, so the RN completed incontinent care before doing the wound care. RN # 1 used the same gloves to do the incontinent care and then proceeded to the wound care without changing gloves. The RN then proceeded to measure the wound and apply the Calmoseptine cream while wearing the same gloves she completed the incontinent care with. The RN then changed gloves to apply a clean brief. During an interview with RN # 1 on 4/12/23 at approximately 1:20 pm, she confirmed she failed to change gloves after completing incontinent care and before completing the wound care.

Responsibilities of skilled professionals CFR(s): 484.75(b) Standard: Responsibilities of skilled professionals. Skilled professionals must assume responsibility for, but not be restricted to, the following: This STANDARD is not met as evidenced by: Based on agency policy, clinical record review and staff interviews the SN [skilled nurse] failed to assess PICC [peripherally inserted central catheter] line measurements for 1 of 2 patients with a PICC line [#17]. The findings included: The policy, PICC Line Dressing change [no date], was provided by the agency director on 4/11/23 at 4:10 pm. The policy stated,” …Dressing changes will be done weekly…Document in the clinical record…Length of catheter visible at the exit site…” Patient # 17 had a Start of Care of 11/17/22 and admitting diagnoses of cellulitis [infection of skin] of right lower limb, osteomyelitis [infection of bone] of lower leg and encounter for adjustment and management of vascular access device [device that allows repeated and long-term access to the blood stream for frequent or repeated administration of medications. Review of the Plan of Care for the certification period 11/17/22 to 1/15/23 included orders for SN [skilled nursing] 2 times a week for 4 weeks, 1 time a week for 5 weeks. Further review of the clinical record revealed Patient # 17 received SN visits on 11/17/22 [start of care], 11/18/22, 11/21/22, 11/22/22, 11/25/22 and 11/28/22. Review of the SN visit notes revealed no PICC [peripherally inserted central catheter] line measurements during any of the SN visits. An interview was conducted with the agency director on 4/12/23 at approximately 2:30 pm. During the interview the director confirmed there were no measurements for the PICC line obtained.

Preparing clinical notes CFR(s): 484.75(b)(6) Preparing clinical notes; This ELEMENT is not met as evidenced by: Based on clinical record review and staff interview, the clinical notes did not accurately reflect the patient status for ___ of ___ patients (#1, 2, 10, 12). Findings included: 1. Patient #1 was admitted on 3/16/23 with diagnoses of cirrhosis of the liver and type 2 diabetes. The Plan of Care for 3/24/23 and 3/16/23-5/14/23 included orders for physical therapy weekly for five weeks. The physical therapist assistant (PTA) notes for 3/31/23 stated that the patient was on anticoagulant/antiplatelet therapy. There was no evidence of the patient taking anticoagulant/antiplatelet medications. An interview with the administrator on 4/12/23 at 2:32 p.m. confirmed there was no evidence the patient was taking anticoagulant/antiplatelet medications. 2. Patient #2 was admitted on 3/20/23 with diagnoses of psoas muscle (muscle that connects vertebrae to femur) abscess, right above the knee amputation, stage 4 pressure ulcers (full thickness tissue loss that may expose muscles, tendon, or bone) of the sacrum (area at the base of the spine), right buttock, and left buttock, and paraplegia (paralysis of lower part of body). The Plan of Care (POC) for 3/20/23-5/18/23 included orders for skilled nursing three times per week for eight weeks, and three as needed visits. There were also orders for wound care to stage 4 wound to the right above the knee amputation (AKA) stump. The initial assessment was conducted on 3/20/23 by RN #1. The assessment stated that the right AKA stump wound was a surgical wound. RN #1 assessment on 3/22/23 stated that the right AKA stump wound was a stage 4 pressure ulcer. The assessment on 3/24/22 by LPN #7 identified it as a stage 4 pressure ulcer. On 3/27/23, the wound was identified as a surgical wound. The visit note by RN #1 stated, “Wound care provided to right knee surgical dehiscence (edges of a surgical wound separate unintentionally) …” On 3/29/23, 3/31/23, 4/3/23, 4/5/23, 4/7/23, and 4/10/23 the wound was identified as stage 4 pressure ulcer. An interview with RN #1 on 4/12/23 at 1:25 p.m. revealed the right AKA wound was a surgical wound dehiscence, not a stage 4 pressure ulcer. 3. Patient #10 was admitted on 3/14/23 with diagnoses of incomplete quadriplegia (weakness but not total paralysis in arms and legs) and type 2 diabetes. The Plan of Care (POC) for 3/14/23-5/12/23 included orders for physical therapy twice weekly for nine weeks. Physical therapy assistant (PTA) #6 notes for 3/17/23, 3/21/23, 3/24/23, 3/28/23, 3/31/23, 4/4/23, 4/6/23, and 4/11/23 stated, “Pt [patient] is on anticoagulant/antiplatelet [medications that thins blood] therapy.” The POC did not indicate the patient was on anticoagulant/antiplatelet medications. An interview with the agency director on 4/12/23 at 2:59 p.m. confirmed the patient was not taking anticoagulant/antiplatelet medications. 4. Patient #12 was admitted to the agency on 3/1/23 with diagnoses of acute cystitis (inflammation or infection of the urinary bladder) without hematuria (blood in urine), type 2 diabetes, hepatic (liver) failure, and hypertensive heart disease with heart failure. The referral from 2/21/23 did not list ordered disciplines. The Plan of Care for 3/1/23-4/29/23 included orders for skilled nursing weekly for nine weeks; physical therapy (PT) evaluate and treat; and occupational therapy (OT) evaluate and treat. On 3/16/23, the OT visit note stated that the patient was on anticoagulant/antiplatelet (medications that thin the blood) therapy. The physical therapy assistant notes for 3/20/23, 3/29/23, and 4/5/23 stated, “Pt [patient] is on anticoagulant/antiplatelet therapy.” The RN visit note for 4/6/23 stated that the patient had no signs of symptoms of problems related to anticoagulant therapy. An interview with the agency director on 4/12/23 at 3:12 p.m. confirmed the patient was not taking anticoagulant/antiplatelet medications.

Communication with physicians CFR(s): 484.75(b)(7) Communication with all physicians involved in the plan of care and other health care practitioners (as appropriate) related to the current plan of care; This ELEMENT is not met as evidenced by: Based on clinical record review and staff interviews the Skilled nurse failed to contact the physician prior to advising patient to stop taking medication for 1 of 5 discharged patients [#15]; and failed to notify the physician when the patient requested a Hospice consult for 1 of 5 discharged patients [#15]. The findings included: 1A. Patient # 15 had a Start of Care date of 2/1/22 with an admitting diagnosis of sepsis [infection of the blood stream]. Review of the Plan of Care [POC] for the certification period 4/2/22 to 5/31/22 listed pressure ulcer of sacral [area at the base of the spine] area, stage 2 [intact blister of shallow crater] as the primary diagnosis. The POC included orders for SN [skilled nurse] 1 time a week for 4 weeks. Review of the clinical record revealed LPN # 12 completed a visit on 4/6/22. LPN # 12 documented the following information, “…SN reviewed patients [sic] medications and he is to call for refills. Patient has bottle of Mirtazapine [antidepressant] 15 mg one at bedtime that is not on our med list. SN advised patient not to take this medication since he is taking Duloxetine [antidepressant]…” Further review of the clinical record revealed no evidence the LPN attempted to clarify the medications prior to educating the patient not to take the Mirtazapine. LPN # 12 made a follow up visit on 4/14/22 and documented the following information, “…patient states he is to continue to take the Mirtazapine 15 mg at night and take the Duloxetine 30 mg two times a day…” LPN # 12 was not available for interview. The agency director was interviewed on 4/12/22 at approximately 3:30 pm. During the interview, the director stated the LPN should have contacted the physician prior to educating the patient not to take both medications. 1B. Patient # 15 had a Start of Care date of 2/1/22 with an admitting diagnosis of sepsis [infection of the blood stream]. Review of the Plan of Care [POC] for the certification period 2/1/22 to 4/1/22 included orders for SN [skilled nursing] 2 times a week for 3 weeks then 1 time a week for 4 weeks. Review of the clinical record revealed RN # 13 completed a recertification [an update to the POC that occurs at least every 60 days] visit on 4/1/22 and documented the following information, “…Patient verbalized that ‘I have requested hospice care due to infectous [sic] disease md [physician] dx [diagnosis] with short time to live…” RN # 13 made a routine visit on 5/12/55 and documented the following information, “…Patient asked this if this SN [skilled nurse] has heard from MD [physician] about hospice services…’ This SN verbalized to touch base with MD with concerns of hospice referral…” Further review of the clinical record revealed no evidence the physician was contacted after the 4/1/22 visit to discuss the patient’s desire to have a hospice consult. The patient remained on service with the home health agency until 5/31/22 when he was discharged with a planned admission to hospice on 6/1/22. RN # 13 was not available for interview. An interview was conducted with the agency director on 4/12/23 at approximately 3:30 pm. During the interview the director confirmed the RN should have notified the physician when the patient requested a hospice consult.

Required items in clinical record CFR(s): 484.110(a)(1) The patient's current comprehensive assessment, including all of the assessments from the most recent home health admission, clinical notes, plans of care, and physician or allowed practitioner orders; This ELEMENT is not met as evidenced by: Based on policy review, clinical record review, and staff interviews, clinical notes were not completed for 2 of 13 current patients reviewed (#9 and 12); and the RN failed to include an order to remove a PICC line (peripherally inserted central line) and discharge a patient for 1 of 2 patients with a PICC line (#12). Findings included: A policy, “Timely Submission of Patient Documentation” (reviewed/revised 10/2017), was provided by the agency director on 4/11/23 at 4:10 p.m. The policy stated, “Physicians’ orders must be submitted to Agency within three (3) business days after receipt…All visit notes must be submitted the next scheduled work day, not exceeding two (2) business days…” A policy, “Physician Orders—Verbal Orders” (reviewed/revised 3/2018), was provided by the office manager on 4/11/23 at 12:26 p.m. The policy stated, “Verbal orders are put into writing and signed and dated by the RN or qualified therapists, responsible for furnishing or supervising the care…” 1. Patient #9 was admitted on 3/8/23 with a diagnosis of hemiplegia (paralysis on one side of the body) following a cerebral infarction (stroke). The Plan of Care (POC) for 3/8/23-5/6/23 included orders for skilled nursing visits weekly for nine weeks. On 4/12/23 at 11:00 a.m., the visit note for 4/6/23 was not completed. An interview with RN #9 on 4/12/23 at 2:24 p.m. revealed the note was not completed and should have been documented as a missed visit. 2. Patient #12 was admitted to the agency on 3/1/23 with diagnoses of acute cystitis (inflammation or infection of the urinary bladder) without hematuria (blood in urine), type 2 diabetes, hepatic (liver) failure, and hypertensive heart disease with heart failure. The Plan of Care for 3/1/23-4/29/23 included orders for skilled nursing weekly for nine weeks. RN #1 conducted a visit on 4/6/23. As of 4/11/23 at 4:49 p.m. the visit note was not complete. An interview with RN #1 on 4/12/23 at 1:48 p.m. revealed the visit note was completed on the night of 4/11/23. RN #1 stated, “I haven’t been able to sync [computer]. 3. Patient #16 was admitted on 5/26/22 with diagnoses of pressure ulcer stage 3, type 2 diabetes, and non-pressure chronic ulcer to the right foot. The Plan of Care (POC) for 7/25/2-9/22/22 included orders for skilled nursing twice weekly for nine weeks. The POC also included for Vancomycin (antibiotic) 1 gm every 24 hours via PICC line (peripherally inserted central catheter). A discharge visit was conducted by RN #9 on 8/11/22. The visit note stated, “Discharge visit made per Dr. _____ [physician name], PICC removed [related to] noncompliance with IV antibiotic…PICC removed…” The record did not include orders for PICC removal or discharge. An interview with the agency director on 4/12/23 at 2:24 p.m. revealed the orders were not included in the clinical record.

An unannounced, onsite complaint investigation was conducted 09/12/22. Standard-level deficiencies to the Medicare Conditions of Participation were identified. -MHB

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, clinical record review, and staff interview, the agency failed to notify the physician regarding a change in the appearance of wound drainage for 1 of 3 patients with wounds (Patient #1). Findings included: Policy 9.16.1, revised March 2018, titled Nursing Services was received from the Agency Director on 09/12/22 at 11:30 AM. This policy revealed, “Patients receiving nursing services will have appropriate assessments, reassessments, care planning and established outcomes performed.” Policy 9.13.1, revised March 2018, titled Coordination of Patient Care, was received from the Office Manager on 09/12/22 at 5:04 PM. This policy revealed, “…6. Staff provides the physician with patient information on an ongoing basis regarding…current condition and changes in condition…” Patient #1 was admitted to the agency on 05/05/22 with a principal diagnosis of pressure ulcer of left hip (wound #1), stage 4 (wound that extends to muscle, cartilage, ligament, or bone). Plan of Care from 05/05/22 to 07/03/22 revealed orders for skilled nursing 2 times per week for 9 weeks for wound care, labs, medication management, disease process teaching, and after-care teaching and to teach PICC line care. During the admission skilled nursing visit on 05/05/22, the wound status was documented as not healing and “…delayed healing, wound bed with granulation tissue (healthy tissue), however wound is suspected of osteomyelitis…” There was no documented evidence of wound drainage during this visit. Employee #5 conducted skilled nursing the visits on 05/09/22, 05/13/22, 05/16/22, 05/31/22, 06/03/22. These visit notes included documentation that Patient #1 declined to receive wound care on these dates. On 05/17/22, Employee #5 conducted a skilled nursing visit and documented the wound status as early/partial granulation (the appearance of pink tissue as wound begins to heal) with “…possible sliver of bone exposed…”, drainage documented as, “large > 75% of drsg (dressing) drainage is serous (clear, thin drainage)” and “…patient has a small area re-opening at top of wound and it was covered with [name of dressing]…” There was no evidence that the physician was notified regarding the changes documented in the wound status during this visit. On 5/23/22, Employee #5 conducted a skilled nursing visit and documented, “…bone visible… large > 75% drainage…maceration (softening or breaking down of skin due to prolonged exposure) at base of wound due to increased drainage/patient packing to [sic] tight…” There was no evidence that the physician was notified regarding the changes documented in the wound status during this visit. On 5/27/22 and 06/04/22 Employee #5 conducted a skilled nursing visit and documented, “…visible bone…large >75% of drsg drainage is sanguineous (bloody drainage) …” There was no evidence that the physician was notified regarding the changes documented in the wound status during this visit. On 06/14/22 Employee #5 conducted a skilled nursing visit and documented, “Wound care completed…shown green drainage on gauze…bottom of wound now has darkened and he reports increased drainage again…large >75% of drsg is green, serosanguineous (light red or pink, thin drainage)…” There was no evidence that the physician was notified regarding the changes documented in the wound status during this visit. There was a documented missed visit on 06/16/22 which noted, “Had scheduled visit with patient for 1130-1230 when close to his home patient texted to say he wanted to sleep in, it was storming out and he declined visit stating he would do his own wound care.” Skilled nursing visits of 06/20/22 and 06/24/22 were also conducted by Employee #5 and include documentation regarding green drainage from wound #1. These visit notes did not include any evidence that the physician was notified regarding any changes of wound #1, including the presence of green drainage in the wound. The first evidence of contact made with the primary care provider was noted during the 06/27/22 skilled nursing visit, the final nursing visit conducted prior to patient discharge and readmission on 07/22/22. During the 06/27/22 visit, Employee #5 documented, “…message left with staff at... [name of physician’s assistant and clinic with phone number] …” There was no documentation regarding the outcome of the message left on 06/27/22. On 07/12/22, Employee #5 documented, “Cert (certification period) ran out, patient declined last SN (skilled nursing) visit due to schedule conflict, I was asked to D/C [discharge from the agency by the Clinical Director]. No visit was actually made answers [sic] are from last nursing visit.” In an interview on 09/12/22 at approximately 4:30 PM, Employee #3, the Clinical Director, stated, “My expectation would be that you (the skilled nurse) would notify the physician with any changes…” In an interview on 09/12/22 at 4:48 PM, Employee #5 stated, “I believe I contacted the wound clinic if he had any changes. I know I have spoken to them about his wounds. It was just the one visit…” When informed that the green drainage was noted on multiple visits and there was no documentation in the record regarding communication with the physician, Employee #5 stated, “…I’m not sure then. I don’t remember it being that much…”

Responsibilities of skilled professionals CFR(s): 484.75(b) Standard: Responsibilities of skilled professionals. Skilled professionals must assume responsibility for, but not be restricted to, the following: This STANDARD is not met as evidenced by: Based on policy review, clinical record review, and staff interview, the agency’s skilled nurses failed to measure the length of a peripherally inserted central catheter (PICC) for 1 of 1 patients with a PICC (Patient #1). Findings include: The undated Policy I-260, titled PICC Line Dressing Change, was received from the Office Manager on 09/12/22 at approximately 3:30 PM. This policy revealed, “…Procedure…8. Inspect catheter and hub for any kinked or weakened areas. Measure length of catheter exposed” and “…Documentation Guidelines…Length of catheter visible at exit site…” Patient #1 was admitted to the agency on 05/05/22 with a principal diagnosis of pressure ulcer of left hip (wound #1), stage 4 (wound that extends to muscle, cartilage, ligament, or bone). Plan of Care from 05/05/22 to 07/03/22 revealed orders for skilled nursing 2 times per week for 9 weeks for wound care, labs, medication management, disease process teaching, and after-care teaching and to teach PICC line care. Employee #5, a registered nurse, conducted the skilled nursing admission visit on 05/05/22. This visit note revealed, “…Left arm PICC line in place…LUA (left upper arm) circumference 35.5 cm (centimeters) patient [sic] denies any information given regarding further measuremtns [sic] of PICC…” There was no documentation in the clinical record that the external length of the PICC catheter was measured. Employee #5 conducted a skilled nursing visit on 05/09/22. This visit note revealed, “…CVL (central venous line) dressing change and labs obtained and taken to [name of hospital] …” There was no documentation in the clinical record that the external length of the PICC catheter was measured. Employee #5 conducted skilled nursing visits on 05/13/22, 05/16/22, 05/17/22. There was no documentation regarding care or assessment of the PICC catheter during these visits. Employee #5 conducted a skilled nursing visit on 05/23/22. This visit note revealed, “…labs obtained via left upper arm Picc [sic] line and dressing changed, left muac measures approx [sic] (approximately) 37 cm (centimeters) and taken to lab [sic]…” There was no documentation in the clinical record that the external length of the PICC catheter was measured. Employee #5 conducted skilled nursing visits on 05/27/22, 05/31/22, and 06/03/22. There was documentation regarding Employee #5 being unable to obtain blood from the PICC catheter for labs to be drawn during these visits and a documented left MUAC measurement of 34 cm during the 05/31/22 visit. There was no documentation in the clinical record that the external length of the PICC catheter was measured during the 05/27/22, 05/31/22, and 06/03/22 skilled nursing visits. Employee #5 conducted a skilled nursing visit on 06/04/22 and pulled the PICC catheter as ordered. There was no documentation in the clinical record that the external length of the PICC catheter was measured at any time while Patient #1 was receiving services from the agency. In an interview on 09/12/22 at approximately 4:30 PM, Employee #3, the Clinical Director, stated, “They’re (skilled nurses) supposed to measure the length [of the catheter] …if there is a difference, they’re to notify the physician…” In an interview on 09/12/22 at 4:48 PM, Employee #5 was asked if PICC measurements were obtained of the external length of the catheter during any of the visits she conducted and stated, “If it’s not documented I didn’t.”

An onsite recertification survey was conducted March 29-31, 2021. No deficiencies to Emergency Preparedness program were identified.

An unannounced onsite recertification survey was conducted March 29-31, 2021. Standard level deficiencies to the Medicare CoP were identified.

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 staff interview, the agency failed to conduct an initial assessment within 48 hours of referral for 5 of 14 patients (#1, 3, 5, 7, and 10). Findings include: A policy, "Initial Assessments/Comprehensive Assessments" revised 3/2018, was provided by the agency director on 3/31/21 at 8:40 a.m. The policy stated, "A RN, PT or SLP must conduct the initial visit within 48 hours of referral, within 48 hours of patient's return home or on the physician-ordered start of care date ...In the absence of a physician specified start of care date, the initial assessment visit is conducted within 48 hours of the referral." 1. Patient #1 was admitted on 3/1/21 with diagnoses of pressure ulcer left heel stage 2, chronic venous hypertension, non-pressure chronic ulcer lower leg, and peripheral vascular disease. The patient demographic sheet included a referral date of 2/25/21 and a planned start of care date of 2/27/21 for skilled nursing. The initial assessment was conducted by RN #2 on 3/1/21. An interview was conducted with RN #2 on 3/31/21 at 9:48 a.m. The RN stated, "there's nothing in the CCN [care coordination note] ...[this patient] was hard to get up with but I haven't put in any notes" [regarding late SOC]. An interview was conducted with the agency director on 3/28/21 at 11:40 a.m. The director stated the "visit was assigned on 2/25" and was "unsure why no note was in" the electronic medical record. 2. Patient #3 was admitted on 3/5/21 with diagnoses of cutaneous abscess of buttock, cellulitis of buttock, and type 2 diabetes. The patient demographic sheet included a referral date of 3/1/21 and a planned start of care date on 3/3/21 for skilled nursing. The initial assessment was conducted by RN #2 on 3/5/21. An interview with RN #2 on 3/31/21 at 9:40 a.m. confirmed "nothing in here [clinical record] about that [late start]. I can't remember what happened with her." An interview was conducted with the agency director on 3/31/21 at 11:45 a.m. The director stated the visit "was assigned 3/2" and confirmed there was no note regarding late assessment. 3A. Patient #5 was admitted on 2/11/21 with diagnoses of epilepsy, dementia, hypertensive urgency, and difficulty in walking. The patient demographic sheet included a referral date of 2/8/21 and a planned start of care date on 2/10/21 for physical therapy. The initial assessment was conducted by PT #4 on 2/11/21. In an interview with PT #4 conducted on 3/31/21 at 10:50 a.m. the PT stated, "I have a different area code and it sometimes takes a little while to get in contact with people...I don't see any info in my email" regarding the late assessment. The agency director stated on 3/31 at 12:00 p.m. the referral was given to clinician 2/8/21 and confirmed there was no note regarding late assessment. 3B. Patient #5 was hospitalized from 3/2/21-3/6/21. The Resumption of Care assessment was conducted on 3/11/21 PT #4. An interview with the agency director was conducted on 3/31/21 at 12:00 p.m. The agency director stated, the referral was "received on 3/6 and processed on 3/8. I don't know where the gap was because there was no note." 4. Patient #7 was admitted on 3/11/21 with a diagnosis of left humerus (bone in the upper arm) fracture . The patient demographic sheet included a referral date of 3/8/21 and a planned start of care date of 3/10/21 for nursing, physical therapy and occupational therapy. The initial assessment was conducted by RN #2 on 3/11/21. In an interview with RN #2 on 3/31/21 at 9:40 a.m. it was stated, "Sometimes there are issues, that the patient doesn't want to be seen...I don't see anything under care coordination" regarding why the assessment was delayed. 5. Patient #10 was admitted on 10/5/20 with diagnoses of pneumonia and chronic obstructive pulmonary disease (COPD-a lung disease). The patient demographic sheet included a referral date of 10/2/20 for skilled nursing, physical therapy and occupational therapy. The initial assessment was conducted RN #3 on 10/5/20. An interview with the agency director on 3/31/21 at 9:22 a.m. confirmed there was no order to delay SOC. The agency director stated she did not specifically remember this admission but has had this patient on service multiple times and the patient was "hard to schedule."

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 agency policy, clinical record review, interviews with staff, patients, and caregivers the Plan of Care [POC] failed to include all medications for 4 of 14 patients [#2, 6, 8, 11]; pertinent functional limitations for 2 of 14 patients (#7 and 8); and patient specific interventions for 2 of 14 patients (#8 and 3). The findings included: The policy, Medication Profile [revised date of March 2018], was provided by the agency administrator on 3/30/21 at 2 pm. The policy stated, " ...The comprehensive assessment (OASIS) performed at time of admission includes a review of all medications that the patient is currently using ...The medication profile will be reviewed every home visit and updated as changes occur ..." 1. Patient # 2 had a Start of Care [SOC] date of 1/29/21 and an admitting diagnosis of Other Acute Osteomyelitis [infection of the bone] Right Ankle. A review of the Plan of Care [POC] for the certification period 1/29/21-3/29/21 revealed orders for SN [skilled nursing] 2 times a week for 5 weeks and 2 PRN [as needed] visits. On 3/30/21 at approximately 10:30 am a virtual visit was conducted with RN # 2. During the virtual visit a medication review was conducted using the most current medication profile provided by the agency. During the medication review Patient # 2 reported he was currently taking 40 mg of Simvastatin [used to lower cholesterol] daily. The POC indicated the patient was only taking 20 mg Simvastatin each day. During an interview with the patient, the patient stated, "I have been taking 40 mg of my cholesterol medicine for several months. That dose has not changed." During an interview with RN # 2 on 3/30/31 at approximately 12:30 pm. The RN confirmed the POC did not include the most current medications/dosages. 2. Patient # 6 had a Start of Care [SOC] date of 12/16/20 and an admitting diagnosis of Pressure Ulcer of Left Buttock, Stage 4. A review of the Plan of Care for the certification period 2/14/21 to 4/14/21 revealed orders for SN [skilled nursing] 2 times a week for 1 week; 3 times a week for 3 weeks and 3 PRN [as needed] visits. A virtual home visit was conducted on 3/30/21 at approximately 9:30 am with RN # 3. During the virtual visit a medication review was conducted using the most current Patient Medication Profile provided by the agency. During the medication review Patient # 6's caregiver indicated the patient was taking Levemir Insulin [Diabetic medication] 50 units daily and Novolog Insulin [diabetic medication] 30 units in the am and 15 units each pm. The caregiver reported the patient had been using these medications for several months. A review of the medication profile did not include the Levemir or the Novolog. A phone interview was conducted with RN # 3 on 3/31/21 at approximately 12 noon. During the interview the RN confirmed the insulins were not included on the patient's current Plan of Care. 3. Patient # 8 had a Start of Care [SOC] date of 3/8/21 and an admitting diagnosis of Encounter for Surgical aftercare following Surgery on the Respiratory System. A review of the clinical record revealed the patient was admitted into the hospital on 3/16/21 and was discharged home on 3/21/21. On 3/30/21 at approximately 2 pm a joint visit was done with PT [physical therapy] # 4 during the resumption of care visit. During the visit a medication review was conducted using the most recent medication profile provided by the agency. The following discrepancies were noted: The agency medication profile listed Oxycodone/Acetaminophen [pain medication] 5/325 mg tablet by mouth 4 times per day as needed for pain and Fentanyl patch [used for pain control] 50 mcg [micrograms] topical every 72 hours three times per day. An interview was conducted with the patient during the visit and the patient reported, "I use 10/325 pills now. And I can take up to 5 times a day; depending on how bad the pain is. I have been on that dose for well over 6 months." During the interview Patient # 8 advised this surveyor he was using the Fentanyl patch and he changed it 1 time every 3 days. An interview was conducted with PT # 4 on 3/30/21 after the visit. PT # 4 confirmed the POC did not include correct medications/dosages the patient was prescribed. 4. Patient # 11 had a Start of Care [SOC] date of 1/5/20 and had admitting diagnoses of Hypertensive Heart Disease with Heart Failure and Dependence on Supplemental Oxygen. A review of the Plan of Care [POC] for the certification period 1/5/20-3/4/20 revealed orders for SN [skilled nursing] 2 times a week for 2 weeks; 1 time a week for 2 weeks and 2 PRN visits. The POC also included the following orders, "Teach oxygen safety including never use near open flam [sic], never [sic] use near cigarettes, never use near grease/oil ..." A review of the Start of Care documentation by RN # 11 revealed the following information, " ...patient is dependent upon 5 liters of oxygen at the present time ..." A review of the Plan of Care did not reveal oxygen listed on the medication profile. RN # 11 was no longer employed by the agency. On 3/31/21 at approximately 1 pm an interview was conducted with the agency administrator. The agency administrator confirmed oxygen should have been listed on the Plan of Care. A policy, "Plan of Care - CMS #485 and Physician Orders" revised 3/2018, was provided by the agency director on 3/31/21 at 8:40 a.m. The policy stated, "The individualized plan of care must include the following ...Functional limitations ...Patient-specific interventions ..." 5. Patient #7 was admitted on 3/11/21 with a diagnosis of left humerus (bone in upper arm) fracture. The Plan of Care (POC) for 3/11/21-5/9/21 included orders for skilled nurse visit 2 times for 1 week, then weekly for 3 weeks; physical therapy weekly for 4 weeks; occupational therapy weekly for 2 weeks; and home health aide 1 time for 1 week then 2 times per week for 2 weeks. The POC included functional limitations of endurance, ambulation, and dyspnea when walking greater than 20 feet. RN #2 conducted an initial assessment on 3/11/21. The visit note stated, "Patient has [sic] fall last [Saturday] that resulted in left arm in sling and left side of body bruising ...Patient is ambulatory with hands on assist. Has a walker but left arm in sling and not able to use." PT #4 conducted an evaluation on 3/12/21. The visit note stated, " ...patient experienced a fall in the home with complaints of L [left] arm pain and findings of L humerus fracture with immobilizer." OT #6 conducted an evaluation on 3/12/21. The visit note stated, "[left upper extremity] non mobile and in sling at this time." The POC did not include the left upper arm restrictions. In an interview with RN #2 on 3/31/2 at 9:35 a.m., RN #2 stated, "I don't know if the arm limitation is on the plan of care...I don't see it on there." In an interview on 3/31/21 at 11:25 a.m. OT #6 confirmed the arm mobility restriction should be on the plan of care. 6A. Patient #8 was admitted on 3/8/21 with diagnoses of surgical after-care (thoracoscopy with decortication-- surgical procedure involving the surgical removal with the surface layer, membrane, or fibrous cover of lung), fibromyalgia (condition that causes pain all over the body, sleep problems, fatigue, and often emotional and mental distress), gastroparesis (a partial paralysis of the stomach), and Parkinson's disease. The Plan of Care (POC) for 3/8/21-5/6/21 included orders for physical therapy 1 time for 1 week then 2 times per week for 2 weeks. The POC included functional limitations of endurance, ambulation and dyspnea with moderate exertion. PT #4 conducted the initial assessment visit on 3/8/21. The hospital discharge summary instructed the patient in "No lifting greater than 10 pounds for the next 4 weeks." The POC did not include the lifting restrictions. In an interview with PT #4 on 3/31/21 at 11:00 a.m., PT #4 stated, "if I didn't write in in, that was nothing I saw" regarding the lifting restriction. 6B. Patient #8 Plan of Care (POC) for 3/8/21-5/6/21 included orders for physical therapy 1 time for 1 week then 2 times per week for 2 weeks; and to notify the physician for temperature greater than 101.5. The hospital discharge summary instructed the patient "Call Doctor's Office if Temperature is Greater than 101..." Then under the hospital discharge instructions it stated to "Call the office if you have difficulty breathing, fever [greater] than 100.4 ..." PT #4 conducted the initial assessment on 3/8/21. There was no evidence the PT clarified the individualized temperature parameters with the physician. In an interview with PT #4 it was revealed the temperature on the POC was the agency standard temperature parameters. PT #4 stated, "I must have missed the temp." In an interview with the agency director on 3/31/21 at 11:45 a.m. it was confirmed the PT should have got clarification from the physician for temperature parameters. 7. Patient #3 was admitted on 3/5/21 with diagnoses of cutaneous abscess of buttock, cellulitis of buttock, and type 2 diabetes. The Plan of Care (POC) for 3/5/21-5/3/21 included orders for skilled nursing weekly for 4 weeks and to notify the physician if blood sugar (bs) is less than 50 or greater than 400. The initial assessment was conducted by RN #2. The visit note stated, "[patient} reports PCP [primary care physician] instructed her to call office is bs fall over 230-250." There was no evidence the RN clarified the individualized blood sugar parameters with the physician. An interview with RN #2 on 3/31/21 at 9:40 a.m. revealed the parameters on the plan of care were the agency standard parameter. RN #2 at stated she called the physician but did not receive call back. In an interview with the agency director on 3/31/21 at 11:45 a.m., it was confirmed the RN should have clarified the parameters.

Conformance with physician orders CFR(s): 484.60(b) Standard: Conformance with physician or allowed practitioner orders. This STANDARD is not met as evidenced by: Based on agency policy, clinical record review and staff interviews the agency failed to follow the Plan of Care [POC] related to PICC [peripherally inserted central catheter] line measurements for 1 of 1 patient [#2]; the size of an indwelling catheter 1 of 1 patient with an indwelling catheter [#11]. The findings included: The policy, Plan of Care-CMS #485 and Physician Orders [revised date of March 2018], was provided by the agency administrator on 3/31/21 at approximately 8:40 am. The policy stated, " ...Care and services provided will be provided according to physician orders ..." 1. Patient # 2 had a Start of Care [SOC] date of 1/29/21 and an admitting diagnosis of Other Acute Osteomyelitis [infection of the bone] Right Ankle. A review of the Plan of Care [POC] for the certification period 1/29/21-3/29/21 revealed orders for SN [skilled nursing] 2 times a week for 5 weeks and 2 PRN [as needed] visits and " ...PICC [peripherally inserted central catheter] line dressing change to right upper arm due once weekly by SN. Sterile technique PICC line measurement [sic] obtain before and after dressing change ..." A review of the clinical record revealed the RN # 11 changed the PICC line dressing on 1/29/21 and 2/4/21. A review of the clinical record revealed no evidence of PICC line measurements. RN # 11 is no longer employed by the agency and was not available for an interview. On 3/31/21 at approximately 1 pm an interview was conducted with the agency administrator. During the interview the administrator confirmed the PICC line was not measured in accordance with the POC. Further review of the clinical record revealed the PICC line dressing was changed on 2/18/21 and 2/25/21 by RN # 2. There are no PICC line measurements documented. An interview as conducted with RN #2 on 3/31/21 at approximately 12 pm. During the interview the RN confirmed the PICC line measurements were not obtained in accordance with the POC. 2. Patient # 11 had a Start of Care [SOC] date of 1/5/20 and an admitting diagnosis of Hypertensive Heart Disease with Heart Failure. A review of the Plan of Care for the certification period 1/5/20-3/4/20 revealed orders for SN [skilled nursing] 2 times a week for 2 weeks; 1 time a week for 2 weeks and 2 PRN visits and change the indwelling catheter every 30 days and as needed with 16 french 10 ml balloon. May flush catheter if needed. A review of the clinical record revealed on 1/13/20 LPN # 10 documented the following information, " ...SN changed foley [indwelling] catheter using sterile technique. SN used 18 fr [French] 10 cc foley catheter ..." LPN # 10 was not available for interview. On 3/31/21 at approximately 1 pm an interview was conducted with the agency administer. The administer confirmed the POC was not followed in relation to the size of the indwelling catheter LPN # 10 inserted.

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 agency policy, clinical record review and staff interviews the agency failed to include orders on the Plan of Care for suprapubic catheter change for 1 of 1 patient with a suprapubic catheter[device that is inserted into the bladder to drain urine] [#6];failed to include orders for a wet to dry dressing for 1 of 6 patients with a wound [#11]. Findings include: The policy, Plan of Care-CMS #485 and Physician Orders [revised date of March 2018], was provided by the agency administrator on 3/31/21 at approximately 8:40 am. The policy stated, " ...All patient care orders, including verbal orders, must be recorded on the plan of care ..." 1. Patient # 6 had a Start of Care [SOC] date of 12/16/20 and an admitting diagnosis of Pressure Ulcer of Left Buttock, Stage 4. A review of the Plan of Care for the certification period 2/14/21 to 4/14/21 revealed orders for SN [skilled nursing] 2 times a week for 1 week; 3 times a week for 3 weeks and 3 PRN [as needed] visits. A virtual home visit was conducted on 3/30/21 at approximately 9:30 am with RN # 3. During the visit RN #3 changed the patient's suprapubic catheter. A review of the Plan of Care for the certification period 2/14/21-4/14/21 revealed no orders related to the change of the suprapubic catheter. A phone interview was conducted with RN # 3 on 3/31/21 at approximately 12:00 pm . During the interview the RN confirmed the POC did not include orders related to the change of the suprapubic catheter. 2. Patient # 11 had a Start of Care [SOC] date of 1/5/20 and an admitting diagnosis of Hypertensive Heart Disease with Heart Failure. A review of the Plan of Care for the certification period 1/5/20-3/4/20 revealed orders for SN [skilled nursing] 2 times a week for 2 weeks; 1 time a week for 2 weeks and 2 PRN visits. A review of the clinical record revealed on 2/14/20 RN # 9 made a visit to see Patient # 11. A review of the SN visit note revealed the following information, " ...He has a right heel unstageable pressure ulcer with hard eschar. SN educated CG on a wet to dry dressing today ..." A review of the POC revealed no order for a wet to dry dressing. RN # 9 was no longer employed with the agency. An interview was conducted with the agency administrator on 3/31/21 at approximately 1 pm. During the interview the agency administrator confirmed the plan of care did not include an order for a wet to dry dressing.

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 agency policy, clinical record review and staff interviews the agency failed to alert the physician of changes in the patient's condition for of 1 of 3 discharged charts reviewed [#11]; and of a patient using oxygen outside the prescribed dose for 1 of 3 patients with oxygen (10); and failed to notify the physician of changed in wound status for 1 of 6 patients with wounds (#12). Findings include: A policy, "Coordination of Patient Care" revised 3/2018, was provided by the agency director on 3/31/21 at 8:40 a.m. The policy stated, "Staff provides the physician with patient information on an ongoing basis regarding: Current condition and change in condition, Outcomes of care and service, Changes in the environment and/or caregiver support ..." The findings included: 1. Patient # 11 had a Start of Care [SOC] date of 1/5/20 and an admitting diagnosis of Hypertensive Heart Disease with Heart Failure. A review of the Plan of Care for the certification period 1/5/20-3/4/20 revealed orders for SN [skilled nursing] 2 times a week for 2 weeks; 1 time a week for 2 weeks and 2 PRN visits. A review of the clinical record revealed on 1/27/21 LPN # 10 made a routine visit to assess patient's buttocks for skin breakdown. LPN # 10 documented the following information, " SN was not able to assess area b/c [because] patient was not able to turn enough. SN ask patient how long he had been soiled and patient stated about an hour and a half ..." On 2/6/20 LPN # 10 made a routine visit to see the patient. A review of the clinical record revealed the following, " ...Patient states he is still having loose stools but is able to get to the BSC [bedside commode] with assist. CG [caregiver] is keeping buttocks cleaned and applied barrier cream. Sn was not able to assess buttock b/c [because] patient had not be [sic] cleaned up from stool per CG ...Patient advised SN that he had area [sic] on his right heel that was bother [sic] him ...SN removed sock to right foot and patient has a stage two ulcer to right heel ..." Further review of the clinical record revealed on 2/14/20 RN # 9 made a visit to see Patient # . A review of the SN visit note revealed the following information, " ...He has a right heel unstageable pressure ulcer with hard eschar. SN educated CG on a wet to dry dressing today ..." LPN # 10 was not available for an interview and RN # 9 is no longer employed with the agency. On 3/31/21 at approximately 1 pm the agency administrator was interviewed. During the interview the agency director confirmed there was no evidence the physician was notified of the findings documented by LPN # 10 or RN # 9. 2. Patient #10 was admitted on 10/5/20 with diagnoses of pneumonia and chronic obstructive pulmonary disease (COPD-a lung disease). The Plan of Care (POC) for 10/5/20-12/3/20 included orders for skilled nursing, occupational therapy, and physical therapy visits; and oxygen (O2)2 L (liters) per min via nasal cannula [NC] as needed for shortness of breath. The initial assessment on 10/5/20 revealed the patient was on 2 liters of oxygen with oxygen saturation of 100%. LPN #9 conducted a home visit on 10/8/20. The visit note stated, "Patient is on O2 at 4 L via NC." LPN #9 also conducted visits on 10/12/20, 10/19/20, 10/26/20. The visit notes stated, "Patient is O2 at 4 L via NC." There was no evidence that physician was notified that the patient was using oxygen 4 liters via nasal cannula instead of 2 liters. An interview with the agency director on 3/31/21 at 10:50 a.m. confirmed the documentation stated the patient was using 4 L and the order was for 2 L and there was no communication with the physician that patient was using 4 L. 3. Patient #12 was admitted on 12/2/20 with diagnoses of stage 2 pressure ulcer sacral region and pressure-induced deep tissue damage of right heel. The Plan of Care (POC) for 12/2/20-1/30/21 included orders for skilled nursing 1 time for 1 week, 2 times per week for 3 weeks, and 1 time per week for 1 week. The initial assessment was conducted on 12/2/20 by RN #10. The assessment revealed a pressure ulcer left heel [sic] that was "boggy, dark tissue" with no measurements of the size of the wound. On 12/8/20, LPN #9 conducted a visit and documented the right heel pressure ulcer measured 3x1.5x0.1 with 100% eschar of the wound bed. On 12/11/20, LPN #9 conducted a home visit. The right heel wound measured 3 x 1.4 x 0.1 with "adherent soft black eschar" of the wound bed. There was no evidence that the physician was notified of the eschar to the left heel.