Every finding on record at Howard County Home Health and Hospice

The Emergency Preparedness regulations were reviewed as part of the Medicare recertification survey completed on 04/22/2025. During the survey it was determined the home health provider is in compliance with the requirements of 42 CFR 484.102 Condition of Participation: Emergency Preparedness for Home Health Providers.

A partial extended survey for Medicare recertification for the home health provider was completed on 04/22/2025. The provider had 18 current patients.

A review of all current medications CFR(s): 484.55(c)(5) A review of all medications the patient is currently using in order to identify any potential adverse effects and drug reactions, including ineffective drug therapy, significant side effects, significant drug interactions, duplicate drug therapy, and noncompliance with drug therapy. This ELEMENT is not met as evidenced by: Based on policy review, record review, home visit observation, and interview, the home health provider failed to maintain an accurate, updated medication profile in one of three home visit observations conducted (Record/Patient #2). This deficient practice has the potential to affect all the patients served by the provider. Findings included: Review of the provider's undated policy titled, "Medication Policy," regarding medication reconciliation showed, in part, upon admission, recertification, resumption of care, discharge and after physician appointments (or medication changes) there will be a complete medication assessment and evaluation with notification of the physician of any discrepancies that are discovered, as well as a drug to drug interaction completed after each new medication is added to patient's medication list. Teaching sheets will be provided and reviewed with patient and/or family as needed for those medications. The patient's in home medication list is to be evaluated at the above intervals as well and updated in clinical software to be accurate. RECORD/PATIENT #2: Review of the clinical record showed the patient was readmitted to home health services on 04/04/2025 after a hospital stay. The patient's primary diagnosis was adenocarcinoma of the prostate (cancer in a gland of the male reproductive system). The patient lived at home with a family caregiver. Observation and interview on 04/21/2025 at 4:15 PM, showed the following discrepancies between the patient's home medications and the provider's medication profile: - The provider's medication profile showed the patient took Alka-Seltzer Plus Cold by mouth two tablets every four hours as needed for cold symptoms. The patient stated that he/she had not taken this medication since 02/27/2025; - The provider's medication profile showed the patient took ciprofloxacin (antibiotic) by mouth 500 milligrams (mg) one tablet every 12 hours, to be started three days prior to Foley catheter (brand, a sterile tube placed in the bladder to drain urine) removal. The patient stated that he/she had not taken this medication for quite some time, that his/her Foley was removed; - The provider's medication profile showed the patient took CVS (brand) Senna Plus (used for constipation) 8.6-50 mg two tablets as needed at bedtime. The patient stated that he/she "didn't take"; - The provider's medication profile showed the patient took Eliquis (used to prevent blood thickening) 5 mg one tablet twice a day. The patient's medication bottle label showed one tablet daily, and the patient stated that was how he/she took this medication; - The provider's medication profile showed the patient took epinephrine injection solution (for allergic reaction) auto injector 0.3 mg/0.3 milliliter (ml). The patient stated "never use, if you take it, you have to go to the hospital"; - The provider's medication profile showed the patient took Klor-Con 10 (potassium supplement) extended release 10 millequivalent (mEq) one tablet daily. The patient's hospital medication list showed Klor-Con 20 mEq (two tablets) daily - The provider's medication profile showed Nucala (treatment for asthma) subcutaneous (inject under the skin) prefilled syringe 100 mg/ml - 1 ml every month. The patient stated he/she did not "have any of this"; - The provider's medication profile showed the patient took quetiapine fumarate (used to treat depressive disorder and sometimes used for sleep) one tablet every AM, and two tablets in the evening. The patient stated that he/she only took this medication in the evening; and - The patient's medication profile failed to show hydrochlorothiazide (HCTZ - used to treat fluid retention and to lower blood pressure) two tablets daily. The medication was listed on the hospital's medication discharge list. The hospital's medication list failed to show the dosage amount. The patient stated "no longer take this medication". During an interview on 04/22/2025 at 3:35 PM, the home health administrator stated that the medication lists were not reconciled and that he/she would expect staff to follow the policy.

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 policy review, home visit observation, and interview, the home health provider failed to follow accepted standards of practice, in hand hygiene, to prevent the transmission of infections in, one of three home visit observations conducted (Record/Patient #3). This deficient practice has the potential to affect all the patients served by the home health provider. Findings included: Review of the home health provider's undated policy titled, "Hand Washing - Hand Hygiene," showed in part, in the event that you are putting gloves on, do hand washing hygiene before applying gloves and after removing them. Do this each time you need to change gloves for any care provided. RECORD/PATIENT #3: Observation on 04/21/2025 at 11:40 AM, showed registered nurse (RN) A: - Completed a full body assessment of the patient; - Failed to perform hand hygiene and applied gloves; - Touched the big toe and assessed it for drainage; - Removed gloves and obtained a band aid dressing to place on the big toe; - Applied new gloves on his/her hands without performing hand hygiene; - Performed hand hygiene and set up supplies for a dressing change to the patient's peripherally inserted central catheter (PICC line, inserted into a peripheral vein and ending in a large vessel above the heart); - Removed his/her exam gloves and applied sterile gloves to perform PICC line dressing change (RN-A failed to perform hand hygiene); - Removed his/her sterile gloves and applied another pair of gloves to withdraw blood from the PICC line tubing (RN-A failed to perform hand hygiene); - Completed the blood draw, removed his/her gloves and performed hand hygiene; and - RN-A failed to perform hand hygiene per the provider’s policy. During an interview immediately following the home visit, RN-A acknowledged that he/she should have performed hand hygiene each time that he/she changed his/her gloves. During an interview on 04/22/2025 at 3:35 PM, the administrator stated that RN-A should have performed hand hygiene before and after each glove application.

Only as ordered by a physician CFR(s): 484.60(b)(1) Drugs, services, and treatments are administered only as ordered by a physician or allowed practitioner. This ELEMENT is not met as evidenced by: Based on policy review, clinical record review, and interview, the agency failed to ensure drugs, services, and treatments are administered only as ordered by a physician or allowed practitioner in one (Record/Patient #2) of three records reviewed. This deficient practice has the potential to affect all patients served by the agency. Findings included: Review of the agency's policy titled, "Physician Orders," dated 07/26/2022, showed "All physicians orders will be followed by agency clinical staff." Review of the agency's policy titled, "Open Skin Area Measurement Procedure," dated/revised 07/09/2004, showed in part, the following: - Wound care will be provided according to physician's orders; and - The doctor will be contacted to determine any possible changes that may need to be made to improve healing. Review of the clinical record showed the patient was admitted to the agency with a diagnosis of sepsis (a potentially life-threatening condition that occurs when the body's response to an infection damages it's own tissues) due to Escherichia coli (E. Coli; a type of bacteria). The patient also had chronic wounds on his/her abdomen, as well as wounds/abrasions on the right arm/elbow, and left lower arm from a fall. He/she goes to the wound center for treatment of the abdominal wounds every three weeks. Review of the plan of care (POC), dated 07/17/2022 through 09/14/2022, showed the skilled nurse (SN) is to: - Change abdominal wound dressing; * Clean with normal saline; * Cover with xeroform (a petrolatum blended non-adherent gauze) and abdominal (ABD, a large dry gauze) pad; * Secure with tape; * Dressing to be changed daily; * Patient is independent with dressing change on days SN doesn't visit; - SN to change patient's dressing (and increase home visits to do so) two times a week; and - Measure the wound and take photo weekly. Review of the SN note, dated 07/19/2022 , showed the SN documented the following: - Wound on the left lower abdomen, top side, was not measured; and - Wound on the left lower abdomen, underside, was not measured. Review of the SN note, dated 07/22/2022, showed the SN documented the following: - Wound on the left lower abdomen, top side, not addressed; - Wound on the left lower abdomen, underside, not addressed; - The patient stated that he/she had just returned from the wound clinic appointment; - The patient declined a dressing change to the area (abdomen) since he/she just had it changed this AM; - The agency failed to get measurements of the abdominal wounds, as ordered, for the week 07/18/2022 through 07/24/2022; and - The agency failed to notify the physician that the ordered weekly measurements were not obtained. During an interview, immediately following a home visit on 07/26/2022 at 10:00 AM, registered nurse (RN) A stated that he/she was not the regular nurse for this patient but the normal process is for the nurse to measure wounds once a week, usually on the first visit of the week. During an interview on 07/26/2022 at 10:38 AM, the agency's chief executive officer (CEO) stated that he/she could not find any photographs or documentation that the wounds were measured during that week.

The Emergency Preparedness regulations were reviewed as part of the Medicare certification survey completed on 06/23/2022. There were no deficiencies identified.

An extended survey for Medicare certification for Hometown Homecare was completed on 06/23/2022. The agency had 18 current patients. Two condition level deficiencies were identified during this survey: - 484.50 Condition of Participation: Patient Rights; and - 484.60 Condition of Participation: Care Planning, Coordination of Services, and Quality of Care. A home health agency that is found out of compliance with any Condition of Participation evaluated as part of a standard survey may not train or competency evaluate their home health aides for a period of two (2) years following the date of this survey. A deficiency has been cited at §484.80(f)(3) – see Tag G788.

Patient rights CFR(s): 484.50 Condition of participation: Patient rights. The patient and representative (if any), have the right to be informed of the patient's rights in a language and manner the individual understands. The HHA must protect and promote the exercise of these rights. This CONDITION is not met as evidenced by: Based on policy review, review of current patient rights information, clinical record review, observation, and interview, the agency failed to develop and provide the patient and/or representative with a written notice of patient rights that included all required information. The agency failed to provide in writing, in advance of furnishing care, the following information: - Written notice of patient's rights and responsibilities under this rule, and the agency transfer and discharge policies as set forth in paragraph (d) of this section. Written notice must be understandable to persons who have limited English proficiency and accessible to individuals with disabilities (G412); - Written notice of patient’s rights and responsibilities under this rule, and the agency transfer and discharge policies as set forth in paragraph (d) of this section to a patient-selected representative within four (4) business days of the initial evaluation visit (G422); - The patient has the right to be advised orally and in writing of financial liability and changes as soon as possible, in advance of the next home health visit (G440); - The patient has the right to be advised of the state toll free home health telephone hotline, its contact information, its hours of operation, and that its purpose is to receive complaints or questions about local HHAs (home health agency) (G444); - The agency must advise the patient or representative, physicians, and healthcare professionals who will be responsible for providing care after discharge, that a discharge for cause is being considered (G464); - The agency must make efforts to resolve the problem presented by the patient's behavior, the behavior of other persons in the home, or situation (G466); - Provide the patient and representative (if any) with contact information for other agencies or providers who may be able to provide care (G468); - Document the problem(s) and efforts made to resolve the problem(s), and enter this documentation in the clinical record (G470); and - Information must be provided to patients in a language and in a manner that is accessible and timely to persons with disabilities, including accessible web sites and the provision of auxiliary aids services are at no cost to the patient (G490). The cumulative effect of these systemic practices resulted in the agency's inability to ensure that all patients and/or representatives were informed of their rights and responsibilities.

Written notice of patient's rights CFR(s): 484.50(a)(1)(i) (i) Written notice of the patient's rights and responsibilities under this rule, and the HHA's transfer and discharge policies as set forth in paragraph (d) of this section. Written notice must be understandable to persons who have limited English proficiency and accessible to individuals with disabilities; This ELEMENT is not met as evidenced by: Based on review of the agency's policy, current patient rights information and interview, the agency failed to update the written notice of patient rights to include: - Rights and responsibilities that are understandable to persons who have limited English proficiency; and - Rights and responsibilities accessible to individuals with disabilities. This deficient practice has the potential to affect the knowledge and comprehension of the rights and responsibilities of all agency patients. Findings included: Review of the agency's policy titled, "Patient Bill of Rights/Responsibilities-Home Health," dated 06/22/2022, showed in part, patient rights and responsibilities acknowledged by this agency will meet or exceed fundamental human, civil, constitutional and/or statutory rights. The agency's chief executive officer (CEO) provided an admission packet for review on 06/21/2022. The agency's notice of patient bill of rights and other information given to a patient during the initial visit contained no written information regarding written notice must be understandable to persons who have limited English proficiency and accessible to individuals with disabilities. The above findings were reviewed with the administrator on 06/23/2022 at 10:30 AM. No additional information was provided.

Written notice within 4 business days CFR(s): 484.50(a)(4) Provide written notice of the patient's rights and responsibilities under this rule and the HHA's transfer and discharge policies as set forth in paragraph (d) of this section to a patient-selected representative within 4 business days of the initial evaluation visit. This ELEMENT is not met as evidenced by: Based on policy review and review of the agency's current patient rights information, the agency failed to provide written notice of patient rights regarding their right to have a copy of the patient's rights and responsibilities provided to a patient-selected representative within four business days of the initial evaluation visit. This deficient practice has the potential to affect all patients served by the agency. Findings included: Review of the agency's policy titled, "Patient Bill of Rights," dated 06/22/2022, showed, in part, the written information of the patient’s rights and responsibilities will be a part of the patient handbook that is presented to the patient during the initial home visit. The agency's chief executive officer (CEO) provided an admission packet for review on 06/21/2022. The agency's notice of patient bill of rights and other information given to a patient during the initial visit contained no written information regarding their right to have a copy of the patient's rights and responsibilities provided to a patient-selected representative within four business days of the initial evaluation visit. The above findings were reviewed with the administrator on 06/23/2022 at 10:30 AM. No additional information was provided.

Payment from federally funded programs CFR(s): 484.50(c)(7)(i, ii, iii, iv) Be advised, orally and in writing, of- (i) The extent to which payment for HHA services may be expected from Medicare, Medicaid, or any other federally-funded or federal aid program known to the HHA, (ii) The charges for services that may not be covered by Medicare, Medicaid, or any other federally-funded or federal aid program known to the HHA, (iii) The charges the individual may have to pay before care is initiated; and (iv) Any changes in the information provided in accordance with paragraph (c)(7) of this section when they occur. The HHA must advise the patient and representative (if any), of these changes as soon as possible, in advance of the next home health visit. The HHA must comply with the patient notice requirements at 42 CFR 411.408(d)(2) and 42 CFR 411.408(f). This ELEMENT is not met as evidenced by: Based on review of the agency's policy, current patient rights information and interview, the agency failed to ensure the patient was advised orally and in writing of the extent to which payment for services may be expected from Medicare, Medicaid, or any other federally-funded aid program, the charges of services that may not be covered. This deficient practice has the potential to adversely affect the patient's ability to pay for services for all agency's patients. Findings included: Review of the agency's policy titled, "Patient Bill of Rights/Responsibilities-Home Health," dated 06/22/2022, showed in part, the patient has the right to be informed, orally and in writing, in advance about the care to be furnished, and any changes in that care. The agency's chief executive officer (CEO) provided an admission packet for review on 06/21/2022. The agency's notice of patient bill of rights and other information given to a patient during the initial visit showed the patient will be advised of the extent to which payment for home health services may be expected from Medicare, Medicaid, or any other federally funded or federal aid program known to the home health agency. The agency failed to include the verbiage orally and writing. The above findings were reviewed with the administrator on 06/23/2022 at 10:30 AM. No additional information was provided.

State toll free HH telephone hotline CFR(s): 484.50(c)(9) Be advised of the state toll free home health telephone hot line, its contact information, its hours of operation, and that its purpose is to receive complaints or questions about local HHAs. This ELEMENT is not met as evidenced by: Based on review of the agency's current patient rights information, observation, home folder review, and interview, the agency failed to ensure staff provided the written notice of the updated state toll free home health telephone hotline hours of operation (7:00 AM to 8:00 PM, seven days a week) in the admission folder in three (Record/Patient #1, #2, and #3) of three home visit observations. This deficient practice has the potential to affect the knowledge and comprehension of the rights and responsibilities for all patients/representatives served by the agency. Findings included: The agency's chief executive officer (CEO) provided an admission packet for review on 06/21/2022. Review of the agency's patient orientation for home health care booklet, revised 09/29/2020, showed you may contact the state’s home care hot line, which receives complaints, or questions about local home care agencies. Their hours are 7:00 AM to 12 midnight central time, 7 days per week. RECORD/PATIENT #1: Observation on 06/22/2022 at 10:45 AM, during the patient's home visit, showed: - The patient folder contained information that the hotline will be answered 7:00 AM to midnight; and - The agency failed to update the patient folder to include the correct hours the hotline will be answered. RECORD/PATIENT #2: Observation on 06/22/2022 at 9:00 AM, during the patient's home visit, showed: - The patient folder contained information that the hotline will be answered 7:00 AM to midnight; and - The agency failed to update the patient folder to include the correct hours the hotline will be answered. RECORD/PATIENT #3: Observation on 06/22/2022 at 10:30 AM, during the patient's home visit, showed: - The patient folder contained information that the hotline will be answered 7:00 AM to midnight; and - The agency failed to update the patient folder to include the correct hours the hotline will be answered. The above findings were reviewed with the CEO on 06/23/2022 at 10:30 AM. Per interview conducted during the review, the CEO stated that he/she did not know the hotline hours changed. No additional information was provided.

Advise the patient of discharge for cause CFR(s): 484.50(d)(5)(i) (i) Advise the patient, representative (if any), the physician(s) or allowed practitioner(s), issuing orders for the home health plan of care, and the patient's primary care practitioner or other health care professional who will be responsible for providing care and services to the patient after discharge from the HHA (if any) that a discharge for cause is being considered; This ELEMENT is not met as evidenced by: Based on review of the agency's current patient rights information and interview, the agency failed to provide written notice of patient rights to include that the agency must advise the patient or representative, physicians, and healthcare professionals who will be responsible for providing care after discharge, that a discharge for cause is being considered. This deficient practice has the potential to affect the knowledge and comprehension of the rights and responsibilities of all agency patients. Findings included: The agency's chief executive officer (CEO) provided an admission packet for review on 06/21/2022. The agency notice of patient rights and other information given to a patient during the initial visit contained no written information regarding that the agency must advise the patient or representative, physicians, and healthcare professionals who will be responsible for providing care after discharge, that a discharge for cause is being considered. The above findings were reviewed with the administrator on 06/23/2022 at 10:30 AM. No additional information was provided.

Make efforts to resolve the problem(s) CFR(s): 484.50(d)(5)(ii) (ii) Make efforts to resolve the problem(s) presented by the patient's behavior, the behavior of other persons in the patient's home, or situation; This ELEMENT is not met as evidenced by: Based on review of the agency's current patient rights information and interview, the agency failed to provide written notice of patient rights to include the agency must make efforts to resolve the problem(s) presented by the patient’s behavior, the behavior of other person’s in the patient’s home, or situation. This deficient practice has the potential to affect the knowledge and comprehension of the rights and responsibilities of all agency patients. Findings included: The agency's chief executive officer (CEO) provided an admission packet for review on 06/21/2022. The agency notice of patient rights and other information given to a patient during the initial visit contained no written information regarding the agency must make efforts to resolve the problem(s) presented by the patient’s behavior, the behavior of other person’s in the patient’s home, or situation. The above findings were reviewed with the administrator on 06/23/2022 at 10:30 AM. No additional information was provided.

Provide contact info other services CFR(s): 484.50(d)(5)(iii) (iii) Provide the patient and representative (if any), with contact information for other agencies or providers who may be able to provide care; and This ELEMENT is not met as evidenced by: Based on review of the agency's current patient rights information and interview, the agency failed to provide written notice of patient rights to include that if the patient is being considered for discharge for cause, the agency must provide the patient and representative (if any), with contact information for other agencies or providers who may be able to provide care after discharge. The deficient practice has the potential to affect the knowledge and comprehension of the rights and responsibilities of all agency patients. Findings included: The agency's chief executive officer (CEO) provided an admission packet for review on 06/21/2022. The agency's notice of patient rights and other information given to a patient during the initial visit contained no written information regarding the patient's right to be informed about the agency's policy to provide the patient and representative (if any) with contact information for other agencies or providers who may be able to provide care after discharge, if patient is being considered for discharge for cause. The above findings were reviewed with the administrator on 06/23/2022 at 10:30 AM. No additional information was provided.

Document efforts to resolve problems CFR(s): 484.50(d)(5)(iv) (iv) Document the problem(s) and efforts made to resolve the problem(s), and enter this documentation into its clinical records; This ELEMENT is not met as evidenced by: Based on review of the agency's current patient rights information and interview, the agency failed to provide written notice of patient rights to include that the agency must document the problem and efforts made to resolve the problem, if the patient is considered for discharge for cause. This deficient practice has the potential to affect the knowledge and comprehension of the rights and responsibilities of all agency patients. Findings included: The agency's chief executive officer (CEO) provided an admission packet for review on 06/21/2022. The agency notice of patient rights and other information given to a patient during the initial visit contained no written information regarding the patient's right to be informed that if the patient is considered for discharge for cause, the agency must document the problem and efforts made to resolve the problem. The above findings were reviewed with the administrator on 06/23/2022 at 10:30 AM. No additional information was provided.

Accessibility CFR(s): 484.50(f)(1,2) Standard: Accessibility. Information must be provided to patients in plain language and in a manner that is accessible and timely to- (1) Persons with disabilities, including accessible web sites and the provision of auxiliary aids and services at no cost to the individual in accordance with the Americans with Disabilities Act and Section 504 of the Rehabilitation Act. (2) Persons with limited English proficiency through the provision of language services at no cost to the individual, including oral interpretation and written translations.Standard: Accessibility Information must be provided to patients in plain language and in a manner that is accessible and timely to- This STANDARD is not met as evidenced by: Based on review of the agency's current patient rights information, home visit observation, and interview the agency failed to ensure the written patient rights information included; information must be provided to patients in a language and in a manner that is accessible and timely to persons with disabilities, including accessible web sites and the provision of auxiliary aids services, that are at no cost to the individual, and must be provided to persons with limited English proficiency, at no cost to the individual including oral interpretation and written translations, in three (Record/Patient #1, #2, and #3) of three home visit observations conducted. This deficient practice has the potential to affect the knowledge and comprehension of the rights and responsibilities of all agency patients. Findings included: The agency's chief executive officer (CEO) provided an admission packet for review on 06/21/2022. The agency's notice of patient rights and other information given to a patient during the initial visit failed to include; written information regarding the patient's right to be informed about information that must be provided to patients in a language and in a manner that is accessible and timely to persons with disabilities, including accessible web sites and the provision of auxiliary aids services are at no cost to the individual, and must be provided to persons with limited English proficiency, at no cost to the individual including oral interpretation and written translations. Observations during Patient #1's home visit on 06/22/2022 at 10:45 AM, Patient #2's home visit on 06/22/2022 at 9:00 AM, and Patient #3's home visit on 06/22/2022 at 10:30 AM, showed the written patient rights in their home folders failed to include the information as shown above. The above findings were reviewed with the administrator on 06/23/2022 at 10:30 AM. No additional information was provided.

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 clinical record review and interview, the agency failed to ensure the patient's current health status was assessed and documented in, but not limited to, one (Patient/Record #2) of five records reviewed. This deficient practice has the potential to affect the identification of patient needs for all patients on service with the agency. Findings included: RECORD/PATIENT #2: Review of the plan of care, dated 06/10/2022 through 08/08/2022, showed the following: - Patient has small incision left side up under breast where the drain (type not specified) was; - Monitor wound for drainage, redness, warmth, or other signs of infection and report physician if found; - Incision open to air; and - Remove sutures 06/7/2022. Review of the start of care OASIS (Outcome and Assessment Information Set - a required set of assessment data submitted to Medicare and Medicaid Services) assessment, dated 06/11/2022 at 6:36 PM, showed the following: - Primary diagnosis was malignant neoplasm (cancerous tumor) of lower lung, left bronchus or lung; - Encounter for attention to surgical dressings and sutures; - OASIS M1340 question regarding does the patient have a surgical wound showed “no” answered; - The assessment summary showed the patient was found to have a “precardial” (pericardial) effusion (buildup of too much fluid around the saclike structure around the heart), cardiac tamponade (compression of the heart caused by fluid collecting in the sac surrounding the heart) and cavity lesion in lung. He/she had three different fluid removals of bloody drainage that was malignant; and - Teaching included keeping left chest incision clean and dry; and - There was no assessment/documentation to show wound measurements, appearance, location, and if sutures were intact and how many. During an interview on 06/23/2022 at 11:00 AM, the chief executive officer stated he/she expected the assessment to include location, description and measurements of the wound. No further documentation provided.

A review of all current medications CFR(s): 484.55(c)(5) A review of all medications the patient is currently using in order to identify any potential adverse effects and drug reactions, including ineffective drug therapy, significant side effects, significant drug interactions, duplicate drug therapy, and noncompliance with drug therapy. This ELEMENT is not met as evidenced by: Based on policy review, record review, home visit observation, and interview, the agency failed to ensure an accurate medication reconciliation was performed in, but not limited to, one (Record/Patient #2) of three home visits. This deficient practice has the potential to affect all patients served by the agency. Findings included: Review of the agency’s undated policy titled, “Medication Policy,” showed in part, the following: - The agency staff shall provide oversight of all medication that are prescribed for any patient; and - Upon admission, recertification, resumption of care, discharge and after physician appointments (or medication changes) there will be a complete medication assessment and evaluation with notification of the physician of any discrepancies that are discovered, as well as a drug-to-drug interaction completed after each new medications is added to patient’s medications list. RECORD/PATIENT #2: Review of the medication profile, dated 06/21/2022, showed the following: - Benadryl allergy 25 mg, one tablet, as needed at bedtime if needed for sleep; and - Citalopram hydrobromide (antidepressant) 40 mg, one tablet daily. Review of the patient’s medications during a home visit on 06/22/2022 at 9:00 AM, showed the following: - Simethicone (used to relieve symptoms of extra gas such as belching, bloating, and feelings of pressure/discomfort in the stomach/gut) 125 micrograms (mcg) chewable, one or two tablets after meals and at bedtime; - Multivitamin for women 50 plus, one tablet daily; - Magnesium citrate (liquid laxative), 100 milligrams (mg) capsule daily; and - Bisacodyl (laxative) 5 mg, as needed for constipation. Review of the medical record showed the agency failed to include the simethicone, multivitamin, magnesium citrate, and biscodyl on the medication profile and the plan of care. During the home visit on 06/22/2022 at 9:00 AM, the patient stated that he/she stopped taking Benadryl about two weeks ago and stopped taking citalopram since he/she was discharge from the hospital. During the home visit on 06/22/2022 at 9:35 AM, the physical therapist stated that the nurses check the medications during skilled nursing visits. The therapist does not look at the medication list or bottles during their visits but will ask the patient if there are any medication changes after the patient has been to the doctor. If there are changes after a visit, or if the patient has questions about their medications, the therapist will send communication to the nurses so the patient’s medication changes can be noted or the patient’s questions can be answered. During an interview on 06/22/2022 at 3:00 PM, the chief executive officer (CEO) stated that medications should be evaluated at every nursing visit. Therapy will ask the patient about medication changes after the patient sees the physician. The CEO stated that he/she would have to double check with the agency’s policy.

Care planning, coordination, quality of care CFR(s): 484.60 Condition of participation: Care planning, coordination of services, and quality of care. Patients are accepted for treatment on the reasonable expectation that an HHA can meet the patient's medical, nursing, rehabilitative, and social needs in his or her place of residence. Each patient must receive an individualized written plan of care, including any revisions or additions. The individualized plan of care must specify the care and services necessary to meet the patient-specific needs as identified in the comprehensive assessment, including identification of the responsible discipline(s), and the measurable outcomes that the HHA anticipates will occur as a result of implementing and coordinating the plan of care. The individualized plan of care must also specify the patient and caregiver education and training. Services must be furnished in accordance with accepted standards of practice. This CONDITION is not met as evidenced by: Based on policy review, clinical record review, observation, and interview, the agency failed to provide an individualized, written plan of care specifying the care and services that met the requirements for the Condition of Participation: Care Planning, coordination of services and quality of care. The agency failed to: - Provide an individualized plan of care that included all required elements (G574); and - Ensure the home health agency (HHA) staff promptly alerted the relevant physician(s) or allowed practitioner(s) to any changes in the patient's condition or needs that suggested outcomes are not being achieved and/or that the POC should be altered (G590). The cumulative effect of these deficient practices has the potential to affect individualized and physician ordered care provided to all the agency's patients. .

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 plan of care (POC) included all of the required elements in, but not limited to, four (Record/Patient #1, #3, #4, and #5) of five full record reviews. This deficient practice has the potential to affect the care of all patients served by the agency. Findings included: Review of the agency’s policy titled, “Plan of Care,” dated 06/05/2018, showed in part, the following: - An individualized plan of care will be developed for each person admitted to the agency; - The goal of the plan of care is to provide individualized care to each of the agency’s patients in accordance to current regulations governing home health services both at state and federal levels; - The actions and interventions outlined in the plan of care will be implemented by each discipline specified; - The plan of care will be developed when the patient is admitted to services and revised as changes occur; - The certification and recertification plan of care will include at least, but not limited to: * Functional limitations; * Safety measures; * Measurable treatment goals with target dates for completion; and - The registered nurse will assume the responsibility for compiling all information necessary to complete the certification plan of care, including any other disciplines, specific interventions and goals. RECORD/PATIENT #1: Review of hospital discharge orders, dated 05/12/2022, showed the following: - Diagnosis included, but not limited to, diabetic ulcer of left foot and diabetes mellitus (diabetes); - Contact wound care for deterioration in wound status or any new concerns; - Monitoring and mitigation of pain management; - Call 911 for: headache, vision changes, weakness, sensation changes; - Call physician for difficulty breathing, extreme fatigue, dizziness, light-headedness, persistent nausea or vomiting, severe uncontrolled pain; - Check blood sugar before meals and at bedtime and record, take record to all doctors’ appointments; and - Patient to have post-op shoe on when out of bed. Review of the plan of care (POC), dated 05/17/2022 through 07/15/2022, failed to include: - Wound care clinic information and how often the patient was going to the clinic; - Individualized interventions of pain management; - Instructions to wear post op shoe when out of bed; - Diabetes mellitus management, and blood sugar parameters and management; - Call 911 for: headache, vision changes, weakness, sensation changes; - Call physician for difficulty breathing, extreme fatigue, dizziness, light-headedness, persistent nausea or vomiting, severe uncontrolled pain. Observation on 06/22/2022 at 10:45 AM, during the patient's home visit, showed the following: - The patient stated that he/she always had problems waking up in the morning due to his/her blood sugars; - This morning his/her blood sugar was a little high at 181 (normal blood sugar recommendation with someone with diabetes is 80-130 milligram (mg)/deciliter (dl); - The patient stated that he/she had arthritis in right shoulder and if he/she moves his/her arm it hurts, so he/she keeps his/her arm down, and takes Tylenol or Ibuprofen as needed; and - Two weeks ago the patient had pain in mid foot for two and half days and the patient’s spouse started massaging foot and a bunch of “gook came out of his/her wound” he/she had to take oxycodone for the pain. During an interview, on 06/22/2022 at 2:00 PM, registered nurse (RN) A stated that he/she should have clarified blood sugar checks and blood sugar parameters and added this information to the plan of care, and pain was not on the plan of care. RCORD/PATIENT #3: Review of the start of care assessment, dated 6/14/22 at 2:28 PM, showed: - Moderate risk for pressure sores (injuries to the skin and underlying tissue, primarily caused by prolonged pressure on the skin; - Moisture associated skin breakdown to both “cheeks”, length in centimeters “two areas about four centimeters (cm) round and beefy red (there was no other description); - Left shin had venous stasis ulcer (a wound on the leg or ankle caused by abnormal damaged veins), 1 cm round with bloody drainage; - The patient went to the hospital with a myocardial infarction (MI) (heart attack); - The area on his/her buttocks are likely due to moisture and pressure, nursing to assess and encouraged to change incontinent briefs more often; and - The plan for nursing services were to assess the patient’s bottom. Review of the plan of care (POC), dated 06/14/2022 through 08/12/2022, failed to address the wounds to coccyx and left shin venous stasis ulcer. During an interview on 6/23/22 at 11:00 AM, the chief executive officer (CEO) stated the plan of care drives what the agency does for each individual patient but there is also nursing judgement that is involved and not all of the nursing judgements need an order. RECORD/PATIENT #4: Review of the start of care assessment, dated 4/13/22 at 10:31 AM, showed: - Diagnosis included lumbar spondylosis (age related wear and tear of spinal discs), neuroforaminal stenosis of lumbar spine (narrowing openings between each vertebra, which nerve roots pass through, and chronic osteomyelitis (infection in a bone) of the right femur; - Pain interferes with patient’s activity or movement all of the time; - Current pain rating with pain assessment in advanced dementia scale (PAINAD) (a reliable assessment tool for dementia patients) a four (moderate pain); - The location is bilateral hips/femur; - Relieved by prescription medications and position changes; - Patient is followed by palliative pain management; and - Patient has chronic pain management. Review of the plan of care (POC), dated 04/12/2022 through 06/10/2022, showed the agency failed to address the patient’s pain, individualized interventions, education and goals for pain control. Review of the recertification assessment, dated 6/08/22 at 7:13 PM, showed: - Pain interferes with patient’s activity or movement all of the time; - The location is right lower extremity; - Relieved by prescription meds; - PAINAID this visit: Patient rates pain in his/her right leg at a six, chronic pain; - Patient was hospitalized on 05/07/2022, due to having seizure activity and returned home on 05/07/2022, primary cause of patient’s problems was found to be related to dependency on oxycodone (treats moderate to severe pain); and - Pain in now managed with Butrans patch (treats pain as well as addiction to narcotic pain relievers) and Dilaudid (used to treat moderate to severe pain). Review of POC, dated 06/11/2022 through 08/09/2022, failed to show the patient’s acceptable level of pain, when the MD should be notified, when pain assessments should be conducted, non-pharmacological pain relief measures, or psychosocial issues patient may be having related to oxycodone dependency. RECORD/PATIENT #5: Review of the start of care assessment dated 05/15/2022 at 4:09 PM showed: - Diagnosis included, but not limited to, degenerative - PAINAD this visit: 3-4 all over; and - Pain all of the time. Review of the plan of care, dated 05/15/2022 through 07/13/2022, showed no acceptable level of pain, pain parameters, when to notify the physician, education and goals. During an interview on 6/22/22 at 3:00 PM, the CEO stated that this was the first time he/she had heard of including pain assessment and involving patient in determining acceptable levels of pain on the plan of care. He/she did understand that the POC should be individualized so they would get pain assessment, interventions and teaching added to the POC.

Promptly alert relevant physician of changes CFR(s): 484.60(c)(1) The HHA must promptly alert the relevant physician(s) or allowed practitioner(s) to any changes in the patient's condition or needs that suggest that outcomes are not being achieved and/or that the plan of care should be altered. This ELEMENT is not met as evidenced by: Based on policy review, record review, observation, and interview, the agency failed to promptly alert the physician to changes in the patient's condition that may suggest a need to alter the plan of care (POC) in, but not limited to, two, (Records/Patients #1 and #5) of five records reviewed. This deficient practice has the potential to affect all patients served by the agency. Findings included: Review of the agency’s policy titled, "Coordination of Patient Care" dated 06/22/2022 showed, in part: - Each staff member providing patient care will be responsible for applying this policy to assessment process and to work together with the patient’s physician to achieve optimal patient outcomes; and - The physician will be notified of significant changes in the patient’s condition such as fall, medication side effects, adverse reactions or other changes which may occur. Review of the undated agency's policy titled, "Pain Management," showed if the patient's pain in not well managed, the primary care or ordering provider for home health services will be notified for possible changes in treatment. RECORD/PATIENT #1: Review of hospital discharge orders, dated 05/12/2022, showed the following: - Contact wound care for deterioration in wound status or any new concerns; - Call 911 for: headache, vision changes, weakness, sensation changes; and - Call physician for difficulty breathing, extreme fatigue, dizziness, light-headedness, persistent nausea or vomiting, and severe uncontrolled pain. Review of the start of care assessment, dated 05/17/2022 at 9:04 PM, showed: - The patient had a left foot diabetic neuropathic (type of nerve damage) ulcer (an open sore), not healing, and not measured; - The wound had 40% slough (necrotic tissue) and 60% granulation (development of new tissue); the surrounding tissue was pale and macerated; - Tunneling (passageway underneath the surface of the skin) was absent; - The patient was admitted to the hospital with osteomyelitis (bone infection) that developed from his/her foot wound; - The patient had a health history of neuropathy and was assessed with no pain; and - PICC line (a type of long catheter that is inserted into a peripheral vein into a larger vein in the body) to right upper arm for antibiotics and no evidence of phlebitis (inflammation in walls of veins); and - Registered nurse (RN) removed dressing from foot, he/she had an ulcerated (formation of a break in the skin or on the surface of an organ) area to the ball of his/her left foot and left great toe was swollen. Review of the plan of care (POC), dated 05/17/2022 through 07/15/2022, showed, in part: - The patient was admitted to home health services on 05/17/2022; - Diagnoses type two diabetes mellitus (a chronic condition that affects the way the body processes blood sugar) with foot ulcer, attention to dressings and sutures, diabetes mellitus with ketoacidosis (a serious diabetes complication where the body produces excess blood acids); - Measure wound on bottom of left foot for drainage, redness, warmth, or other signs of infection and report to doctor if found; - Cleanse with Vashe (used to cleanse a wound), apply santyl (removes dead tissue from wounds) to wound bed, pack with 1-inch Nu Gauze (fine mesh gauze), cover with 4x4 (gauze pad), wrap with Kerlix (bandage rolls) and ace wrap; - Assess PICC line site for redness, drainage, tenderness at site and notify doctor, instruct on signs and symptoms of intravenous (IV) access problems and report to doctor/registered nurse (RN); - Goals: Patient's venous access will remain patent and without complications through 06/22/2022 and the wound will be showing signs of healing by 05/30/2022. Review of the skilled nurse visit note, dated 05/18/2022 at 10:58 AM, showed: - Left foot diabetic neuropathic ulcer, not healing; - Measurements: length 1.8 centimeters (cm) by width 1.5 cm by depth 0.9 cm; - Slough 40% and granulation 60% and surrounding tissue pale; and - Tunneling location: 9 o’clock (the longest length of the wound by imagining the face of the clock over the wound bed, on the feet, the heels are always 12 o’clock and the toes are always 6 o’clock) 1.4 cm; and - Undermining (occurs when significant erosion occurs underneath the outwardly visible wound margins resulting in more extensive damage beneath the skin surface) location: 1 cm surrounding entire open area. Review of infectious disease physician orders, dated 05/24/2022, showed dressing change to bottom of left foot: Clean with normal saline, apply lodosorb (a sterile antimicrobial dressing), cover with calcium alginate (dressing used on moderate to heavily exudative wounds during the transition from debridement to repair phase of wound healing), gauze, and secure with Kerlix. Dressing changed daily. Review of the skilled nurse visit note, dated 05/25/2022 at 2:46 PM, showed: - Left foot diabetic neuropathic ulcer, not healing; - Measurements: length 1.5 centimeters (cm) by width 1.4 cm by depth 1.3 cm (the wound size increased in seven days and the documentation failed to include physician notification); - No assessment of slough, granulation, and surrounding tissue pale and macerated; - Tunneling: No assessment; - Undermining location: 4-6 o’clock 1.6 cm (undermining had increased .6 cm increase in seven days and the documentation failed to include physician notification); - Patient went to the wound clinic Monday 05/23/2022 and the wound clinic changed the wound dressing orders; - Patient has swelling to left great toe; and - The RN reported to the home infusion pharmacy that the PICC line would not give blood return but was infusing fine. The pharmacy will contact the physician to see if the physician would allow Cathflo (thrombolytic agent that is a treatment option for central venous access device occlusions as assessed by the ability to draw blood). Review of a clinical note, dated 06/01/2022 at 3:48 PM, the RN called the home infusion pharmacy and spoke to pharmacist regarding Cathflo (seven days after the initial notification). The pharmacist was not aware of the need for Cathflo. The RN relayed the PICC line was flushing and infusing okay but they were unable to get a blood return. The PICC line was infusing okay so if “they” do not want to use Cathflo that is fine. The pharmacist will contact the physician to see what they want to do. Review of the skilled nurse visit note, dated 06/01/2022, and completed on 06/02/2022 at 3:06 PM showed: - Left foot diabetic neuropathic ulcer, not healing; - Measurements: length 1cm by width 1.5 cm by depth 0.9 cm; - No assessment of slough, granulation, and surrounding tissue pale and macerated; - Tunneling: No assessment; -Undermining location: 4-6 o’clock 1.9 cm (undermining had increased .3 cm in seven days and the documentation failed to include physician notification); - Patient has trace edema to left great toe; - The patient reported sometimes at night the PICC line will be sore, he/she thinks it is the way he/she is laying; - There was a small amount of dried blood at the insertion site that was cleaned off and the nurse was unable to get a blood return (No blood return since 05/25 and the documentation failed to include the physician notification); and - The patient sees the wound clinic this afternoon (undermining increased .3 cm in seven days and the documentation failed to show the physician notification). Review of the skilled nurse visit note, dated 06/08/2022, and completed on 06/10/2022 at 1:48 PM, showed: - Left foot diabetic neuropathic ulcer, not healing; - Measurements: length 1.2 cm by width 1.3 cm by depth 0.9 cm; - No assessment of slough, granulation, and surrounding tissue pale and macerated; - Tunneling: No assessment; -Undermining location: 6 o’clock 2.1 cm (the undermining increased .2 cm in seven days and the documentation failed to include physician notification); - Dressing changed per 06/08/2022 physician orders; - Patient has trace edema to left great toe; - Cathflo sent from the home infusion pharmacy and administered into PICC line and blood return obtained; - The patient reported sometimes at night the PICC line will be sore sometimes at night and could have been the way he/she was lying; - RN did relay that the “secure a cath” (a single-use device to secure percutaneous catheters in position on the skin) has little prongs that go out from either side under the skin to hold the PICC line in place, so it may be positioned to where it is irritating him/her; - Patient reported intermittent nausea with antibiotic (the documentation failed to include physician notification); and - The patient had some blood backflow into the PICC line before the cap was applied, and the RN advised the patient to call the nurse if he/she notices any blood backflow in line. Review of infectious disease physician orders, dated 06/08/2022, showed dressing change to left foot: - Clean with normal saline; - Apply silvadene cream (topical agent with antibacterial and antifungal activity) to corner of a 2 x 2 (gauze pad), tuck corner into the depth of the wound, fold remaining 2 X 2 over the wound; - Cover with 4 X 4 and wrap with kerlix; and - There was no documentation to show wound care physician notification of the change in orders. Review of the skilled nurse visit note, dated 06/15/2022, and completed on 06/16/2022 at 9:23 PM, showed: - Patient reported pain to bottom of left foot related to chronic foot wound; - The pain was intermittent and burning, and relieved by rest; - Left foot diabetic neuropathic ulcer, not healing; - Measurements: length 0.8 cm by width 1 cm by depth 0.9 cm; - No assessment of slough, granulation, and surrounding tissue pale and macerated; - Tunneling: No assessment; -Undermining location: 5 o’clock to 9 o’clock 2.3 cm (the undermining increased .2 cm in seven days and the documentation failed to show physician notification); - Dressing changed per 06/08/2022 physician orders; - The patient reported that his/her foot had a mild burning sensation today and on Friday his/her foot was more red and hot, and was very painful but is better now; - The RN advised that “if this develops” he/she needs to go to the emergency room and have his/her foot evaluated and patient voiced understanding; - The patient reported very subtle nausea with antibiotic (the documentation failed to show physician notification); and - The RN called the wound clinic regarding foot and the wound clinic relayed the patient may need to go to the emergency room if the wound looks infected as he/she may need IV antibiotics, the RN replied the patient is already on IV antibiotics and the patient sees the infectious disease physician tomorrow. The wound clinic suggested the RN called the infectious disease physician and the RN left message with the infectious disease physician’s office. There was no further documentation. During the home visit observation on 06/22/2022 at 10:45 AM, showed the following: - The patient stated he/she had pain in left mid foot for two and ½ days and his/her spouse started massaging it and a lot of “gunk” came out of the wound; - The left foot was red and swollen around toes and upper foot and the patient stated that started yesterday; - The left wound on the bottom of the patient’s foot measured: Length 0.9 cm by width 1.3 cm by depth 1.2 cm; - Undermining location: 6 o’clock to 8 o’clock 3.8 cm and tunneling location: at 9 o’clock 1.9 cm; - The surrounding tissue of the wound was macerated, pale, and measured .6 cm; - The wound bed showed exposed tendon and bone; - The skilled nurse was able to draw blood using PICC line; and - The RN encouraged the patient to go to the emergency room. During an interview on 06/22/2022 at 2:00 PM, RN A stated that: - He/she notified the wound clinic last week of the patient’s change in condition and he/she could not recall notifying wound clinic/physician of any other changes prior to last week; - He/she usually does not notify the wound clinic because most days the patient has an appointment with the wound clinic so the clinic would address changes with the wound; - He/she should notify the physician when there is a change in condition; - When the nurse is having issues with the PICC line, the home infusion pharmacy is notified and they notify the infectious disease physician; and - The wound clinic was not listed on the plan of care. During an interview on 06/23/2022 at 9:23 AM, the chief executive officer stated that: - The patient was admitted to the hospital on 06/22/2022 with antibiotic failure and transmetatarsal amputation (surgery to remove part of the foot); - It would depend on the change in condition if a physician is notified of a wound, a .2 cm increase in wound measurement is minimal, the physician wouldn’t necessarily be notified, and staff should continue to assess the wound; - There usually is no communication with the wound clinic if they are seeing the patient; - If the nurse is unable to get a blood return with PICC line the nurse will call the home infusion pharmacy and they will notify the physician and the pharmacy gives orders; - No blood return from PICC line is normal and as long and as the length of the PICC line hasn’t it changed it is still in place (there was no measurements of the PICC line only the arm circumference in the clinical record); and - There was no further information provided. RECORD/PATIENT #5: Review of the start of care assessment, dated 05/15/2022 at 4:09 PM, showed: - Diagnosis included, but not limited to, degenerative joint disease involving multiple joints and fall on same level; - Pain interfering with patient’s activity or movement all of the time; - Pain rating with pain assessment in advanced dementia scale (PAINAD) (a reliable assessment tool for dementia patients) showed dementia; - Pain generalized throughout; - Acetaminophen (used to treat minor aches and pain) 500 milligram (mg) two tablets as needed every six hours as needed for mild pain; - Diclofenac sodium transdermal cream (used to relieve pain, swelling, and joint stiffness caused by arthritis) 2.5% as needed four times per day as needed for knee pain; - Oxycodone hydrochloride (it can treat moderate to severe pain) 5 mg twice a day as needed for severe pain; and - Tramadol (it can treat moderate to severe pain) 50 mg every six hours as needed for moderate pain twice a day. Review of the plan of care, dated 05/15/2022 through 07/13/2022, did not include pain interventions, pain parameters, when to notify the physician, education, and goals. Review of an occupational therapy (OT) initial visit note, dated 05/18/2022 and completed 05/19/2022 at 8:46 AM, showed: - Current pain regimen: Pain is well controlled with current plan of care; - Location of current pain: Joints; - Current joint site pain: Limits activities of daily living (ADL’s); - Location of pain: neck, knees, and fingers; - Type: Arthritic and constant; - Rating for current pain: Current rating with 0-10 scale (zero representing no pain and 10 representing the worst possible pain): 6/10; - Relieved by prescription medications. Other: patient takes two 50 mg Tramadol per day; and - Patient had recent multiple falls. Review of an occupational therapy (OT) initial visit note, dated 05/19/2022, and completed on 05/23/2022 at 6:15 AM, showed: - The patient rated pain in bilateral fingers one to three at 7/10; - The patient stated that the pain is chronic and related to osteoarthritis and he/she also has carpal tunnel syndrome which he/she wears braces at night (This was not on the plan of care); - The daughter applied diclofenac sodium cream to bilateral hands during visit for joint pain; and - The documentation failed to show physician notification of pain. Review of an OT visit note, dated 05/25/2022, and completed on 05/31/2022 at 6:19 AM, showed: - The patient rated pain 5/10; - The patient rated pain in bilateral hands 8/10 and reported relief with taking Tramadol and use of diclofenac sodium cream on hands; - He/she does have bilateral wrist braces which help but the patient has yet to wear them (the plan of care was not updated to include braces and education); and - The documentation failed to show physician notification of pain. Review of an OT initial visit note, dated 05/27/2022, and completed on 05/31/2022 at 7:07 PM, showed: - The patient stated he/she had “pain all the time”, and did not enumerate pain level; and - The documentation failed to show physician notification of pain and constipation. Review of an OT initial visit note, dated 06/01/2022, and completed on 06/02/2022 at 12:12 PM, showed: - The patient stated that he/she was feeling “fair”, “not as good as usual”, however, did not further describe; - Rated pain in bilateral fingers and knees (described arthritic in nature) a 6/10; and - The documentation failed to show physician notification of pain. Review of the skilled nurse discharge from agency assessment, dated 06/02/2022, and completed on 06/03/2022 at 2:43 PM, showed: - Current pain regimen: Pain is well controlled with current plan of care; - Pain is generalized throughout; - PAINAD- dementia; - Occasional moan or groan and low level speech with a negative or disapproving quality; - The patient has chronic pain that is controlled with Tylenol and tramadol; - The patient stated that the pain is generally in the left hip, which is where he/she had a fall in the past; and - The documentation failed to show physician notification of pain in left hip and the patient was discharged. The above findings were reviewed with the CEO on 06/23/2022 at 9:23 AM, and no further information was provided.

Competency evaluation CFR(s): 484.80(c)(1)(2)(3) Standard: Competency evaluation. An individual may furnish home health services on behalf of an HHA only after that individual has successfully completed a competency evaluation program as described in this section. (1) The competency evaluation must address each of the subjects listed in paragraph (b)(3) of this section. Subject areas specified under paragraphs (b)(3)(i), (iii), (ix), (x), and (xi) of this section must be evaluated by observing an aide's performance of the task with a patient or pseudo-patient. The remaining subject areas may be evaluated through written examination, oral examination, or after observation of a home health aide with a patient, or with a pseudo-patient as part of a simulation. (2) A home health aide competency evaluation program may be offered by any organization, except as specified in paragraph (f) of this section. (3) The competency evaluation must be performed by a registered nurse in consultation with other skilled professionals, as appropriate. This STANDARD is not met as evidenced by: Based on the results of this extended level survey, resulting in noncompliance with two Conditions of Participation: Patient rights and Care Planning, Coordination of Services and Quality of Care, the agency may not train or competency evaluate their home health aides for a period of two (2) years following the date of this survey. The restriction ends 06/23/2024. .