Every finding on record at Hope Land Home Health Care Inc

A relicensure/recertification survey entrance conference was conducted with Adm/DON, Alt Adm/ADON and office assistant on 07/18/2023. The census was: LCHHS: 2 LHH: 0 PAS: 0 The agency was found in compliance with 42 CFR Part 484.102 Emergency Preparedness Requirements for Home Health Agencies and no deficiencies were cited.

A relicensure/recertification survey entrance conference was conducted with Adm/DON, Alt Adm/ADON and office assistant on 07/18/2023. The census was LCHHS: 2 LHHS: 0 PAS: 0 Abbreviations: ADL – activities of daily living Adm – Administrator ADON – alternate director of nurses Alt – Alternate AM - Ante meridiem cg – caregiver CMS - The Centers for Medicare & Medicaid Services DON - Director of Nurses G - gastrostomy Hrs – hours H or h - hour LCHHS - Licensed and Certified Home Health LHHS - Licensed Home Health Services mg - milligram ml - milliliter NA – not applicable OASIS- Outcome and Assessment Information Set PAS – personal assistance services PEG - percutaneous endoscopic gastrostomy PM - Post meridiem po -by mouth prn - as needed prev - previous Pt – Patient POC - plan of care Q - every rehab - rehabilitation ROC – resumption of care SN - skilled nurse SOC – start of care Tab - tablet

Accuracy of encoded OASIS data CFR(s): 484.45(b) Standard: The encoded OASIS data must accurately reflect the patient's status at the time of assessment. This STANDARD is not met as evidenced by: Based on record review and interview, the agency failed to ensure that encoded OASIS data (a data set tool designed to measure outcomes for patients receiving home health services) accurately reflected the patient's status at the time of assessment for six of ten patients (Patient 1, 2, 3, 4, 5 and 6) whose records were reviewed in that: Patient 1, 2, 4, 5 and 6’s OASIS assessments included OASIS data items that were not answered. Patient 3’s OASIS assessment included inaccurate answers for OASIS data items. This failure placed agency patients at risk for having a plan of care developed that did not meet their care and service needs placing them at harm and at risk of receiving care from an agency with an inaccurate CMS quality of care rating. Findings Include: Patient 1: Record review of the medical record included a POC dated 07/08/2023 to 09/05/2023 that was signed by Alt Adm/ADON on 07/08/2023. The medical record included a SOC OASIS assessment completed and signed by Alt Adm/ADON on 07/08/2023. OASIS question C0100 asked the following, “Should Brief Interview for Mental Status…be Conducted?” C0100 was not answered. OASIS question D0150 asked the following, “Patient Mood Interview.” D0150 was not answered. OASIS question D0160 asked for the Total Severity Score from OASIS question D0150. D0160 was not answered. OASIS question D0700 asked the following, “How often do you feel lonely or isolated from those around you?” D0700 was not answered. In an email to Alt Adm/ADON on 07/20/2023 at 11:55 AM, the surveyor asked why C0100, D0160 and D0700 were not answered on the SOC OASIS assessment. In an email received on 07/20/2023 at 12:44 PM, Alt Adm/ADON replied: C0100: “Patient did not answer me when I asked him to repeat the words…” D0160: “Patient did not answer me. He has a history of dementia and was not willing to answer my questions.” D0700: “Patient did not answer.” During an interview with Alt Adm/ADON on 07/21/2023 at 1230 PM, the surveyor asked why D0150 was not answered. The Alt Adm/ADON stated she missed that question. Patient 2: Record review of the medical record included a POC dated 04/17/2023 to 06/15/2023 that was completed and signed by Alt Adm/ADON on 02/15/2023. The medical record included a recertification OASIS assessment completed and signed by Alt Adm/ADON on 06/12/2023. OASIS question M1030 asked the following, “…Therapies the patient recieves (sic) at home…” M1030 was not answered. OASIS question M1200 asked the following, “…Vision (with corrective lenses if the patient usually wears them)…? M1200 was not answered. OASIS question M1242 asked the following, “…Frequency of Pain Interfering with patient's activity or movement…? M1242 was not answered. OASIS question M1322 asked the following, “…Current Number of Stage I Pressure Ulcers: Intact skin with non-blanchable redness of a localized area usually over a bony prominence. The area may be painful, firm, soft, warmer, or cooler as compared to adjacent tissue. Darkly pigmented skin may not have a visible blanching; in dark skin tones only it may appear with persistent blue or purple hues. M1322 was not answered. OASIS question M1324 asked the following, “…Stage of Most Problematic Unhealed Pressure Ulcer that is Stageable…”. M1324 was not answered. OASIS question M1330 asked the following, “…Does this patient have a Stasis Ulcer…” M1330 was not answered. OASIS question M1400 asked the following, “…When is the patient dyspneic or noticeably Short of Breath…” M1400 was not answered. OASIS question M1630 asked the following, “…Does this patient have an ostomy for bowel elimination that (within the last 14 days): a) was related to an inpatient facility stay, or b) necessitated a change in medical or treatment regimen…” M1630 was not answered. In an email to Alt Adm/ADON on 07/21/2023 at 10:35 AM, the surveyor asked why M1030, M1200, M1242, M1322, M1324, M1330 M1400 and M1630 were not answered on the recertification OASIS assessment. In an email received on 06/21/2023 at 11:44 AM, Alt Adm/ADON replied: There is a system issue with OASIS D and E. I experienced it this morning. I think this might be why the codes are blank.” Patient 3: Record review of the medical record included a POC dated 01/14/2023 to 03/14/2023 that was signed by Alt Adm/ADON on 01/13/2023. The medical record included a Transfer to Inpatient Facility OASIS assessment completed and signed by Alt Adm/ADON on 02/22/2023. OASIS question A2120 asked the following, “At the time of transfer to another provider, did your agency provide the patient…current reconciled medication list to the subsequent provider?” Alt Adm/ADON documented, “No…Current reconciled medication list not provided to the subsequent provider.” OASIS question M2005 asked the following, “Did the agency contact and complete physician (or physician-designee) prescribed/recommended actions by midnight of the next calendar day each time potential clinically significant medication issues were identified since the SOC/ROC?” Alt Adm/ADON documented, “No.” In an email to Alt Adm/ADON on 07/20/2023 at 4:24 PM, the surveyor asked why the agency did not send a reconciled medication list to the subsequent provider (rehabilitation facility) [A2120] and contact and complete physician (or physician-designee) prescribed/recommended actions by midnight of the next calendar day each time potential clinically significant medication issues identified since the SOC/ROC [M2005] on the Transfer to Inpatient Facility OASIS assessment dated 02/22/2023. In an email received on 07/21/2023 at 11:44 AM, Adm/DON replied: A2120: “a medication list was sent to…rehab facility” M2005: “Documentation error: It should be…NA…” During an interview with Alt Adm/ADON on 07/21/2023 at 12:28 PM, the surveyor asked if A2120 was answered incorrectly. Alt Adm/ADON stated, yes because she did send the medication list. During an interview with Alt Adm/ADON on 7/21/2023 at 1230 PM, the surveyor asked why M2005 should have been answered NA. Alt Adm/ADON stated there weren’t any issues with the medications. During an interview with Alt Adm/ADON on 07/21/2023 at 1:00 PM, the surveyor asked who answered the questions from the email regarding Patient 3. Adm/DON and Alt Adm/ADON stated they both answered the questions and agreed upon the answers emailed to the surveyor. Patient 4: Record review of the medical record included a POC dated 04/10/2022 to 06/08/2022 that was signed by Adm/DON on 04/12/2022. The medical record included a Discharge OASIS assessment completed and signed by Adm/DON on 06/08/2022. OASIS question M1046 asked the following, “Did the patient recieve (sic) the influenza vaccine from your agency for this year's flu season?” M1046 was not answered. In an email to Adm/DON on 07/20/2023 at 12:23 PM, the surveyor asked why M1026 was not answered on discharge OASIS dated 06/08/2022. In an email received on 07/20/2023 at 7:58 PM, Adm/DON replied, “We may have missed selecting a choice.” During an interview with Adm/DON on 07/21/2023 at 12:50 PM, the surveyor clarified the email sent 07/20/2023 regarding M1026 not answered, it should have read M1046, and asked if his answer remained unchanged. Adm/DON stated, “Yes.” Patient 5: Record review of the medical record included a POC dated 03/04/2021 to 05/02/2021 that was signed by Adm/DON on 03/03/2021. The medical record included a Discharge OASIS assessment completed and signed by Adm/DON on 04/26/2021. OASIS question M1046 asked the following, “Did the patient recieve (sic) the influenza vaccine for this year’s flu season?” M1046 was not answered. In an email to Adm/DON on 07/20/2023 at 3:19 PM, the surveyor asked why M1026 was not answered on discharge OASIS dated 06/08/2022. In an email received on 07/20/2023 at 8:01 PM, Adm/DON replied, “We may have missed selecting a choice.” Patient 6: Record review of the medical record included a POC dated 09/26/2021 to 11/24/2021 that was signed by Adm/DON on 09/25/2021. The medical record included a Discharge OASIS assessment completed and signed by Adm/DON on 11/24/2021. OASIS question M1600 asked the following, “Has this patient been treated for a Urinary Track (sic) Infection in the past 14 days?” M1600 was not answered. In an email sent to Adm/DON and Alt Adm/ADON on 07/20/2023 2:11 PM, the surveyor asked why M1600 was not answered on discharge OASIS dated 11/24/2021. In an email received 07/20/2023 at 8:00 PM, Adm/DON replied, “We may have missed selecting an option.” In an email sent to the agency on 07/21/2023 at 1:06 PM, the surveyor asked who answered the questions from the email regarding Patient 6. In an email received from the agency on 07/21/2023 at 1:12 PM read Alt Adm/ADON answered the questions. Agency policy titled, “Initial Patient Comprehensive Assessment PE.3” with a revision date of 01/11/2005 read in part, “PURPOSE To identify data collection needed on multiple aspects of the patient and the environment as a basis for individualized intervention and outcome-oriented care. POLICY Each patient will receive a patient specific, comprehensive assessment, that incorporates OASIS data set for Medicare/Medicaid patients…The assessment will accurately reflect the patient’s current health status and assist in uniformly and consistently measuring patient outcomes…PROCEDURE…A. 6. The comprehensive assessment will include…the following…OASIS data set…which would include pertinent diagnoses…physical findings…ADLs/Functional status…Medication history…Psycho-social status…7. All medications…”

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 and interview, the agency failed to ensure a patient received home health services as ordered in the individualized POC in six of ten patient records reviewed (Patient 2, 3, 4, 5, 7 and 8) where nursing visits were not made as ordered. This failure placed the patient at risk of not receiving interventions as ordered and could potentially cause complications and a decline in health status. Findings Include: Patient 2: Record review of the medical record included a POC dated 04/17/2023 to 06/15/2023 that was signed by Alt Adm/ADON on 02/15/2023. The POC included an order for the nurse to visit the patient once a week for nine weeks beginning the week of 04/17/2023 with three prn visits for problems related to wounds and lab draws. The record included two nurse visits the week of 04/30/2023 to 05/06/2023 signed by Alt Adm/ADON. The record did not include a nurse visit the week of 05/07/2023 to 05/13/2023. In an email to Alt Adm/ADON on 07/21/2023 at 10:35 AM, the surveyor asked why two nurse visits were made the week of 04/30/2023 to 05/06/2023 and zero nurse visit the week of 05/07/2023 to 05/13/2023. In an email received on 07/21/2023 at 11:44 AM, Alt Adm/ADON replied the nurse frequency was entered wrong. Patient 3: Record review of the medical record included a POC dated 01/14/2023 to 03/14/2023 that was signed by Alt Adm/ADON on 01/13/2023. The POC included an order for the nurse to visit the patient once a week for two weeks beginning the week of 01/14/2023 with three prn visits for problems related to [blank]. The record did not include a nurse visit on 01/14/2023. In an email to Adm/DON and Alt Adm/ADON on 07/20/2023 at 4:24 PM, the surveyor asked why the nurse frequency was not followed. In an email received on 07/21/2023 at 11:44 AM, the agency replied the frequency was wrong. During an interview with Adm/DON and Alt Adm/ADON on 07/21/2023 at 1:00 PM, the surveyor asked who answered the question in the email received on 07/21/2023 at 11:44 AM. Adm/DON and Alt Adm/ADON stated they both answered the question and agreed upon the answer. Patient 4: Record review of the medical record included a POC dated 04/10/2022 to 06/08/2022 that was signed by Adm/DON on 04/12/2022. The POC included an order for the nurse to visit the patient twice a week for four weeks then once a week for five weeks beginning the week of 04/10/2022 with three prn visits for problems related to wounds and lab draws. The record included two nurse visits the week of 05/22/22 to 05/28/2022 and did not include a nurse visit the week of 05/29/2022 to 06/04/2022. In an email to Adm/DON and Alt Adm/ADON on 07/20/2023 at 12:23 PM, the surveyor asked why two nurse visits were made the week of 05/22/22 to 05/28/2022 and zero nurse visit the week of 05/29/2022 to 06/04/2022. In an email received on 07/21/2023 at 11:44 AM, Adm/DON replied they were not sure what happened with the dates. Patient 5: Record review of the medical record included a POC dated 03/04/2021 to 05/02/2021 that was signed by Adm/DON on 03/03/2021. The POC included an order for the nurse to visit the patient zero times a week the first week then once a week for nine weeks with three prn visits for problems related to wounds, lab draws and falls. The record included a nurse visit the week of 03/04/2021 to 03/06/2021. In an email to Adm/DON and Alt Adm/ADON on 07/20/2023 at 3:19 PM, the surveyor asked why one nurse visit was made the week of 03/04/2021 to 03/06/2021. In an email received on 07/20/2023 at 8:01 PM, Adm/DON replied it was an error in the frequency. Patient 7: Record review of the medical record included a POC dated 10/16/2020 to 12/14/2020 that was signed by Adm/DON on 10/14/2020. The POC included an order for the nurse to visit the patient once a week for nine weeks then zero times for one week with three prn visits for problems related to lab draws, assess and monitor. The record did not include a nurse visit the week 12/06/2020 to 12/12/2020. In an email to Adm/DON and Alt Adm/ADON on 07/20/2023 at 12:23 PM, the surveyor asked why a nurse visit was not made the week of 12/06/2020 to 12/12/2020. In an email received on 07/20/2023 at 7:58 PM, Adm/DON replied the frequency was entered wrong. Patient 8: Record review of the medical record included a POC dated 10/14/2020 to 12/12/2020 that was signed by Adm/DON on 10/13/2020. The POC included an order for the nurse to visit the patient once a week for nine weeks beginning the week of 10/14/2020 with three prn visits for problems related to lab draws and assessment. The record did not include a nurse visit the week of 10/18/2020 to 10/24/2020. In an email to Adm/DON and Alt Adm/ADON on 07/20/2023 at 12:16 PM, the surveyor asked why a nurse visit was not made the week of 10/18/2020 to 10/24/2020. In an email received on 07/20/2023 at 7:58 PM, Adm/DON replied it was a frequency error. Record review of the agency policy manual included a seven page document titled, “Patient Rights” that read in part, “…The Law provides certain rights to all home health patients/clients. These include the right to…5. Receive all services outlined in the plan of care…Agency Responsibilities…3. To follow the plan of care as ordered by the physician…” Agency policy titled, “Orders for Care TX.5” with a revision date of 10/01/2013 read in part, “PURPOSE To ensure patient care is provided in accordance with federal and state laws and regulations… POLICY Agency will obtain orders and provide care in accordance with physician’s orders…”

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 record review and interview, the agency failed to ensure the POC included all pertinent diagnoses; patient-specific interventions and information related to any advanced directives (legal documents that allow you to spell out your decisions about end-of-life care ahead of time) in ten of ten records reviewed. In ten of ten records reviewed (Patient 1, 2 ,3, 4, 5, 6, 7, 8, 9 and 10) where the patient had pain, the POC did not include pain parameters to report to the physician. In five of ten records reviewed (Patient 1, 2 ,3, 5 and 10), the POC did not include information related to any advanced directives. In two of ten records reviewed (Patient 1 and 2), the POC did not include pertinent diagnoses. In two of three records reviewed (Patient 1 and 2) where the patient had a feeding tube (feeding tubes are often called PEG tubes or G tubes. The tube allows a patient to receive nutrition directly through their stomach), the POC did not include how the tube feedings were to be administered. In one of three records reviewed (Patient 2) where the patient had a feeding tube, the POC did not include what to flush the feeding tube with (feeding tubes must be flushed to prevent clogging, typically after each feeding and before and after medication administration via the feeding tube) and frequency and amount of feeding tube flushes. These failures placed agency patients at risk of not receiving interventions from clogged tubes preventing the administration of proper nutrition, weight loss or weight gain. The failure to include pain parameters on the POC prevented the nurses from knowing when the patients’ pain levels needed to be reported to their physicians. The failure to include information related to any advanced directives could result in patient treatment preferences in end-of-life situations not being carried out when patients cannot speak for themselves. Findings include: Patient 1: Record review of the medical record included a POC dated 07/08/2023 to 09/05/2023 that was signed by Alt Adm/ADON on 07/08/2023. The POC included diagnoses of: dysphagia oropharyngeal phase (swallowing problems occurring in the mouth and/or the throat), enterocolitis due to clostridium difficile (a type of bacteria that can cause colitis, a serious inflammation of the colon), atherosclerotic heart disease (buildup of fats, cholesterol and other substances in and on artery walls), high blood pressure, chronic obstructive pulmonary disease (chronic inflammatory lung disease that causes obstructed airflow from the lungs), depressive episodes, insomnia (difficulty sleeping) , atrial fibrillation (irregular and often very rapid heart rhythm), unsteadiness on feet, lack of coordination, cognitive communication deficit (difficulty thinking and communicating needs), muscle wasting/atrophy (decrease in size and wasting of muscle tissue) and muscle weakness. The POC read in part, “…Nutren (a ready-to-use liquid tube feeding formula) 2.0 250ml 4 times daily (0600-1000-1400-1800) G tube…free water flush 100 ml every 4hrs after feed G tube…free water flush 30 ml after medication administration (sic) G tube …Nutritional Requirement Nutrien (sic) 2.0 250ml every 4hrs, (4 times/day)…SN to assess/instruct pt/cg on interventions in pain management, including pharmacological and comfort measures…” The medical record included a SOC OASIS nursing assessment dated and signed by Alt Adm/ADON on 07/08/2023 that read in part, “…(J0510) Pain Effect on Sleep…Occasionally… (J0520) Pain Interference with Therapy Activities…Occasionally… (J0530) Pain Interference with Day-to-Day Activities…Occasionally…SN…to assess…pain… SN to assess/instruct pt/cg on interventions in pain management, including pharmacological and comfort measures…” The POC did not include pain parameters to report to the physician, information related to any advanced directives, a diagnosis for the feeding tube and how to administer the tube feeding [gravity, feeding pump, bolus (a single dose of a drug or other medicinal preparation given all at once)]. In an email to Alt Adm/ADON on 07/20/2023 at 11:55 AM, the surveyor asked why the POC did not include a diagnosis for the feeding tube and how the tube feedings were to be administered. In an email received on 07/20/2023 at 12:44 PM, Alt Adm/ADON replied the feeding tube was included in the medication section of the POC and tube feedings were administered by bolus feed four times daily. Patient 2: Record review of the medical record included a POC dated 04/17/2023 to 06/15/2023 that was signed by Alt Adm/ADON on 02/15/2023. The POC included diagnoses of: epilepsy with status epilepticus (seizure that lasts at least 30 minutes), urinary tract infection (infection in any part of the urinary system), congenital stenosis of aortic valve (narrowed aortic valve with varying degrees of obstruction), gastro-esophageal reflux disease (condition in which the stomach contents move up into the esophagus), wrist drop (difficulty extending the fingers) and foot drop (difficulty lifting the front part of the foot). The POC read in part, “…Nutritional Requirement PEG feeding and hydration… SN to assess/instruct pt/cg on interventions in pain management, including pharmacological and comfort measures… SN to assess/instruct pt/cg on all aspects of G-tube feeding, including administration of feeding formula and medications, and residual checks before feedings…goals… Pt's pain will be managed at < 2 on the scale of 0-10 within 60 days…tube will remain patent and free from complications for next 60 days…” The medical record included a recertification OASIS nursing assessment signed by Alt Adm/ADON on 06/12/2023 that read in part, “…process of care measures identified and addressed this certification period… Intervention(s) to monitor and mitigate pain [yes]…SN…to assess…pain… SN to assess/instruct pt/cg on interventions in pain management, including pharmacological and comfort measures…goals… Pt's pain will be managed at < 2 on the scale of 1-10 within 60 days…” The POC did not include pain parameters to report to the physician, information related to any advanced directives, a diagnosis for the feeding tube, how the tube feedings were to be administered, what to flush the feeding tube with and the frequency and amount of feeding tube flushes. In an email to Alt Adm/ADON on 07/21/2023 at 10:35 AM, the surveyor asked why the POC did not include a diagnosis for the feeding tube, how the tube feedings were to be administered, what to flush the feeding tube with and the frequency and amount of feeding tube flushes. In an email received on 07/21/2023 at 11:44 AM, Alt Adm/ADON replied the feeding tube diagnosis was included in the previous episode and she did not know what happened; the tube feeding was a bolus feed of four cans daily and flushed with water before and after feeding or medication. During an interview with the Alt Adm/ADON on 07/21/2023 at 1:46 PM, the Alt Adm/ADON stated she was supposed to include an order on the POC for feeding tube flushes with the frequency and amount and it was her mistake it wasn’t included. During an interview with the Alt Adm/ADON on 07/21/2023 at 12:55 PM, the surveyor asked who answered the questions included in the email sent by the surveyor on 07/21/2023 at 10:45 AM. Alt Adm/ADON stated she answered the questions. The Alt Adm/ADON stated they [Adm/DON and Alt Adm/ADON] were under the impression the only diagnoses that needed to be listed on the POC were the ones included on the face to face encounter (documentation that a practitioner had an encounter with the patient related to the primary reason the patient was receiving home health services) and diagnoses the agency had orders to address. Patient 3: Record review of the medical record included a POC dated 01/14/2023 to 03/14/2023 that was signed by Alt Adm/ADON on 01/13/2023. The POC included diagnoses of: femur fracture, post hemorrhagic anemia (loss of a large amount of blood quickly), diabetes (condition that happens when blood sugar is too high), Parkinson’s disease (progressive disorder that affects the nervous system), high blood pressure, osteoporosis (disease that weakens bones), right artificial hip joint, falls, history of breast cancer and urinary tract infection. The POC read in part, “…Medications… Tizanidine Hydrochloride 2mg evening oral (a short-acting muscle relaxer that works by blocking nerve impulses/pain sensations that are sent to the brain)… Tylenol Extra strength 500 mg q6h oral (a pain reliever)…SN…to assess…pain…SN to assess/instruct pt/cg on interventions in pain management, including pharmacological and comfort measures…” The medical record included nursing visit notes dated and signed by Alt Adm/ADON on 01/21/2022 and 01/25/2022 that read in part, “…Pain assessment…Prev. Intensity: 7 Post Intensity: 2 Intensity of Pain: 4… Current Pain Medication: Tylenol extra strength… Pain Location: lower back… Pain Duration: every 6 hrs… Other Pain Management Interventions: Medication, repositioning while on wheel chair, rest and relaxation… Description of Pain: Stinging, burning pain that moves from lower back to the back of thigs…Progress toward goals…Pain…will remain until (sic) control… The medical record included nursing visit notes dated and signed by Alt Adm/ADON on 02/03/2022, 02/08/2022 and 02/17/2022 that read in part, “…Pain assessment…Prev. Intensity: 6 Post Intensity: 2 Intensity of Pain: 4… Current Pain Medication: Tylenol extra strength… Pain Location: lower back… Pain Duration: every 6 hrs… Other Pain Management Interventions: Medication, repositioning while on wheel chair, rest and relaxation… Description of Pain: Stinging, burning pain that moves from lower back to the back of thigs…Progress toward goals…Pain…will remain until (sic) control…” The POC did not include pain parameters to report to the physician and information related to any advanced directives. Patient 4: Record review of the medical record included a POC dated 04/10/2022 to 06/08/2022 that was signed by Adm/DON on 04/12/2022. The POC included diagnoses of: atherosclerotic heart disease, anxiety, depression, high blood pressure, cardiomegaly (enlarged heart), gastro-esophageal reflux disease, hyperlipidemia (extra fats in the blood), surgical wound dressing and surgical aftercare. The POC read in part, “…Medications… Hydrocodone Bitartrate and Acetaminophen 5/325 q6h prn po (a relatively potent drug for moderate-to-severe pain control)…patient complained of pain during ambulation (walking) and when he take (sic) a deep breath…SN…instructed…taking pain medications can decrease pain…Reason Homebound/Prior Functional Status…painful ambulation…use of narcotic pain meds…SN…to assess…pain…SN to assess/instruct pt/cg on interventions in pain management, including pharmacological and comfort measures…” The POC did not include pain parameters to report to the physician. Patient 5: Record review of the medical record included a POC dated 03/04/2021 to 05/02/2021 that was signed by Adm/DON on 03/03/2021. The POC included diagnoses of: right heel pressure ulcer, benign prostatic hyperplasia (enlarged prostate), urinary tract infection, dementia (loss of memory, language, problem-solving and other thinking abilities), anemia (low amount of red blood cells), high blood pressure and high cholesterol. The POC read in part, “…Medications…Tylenol 325mg, 2tab Q8H, PRN for pain PO…SN to assess…pain…SN to assess/instruct pt/cg on interventions in pain management, including pharmacological and comfort measures…SN GOALS…Pt's pain will be managed at <3 on the scale of 0-10…” The medical record included nursing visit notes dated and signed by Adm/DON on 03/05/2021, 03/11/2021, 03/17/2021, 03/23/2021, 04/03/2021, 04/07/2021, 04/14/2021 and 04/20/2021 that read in part, “…Joint Pain/Stiffness…Pain assessment…Prev. Intensity: 5 Post Intensity: 2 Intensity of Pain: 3…Pain Location: lower back…” The POC did not include pain parameters to report to the physician and information related to any advanced directives. Patient 6: Record review of the medical record included a POC dated 09/26/2021 to 11/24/2021 that was signed by Adm/DON on 09/25/2021. The POC included diagnoses of: dementia, effusion right knee (fluid accumulation in knee), hyperlipidemia, anxiety, insomnia and constipation. The POC read in part, “…Medications…Tylenol Extended release 650mg prn, every 8 hours po… Napoxen 500 mg Q 12 hour (sic) PO (pain reliever)… Meloxicam 7.5 mg daily po (used to treat pain or inflammation)… SN to assess…pain…SN to assess/instruct pt/cg on interventions in pain management, including pharmacological and comfort measures…Goals…pain will be managed at 0 on the scale of 0-10 within 60 days…” The POC did not include pain parameters to report to the physician. Patient 7: Record review of the medical record included a POC dated 10/16/2020 to 12/14/2020 that was signed by Adm/DON on 10/14/2020. The POC included diagnoses of: right fibula fracture (fractured calf bone), insomnia, diabetes, high blood pressure, hyperlipidemia, acute pain due to trauma, gastro-esophageal reflux disease and chronic pain. The POC read in part, “…Medications… Tramadol Hydrochloride 50mg, 1 tab Q6H, PRN for pain po (strong pain medication used to treat moderate to severe pain)…Patient does have limitations to mobility due right leg pain…Reported pain on ambulation and continue taking tramadol for pain management…Reason Homebound/Prior Functional Status…severe pain in the right foot from fracture of right ankle…” The medical record included nursing visit notes dated and signed by Adm/DON on 10/19/2020, 10/26/2020, 11/03/2020, 11/10/2020, 11/17/2020, 11/24/2020 and 12/01/2020 that read in part, “…Joint Pain/Stiffness…Pain assessment…Prev. Intensity: 6…Intensity of Pain: 2…Current Pain Medication: tramadol…Pain Location: lower back, right leg, ankle…Pain Management Interventions: Rest and prn pain medications…Description of Pain: pain in the right ankle while walking and chronic back pain…ADLs are limited by severe low back pain…” The medical record included a discharge OASIS nursing assessment dated and signed by Adm/DON on 12/14/2020 that read in part, “…Pain Level (Scale 0-10): 4…(M1242) Frequency of Pain Interfering with patient's activity or movement…daily, but not constantly… Abnormal pain…lower back chronic… Pain or cramps…both legs…” The POC did not include pain parameters to report to the physician. Patient 8: Record review of the medical record included a POC dated 10/14/2020 to 12/12/2020 that was signed by Adm/DON on 10/13/2020. The POC included diagnoses of: thoracic vertebra fracture (broken vertebra in middle section of the spine), lumbar vertebral disc displacement (breakdown of low back spinal disc), fracture of lumbar vertebra, high blood pressure, activity limitations due to disability and chemotherapy. The POC read in part, “…Medications… Tylenol 500 mg, 1 tab q 6 hrs, PRN for pain PO…Tramadol Hydrochloride 50 mg, 1 tab q 4 hrs, PRN po…pain in the back and hips…patient also complaints of severe pain to right posterior back and Axilla (armpit)… patient is home bound because of debilitating chronic osteoarthritis (inflammation of one or more joints)…pain that interferes with functional limitations…SN…to assess…pain… SN to assess/instruct pt/cg on interventions in pain management, including pharmacological and comfort measures…Goals… Pt's pain will be managed at 0-3 on the scale of 0-10 within 60days…” The medical record included a discharge OASIS nursing assessment dated and signed by Adm/DON on 12/14/2020 that read in part, “…chronic Pain Level (Scale 0-10): 5 Current pain control regimen… Tramadol Hydrochloride 50mg PO, Q4h, prn… (M1242) Frequency of Pain Interfering with patient's activity or movement…Daily, but not constantly… Pt is home bound due to mobility issues and chronic back pain. Patient Wearing back braces to keep posture straight during the day, and it helps with back pain. patient still receives iv chemotherapy for multiple myeloma…” The POC did not include pain parameters to report to the physician. Patient 9: Record review of the medical record included a POC dated 06/26/2021 to 08/24/2021 that was signed by Adm/DON on 06/25/2021. The POC included diagnoses of: atherosclerotic heart disease, heart failure, ischemic cardiomyopathy (heart muscle that can't pump well because of damage from a lack of blood supply to the muscle), hyperlipidemia, sleep apnea (sleep disorder in which breathing repeatedly stops and starts), high blood pressure, dilated cardiomyopathy (enlargement of heart’s main pumping chamber) and kidney failure. The POC read in part, “…Medications… Nitrostat 0.4mg prn for chest pain sublingual (under the tongue)…Tylenol 500 mg tab Q6h for pain po… reported occasional chest pain… Patient complains of pain on left hip area. Patient takes Tylenol for pain management…SN…to assess…pain… SN to assess/instruct pt/cg on interventions in pain management, including pharmacological and comfort measures…Goals… pain will be managed at 0-3 on the scale of 0-10 within 60 days…” The POC did not include pain parameters to report to the physician. Patient 10: Record review of the medical record included a POC dated 05/23/2022 to 07/21/2022 that was signed by Adm/DON on 05/21/2022. The POC included diagnoses of: pressure ulcer of sacrum (triangular bone at the base of spine), heart failure, anxiety, depression, atherosclerotic heart disease, Parkinson’s disease, transient cerebral ischemic attack (temporary period of symptoms similar to those of a stroke), high cholesterol, gastrostomy (opening into the stomach from the abdominal wall, made surgically for the introduction of food) and high blood pressure. The POC read in part, “…Tramadol Hydrochloride 50 mg every 6 hrs G tube…Acetaminophen 325 mg 2 tab every 6hrsPRN G tube…Patient is on Tramadol and Tylenol for pain management…SN to assess…pain… pain will be managed at 0 on the scale of 0-10 within 60 days…” The medical record included nursing visit notes dated and signed by Adm/DON on 05/27/2022, 06/03/2022 and 06/21/2022 that read in part, “…Joint Pain/Stiffness…Pain assessment…Prev. Intensity: 6…Post Intensity: 1…Intensity of Pain: 3…Current Pain Medication: tramadol 50 mg…Pain Location: lower back, shoulders…Pain Management Interventions: pain medications, repositioning, supportive pillows…complained of pain, patient’s medication is on hold since this morning…” The medical record included nursing visit notes dated and signed by Adm/DON on 06/10/2022, 06/17/2022, 07/01/2022, 07/03/2022, 07/10/2022, 07/12/2022 and 07/16/2022 that read in part, “…Joint Pain/Stiffness…Pain assessment…Prev. Intensity: 6…Post Intensity: 1…Intensity of Pain: 3…Current Pain Medication: tramadol 50 mg…Pain Location: lower back, shoulders…Pain Management Interventions: pain medications, repositioning, supportive pillows…” In an email to Adm/DON and Alt Adm/ADON on 07/20/2023 at 4:35 PM, the surveyor asked why the POC’s for Patients 1, 2, 3, 5 and 10 did not include if the patient had an advanced directive and why the POC for patients with pain did not include pain parameters to report to the physician. In an email received on 07/21/2023 at 12:22 PM, Alt Adm/ADON stated she did not know why advanced directive information was not populated on the POCs. The Alt Adm/ADON stated pain meds were usually ordered as prn for pain and the agency did not see pain parameters in the physician orders. Agency policy titled, “Plan of Care TX.6” with a revision date of 03/16/2004 read in part, “PURPOSE To ensure that care provided is appropriately planned in a timely manner to meet the patient’s specific needs and problems…POLICY Agency will identify data/information gathered during patient assessments in the care planning process which involved identification of…actions or interventions that will resolve or alleviate the patient’s problems and/or needs…PROCEDURE…3. The 485 [POC], which includes the following plan of care elements, will serve as the initial plan of care…patient diagnosis/problems…interventions and care…”