Every finding on record at Heartland Regional Medical Center

The Emergency Preparedness regulations were reviewed as part of the Medicare recertification survey completed on 04/30/2024. During the survey it was determined the home health provider is in compliance with the requirements of 42 CFR 484.102 Condition of Participation: Emergency Preparedness for Home Health Agencies.

A partial extended survey for Medicare recertification for the home health provider was completed on 4/30/2024. The provider had 200 current patients.

RN performs assessment CFR(s): 484.55(a)(1) A registered nurse must conduct an initial assessment visit to determine the immediate care and support needs of the patient; and, for Medicare patients, to determine eligibility for the Medicare home health benefit, including homebound status. The initial assessment visit must be held either within 48 hours of referral, or within 48 hours of the patient's return home, or on the physician or allowed practitioner - ordered start of care date. This ELEMENT is not met as evidenced by: Based on policy review, record review, and interview, the home health provider failed to ensure the initial assessment was completed within 48 (forty-eight) hours of the referral in one of five full records reviewed (Record/Patient #4). This deficient practice has the potential to affect the immediate care needs of all the provider’s patients. Findings included: Review of the provider’s policy titled, “Initial & Ongoing Assessment, Communication and Care Planning Process in Home Health,” with an approval date of 06/05/2023, showed admission and resumption of care visits are completed within 48 (forty-eight) hours of referral or discharge from inpatient facility unless otherwise specified by provider. RECORD/PATIENT #4: Review of a referral #2411657 showed, in part: - A creation date of 04/04/2024 for SN (skilled nursing); and - Requested SOC (Start of Care) Date failed to be documented (it was left blank). Review of the clinical record showed the patient was admitted to home health services on 04/09/2024 with a primary diagnosis of pressure ulcer (a lesion caused by unrelieved pressure resulting in damage of underlying tissue) of right ankle, stage 2 (a partial thickness loss of skin layers that presents clinically as an abrasion, blister, or shallow crater). Review of the SOC OASIS (Start of Care Outcome and Assessment Information Set; a standardized data collection tool) dated 04/09/2024 (five days following referral) showed: - Item M0090: Date assessment completed: 04/09/2024 (five days after referral received) - Item M1000: Inpatient Facilities- From which of the following Inpatient Facilities was the patient discharged within the last 14 (fourteen) days? Documented as N/A- Patient was not discharged from an inpatient facility; and - Item M0102: Date of physician-ordered SOC marked N/A, no specific SOC date ordered by physician. Further review of the clinical record showed, in part: - A telephone conversation note dated and timed 04/05/2024 at 10:21 AM between the provider and a MD (Doctor of Medicine) documented the following: Courtesy note to let you know “Named Home Health” will be admitting late d/t (due to) scheduling availability. Thank you. (It failed to clarify if the scheduling availability was an issue of the provider or the patient); and - The clinical record failed to include a specific physician and/or allowed practitioner ordered start of care date. During an interview on 04/30/2024 starting at 1:15 PM the clinical manager stated that: - The SOC should be within 48 hours of referral or discharge home from an inpatient facility; and - He/she agreed the telephone documentation failed to specify who had the scheduling availability issue (the patient or the provider).

A review of all current medications CFR(s): 484.55(c)(5) A review of all medications the patient is currently using in order to identify any potential adverse effects and drug reactions, including ineffective drug therapy, significant side effects, significant drug interactions, duplicate drug therapy, and noncompliance with drug therapy. This ELEMENT is not met as evidenced by: Based on policy review, record review, observation and interview, the home health provider failed to ensure staff maintain an accurate and updated medication profile in, but not limited to, two of three home visit observations (Records/Patients #1, and #2). This deficient practice has the potential to affect all patients served by the provider. Findings included: Review of the provider’s policy titled, “Medication Administration, Disposition Including the Delivery of Medication and Medical Provider Orders for Home Health and Hospice”, dated 4/28 2021, showed, in part; - Stock Medications: An order is necessary for the use of stock medications. If the strength or indication for the medication is outside of the standard, a specific order is obtained; - Current medications, including vitamins, supplements, and herbal therapies are listed on the medication profile. Patients have a current medication profile in the medical record. Medication orders include the patient's name, date, time, medication name, dose, frequency, route of administration, practitioner ordering and indication if ordered PRN (as needed); and - A nurse reviews the medication profile on admission for accuracy and contra-indications (allergies, drug interactions.). The nurse also reviews the medication profile upon receiving new medication orders and prior to administration of medications. If the nurse has questions or concerns about medications, she/he will consult with the Associate Director. Major medication interactions identified with medication validation will be reported to the medical provider. RECORD/PATIENT #1: Review of the clinical record showed the patient admitted to home health services on 01/17/2024 with a primary diagnosis of diabetes (a group of diseases that results in too much sugar in the blood), and a pressure sore on the great toe of the left foot. The patient lived at home alone, and was discharged from services on 04/29/2024, after the home visit. Observation and interview on 04/29/2024 at 2:30 PM, during the patient’s home visit, showed Registered Nurse (RN)- A failed to perform a comprehensive medication reconciliation during the visit. The following medication discrepancies were discovered: - The provider’s medication profile showed a physician's order for glipizide (a diabetic medication to regulate blood sugar levels), 10 milligrams (mg), take one tablet daily. The patient’s stated that he/she had taken the last dose of the medication on 4/28/2024 and was currently "out" of the medication; - Observation and interview showed the patient stated he/she was currently taking hydrocodone / acetaminophen (a narcotic medication taken for pain) 5 mg /325 mg 1 tablet every 4 to 6 hours for pain as needed. The medication was not listed on the current provider's list; and - Observation and interview showed the patient stated he/she was taking Vitamin B complex (a dietary supplement) 500 mg 1 tablet daily. The medication was not listed on the current provider's list. During an interview on 04/30/2024 at 9:00 AM, the Director of Nursing (DON) stated that the staff are responsible for following the medication policy and perform medication reconciliation during each home visit to ensure accuracy. RECORD/PATIENT #2: Review of the clinical record showed the patient admitted to home health services on 04/26/2024 with a primary diagnosis of aftercare following joint replacement surgery (left knee) with PT (physical therapy) only. The patient lived at home with his/her sibling. Review of the medication list at discharge from the inpatient facility dated as of 4/24/2024 at 10:53 AM showed, in part, Acetaminophen 325mg tablet (medication for mild to moderate pain) take 650mg by mouth (there failed to be any further directions with frequency limits or if it was scheduled or as needed). Observation on 04/29/2024 at 1:30PM, during the patient’s home visit, the PTA (Physical Therapy Assistant) questioned the patient if there had been any medication changes but failed to do a medication reconciliation. A reconciliation was done by this surveyor utilizing the current medication profile supplied by the agency and a review of the patient’s medication bottles and their list from the inpatient facility discharge (the only medication list in the home) and the following discrepancies were noted: - The patient’s medication list from the inpatient facility showed Acetaminophen 325mg (milligram) tablet (medication for mild to moderate pain) take 650mg by mouth; The provider’s list failed to include the acetaminophen; - The current medication profile supplied by the provider showed Ascorbic acid (Vitamin C) 100mg tablet, take one in the morning; The patient’s bottle label showed 500mg tablets; - The current medication profile supplied by the provider showed biotin 1mg tablet take 1,000mcg (micrograms) by mouth in the morning; The patient’s bottle label showed 5,000mcg tablets. Per interview conducted during observation, the PTA (physical therapy assistant) stated that he/she did not do a complete medication reconciliation because they are done weekly and the PT (physical therapist had just done it Friday (three days prior). Per interview conducted during observation, the patient stated that: - They were taking Tylenol (acetaminophen) as needed (which failed to be on the provider’s medication profile); - They take one of the vitamin C tablets a day (from the bottle labeled with 500mg tablets) (Ordered strength was on the provider’s medication profile was 100mg every morning); and - They take one biotin every day (from the bottled labeled with Biotin 5,000mcg) (Ordered strength was on the provider’s medication profile was 1,000mcg every morning) During an interview on 04/30/2024 starting at 1:15PM, the clinical manager stated that: - This patient was a new admit; - It looked like the Tylenol had “fell off” the bottom of the page; and - The medication doses would be clarified.

Only as ordered by a physician CFR(s): 484.60(b)(1) Drugs, services, and treatments are administered only as ordered by a physician or allowed practitioner. This ELEMENT is not met as evidenced by: Based on policy review, record review, observation, and interview, the provider failed to obtain orders to provide services and treatments only as ordered by a physician or allowed practitioner in one of five full records reviewed (Record/Patient #2) . This deficient practice has the potential to affect the care of all the provider's patients. Findings included: Review of the home health provider's policy titled, "Initial & Ongoing Assessment, Communication and Care Planning Process in Home Health," approval date of 06/05/2023, showed, in part, the following: -Purpose: Provide guidelines for initial and ongoing assessment, treatment, interdisciplinary collaboration, care planning and updating the plan of care to facilitate realistic patient goals; -Plan of care is initiated upon admission; -The plan of care is developed in collaboration with the physician, to facilitate progressive resolution of problems identified on admission; and - Patient care shall follow a developed plan, which is periodically reviewed by the supervising nurses or other appropriate health professionals. RECORD/PATIENT #2: Review of the clinical record showed the patient admitted to home health services on 04/26/2024 with a primary diagnosis of aftercare following joint replacement surgery (left knee) with PT (physical therapy) only. The patient lived at home with his/her sibling. Review of the plan of care dated 04/26/2024 to 06/24/2024 failed to show: - An order for application of ice; and - An order for Miralax (medication used to treat constipation), milk of magnesia (medication used to treat constipation), or Dulcolax (medication used to treat constipation). Review of the PT OASIS (Outcome and Assessment Information Set; a standardized data collection tool) Start of Care note dated 04/26/2024 showed, in part, under the SOC summary section: PT also instructs patient and daughter in adding milk of magnesia, Miralax, and Dulcolax per constipation protocol. (The clinical record failed to contain an order from the physician to initiate this protocol). During a home visit observation on 04/29/2024 starting at 1:30 PM with the PTA (physical therapy assistant): - He/she questioned if the patient had utilized ice as needed to the incisional area , the patient responded yes. (Review of the plan of care and all orders, failed to show an order for patient to use ice.)(The PTA failed to instruct the patient there currently were no orders for ice); - He/she questioned the patient regarding the activity of their bowels and the patient stated that he/she had no issues with bowels now, but did have some right after getting home. The patient also stated that he/she took Miralax granules this morning. (The PTA failed to instruct the patient there currently were no orders for Miralax). During an interview on 04/30/2024 starting at 1:15 PM the clinical manager stated that: - He/she would expect an order for ice with the frequency, location and duration if the patient was utilizing it; and - An order would be expected to follow bowel protocol, if the patient was being instructed to do so.

The Emergency Preparedness regulations were reviewed as part of the Medicare certification survey completed on 10/27/2021. During the survey it was determined Mosaic Life Care Home Health Agency is in compliance with the requirements of 42 CFR 484.102 Condition of Participation: Emergency Preparedness for Home Health Agencies.

A partial extended survey for Medicare certification for Mosaic Life Care Home Health Agency was completed on 10/27/2021. The agency had 203 current patients. A COVID-19 Focused Infection Control Survey was completed in conjunction with the survey and one deficiency was identified related to the Focused Infection Control Survey.

A review of all current medications CFR(s): 484.55(c)(5) A review of all medications the patient is currently using in order to identify any potential adverse effects and drug reactions, including ineffective drug therapy, significant side effects, significant drug interactions, duplicate drug therapy, and noncompliance with drug therapy. This ELEMENT is not met as evidenced by: Based on policy review, record review, home visit observation, and interviews, the agency failed to ensure the patient's medications were reconciled during the start of care comprehensive assessment and that the medication profile was updated with medication changes in, three (Records/Patients #1, #2 and #3) of six full records reviewed. This deficient practice has the potential to adversely affect the accuracy and safety of medication administration for all the agency's patients. Findings included: Review of the agency's policy titled, "Medication Administration, Disposition, Including the Delivery of Medication and Medical Provider Orders for Home Health and Hospice," dated 04/28/2021 showed, in part, the following: - Purpose: Provide guidelines for safe and accurate medication ordering, delivery, administration and disposition in the home health setting; - Current medications, including vitamins, supplements, and herbal therapies are listed on the medication profile; - A nurse reviews the medication profile on admission for accuracy and contra-indications; and - The nurse also reviews the medication profile upon receiving new medication orders and prior to administration of medications. RECORD/PATIENT #1: During the patient’s home visit observation on 10/25/2021 beginning at 1:45 PM, showed the following discrepancies with the agency’s current medication profile: - The agency’s medication profile showed an order for Novolog (rapid acting insulin that helps lower mealtime blood sugar spikes) 100 units/ml (milliliter) injectable solution, inject 12 units three times a day before meals. The patient stated he/she follows the physician’s medication list and he/she takes Novolog 18 units three times a day. Review of the medication list from the patient’s physician, dated 10/21/2021 showed Novolog 100 units/ml; inject 18 units three times a day before meals; - The medication profile showed acetaminophen-codeine phosphate (used to relieve moderate to severe pain) 300 mg-30mg, take one tablet orally every six hours as needed for pain. The patient stated he/she stopped taking acetaminophen with codeine because it was only working for a few hours and the doctor prescribed norco (hydrocodone-acetaminophen) (relieves moderate to severe pain). Review of the patient’s medication prescription bottle showed hydrocodone-acetaminophen 5mg-325 mg one tablet every six hours and was filled on 10/19/2021 and this was not on the agency’s medication profile; and - Review of the patient’s medication prescription bottle showed clindamycin (antibiotic used to treat serious infections caused by bacteria) 300 mg, take 600 mg three times a day for 10 days (review of a physician note dated 10/12/2021 showed an order for clindamycin for cellulitis (a common and potentially serious skin infection) of the right leg). The medication failed to be listed on the current medication profile. During an interview on 10/25/2021 at 2:26 PM, the registered nurse (RN) C stated a licensed practical nurse (LPN) had been to see the patient since the medication changes and he/she is supposed to ask the patient if there was any changes in his/her medications. During interview on 10/26/2021 at 10:59 AM, registered nurse lead B said the patient’s acetaminophen with codeine was changed to hydrocodone on 10/18/2021. A nurse had not been to the patient’s home since the change took place until yesterday (10/25/2021). He/she got the progress note from the physician visit that showed the physician ordered clindamycin and there was no communication at that time. (The current medication list provided by the agency dated 10/25/2021 did not show clindamycin and hydrocodone-acetaminophen listed.) RECORD/PATIENT #2: During a home visit observation on 10/26/2021 starting at 10:30 AM, PT D asked the patient if any there were any changes to their medications since the previous visit. The patient stated that there were no changes to the medications. PT D did not review the medication list with the patient or compare the medication bottles to the medication list to confirm accuracy. The surveyor reviewed the medication list in the patient’s home folder. The medication list was a list that was provided to the patient from the PCP (primary care provider). The patient stated that he/she was not sure if he/she received a medication list from the agency. The patient’s medication bottles were compared with a current medication profile provided by the agency on 10/25/2021 and the medication list in the patient’s home folder from the PCP. The following discrepancies were found: - The agency medication profile had the patient taking Potassium Chloride 10mEq (milliequivalents) 1 capsule every other day and take with Lasix. The patient’s medication list from the PCP did not have potassium as a medication and no potassium bottle was in the home; - The agency and PCP medication lists failed to show the patient was taking probiotic or simethicone. The patient had bottles for and was taking 1 probiotic capsule daily as well as simethicone 180mg before meals as needed; and - The agency medication profile listed vitamin D 125mcg oral capsule daily. The PCP medication list had vitamin D 2,000IU (international unit) by mouth daily. The medication bottle in the home was vitamin D 1,000IU and the patient reported only taking 1 capsule daily. The medication discrepancies were reviewed with PT D and RN Lead A on 10/26/2021 at 11:00 AM. PT D and RN Lead A acknowledged the discrepancies. PT D contacted the PCP office to report medication discrepancies and confirm orders. PT D confirmed with the PCP office that patient is no longer taking potassium and verbal orders were obtained for patient to take probiotic and simethicone. RECORD/PATIENT #3: Review of the clinical record showed the patient was admitted on 10/01/2021 with, in part, diagnoses of a displaced fracture (the bone is broken and is out of alignment) of the 2nd cervical vertebrae (vertebrae of the neck), type II diabetes mellitus with hyperglycemia (a chronic disease characterized by high levels of sugar in the blood) and hypertension (high blood pressure). During a home visit observation on 10/26/2021 starting at 10:00 AM OT E looked at the medication list in the home folder and asked the patient if any of their medications had changed and if he/she had any questions about their medications. The patient stated no and that he/she had been on all their meds quite a while. OT E also questioned the patient if they were taking anything for pain. The patient stated that he/she was taking the muscle relaxer three times a day and taking Tylenol every morning. At the conclusion of the OT visit the surveyor requested to see all the patient’s medication bottles and compared them with a current medication profile provided by the agency on 10/25/2021. The following discrepancies were found: - The patient had a bottle of juice plus vitamin supplement and stated they took two tablets daily. The medication profile showed one tablet daily; - The patient had a bottle of Omega 3 2,000mg (milligram) plus D3 1,000 iu (international units) and stated they took two daily. The medication profile showed one daily; - The patient had a bottle of methocarbamol 500mg with a filled date of 10/13/2021 labeled to take one tablet three times daily for 14 days. The patient stated they took it routinely three times a day as labeled. The medication profile showed one tablet three times daily as needed for muscle pain; and - The patient stated they were taking Tylenol 500mg one tablet every morning. Tylenol failed to be on the current medication profile. The medication discrepancies were reviewed with RN Lead B on 10/26/2021 at 12:15 PM. He/she failed to provide orders for the discrepancies.

Only as ordered by a physician CFR(s): 484.60(b)(1) Drugs, services, and treatments are administered only as ordered by a physician or allowed practitioner. This ELEMENT is not met as evidenced by: Based on policy review, record review, and interview, the agency failed to ensure treatments were administered only as ordered by the physician in, but not limited to, two (Record/Patient #1 and #3) of six full records reviewed. This deficient practice has the potential to affect all patients served by the agency. Findings included: Review of the agency policy titled, "Initial and Ongoing Assessment, Communication and Care Planning Process in Home Health," dated 02/26/2019, showed in part, admission and treatment require either written or verbal physician’s order. RECORD/PATIENT #1: Review of the POC dated 10/06/2021 to 12/04/2021, showed, in part: - The patient was admitted to home health services on 10/06/2021; and - Diagnoses included encounter for change or removal of nonsurgical wound dressing and non-pressure ulcer of the right thigh with fat layer. Review of a physician order dated 10/21/2021 showed the patient to apply Aquaphor (multi-purpose ointment formulated to help heal and repair skin) to lower right leg and wear compression stockings. Wound care to right upper medial (toward the middle or center), change wet to dry dressings (a dressing that is applied moist and allowed to dry before it is removed) twice a day. During a home visit observation on 10/25/2021 at 2:45 PM showed Registered Nurse (RN) C placed a wet to dry dressing over two blisters on the patient’s right foot and covered with an ABD pad (absorbent dressing). RN C applied a netting to keep the dressing in place. During an interview on 10/25/2021 at 2:45 PM, RN C said a nurse called the physician last Thursday (10/21/2021) and received orders for application of Aquaphor to the blisters. During an interview on 10/26/2021 at 3:05 PM registered nurse (RN) lead B stated the physician called on 10/21/2021 and said there was some blisters to the patient’s feet. RN C said he/she got the order but documented the order was to the right lower leg and not to the right foot. There was no physician orders for a wet to dry dressing to the right foot. RECORD/PATIENT #3 Review of the clinical record showed the patient was admitted on 10/01/2021 with, in part, diagnoses of a displaced fracture (the bone is broken and is out of alignment) of the 2nd cervical vertebrae (vertebrae of the neck), type II diabetes mellitus with hyperglycemia (a chronic disease characterized by high levels of sugar in the blood) and hypertension (high blood pressure). Review of the plan of care dated 10/01/2021 through 11/29/2021 showed, in part, SN (skilled nurse) to assess blood sugar monitoring and results. Notify MD (Doctor of medicine) as indicated. Patient to check blood sugar 4 times daily before meals and at bedtime. Review of the skilled notes 10/07/2021, 10/14/2021 and 10/21/2021 showed glucose monitoring frequency document as once daily. During an interview with the patient during a home visit observation on 10/26/2021 starting at 10:00 AM the patient stated that he/she only checked their blood sugar daily. He/she proceeded to show the surveyor the daily log of blood sugars he/she kept. The blood sugar frequency discrepancies were reviewed with RN Lead B on 10/26/2021 at 12:15 PM. He/she failed to provide orders for the discrepancies.

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 record review, observation, and interview, the agency failed to promptly alert the physician to changes in the patient's condition that may suggest a need to alter the plan of care (POC) in three (Record/Patient #1, #2, and #7) of seven records reviewed. This deficient practice has the potential to affect all patients served by the agency. Findings included: Review of the agency policy titled, "Initial and Ongoing Assessment, Communication and Care Planning Process In Home Health," dated 02/26/2019, showed, in part: - The agency is to notify physician of findings PRN (as needed) and ongoing visits; and - The Physician is to be notified of: physical, mental or emotional concerns of changes, vital signs according to parameters, blood sugar per glucose monitor of less than 50mg/dl (milligrams per deciliter, which is a unit of measure that shows the concentration sugar in the blood) or greater than 400mg/dl, significant change in support system which impacts patient care, noncompliance and discrepancies or concerns identified during medication reconciliation. RECORD/PATIENT #1: Review of the start of care assessment dated 10/06/2021 showed the patient had pain in his/her lower back daily that interfered with movement. The pain was chronic and the worst pain was rated two (a pain scale of 0-10 with zero being no pain and 10 being the worst possible pain) and the best relief was zero. Review of the plan of care (POC) dated 10/06/2021 through 12/04/2021, showed: - The patient was admitted to home health services on 10/06/2021; - Diagnoses included encounter for change or removal of nonsurgical wound dressing and non-pressure ulcer of the right thigh with fat layer; - Acetaminophen-Codeine Phosphate (Tylenol #3-used to relieve pain); - The patient will be pain free or verbalize an acceptable pain level with current pain management regimen; and - The plan of care failed to show what an acceptable level of pain was and when to notify the physician. Review of a skilled nursing visit note dated 10/17/2021 showed the patient’s current pain was rated 8 (on a scale of 0-10), described as horrible. The patient took pain medication 15 minutes prior to the nurse’s arrival. The patient had three doses of narcotic analgesic in the past 24 hours. The documentation failed to include physician notification. Review of physician office/clinic message dated 10/18/2021 showed the patient called the physician office to report the current pain medication of Tylenol #3 was not working. He/she said it dulls the pain but the pain was still really bad. The patient also stated that his/her leg pain is not relieved by taking Tylenol #3. The patient is requesting different medication. The physician ordered Norco (acetaminophen and hydrocodone) (used to treat moderate to moderately severe pain), a prescription was sent and the patient was advised. During a home visit observation on 10/25/2021 at 1:45 PM, the patient stated his/her physician ordered Norco and he/she stopped taking his/her Tylenol with codeine because it stopped working after a few hours. RECORD/PATIENT #2: Review of the clinical record, showed, in part: - The patient was admitted to home health services on 09/28/2021with a primary diagnosis of hypertensive heart disease with heart failure (high blood pressure that causes the heart’s pumping power to become weak); and - Physical therapy visit on 10/22/2021 has patient heart rate of 56 beats per minute (parameters are 60 to 100 beats per minute) with increased fatigue and unsteadiness noted; and - No documentation of physician notification noted. RECORD/PATIENT #7: Review of a clinical record showed, in part: - The patient was admitted to home health services on 10/03/2021 with a primary diagnosis of respiratory syncytial virus pneumonia (infections of the respiratory tract); - The patient has a medical history of major depressive disorder and generalized anxiety disorder; - SN (skilled nurse) note during the SOC (start of care) showed that the patient was having increased depression, anxiety at all times, family dynamic issues increasing depression, and assistance needed for an advance directive; and - Medical social worker note on 10/04/2021 showed that the patient was not interested in a social work visit. No documentation of the physician being notified of patient refusal. On 10/27/2021 at 10:45 AM, RN Lead A reported the physician was not notified of the missed visit with the medical social worker.

Revised plan of care CFR(s): 484.60(c)(2) A revised plan of care must reflect current information from the patient's updated comprehensive assessment, and contain information concerning the patient's progress toward the measurable outcomes and goals identified by the HHA and patient in the plan of care. This ELEMENT is not met as evidenced by: Based on policy review, job description, record review, and interview, the agency failed to ensure the plan of care was revised/updated to address patients' needs for one (Record/Patient #1) of six full records reviewed. This deficient practice has the potential to affect all patients served by the agency. Findings included: Review of the agency's policy dated 02/26/2019 titled, "Initial and Ongoing Assessment, Communication and Care Planning Process in Home Health,” showed, in part, the following: - Purpose: Provide guidelines for initial and ongoing assessment, treatment, and interdisciplinary collaboration, care planning and updating the plan of care to facilitate realistic patient goals; - Care planning is an interdisciplinary process that includes assessment, problem identification, goal setting, interventions and evaluation; - The physician is contacted with assessment findings and recommendations for the plan of care. The plan of care is developed, in collaboration with the physician, to facilitate progressive resolution of problems identified on admission; and - Patient care shall follow a developed plan, which is periodically reviewed by the supervising nurses or other appropriate health professionals. RECORD/PATIENT #1 Review of the plan of care (POC) dated 10/06/2021 through 12/04/2021, showed: - The patient was admitted to home health services on 10/06/2021; - Diagnoses included encounter for change or removal of nonsurgical wound dressing and non-pressure ulcer of the right thigh with fat layer; - Acetaminophen-Codeine Phosphate (Tylenol #3-used to relieve pain); - The patient will be pain free or verbalize an acceptable pain level with current pain management regimen; and - The plan of care failed to show what an acceptable level of pain was and when to notify the physician. Review of a skilled nursing note dated 10/11/2021 showed the patient had 2+ pitting edema (when excess fluid builds up in the body, causing swelling: when pressure is applied to the swollen area, an indentation, will remain) in his/her ankle, feet, and calf. The patient states it is painful when you touch the leg. The leg is red and purple in color with no open skin noted. The patient has a doctor’s appointment tomorrow (10/12/2021). - The plan of care failed to be updated to address the pitting edema. Review of a physician office/clinic note dated 10/12/2021 showed the following: - The patient’s right leg is red and swollen since last Friday (10/08/2021); - He/she has developed redness and heat on the lower part of the right leg and is tender to the touch; - Pain assessment showed: * Intensity: 10 * Location: Lower leg * Laterality: Right; - Impression: cellulitis right leg, Rocephin (treats infection) 1 gram intramuscularly (IM) today and tomorrow; and - Medication changes this visit clindamycin 600 milligrams three times a day for 10 days (the agency requested this note from the patient’s physician office after the patient’s home visit on 10/25/2021). - The plan of care failed to be updated to address the cellulitis, pain and clindamycin. Review of a skilled nursing note dated 10/14/2021 showed the patient’s right lower leg had 2+ pitting edema in his/her ankle, feet, and calf. The patient was educated to elevate feet during the day to reduce swelling per the plan of care. The patient’s right lower extremity was red and swollen due to cellulitis. - The plan of care failed to be updated to address the pitting edema and cellulitis. Review of a skilled nursing visit note dated 10/17/2021 showed the patient’s current pain was 8 (on a scale of 0-10) and “horrible”. The patient took pain medication 15 minutes prior to the nurse’s arrival. The patient had 2+ pitting edema to the right lower extremity. The patient had cellulitis and the location was the right leg with pain and tenderness of area. The skin was reddened with inflammation. - The plan of care failed to be updated to address the pain, pitting edema and cellulitis. Review of physician office/clinic message dated 10/18/2021 showed the patient called the physician office. The patient called the office and stated that his/her current pain medication of Tylenol #3 was not working. He/she said it dulls the pain but the pain was still really bad. The patient also stated that his/her leg pain is not relieved by taking Tylenol #3. The patient is requesting different medication. The physician ordered Norco (acetaminophen and hydrocodone) (used to treat moderate to moderately severe pain), a prescription was sent and the patient was advised. - The plan of care failed to be updated to address the patient’s pain and change in pain medication. During a home visit with registered nurse (RN) C on 10/25/2021 at 1:45 PM, showed the following: - Review of the patient’s medication prescription bottle showed clindamycin (antibiotic used to treat serious infections caused by bacteria) 300 mg, take 600 mg three times a day for 10 days (review of a physician note dated 10/12/2021 showed an order for clindamycin for cellulitis (a common and potentially serious skin infection) of the right leg); - The patient stated his/her physician ordered Norco and he/she stopped taking his/her Tylenol with codeine because it stopped working after a few hours; - The patient had two blisters (proximal 2 centimeters (cm) length by 5 1/2 cm width and distal 3 cm length by 1 cm width) on the top of his/her right foot; - RN C stated the blisters to the right foot started when the patient developed cellulitis; - RN C placed a wet to dry dressing over two blisters on the patient’s right foot and covered with an ABD pad (absorbent dressing). RN C applied a netting to keep the dressing in place (there was no order for treatment to the patient’s right foot); and - During a dressing change of the patient’s right inner thigh, the patient moaned aloud and said he/she normally takes Xanax (anti-anxiety) and pain medication prior to the dressing change; and - RN C said he/she did not know this and would make sure he/she called first, before the next visit, so the patient could take his/her pain medication prior to dressing change. - The plan of care failed to be updated to address the patient’s cellulitis, treatment to the right foot, and pain. During interview on 10/26/2021 at 12:14 PM, RN lead B stated he/she would expect the plan of care to be updated with changes in the patient’s condition. During interview on 10/26/2021 at 3:05 PM RN lead B stated he/she received, a progress note from the physician’s office and it showed an order for clindamycin and there was no communication of this in the patient’s medical record.

Treatments and therapy services CFR(s): 484.60(e)(3) Any treatments to be administered by HHA personnel and personnel acting on behalf of the HHA, including therapy services. This ELEMENT is not met as evidenced by: Based on record review, home visit observation, and interview, the agency failed to provide the patient/caregiver with a copy of written instructions for any treatments being administered by the agency in two (Record/Patient #1 and #2) of three home visits conducted. This deficient practice has the potential to affect all patients served by the agency. Findings included: RECORD/PATIENT #1: Review of the POC dated 10/06/2021 to 12/04/2021, showed, in part: - The patient was admitted to home health services on 10/06/2021; - Diagnoses included encounter for change or removal of nonsurgical wound dressing and non-pressure ulcer of the right thigh with fat layer; - Skilled nursing two times a week for three weeks beginning week on 10/10/2021 through 10/30/2021; and - Skilled nursing was to instruct the patient on how to apply a wet to dry dressing (a dressing that is applied moist and allowed to dry before it is removed) if the wound vacuum (type of therapy that helps wounds heal) malfunctions at night. Review of a skilled nursing visit note dated 10/17/2021 showed: - The nurse made a visit to the patient because the wound vacuum came off; - The patient couldn’t apply a wet to dry dressing until nursing could come; and - Patient educated on wet to dry dressing if wound vacuum would malfunction. During a home visit on 10/25/2021 at 1:45 PM registered nurse C stated there was no instructions for the patient, in the home, on how to change a wet to dry dressing. RECORD/PATIENT #2: Review of the clinical record showed, in part: - The patient was admitted to home health services on 09/28/2021with a primary diagnosis of hypertensive heart disease with heart failure (high blood pressure that causes that causes the heart’s pumping power to become weak); - Physical therapy needed due to increased weakness and unsteady gait/balance; and - Physical therapy visit frequency of 1 time for 1 week and 2 times a week for 5 weeks. During a home visit observation on 10/26/2021 at 10:30 AM with Physical Therapist D, the surveyor observed the patient's home admission packet. The agency failed to provide written therapy instructions. RN Lead A acknowledged findings during the observation visit. No further documentation was provided.

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 agency policy, observation, and interview, the agency failed to use standard precautions to prevent the transmission of infections and communicable diseases in one (Record/Patient #1) of three home visit observations and failed to screen visitors/non-employees for COVID-19 (pandemic infection) who entered the home health agency office. This deficient practice has the potential to affect infection control needs for all visitors/non-employees, employees and patients served by the agency. Findings included: Review of the agency's policy titled, "Hand Hygiene,” dated 11/09/2020, showed: - Purpose: To define the basic elements and procedures for hand hygiene and follow the hand hygiene guidelines published by the Centers for Disease Control and Prevention; and - Hand hygiene is the single most important measure for preventing transmission of infection, disease, and illness. Review of the agency’s policy titled, “Bag Technique for the Home Care Environment,” dated 05/06/2019, showed: - Purpose: To provide process to reduce exposure to infectious materials and protect against contamination of supplies and equipment; - The bag and its contents should be treated as clean equipment; - The bag should not be entered until hand hygiene has been completed; - When not in use, the bag should be zipped closed; and - Clean/disinfect reusable equipment prior to placing back in bag. Equipment is cleaned with alcohol wipes or approved disinfectant wipes; - Expected outcome: The bag technique process is utilized to reduce exposure to infectious materials and contamination of supplies and equipment will be minimized. RECORD/PATIENT #1: During the home visit observation on 10/25/2021 at 2:45 PM with registered nurse (RN) E showed the nurse: - Removed a zip lock bag filled with gloves from his/her bag and tossed the zip lock bag on the carpeted floor with no barrier; - Sanitized his/her hands and picked the zip lock bag off the floor and removed a pair of gloves from the bag and laid the zip lock bag back on the carpeted floor; - Laid a barrier over a chair and placed tape on top of the barrier and laid his/her lap top on another chair with no barrier; - Picked the laptop up and laid it on the chair with the clean barrier and tape; - Coughed into his/her ungloved hands; - Did not disinfect his/her hands; - Placed a clean drape on the couch and placed scissors and gauze on the clean drape; - Rummaged through a box on the side of the patient’s couch and removed a bottle of saline; - Disinfected hands and picked up the zip lock bag from the carpeted floor and removed a pair of gloves from the bag, donned gloves and used gloved hands to place the zip lock bag back on carpeted floor; - Removed dressing from the patient’s right leg inner thigh wound and placed the dirty dressing on the clean barrier on the couch; - Disinfected hands and picked up the zip lock bag from the carpeted floor and removed a pair of gloves from the bag, donned gloves and used gloved hands to place the zip lock bag back on carpeted floor; - Placed normal saline on a gauze, opened an ABD pad and placed the wet to dry dressing on the patient’s inner thigh wound; - Held his/her laptop and laid it on a chair with no barrier, did not sanitize hands and reached into the boxes on the side of the couch and removed a non-adherent dressing from the patient’s wound supplies and laid on chair with clean barrier and then placed on laptop; - Disinfected hands and picked up the zip lock bag from the carpeted floor and removed a pair of gloves from the bag, donned gloves and used gloved hands to place the zip lock bag back on carpeted floor; - Applied the a wet to dry dressing to right foot and applied the non-adherent dressing; - Disinfected hands and picked up the zip lock bag from the carpeted floor and removed a pair of gloves from the bag, donned gloves and used gloved hands to place the zip lock bag back on carpeted floor; and - Placed the zip lock bag with gloves in his/her bag without disinfecting the zip lock bag, he/she disinfected the lap top and placed in his/her bag. During an interview on 10/25/2021 at 3:13 PM, the findings were reviewed with RN C and he/she agreed with the findings. During an interview on 10/26/2021 at 12:14 PM, RN lead B stated he/she expected staff to use two barriers, one used for clean items and one used for dirty items. RN E told RN lead B he/she placed the dirty dressing on the clean barrier; the patient was in so much pain he/she messed up with the dirty dressing. No further information was provided. Related to COVID 19 Screening: The surveyors entered the agency for a recertification survey on 10/25/2021 at 10:00 AM with appropriate facemasks in place. The surveyors were greeted by staff, introductions were made and staff escorted the surveyors to a conference room. Staff failed to screen the surveyors for temperature or ask COVID-19 screening questions upon entrance. During an interview on 10/25/2021 at 3:40 PM, the clinical manager acknowledged the agency failed to provide temperature checks or COVID-19 screening to visitors upon entry and staff are responsible for their own temperature checks and COVID-19 screening.