Every finding on record at Henderson County Hospital Corporation

An onsite, un-announced recertification survey was conducted 7/14/25-7/17/25. No deficiencies to the Emergency Preparedness Plan were identified.

An onsite, unannounced recertification survey was conducted 7/14/25-7/17/25. Standard level deficiencies to the Medicare CoPs were identified.

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, direct observation, clinical record review, and staff interviews the Plan of Care [POC] failed to include all the correct/current medications the patient was taking for 3 of 6 patients who received a home visit [#6, 7, 10 ]; and failed to include complete interventions/goals for 1 of 1 patients [#6] with a PICC [peripherally inserted central catheter-intravenous access that can be used for a prolonged period of time] line; and resolved nursing interventions prematurely for 1 of 1 patients who had complications after an amputation [#12]. The findings included: 4. Patient # 6 had a Start of Care date of 7/7/25 with an admitting diagnosis of abscess of liver. Review of the Plan of Care for the certification period 7/7/25-9/4/25 included orders for SN [skilled nursing] 1 time a week for 9 weeks. Further review of the POC included the following goal: “Patient/caregiver will demonstrate proper technique for administering IV medication, flushing and maintenance of line by *”. The goal did not include a date. During an interview with the clinical manager on 7/17/25 at 2 pm the manager stated, “Yes, there should be a date there.” 5. Patient # 12 had a Start of Care date of 6/5/25 with an admitting diagnosis of other complications of amputation stump. Review of the Plan of Care [POC] for the certification period /5/25-8/3/25 included orders for SN [skilled nursing] 1 visit every week for 1 week, 2 times a week for 2 weeks, 1 time a week for 6 weeks. Review of the clinical record revealed the following nursing interventions: “Vital signs outside of established parameters will be reported to the MD in a timely fashion”. The intervention had a start date of 6/5/25 with a resolved date of 6/10/25. Review of the clinical record revealed this intervention should not have been resolved. “SN discharge planning.” The intervention had a start date of 6/5/25 with a resolved date of 6/10/25. Review of the clinical record revealed the patient was still receiving nursing services as of 6/18/25 and this intervention should not have been resolved. “SN discharge summary will be sent upon discharge.” The intervention had a start date of 6/5/25 with a resolved date of 6/5/25. Review of the clinical record revealed the patient was still receiving nursing services as of 6/18/25 and this intervention should not have been resolved. “SN to assess surgical incision site.” The intervention had a start date of 6/5/25 with a resolved date of 6/5/25. Review of the clinical record revealed the patient continued to have a wound assessment/treatment until 6/18/25. During an interview with the clinical manager on 7/17/25 at approximately 2 pm, the clinical manger stated, “We have been talking to the clinicians about resolving interventions as the patient meets each intervention, but clearly this clinician just got ahead of herself.” The clinical manager confirmed the interventions should not have been resolved. The policy, Home Health Care Planning Process [revised 1/2022], was provided by the agency director on 7/17/25 at approximately 10:52 am. The policy stated, “...A written plan of care will be initiated within five days of start of care...All clinicians will consider the conclusions of initial and ongoing assessments...not limited to...Based on the assessment and conclusions, the plan of care will include but not limited to...patient specific interventions and education...Reasonable, measurable, and individualized goals and outcomes identified...Specific services and treatments to be provided...All medications...” The policy, Home Health Medication Profile [revised 8/2024], was provided by the agency director on 7/17/25 at approximately 10:52 am. The policy stated, "...Medication profiles will be updated for each change to reflect current medications and new and/or discontinued medications..." 1. Patient #6 had a Start of Care date of 7/7/25 with an admitting diagnosis of Abscess of liver (infection in the liver that forms a puss-filled pocket). Review of the Plan of Care (POC) for the certification period 7/7/25-9/4/25 included orders for SN (skilled nursing) 1 time a week for 9 weeks. On 7/15/25 at approximately 10:15 am a joint visit was made with RN (registered nurse) #2 . During the visit a medication review was conducted using a medication profile provided by the agency. The following discrepancies were noted: The medication profile listed Magnesium Gluconate (over the counter magnesium supplement) 27.5 mg (500 mg magnesium) 1 tablet daily. The patient presented a bottle of Magnesium Tartrate 125 mg stating the patient takes 1 tablet daily. The medication profile did not list Amlodipine (used to treat high blood pressure) 5 mg 1 tablet daily, which the patient presented during the medication reconciliation and revealed she started this medication on 7/8/2025. The medication profile did not list Progesterone (hormone replacement) 100 mg daily, which the patient presented during the medication reconciliation and revealed she has been on this medication for 2 years. During an interview with the clinical manager on 7/17/25 at approximately 2:45 pm, the clinical manager confirmed the POC did not include all/correct medications. 2. Patient #7 had a Start of Care date of 6/12/25 with an admitting diagnosis of Secondary malignant neoplasm of brain (cancer that has spread to the brain). Review of the Plan of Care (POC) for the certification period 6/12/25-8/10/25 included orders for PT (physical therapy) 1 time a week for 1 week, 2 times a week for 3 weeks. On 7/15/25 at approximately 11:30 am a joint visit was made with PT #3. During the visit a medication review was conducted using a medication profile provided by the agency. The following discrepancies were noted: The medication profile listed Cholecalciferol/ Vitamin D3/ Vitamin K2 (over the counter vitamin D supplement) 125 mcg 1 tablet daily. The patient’s caregiver stated the patient took 2 tablets daily. The medication profile listed Dexamethasone (a steroid) 4 mg 1 tablet every 6 hours. The patient’s caregiver revealed that the patient was on a taper-down schedule and was now only taking 0.5 tablet daily. The medication profile listed Tizanidine (used to treat muscle spasms) 4mg 1 tablet every 8 hours as needed. During an interview with the patient’s caregiver on 7/15/25 at approximately 11:55 am, the patient’s caregiver stated, “She hasn’t been taking that for a while now.” During an interview with the clinical manager on 7/17/25 at approximately 2:50 pm, the clinical manager confirmed the POC did not include all/correct medications. 3. Patient #10 had a Start of Care date of 6/18/25 with admitting diagnoses of Non-displaced fracture of second cervical vertebra, subsequent encounter (a break in the bone of the second vertebra in the neck). Review of the Plan of Care (POC) for the certification period 6/18/25-8/16/25 included orders for OT (occupational therapy) 1 time every 2 weeks for 2 weeks, 1 time a week for 4 weeks. On 7/16/25 at approximately 1:15 pm, a joint visit was made with OT #1. During the visit a medication review was conducted using a medication profile provided by the agency. The following discrepancies were noted: The medication profile listed Hydrocodone-Acetaminophen (Opioid pain medicine) 5-325mg 1 tablet every 6 hours as needed for pain. During an interview with the patient on 7/16/25 at approximately 1:35 pm, the patient’s caregiver stated, “She was only on that for 2 doses. That’s been stopped a couple of weeks now.” The medication profile listed Furosemide (used to treat excess fluid retention) 20 mg 1 tablet daily. The patient’s caregiver stated that on Sundays, the patient takes 2 tablets. During an interview with the clinical manager on 7/17/25 at approximately 2:40 pm, the clinical manager confirmed the POC did not include all/correct medications.

Only as ordered by a physician CFR(s): 484.60(b)(1) Drugs, services, and treatments are administered only as ordered by a physician or allowed practitioner. This ELEMENT is not met as evidenced by: Based on clinical record review and staff interviews the agency failed to follow physician's orders related to wound care for 1 of 5 discharged patients [#1]. The findings included: Patient # 3 had a Start of Care date of 1/3/25 with admitting diagnoses of pressure ulcer of sacral region [base of the spine] and pressure ulcer of left and right buttock, stage 4 [severe, deep wound that extends to muscle, tendon or bone]. Review of the Plan of Care [POC] for the certification period 1/3/25-3/3/25 included orders for SN [skilled nursing] 1 visit every week for 1 week, 3 times a week for 8 weeks, 1 visit every week for 1 week and “SN to assess wound and measure every 7 days” and “Dressing instructions: Sacrum, left and Right Ischium [buttocks]-Instructions-First layer [directly against the wound] Zinc to periwound skin, Hydrofera Blue Ready Transfer. Second layer-Abd pads and tape”. Review of the clinical record revealed the patient received 20 SN visits from 1/3/25 through 2/28/25. The clinical record revealed no visit when the wounds on the sacral region or the left/right buttock was measured or assessed by the SN. The patient would refuse to allow the SN to assess or do the dressing changes. During an interview with the clinical manager on 7/16/25 at approximately 2 pm, the clinical manager stated, “He just wouldn’t let them do that wound care.” The clinical manager confirmed the physician’s order, related to the assessment and measuring the wounds, was not followed.

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, direct observations during joint visits, and staff interviews the agency failed to follow proper infections control policies for 2 of 6 patients who received a home visit [#9 and 12]. The findings included: The policy, Hand Hygiene and the Use of Skin Antiseptics [revised 9/2022] was provided by the agency director on 7/17/25 at approximately 10:52 am. The policy stated, "...Always wash/sanitize hands upon entry to the patient care area/room, and prior to departure of the patient care area/room [WASH IN/WASH OUT]...Wash/sanitize hands before having direct contact with patients, even if gloves are worn...Wash/sanitize hands after contact with inanimate objects..." The policy, Infection Control - Home Health [revised 3/24], was provided on 7/17/25 at approximately 10:52 am. The policy stated, "...Infection control includes activities at the direct care level and at the level of supporting care or services that reduce the risks of device-related and procedure related infections in patients as follows...Wound procedures..." 1.Patient # 9 had a Start of Care date of 5/22/25 with an admitting diagnosis of non-pressure chronic ulcer of other part of right foot with other specified severity. Review of the clinical record revealed a resumption of care [ROC-type of visit that is made after patient has had an in-patient stay with admission for at least 24 hours] Plan of Care [POC] dated 7/11/25-7/20/25. The diagnosis associated with the ROC POC included encounter for surgical aftercare following surgery on circulatory system. Review of the ROC POC included orders for SN [skilled nursing] 1 time a week for 1 week, 2 times a week for 1 week and “SN to perform/instruct caregiver on incision care as follows: Apply sterile 4x4s folded in half secured with medipore tape daily.” 7/16/25 at approximately 9 am a joint visit was made with RN # 7 to observe wound care to the left groin area. RN # 7 removed the old dressing and cleaned the incision site to left groin. The RN then placed a folded sterile 4x4 to the area and secured the 4x4 with tape that she had adhered to her nursing uniform pants just prior to removing the old dressing. During an interview with the agency director on 7/16/25 at approximately 4 pm, the director confirmed the RN should not have used the tape she had previously stuck to her uniform pants. 2. Patient # 12 had a Start of Care date of 6/22/25 with an admitting diagnosis of infection and inflammatory reaction due to other internal prosthetic device. Review of the Plan of Care for the certification period 6/22/25-8/20/25 included orders for PT [physical therapy] 2 times a week for 4 weeks, 1 time a week for 1 week. On 7/16/25 at approximately 3 pm a joint visit was made with PT # 4. Upon entering the residence, PT # 4 was noted to be wearing disposable gloves. PT # 4 identified the patient and began the visit. Prior to PT # 4 obtaining vital signs, she went to visit bag and removed hand sanitizer and placed on the disposable gloves and rubbed her hand together and obtained the vital signs. PT # 4 proceeded with treatment for the patient. After completing the treatment, PT # 4 went back to the visit bag and removed hand sanitizer and placed more hand sanitizer on the same disposable gloves she had been wearing when entering the home. During an interview with the agency director on 7/16/25 at approximately 4 pm, the director confirmed this was not an acceptable manner to complete hand hygiene during a home visit.

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 communicate with the physician when 1 of 1 patients failed to completed wound care as ordered [#9]; failed to communicate with the physician when 1 of 1 patients was noted to be smoking when wearing supplemental oxygen [#13]. The findings included: 2. Patient #13 had a Start of Care (SOC) date of 6/19/2025 with admitting diagnoses of Chronic Obstructive Pulmonary Disease (also known as COPD which is a group of lung diseases that block airflow and make it difficult to breathe) with acute exacerbation (sudden worsening of symptoms) and Congestive Heart Failure (also known as CHF which is a condition that happens when the heart can’t pump blood well enough to give the body a normal supply). The Plan of Care for the certification period 6/19/2025 – 8/17/2025 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 4 weeks and “SN to instruct patient/caregiver compliance with oxygen and oxygen safety precautions…call for O2 sats (saturations) less than 90% at rest”. The agency oxygen (O2) safety form lists “instructions provided on … keep oxygen away from open flame…stay at least 10 feet from anyone who is smoking”. Review of the clinical record revealed the following information: On the 7/11/25 SN visit, the LPN (licensed practical nurse) #2 charted “Pt smoking at the counter wearing 2.5L (liters) O2 (oxygen) via n/c (nasal canula). She extinguished the cigarette after SN entered home and upon sitting her O2 sat (saturation) was 87%, ranging 85-92% throughout visit.” Further review of the clinical record revealed no evidence of communication with the physician concerning the patient smoking with O2 on. During an interview with the clinical manager on 7/17/25 at 2:40 pm, the clinical manager confirmed the physician was not notified concerning the patient smoking while wearing O2. 1.Patient # 9 had a Start of Care date of 5/22/25 with an admitting diagnosis of non-pressure chronic ulcer of other part of right foot with other specified severity. The Plan of Care [POC] for the certification period 5/22/25-7/20/25 included orders for SN [skilled nursing] 1 time week for 1 week, 2 times a week for 8 weeks and “SN to perform wound care as follows: Right 4th and 5th toe daily, SN 2 times a week; Pt [patient] can do on days SN doesn’t. First layer [directly against the wound] Floss between toes with gauze moistened with vashe. Apply betadine to 5th toe and between 4th toe [sic]. Second layer: Cut aquacell [sic] [alginate] dressing to size and weave around 5th toe and secure with tape.” Review of the clinical record revealed the following information: On 5/30/25 RN # 6 entered a communication note to RN # 7. The note stated, “Pt had not been wrapping toe with alginate but has been applying betadine...” Further review of the clinical record revealed no evidence the physician was notified that the patient was not completing wound care in accordance with the physician’s order. During an interview with the clinical manager on 7/17/25 at approximately 2 pm, the clinical manager confirmed the physician was notified when the physician’s order for wound care was not being followed.

An onsite recertification survey was conducted 08/15/22-08/17/22. No deficiencies to the Emergency Preparedness Program were identified. ABH

An onsite recertification survey was conducted 08/15/22-08/17/22. Deficiencies to the Medicare Conditions of Participation were identified. ABH

Health, psychosocial, functional, cognition CFR(s): 484.55(c)(1) The patient's current health, psychosocial, functional, and cognitive status; This ELEMENT is not met as evidenced by: Based on policy review, clinical record review and staff interview the agency failed to document all wound measurements on the initial comprehensive assessment for 1 of 4 patients [#13] with a wound. The findings included: The agency policy, “Home Health wound measurements”, revised 1/2022 and provided by the agency director on 8/18/2022 at approximately 10:00 am, stated “information about the dimensions of the wounds will be collected and recorded on the initial assessment… if more than one wound is being treated, measurements for all wounds will be collected and clearly recorded for each wound number.” Patient #13 had a Start of Care of 7/14/2022 with diagnosis of Non-pressure chronic ulcer of other part of left lower leg with fat layer exposed; non- pressure chronic ulcer of other part of right lower leg with fat layer exposed. A review of the Plan of Care [POC] for the certification period 7/14/2022 through 9/11/2022 included orders for Skilled nursing [SN] 1 visit every week for 1 week; 2 visits every week for 8 weeks with 2 PRN [as needed] for any complications with a wound. The wound care orders were, “SN to cleanse wound… apply xeroform dressing… of left and right lower leg.” Documentation of the initial comprehensive assessment dated 7/14/2022 by SN #7 revealed a non-pressure chronic wounds of both legs. There was no evidence that measurements were obtained for the right leg wound. An interview with the SN #4 on 8/17/2022 at 12:25 pm, confirmed there were no measurements documented for the right leg wound on the initial comprehensive assessment.

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, client record review, and staff interview the agency failed to include all medications on the plan of care for 1 of 2 patients on oxygen (#11). Findings included: Review of a policy “Home Health Care Planning Process”, revised 01/2022 was received from the agency director on 08/18/22 at 10:50 a.m. The policy stated,” … the plan of care will include… all medications…”. Patient #11 was admitted on 07/26/22 with diagnoses of sepsis (blood infection), pneumonia, acute respiratory failure with hypoxia, anemia, atrial fibrillation, and dependence on supplemental oxygen. Review of the start of care oasis visit on 07/26/22 revealed the patient was on oxygen therapy, but it was not included on the plan of care. Interview with the nurse manager on 08/17/22 at 12:17 p.m. revealed “the patient is indeed on 4 liters of oxygen, and it is missing from the med profile and needs to be added”.

Only as ordered by a physician CFR(s): 484.60(b)(1) Drugs, services, and treatments are administered only as ordered by a physician or allowed practitioner. This ELEMENT is not met as evidenced by: Based on clinical record review and staff interview, the agency failed to obtain an order for AZO (medication used for relief of urinary discomfort) for 1 of 5 discharged patients with complaints of urinary discomfort [patient #1]; and failed to obtain an order for barrier cream for 1 of 4 patients with a wound [patient #19]. The findings included: 1. Patient #1 had a Start of Care date of 6/21/21 with a diagnosis of aftercare following joint replacement surgery. A review of the Plan of Care for the certification period of 6/21/21 through 8/19/21 had orders for physical therapy 3 visits every week for 2 weeks then 2 visits every week for 1 week. A case communication note entered by SN #4 revealed a telephone conversation with patient #1 in which the patient stated, “has some burning upon urination…” It is documented SN#4 instructed the patient to “possibly try AZO for her urinary symptoms.” Nursing director #3 on 8/16/22 at 1:37 pm stated her “instruction to my nurses is to only educate on medications on the patients medication list and not homeopathic [ pseudoscientific system of alternative medication] medications.” An interview on 8/16/22 at 1:37 pm with SN #4 confirmed she did not contact the physician to obtain an order for AZO. 2. Patient #19 had a Start of Care of 1/23/21 with a diagnosis of “pressure ulcer of right buttock, stage 3 [extends into the tissue beneath the skin]; morbid (severe) obesity…” A review of the Plan of Care for the certification period of 7/17/22 through 9/14/22 had orders for skilled nursing of 3 visits every week for 8 weeks; 2 visits every week for 1 week with 6 PRN [as needed] …” Documentation by skilled nurse [SN] #5 reported patient #19 had a “rash located on left chest in skin folds…barrier cream applied…encouraged patient to apply barrier cream…” An interview on 8/17/22 at 12:39 pm with nursing director #3 and SN #4 verified there was no evidence of an order for barrier cream to the rash.

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 policy review, clinical record review, and staff interviews the agency failed to notify the physician of urinary tract infection symptoms for 1 of 5 discharged patients [ patient #1], and a rash for 1 of 4 patients [patient #19] with a wound. Findings included: The policy “Home Health Care Coordination” revised 1/20/22, received from agency director on 8/18/22 at approximately 10:00 am stated, “It will be the responsibility of the case manager to facilitate communications about changes in the patient status among assigned personnel”. 1. Patient #1 had a Start of Care date of 6/21/21 with a diagnosis of aftercare following joint replacement surgery. A review of the Plan of Care for the certification period of 6/21/21 through 8/19/21 had orders for physical therapy 3 visits every week for 2 weeks then 2 visits every week for 1 week. A case communication note entered on 6/22/21 by employee #4 stated “pt [patient] states that she has some burning upon urination but otherwise no other s/s [signs or symptoms] UTI [urinary tract infection] …” An order on 6/24/21 stated, “Please collect U/A with culture reflex {lab that identified presence or absence UTI and appropriate antibiotic if infection is present] on 6/24/21.” Lab confirmed the patient did have a UTI. An interview with SN #4 confirmed no evidence the agency contacted the physician between 6/22/21 to 6/24/21 regarding patient #1 complaint. 2. Patient #19 had a Start of Care of 1/23/21 with a diagnosis of “pressure ulcer of right buttock, stage 3 [extends into the tissue beneath the skin]; morbid (severe) obesity…” A review of the Plan of Care for the certification period of 7/17/22 through 9/14/22 had orders for skilled nursing of 3 visits every week for 8 weeks; 2 visits every week for 1 week with 6 PRN [as needed] …” On 8/8/22 a case communication note from employee #6 to the other clinicians on patient #19 care team, stated there was “skin breakdown under left breast area which is very red.” A skilled nurse visit was also made on 8/8/22 by employee #5 It was documented, “there is a reddened area in skin folds in the left side of … chest.” Employee #5 communicated this information to the case manager. An interview with nursing director, therapy director and nurse supervisor on 8/17/22 at 12:39 pm confirmed there was no communication with the physician regarding a rash.