Every finding on record at Holton Home Health LLC

On behalf of the Centers for Medicare & Medicaid Services (CMS), an unannounced on-site Recertification Survey (643B5-H1) at the above-named Home Health Agency on 09/24/24-09/25/24, resulted in the following standard level deficiency respective to the Emergency Preparedness Program Conditions of Participation under 42 CFR 484.102.

HHA Comprehensive Assessment in Disaster CFR(s): 484.102(b)(1) §484.102(b)(1) Condition for Participation: [(b) Policies and procedures. The HHA must develop and implement emergency preparedness policies and procedures, based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, and the communication plan at paragraph (c) of this section. The policies and procedures must be reviewed and updated at least every 2 years. At a minimum, the policies and procedures must address the following:] (1) The plans for the HHA's patients during a natural or man-made disaster. Individual plans for each patient must be included as part of the comprehensive patient assessment, which must be conducted according to the provisions at §484.55. This STANDARD is not met as evidenced by: Based on record review, observation, document review and interview, the Home Health Agency (HHA) failed to develop and implement an individual Emergency Preparedness Plan (EPP) for each patient, as a part of the comprehensive assessment for 7 (Patients 1-7) of 7 sample patients reviewed. This failure to develop individual EPP plans for each patient placed all patients at risk for harm during an emergency situation. Findings Include: Observations during three home visits on 09/25/24, between 10:00AM and 11:45 AM, showed there were no individualized plans documented for the patients. Review of agency documentation provided to patients and discussion of emergency preparedness plans confirmed there were no individualized developed and implemented found for patients. Review of Patient records 1 through 7 showed the agency lacked documented evidence by agency professional staff of an individual emergency preparedness plan developed as part of the comprehensive assessment for each patient. Review of the agency's Emergency Preparedness Program showed the agency failed to include plans for individual patients during a natural or man-made disaster. During an interview on 09/25/24 at 4:05 PM, Staff A, Administrator, confirmed there were no individualized emergency preparedness plans for patients, based upon the comprehensive assessment of the patients.

On behalf of the Centers for Medicare & Medicaid Services (CMS), an unannounced on-site Recertification survey (#643B5-H1) conducted at the above-named Home Health Agency (HHA) from 09/24/24 to 09/25/24 resulted in a finding of substantial compliance respective to applicable Condition of Participation (CoP) under 42 CFR 484, Subpart A through C with the following standard-level deficiencies cited.

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 record review and staff interview, the Home Health Agency (HHA) failed to obtain physician orders, prior to providing wound care treatments for 1 (Patient 1) of 7 sample patients reviewed. This deficient practice placed all patients at risk for adverse outcomes due to provision of treatments without physician orders. Findings Include: Review of Patient 1's clinical record showed the, "Home Health Certification and Plan of Care," (POC), with a Start of Care date of 09/06/24 and a certification period from 09/06/24 to 11/04/24. The principal diagnosis showed: spinal stenosis with orders for Skilled Nursing one time per week for three weeks. The POC showed Physical Therapy one time per week for four weeks and Occupational Therapy two times per week for one week, then three times per week for two weeks, and then two times per week for one week. There were no orders found for Skilled Nursing to provide wound care. Review of the start of care note from Staff B, Registered Nurse (RN), showed wound care had been provided to a small pressure sore. Staff B documented, "Patient has small pressure sore on coccyx, cleansed with his pressure sore cleanser and cream applied." Review of the patient medications listed on the Plan of Care lacked documentation of cleansers or creams, ordered to be used on the patient. There was no documentation to support Staff B spoke with a physician to clarify the need for wound care, prior to performing the wound care treatment. During an interview on 09/25/24 at 3:50 PM, Staff A, Administrator confirmed that no order had been obtained from the physician, prior to providing wound care for the patient.

On behalf of the Centers for Medicare & Medicaid Services (CMS), an unannounced on-site Recertification Survey ASPEN #RL1Y11 at the above-named Home Health Agency (HHA) from 10/06/21 to 10/09/21 resulted in a finding of no deficiency citations respective to the Emergency Preparedness Program Condition of Participation under 42 CFR 484.22.

On behalf of the Centers for Medicare & Medicaid Services (CMS), an unannounced on-site Recertification Survey RL1Y11 conducted at the above-named Home Health Agency (HHA) from 10/06/21 to 10/09/21 resulted in a finding of substantial compliance respective to applicable Condition of Participation (CoP) under 42 CFR 484, Subpart A through C with the following standard-level deficiencies cited: Unduplicated census: 181 Sample Size: 7

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 observations, interviews, record reviews and policy reviews, the Home Health agency failed to conduct a medication regimen review (a review of all patient medications done to avoid medication errors such as duplications or drug interactions) for 1 of 7 patients (Patient 5) at the time of Patient 5's admission. This failure resulted in a duplicate medication showing on Patient 5's Plan of Care (POC - a comprehensive plan that includes medications and interventions that guides the staff in providing patient care) and had the potential for the patient to take an incorrect dosage of the medication and become ill. Findings Include: Review of an agency policy titled, "Drug Regimen Review- Home Health and Hospice," revised 05/2021, showed that medication regimen reviews were to be done at the time of a patient's admission to the agency. Review of Patient 5's clinical record, "Home Health Certification and Plan of Care (POC)," dated 09/20/2021, showed that Patient 5 was admitted to the agency on 09/13/21, with diagnoses that included hypertension (high blood pressure) and falls. During an observation conducted in Patient 5's home on 10/07/21 at 1:00 PM, Staff B, Clinical Manager (CM) reviewed Patient 5's list of medications and stated that the list contained a duplicate order for metoprolol (a medication to treat high blood pressure). Review of Patient 5's clinical record, "POC," dated 09/20/21, showed that Patient 5 was taking metoprolol succinate extended release (ER) 25 milligram (mg), one tablet by mouth per day starting 09/13/21 and metoprolol succinate ER 25 mg one tablet by mouth per day for hypertension, hold for pulse less than 60 beats per minute, starting 09/13/21. Review of Patient 5's clinical record, "Verbal Order," dated 10/07/21, showed that the order for metoprolol succinate ER 25 mg, one tablet by mouth per day starting 09/13/21, was discontinued on 10/07/21. During an interview conducted on 10/08/21 at 2:05 PM, Staff B, CM confirmed that Patient 5's POC dated 09/20/21contained a duplicate order for metoprolol that was not discontinued until 10/07/21. Staff B stated that drug regimen reviews were to be completed at the time of a patient's admission to identify duplicate medication orders and acknowledged that the agency had not followed policy.

Rehab services supervised by PT, OT CFR(s): 484.75(c)(2) Rehabilitative therapy services are provided under the supervision of an occupational therapist or physical therapist that meets the requirements of §484.115(f) or (h), respectively. This ELEMENT is not met as evidenced by: Based on interview, record reviews, and policy reviews, the Home Health agency failed to ensure the Physical Therapist (PT) supervised a Physical Therapy Assistant (PTA) for 1 of 1 patient (Patient 1). This failure had the potential for Patient 1 to not receive treatments as ordered or additional therapy assessments if needed. Findings Include: Review of an agency policy titled, "Coordination of Service- Physical Therapy," revised 07/2014, showed that the agency provided physical therapy services to patients by a Physical Therapist (PT) or by a PTA under the supervision of a PT. Review of Patient 1's clinical record, "Home Health Certification and Plan of Care (POC)," dated 09/08/21, showed that Patient 1 was admitted to the agency on 09/02/21, with diagnoses that included aftercare following a joint replacement surgery, an artificial left knee, a history of falling, and high blood pressure. Further review indicated that Patient 1 was assessed by a PT on 09/02/21, and that Patient 1 was to receive ongoing physical therapy services from the agency. Review of Patient 1's clinical record, "Physical Therapy Visit Notes," showed that Patient 1 received physical therapy services from a PTA on 09/14/21, 09/16/21, 09/17/21, 09/21/21, 09/22/21, 09/24/21, 09/27/21, 09/29/21, and 10/08/21. Review of Patient 1's entire clinical record did not show documentation of PT supervision of the PTA. During an interview conducted on 10/08/21 at 2:05 PM Staff B, Clinical Manager (CM), stated that agency policy was that a PT completed a supervisory PTA visit every 30 days. Staff B confirmed that Patient 1 was receiving physical therapy services for at least 30 days. Staff B was unable to provide any documentation of a completed supervisory PTA visit. Staff B confirmed that a supervisory visit was not done and acknowledged that the agency was not following policy.

Assure patient needs are continually assessed CFR(s): 484.105(c)(4) Assuring that patient needs are continually assessed, and This ELEMENT is not met as evidenced by: Based on observations, interviews, and record reviews, the Home Health agency failed to ensure that the medication profile (a list of all the medications that a patient was taking) assessments were completed during every Physical Therapy Assistant (PTA) visit for five of six patients (Patients 1, 3, 4, 5, and 6). This failure had the potential to increase the risk of medication duplications or other medication errors for these patients. Findings Include: 1. Review of Patient 1's clinical record, "POC," dated 09/08/21, showed that Patient 1 was admitted to the agency on 09/02/21 with diagnoses that included aftercare following a joint replacement surgery, an artificial left knee, a history of falling, and high blood pressure. Further review indicated that Patient 1 was assessed by a Physical Therapy (PT) on 09/02/21, and that Patient 1 was to receive ongoing physical therapy services from the agency. Review of Patient 1's clinical record, "Physical Therapy Visit Notes," showed that Patient 1 received physical therapy services from a PTA on 09/14/21, 09/16/21, 09/17/21, 09/21/21, 09/22/21, 09/24/21, 09/27/21, 09/29/21, and 10/8/21, and that Patient 1's medication profile was documented as "not assessed" during each of these visits. 2. Review of Patient 3's clinical record, "Home Health Certification and Plan of Care (POC)," dated 10/06/21, showed that Patient 3 was admitted to the agency on 10/01/21 with diagnoses that included cellulitis of the left leg (a serious infection of the skin), methicillin resistant staph infection (MRSA - a bacteria that is resistive to most antibiotics), depression, and heart disease. Further review showed that Patient 3 was assessed by a PT on 10/01/21 and was to receive ongoing physical therapy services from the agency. During an observation conducted in Patient 3's home in an assisted living facility (ALF) on 10/07/21 at 10:40 AM, Staff D, PTA did not assess Patient 3's medication profile. During an interview on 10/07/21 at 11:35 AM Staff C, PTA confirmed that they did not assess Patient 3's medication profile during Patient 3's 10/07/21 visit, and that sometimes the PTA would ask patients if they had any changes to their medications if the patient was recently seen by a doctor prior to Staff D visiting the patient. Review of Patient 3's clinical record, "Physical Therapy Visit Notes," showed that Patient 3 received physical therapy services from a PTA on 10/04/21, 10/05/21, and 10/07/21, and that Patient 3's medication profile was documented as "not assessed" during each of these visits. 3. Review of Patient 4's clinical record, "POC," dated 09/28/21, showed that Patient 4 was admitted to the agency on 09/24/21 with diagnoses that included cervical disc degeneration (a condition where the cushioning discs in the spine break down and cause pain), bilateral osteoarthritis of the knee (a condition where a joint becomes swollen and painful), gout (a condition where joints become inflamed), and hyperlipidemia (an increase of cholesterol in the body). Further review showed that Patient 4 was assessed by a PT on 09/24/21, and was to receive ongoing physical therapy services from the agency. Review of Patient 4's clinical record, "Physical Therapy Visit Notes," showed that Patient 4 received physical therapy services from a PTA on 09/028/21, 09/30/21, 10/04/21, and 10/08/21, and that Patient 4's medication profile was documented as "not assessed" during each of these visits. 4. Review of Patient 5's clinical record, "POC," dated 09/20/21, showed that Patient 5 was admitted to the agency on 09/13/21, with diagnoses that included a spinal fracture, pain, osteoarthritis, depression, hyperlipidemia, and high blood pressure. Further review indicated that Patient 5 was assessed by a PT on 09/13/21, and that Patient 5 was to receive ongoing physical therapy services from the agency. Review of Patient 5's clinical record, "Physical Therapy Visit Notes," showed that Patient 5 received physical therapy services from a PTA on 09/16/21, 09/17/21, 09/21/21, 09/22/21, 09/28/21, 09/29/21, 10/04/21, and 10/05/21, and that Patient 5's medication profile was documented as "not assessed" during each of these visits. 5. Review of Patient 6's clinical record, "POC," dated 04/15/21, showed that Patient 6 was admitted to the agency on 04/14/21 with diagnoses that included sciatica (severe pain caused by compression of a nerve in the person ' s spine) of the right side, muscle weakness, chronic obstructive pulmonary disease (COPD - a condition where the airway in the lung narrow making it had to breathe), heart failure, chronic kidney disease, and gastro-esophageal reflux disease (GERD - a condition where stomach acid flows up into the throat). Further review indicated that Patient 6 was assessed by a PT on 04/14/21, and that Patient 6 was to receive ongoing physical therapy services from the agency. Review of Patient 6 ' s clinical record, "Physical Therapy Visit Notes," showed that Patient 6 received physical therapy services from a PTA on 04/16/21, 04/21/21, and 04/30/21, and that Patient 6's medication profile was documented as "not assessed" during each of these visits. During an interview on 10/08/21 at 8:54 AM, Staff A, Home Health Director (HHD), stated that the facility policy was that PTAs were to assess patients' medication profiles at each visit. Staff A acknowledged that the agency was not following policy. The agency did not provide a policy related to medication profile assessment.

Interventions and patient response CFR(s): 484.110(a)(2) All interventions, including medication administration, treatments, and services, and responses to those interventions; This ELEMENT is not met as evidenced by: Based on interviews, record reviews, and agency document reviews, the Home Health agency failed to ensure that patients' clinical records included all patient interventions performed by staff when physical therapy staff did not record vital signs at every visit for 4 of 7 patients (Patients 1, 4, 5 and 6). This failure had the potential for these patients to experience signs and symptoms of a decline in their health that were unrecorded by staff. Findings Include: 1. Review of Patient 1's clinical record, "Home Health Certification and Plan of Care (POC)," dated 09/08/21, showed that Patient 1 was admitted to the agency on 09/02/21, with diagnoses that included aftercare following a joint replacement surgery, an artificial left knee, a history of falling, and high blood pressure. Review of Patient 1's clinical record, "Physical Therapy Visit Notes," dated 09/07/21, showed no documentation of Patient 1's temperature measurement. Review of Patient 1's clinical record, "Physical Therapy Visit Notes," dated 09/24/21, showed no documentation of Patient 1's blood pressure measurement. Review of Patient 1's clinical record, "Physical Therapy Visit Notes," dated 09/29/21, showed no documentation of Patient 1's temperature measurement. Review of Patient 1 ' s clinical record, "Physical Therapy Visit Notes," dated 10/20/21, showed no documentation of Patient 1's temperature or pulse (heart rate) measurements. During an interview on 10/08/21 at 8:54 AM Staff B, Clinical Manager (CM), stated that the facility policy was that therapy staff were to measure a patient's temperature, pulse, and blood pressure at each therapy visit and document the measurements in the patients' clinical records. 2. Review of Patient 4's clinical record, "POC," dated 09/28/21, showed that Patient 4 was admitted to the agency on 09/24/21, with diagnoses that included cervical disc degeneration (a condition where the cushioning discs in the spine break down and cause pain), bilateral osteoarthritis of the knee (a condition where a joint becomes swollen and painful), gout (a condition where joints become inflamed), and hyperlipidemia (an increase of cholesterol in the body). Review of Patient 4's clinical record, "Physical Therapy Visit Notes," dated 09/28/21, showed no documentation of Patient 4's temperature measurement. Review of Patient 4's clinical record, "Physical Therapy Visit Notes," dated 10/08/21, showed no documentation of Patient 4's temperature measurement. 3. Review of Patient 5's clinical record, "POC," dated 09/20/21, showed that Patient 5 was admitted to the agency on 09/13/21, with diagnoses that included a spinal fracture, pain, osteoarthritis, depression, hyperlipidemia, and high blood pressure. Review of Patient 5's clinical record, "Physical Therapy Visit Notes," dated 09/16/21, showed no documentation of Patient 5's temperature measurement. Review of Patient 5's clinical record, "Physical Therapy Visit Notes," dated 09/22/21, showed no documentation of Patient 5's pulse or blood pressure measurements. Review of Patient 5 ' s clinical record, "Physical Therapy Visit Notes," dated 10/01/21, showed no documentation of Patient 5 ' s pulse or blood pressure measurements. Review of Patient 5's clinical record, "Physical Therapy Visit Notes," dated 10/04/21, showed no documentation of Patient 5 ' s temperature measurement. Review of Patient 5's clinical record, "Physical Therapy Visit Notes," dated 10/07/21, showed no documentation of Patient 5's temperature measurement. 4. Review of Patient 6's clinical record, "POC," dated 04/15/21, showed that Patient 6 was admitted to the agency on 04/14/21, with diagnoses that included sciatica (severe pain caused by compression of a nerve in the person ' s back) of the right side, muscle weakness, chronic obstructive pulmonary disease (COPD - a condition where the airway in the lung narrow making it had to breathe), heart failure, chronic kidney disease, and gastro-esophageal reflux disease (GERD-a condition where stomach acid flows up into the throat). Review of Patient 6's clinical record, "Physical Therapy Visit Notes," dated 04/23/21, showed no documentation of Patient 6's temperature measurement. During a concurrent interview and record review on 10/08/21 at 2:00 PM, Staff B, Clinical Manager (CM), confirmed that therapy staff were not documenting patients' temperatures, pulse rates, and blood pressure measurements at each therapy visit in the clinical record and acknowledged that the agency was not following policy. The agency did not provide a policy related to vital sign documentation in the clinical record.

Registered Nurse CFR(s): 484.115(k) Standard: Registered nurse. A graduate of an approved school of professional nursing who is licensed in the state where practicing. This STANDARD is not met as evidenced by: Based on interviews, facility document reviews, and review of the State of Kansas nursing licensure board website, the Home Health agency failed to ensure that all licensed nursing staff had a current state license. This failure had the potential for patients to receive care from a nurse who may not be eligible for re-licensure due to quality of care or other performance issues. Findings Include: Review of Staff E, Registered Nurse (RN)'s employee file did not show a current nursing license. A concurrent review of the Kansas State Board of Nursing Licensure website and interview conducted on 10/08/21 at 2:37 PM with Staff B, Clinical Manager (CM) showed that Staff E's RN nursing license had expired on 09/30/2021 and did not show a current state nursing license for Staff E. Staff B stated that Staff E, RN had made visits to patients' homes since 09/30/21 in a training role with another RN. During an interview on 10/09/21 at 9:40 AM, Staff A, Administrator (Admin), stated that agency policy was that all registered nurses must have a current nursing license to be employed.