Every finding on record at Hillcrest Home Care Inc.

Hillcrest Home Care is in compliance with the requirements of CFR 484.102 Condition of Participation for Home Health Agencies,

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 record review, policy and procedure review, and staff interview, the agency failed to ensure the patient's medication orders on the Plan of Care and the medication profile (a real-time document used by the agency that lists the patient’s medications), were accurate, for 6 of 17 patient records reviewed (Patient 1, 4, 7, 9, 17, and 18). The total sample size was 17. The census was 377 (279 in the Bellevue office and 98 in the Lincoln branch). Findings are: A. Review of the agency’s policy and procedure titled 6.3 Medication Reconciliation And Administration, revised date 10/18/22, revealed: 1.On admission and during the comprehensive assessment, the professional team member was to reconcile all medications, including over-the counter medications. 2. The clinician was to report any identified problems to the client’s physician within one day of an identified discrepancy. 3. The nurse/therapist was to record all medications the client was taking on the Plan of Care and the Medication Profile. B. Review of Patient 1’s clinical record revealed: 1.The Order Summary Report from Fallbrook Assisted Living and Memory Care to the agency, dated 9/10/24, included orders for: a. Antacid Chew (medication that relieves indigestion and heartburn) 750 mg (milligrams), 2 tablets, orally, after every evening meal. b. Clotrimazole Cream (medication used to treat fungal skin infection) 1%, apply topically between left great toe and 2nd toe, two times daily, as needed for skin breakdown. c. Dorzol/Timol Solution (medication used to treat increased eye pressure) 22.3-6.8, instill 1 drop in each eye, two times daily. d. Warfarin (medication used to treat or prevent blood clots) 1mg, 1 tablet, orally, on Mondays. e. Warfarin 3mg, 1 tablet, orally, on Tuesdays, Thursdays, Fridays, and Saturdays. 2. The Patient’s Home Health Certification and Plan of Care (POC) for the certification period 9/11/24 through 11/9/24, and the medication profile, revealed: a. Calcium Carbonate Antacid (same as Antacid Chew), 750mg, 2 tablets, every night at bedtime. b. Clotrimazole Cream 1%, apply topically to feet and in between toes, daily, as needed for fungal infection. c. Dorzolamide HCL – Timolol Mal 2-0.5% (same as Dorzol/Timol Solution), instill 1 drop in each eye, daily. d. Warfarin 4mg, orally, 1 tablet, four times weekly, on Mondays, Wednesdays, Fridays, and Saturdays. 3. There was no documentation in the clinical record of medication reconciliation of Calcium Carbonate Antacid, Clotrimazole Cream, Dorzolamide HCL, and Warfarin, with the physician. C. Review of Patient 4’s clinical record revealed: 1. The Order Summary Report from Hillcrest Health & Rehab to the agency, dated 10/1/24, included orders: a. Tramadol (a medication used to treat pain) 50 mg, orally, 1 tablet, every 6 hours, as needed for pain. b. Cholecalciferol (a Vitamin D supplement) 25 mcg (microgram), 1 tablet, orally, every morning. c. Lidocaine External Patch (a medication to treat pain) 4%, apply topically to lower back, every 24 hours, as needed for pain. 2.The POC for the certification period 10/4/24 through 12/2/24, and the medication profile, revealed: a. Cholecalciferol 50 mcg, 1 capsule, orally, every morning. b. Tramadol and Lidocaine External Patch were not included. 3. There was no documentation in the clinical record of medication reconciliation of Cholecalciferol, Tramadol, and Lidocaine External Patch, with the physician. D. Review of Patient 7’s clinical record revealed: 1.The Medication Review Report from Hillcrest Millard to the agency, dated 10/1/24, included orders, and the POC for the certification period 10/5/24 through 12/3/24, and the medication profile, failed to include: a. Albuterol Sulfate (a medication used to treat difficult breathing), 2 puffs, inhale, every 6 hours, as needed for shortness of breath/wheezing. b. Allopurinol (a medication used to treat joint pain and inflammation) 100 mg, 1 tablet, orally, one time daily. c. Antacid tablet 500 mg, 2 tablets, orally, every 4 hours, as needed, for heartburn/indigestion. d. Atorvastatin Calcium (a medication used to treat high cholesterol) 40 mg, orally, 1 tablet at bedtime. e. Bisacodyl Laxative Suppository (a medication to treat constipation) 10 mg, 1 suppository inserted rectally, every 48 hours, as needed for constipation. f. Fleets Enema (a treatment used to treat constipation) 1 application inserted rectally, every 24 hours, as needed for constipation. g. Glucagon Emergency Injection Kit (used to treat low blood sugar) 1 millimeter, injected intramuscularly, as needed for low blood sugars. h. Ibuprofen (a medication used to treat pain) 200 mg, orally, 1 tablet, every 6 hours, as needed for pain. i. Insulin Aspart (a medication used to treat diabetes) 100 units/ml (a measurement of medication) inject subcutaneously (beneath the skin) three times daily with meals, per sliding scale (number of units of insulin injected based on blood sugar reading). j. Insulin Glargine (a medication used to treat diabetes) 100 units/ml, 35 units, injected subcutaneously, every day at bedtime. k. Jardiance (a medication used to treat diabetes) 10 mg, orally, 1 tablet, one time daily. l. Metformin (a medication used to treat diabetes) 1000 mg, orally 1 tablet, two times daily. m. Naloxone (a medication used to treat opioid overdose) 0.4 mg/ml (milliliter), inject 1 ml intramuscularly every 2 minutes as needed, for opioid overdose. n. Polyethylene Glycol (a medication used to treat constipation) 17 grams, orally, two times daily. o. Senna Plus (a medication used to treat constipation) 8.6-50 mg, orally, 2 tablets two times daily, as needed for constipation. p. Spironolactone (a medication used to treat high blood pressure) 25 mg, orally, ½ tablet, one time daily. q. Thiamine (a vitamin B1 supplement) 100 mg, orally, 1 tablet, every morning. 2. There was no documentation in the clinical record of medication reconciliation, with the physician. E. Review of Patient 9’s clinical record revealed: 1.The referral orders and the After Visit Summary from Nebraska Medicine Neurology Clinic, dated 8/29/24, to the agency, included: a. Pyridium (a medication used to relieve irritation in the urinary tract) 95 mg, 1 tablet, orally, three times daily, as needed for pain. b. CatecholaCalm (an herbal supplement to improve mood), dosage and frequency not listed. This was a patient reported medication. c. NeuroCalm (a supplement to improve mood), dosage and frequency not listed. This was a patient reported medication. 2. The POC for the certification period 9/5/24 through 11/3/24, and the medication profile, failed to include Pyridium, CatecholaCalm and NeuroCalm. 3. There was no documentation in the clinical record of medication reconciliation of Pyridium, CatecholaCalm, and NeuroCalm, to the physician. F. Review of Patient 17’s clinical record revealed: 1.The referral orders and Medication Review Report from Pemberly Place Senior Living, dated 5/20/24, to the agency, included orders for Aspirin low dose (a medication used to prevent heart attack and stroke) 81 mg, orally, 1 tablet, on Mondays, Wednesdays, and Fridays. 2. The POC for the certification period 5/22/24 through 7/20/24, and the medication profile, revealed, Aspirin 81 mg, orally, 1 tablet, as needed, on Mondays, Wednesdays, and Fridays. 3. There was no documentation in the clinical record of medication reconciliation, with the physician. G. Review of Patient 18’s clinical record revealed: 1.The Order Summary Report from Hillcrest Heath and Rehab, dated 10/21/24, to the agency, included orders: a. Alendronate Sodium (a medication to help keep bones strong) 70 mg, 1 tablet, orally, every Friday. b. Metformin HCL (a medication to treat diabetes) 500 mg, orally, 1 tablet, two times daily. c. Senna Plus (a medication to treat constipation) 8.6-50 mg, orally, 2 tablets, two times daily, as needed for constipation, was discontinued. 2. The POC for the certification period 10/24/24 through 12/22/24, and the medication profile, revealed: a. Alendronate Sodium 70 mg, orally, 1 tablet, daily. b. Sennosides-Docusate Sodium (same as Senna Plus) 8.6-50 mg. Dosage and frequency were not included. c. Metformin was not included. 3. There was no documentation in the clinical record of medication reconciliation, with the physician. H. During an interview on 10/31/24 at 2:00 PM, the Administrator confirmed, the agency failed to follow the agencies policy and procedure to ensure the patient's medication orders on the Plan of Care and the medication profile, were accurate, for 6 of 17 patient records (Patient 1, 4, 7, 9, 17, and 18).

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 record review, policy and procedure review, observation of the provision of care, and staff interview, the agency failed to ensure 1 of 7 staff (Staff I), observed during the provision of care for 1 of 7 patients (Patient 6), performed proper hand hygiene and bag technique, according to the agency's policies and procedures. The total sample size was 17. The census was 377 (279 in the Bellevue office and 98 in the Lincoln branch). Findings are: A. Review of the agency’s policy and procedure titled 4.3 Bag Technique, effective date 3/1/24, revealed the home care bag was not to be placed on the floor unless it is a wheeled bag. B. Review of the agency’s policy and procedure titled 4.0 Infection Prevention, effective date 3/1/24, revealed hand hygiene was to be performed: 1.Before performing an aseptic task. 2. When moving from a contaminated body site to a clean body site, during client care. 3. Before application of and after removal of personal protective equipment. C. Review of Patient 6’s Home Health Certification and Plan of Care (POC) for the certification period 9/20/24 through 11/17/24, included orders for Skilled Nursing, to change the suprapubic catheter (a tube inserted into the bladder from an incision in the lower abdomen, to drain urine) every 2 weeks and as needed for leaking. D. The observation of the provision of care to Patient 6 on 10/30/24 at 1:00 PM, revealed Staff I failed to: 1. Place the nursing bag on a surface off the floor. 2. Sanitize hands prior to applying gloves, to set up catheter equipment. 3. Sanitize hands after removing the suprapubic catheter from the patient’s bladder, and prior to applying sterile gloves, to insert a new suprapubic catheter into the bladder. E. During an interview on 10/31/24 at 2:00 PM, the Administrator confirmed Staff I failed to follow the agency’s policies and procedures for bag technique and hand hygiene, during the provision of care for Patient 6.

An unannounced recertification survey and a complaint investigation were completed on 10/21/21. The allegations were unsubstantiated and no deficiencies were cited. The agency census was 348. Hillcrest Home Care is in compliance with the requirements of 42 CFR 484.102 Condition of Participation for Home Health Agencies.

An unannounced recertification survey and complaint investigation were completed on 10/21/21. The allegations were unsubstantiated and no deficiencies were cited related to the allegations. Unrelated deficiencies were cited at G520 and G572. The agency census was 348.

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 record review, policy and procedure review, and staff interview the agency failed to ensure Physical Therapy (PT) and/or Occupation Therapy (OT) performed a comprehensive assessment in a timely manner unless a delay was requested by the patient or the patient’s physician for 4 of 17 clinical records reviewed (Patient 9, 10, 11, and 17). The census was 348. Findings are: A. Review of the agency policy and procedure titled 1.11 Range of Services to be Provided, revised 8/10/2020, revealed PT and OT services are to be provided according to physician orders and plan of care. It does not provide a time frame for timely implementation of the physician orders for services. B. Review of the agency policy and procedure titled 6.0 Coordination of Care, effective 1/31/19, revealed the Clinical Care Coordinator (Clinical Manager) was to direct client-team member assignments to allow for maximum efficacy of quality of care delivery. This policy does not provide time frames for the timely implementation of services. C. Review of Patient 9’s clinical record revealed: 1. The Start of Care (SOC) assessment was completed by the PT on 9/16/21. The assessment identified the patient needed assistance by another person to use the tub or shower, falls in bathroom within past year with fractures, and needed maximum assist with dressing. The assessment revealed coordination was conducted with the physician, the patient, and OT. 2. An order on 9/16/21 to the patient’s physician included the patient was being seen by home health care (HHC) PT/OT following hospitalization. 3. A case conference note with the HHC team included an OT evaluation needed for cognition and bathing safety the week of 9/20/21 (9/19/21 through 9/25/21). 4. An OT evaluation and Plan of Care was completed on 9/27/21 (11 days after the need identified by PT and the physician order dated 9/16/21). 5. There was no documentation in the clinical record the patient or physician requested a later OT evaluation date. D. Review of Patient 10’s clinical record revealed: 1. A physician order signed 8/17/21 for home health PT, OT, HHA, RN and SW. 2. The Skilled Nurse SOC assessment dated 8/19/21, identified the need for OT evaluation to include a shower assessment. The assessment revealed coordination was conducted with the physician, the patient and OT. 3. An OT evaluation and Plan of Care was completed on 8/27/21 (8 days after the SOC date). 4. There was no documentation in the clinical record the patient requested a delay in the OT evaluation. E. Review of Patient 11’s clinical record revealed: 1. A referral for home health care with verbal orders for Skilled Nurse (SN), PT, OT, and Home Health Aide (HHA), from the certifying physician dated 9/13/21. 2. The patients SOC date was 9/15/21. 3. There was no documentation to indicate a PT assessment was attempted prior to 9/30/21 (15 days after SOC). 4. A PT note dated 9/30/21 noted the patient’s daughter requested a PT evaluation be completed the week of 10/3/21 through 10/9/21) due to multiple oncology appointments. 5. Patient was hospitalized 9/27/21 through 9/28/21. F. Review of Patient 17’s clinical record revealed: 1. A referral to HHC on 7/27/21 included orders for PT, OT, SN, and HHA. 2. The patient’s SOC was 8/2/21. 3. A case conference note sent to the patient’s physician dated 8/2/21, included information that PT was to see patient “this week” (8/2/21 through 8/7/21), and OT “next week” 8/8/21 through 8/14/21). 4. The patient was hospitalized 8/13/21. 5. There was no documentation in the clinical record of a PT or OT evaluation completed prior to 8/13/21 (11 days after SOC). 6. There was no documentation in the clinical record to indicate the patient or physician requested a delay in the PT or OT evaluations. G. During an interview on 10/21/21 at 08:30 AM, the Administrator confirmed the PT and/or OT did not complete a comprehensive therapy assessment in a timely manner, did not document a request by the patients physician or the patient to delay a PT and/or OT assessment, and did not have a policy defining a when timely assessment implementation is expected.

Plan of care CFR(s): 484.60(a)(1) Each patient must receive the home health services that are written in an individualized plan of care that identifies patient-specific measurable outcomes and goals, and which is established, periodically reviewed, and signed by a doctor of medicine, osteopathy, or podiatry acting within the scope of his or her state license, certification, or registration. If a physician or allowed practitioner refers a patient under a plan of care that cannot be completed until after an evaluation visit, the physician or allowed practitioner is consulted to approve additions or modifications to the original plan. This STANDARD is not met as evidenced by: Based on record review, policy and procedure review, and staff interview, the agency failed to notify the physician when the agency staff were unable to complete Skilled Nursing (SN) and or Home Health Aide (HHA) services according to the frequency ordered on the physician approved plan of care for 5 of 17 clinical records reviewed (Patient 1, 2, 10, 11, and 15). The census was 348. Findings are: A. Review of the agency policy and procedure titled, 2.4 Client Cancellations, revised 7/8/18, revealed the agency was to send a missed visit report to the physician of missed visits that result in a deviation from the ordered plan of care. B. Review of Patient 1’s clinical record revealed: 1. The Plan of Care for the certification period of 8/19/21 through 10/17/21 included orders for SN 2 times a week for 1 week, then 1 time a week for 3 weeks. 2. One SN visit was conducted the week of 8/15/21 through 8/21/21 (patient week 1). There was no second SN visit conducted. 3. There was no documentation in the clinical record that the physician was notified of the missed SN visit the week of 8/15/21 through 8/21/21. C. Review of Patient 2’s clinical record revealed: 1. The Plan of Care for the certification period of 9/25/21 through 11/23/21 included orders for HHA services 2 times per week starting 9/27/21. 2. A HHA visit was conducted on 10/1/21. There was no documentation of a second visit conducted the week of 9/26/21 through 10/2/21. There was no documentation the clinical manager was notified of the missed visit. 3. A HHA Patient Missed Visit form notifying the clinical manager of the patient’s refusal of a second visit by the HHA the week of 10/3/21 through 10/9/21. 4. There was no documentation the physician was notified of a missed second visits by the HHA the weeks of 9/26/21 through 10/2/21 and 10/3/21 through 10/9/21. D. Review of Patient 10’s clinical record revealed: 1. The Plan of Care for the certification period of 8/19/21 through 10/17/21 included orders for HHA services 2 times per week. 2. A HHA Patient Missed Visit form notifying the clinical manager of the patient’s refusal of a second visit by the HHA the week of 9/19/21 through 9/25/21. 3. There was no documentation the physician was notified of a missed second visit by the HHA the week of 9/19/21 through 9/25/21. E. Review of Patient 11’s clinical record revealed: 1. A resumption of care order dated 10/5/21 included orders for SN 1 time per week for 3 weeks. 2. There was no documentation of a SN visit the week of 10/10/21 through 10/16/21. 3. There was no documentation the physician was notified of the missed visit by the SN the week of 10/10/21 through 10/16/21. F. Review of Patient 15’s clinical record revealed: 1. The Plan of Care for the certification period 5/3/21 through 7/1/21 included orders for SN services 2 times a week for 1 week, then 1 times a week for 3 weeks. 2. There was no documentation of a SN visit the week of 5/23/21 through 5/29/21. 3. There was no documentation the physician was notified of the missed SN visit the week of 5/23/21 through 5/29/21. G. During an interview on 10/21/21 at 08:30 AM, the Administrator confirmed the SN and/or HHA did not complete visits as ordered on the POC and there was no documentation the physician was notified of the missed SN and/or HHA visits for Patients 1, 2, 10, 11, and 15.