Every finding on record at Innovative Senior Care Home Health of High Point LLC

An onsite recertification survey was conducted 2/10/25-2/12/25. No deficiencies to the Emergency Preparedness Program were identified.

An onsite recertification survey was conducted 2/10/25-2/12/25. Deficiencies to the Medicare Conditions of Participation were identified.

Last 5 days of every 60 days unless: CFR(s): 484.55(d)(1)(i,ii,iii) The last 5 days of every 60 days beginning with the start-of-care date, unless there is a- (i) Beneficiary elected transfer; (ii) Significant change in condition; or (iii) Discharge and return to the same HHA during the 60-day episode. This ELEMENT is not met as evidenced by: Based on agency policy review, clinical record review, and staff interviews the Recertification OASIS [Outcome and Assessment Information Set-assessment on a patient to re-certify their needs for continued home health services] was completed outside the 5-day window for 1 of 1 patient requiring VA [veteran's administration] approval [#13]. The findings included: The policy, Patient Assessment, Initial and Reassessment [9/1/24], was provided by the agency director on 2/11/25 at approximately 10:26 am. The policy stated, "...A qualified clinician performs a comprehensive assessment or reassessment visit in the following situations...Periodic reassessment during the last 5 days of the recertification..." Patient #12 had a Start of Care date of 9/25/24 with an admitting diagnosis of chronic venous hypertension [increased pressure inside the veins] with ulcer of bilateral lower extremity. Review of the Plan of care for the certification period 1/23/25-3/23/25 included orders for SN [skilled nursing] 2 times a week for 7 weeks. Review of the clinical record revealed RN # 3 completed the recertification OASIS [Outcome and Assessment Information Set-assessment on a patient to re-certify their needs for continued home health services] on 1/28/25. The last day of the previous episode was 1/22/25 with the new episode beginning on 1/23/25. During an interview with the agency administrator on 2/12/25 at 10 am, the administrator explained “This issue was caused at a corporate level.” The administrator confirmed the OASIS was late.

Plan of care must include the following CFR(s): 484.60(a)(2)(i-xvi) The individualized plan of care must include the following: (i) All pertinent diagnoses; (ii) The patient's mental, psychosocial, and cognitive status; (iii) The types of services, supplies, and equipment required; (iv) The frequency and duration of visits to be made; (v) Prognosis; (vi) Rehabilitation potential; (vii) Functional limitations; (viii) Activities permitted; (ix) Nutritional requirements; (x) All medications and treatments; (xi) Safety measures to protect against injury; (xii) A description of the patient's risk for emergency department visits and hospital re-admission, and all necessary interventions to address the underlying risk factors. (xiii) Patient and caregiver education and training to facilitate timely discharge; (xiv) Patient-specific interventions and education; measurable outcomes and goals identified by the HHA and the patient; (xv) Information related to any advanced directives; and (xvi) Any additional items the HHA or physician or allowed practitioner may choose to include. This ELEMENT is not met as evidenced by: Based on agency policy, direct observation, clinical record review, and staff interviews the Plan of Care [POC] failed to included all/correct medications the patient was using for 3 of 18 patients [#7, 12 13]; and failed to include TPN [total parenteral nutrition-medical treatment where all necessary nutrients are provided directly into the bloodstream] information for 1 of 1 patient receiving TPN [#18]. The findings included: The policy, Monitoring Medications [7/1/24], was provided by the agency director on 2/11/25 at approximately 10:26 am. The policy stated, "To provide a process to ensure continuous monitoring of medications in the patient's home. A drug regimen review will be performed on all patients in conjunction with all comprehensive assessments. Additionally, all clinicians will participate in medication review and reconciliations throughout the episode. The policy, Plan of Care [POC] [9/1/24], was provided by the agency director on 2/11/25 at approximately 10:am. The policy stated, "...The POC includes: ...Nutritional requirements, Medications and treatments..." 2. Patient # 12 had a Start of Care date of 9/25/24 with an admitting diagnosis of chronic venous hypertension [increased pressure inside the veins] with ulcer of bilateral lower extremity. Review of the Plan of care for the certification period 1/23/25-3/23/25 included orders for SN [skilled nursing] 2 times a week for 7 weeks and “skilled nurse to instruct on new and changed medications...” A joint visit was conducted with RN # 3 on 2/10/25 at approximately 1 pm. During the visit a medication review was conducted using a medication profile provided by the agency. The following discrepancies were noted: The medication profile listed ibuprofen 600 mg 2 tablets 2 times a day and Ferrous Sulfate [iron supplement] 325 mg daily. During an interview with the patient, the patient stated, “I don’t take those medicines anymore.” During an interview with RN # 3 she confirmed the POC did not include all/correct medications the patient was taking. 3. Patient # 13 had a Start of Care date of 11/1/24 with a diagnosis of unspecified wound to left lower leg. Review of the Plan of Care for the certification period 12/31/24-2/28/25 included orders for SN [skilled nursing] 1 time a week for 1 week, 2 times a week for 3 weeks, 1 time a week for 2 weeks and skilled nurse to instruct on new and changed medications...” On 2/11/25 at approximately 10 am a joint visit was conducted with RN # 4. During the visit a medication review was conducted using a medication profile provided by the agency. The following discrepancies were noted: The medication profile listed Acidophilus Probiotic [used to replace good bacteria in the stomach] 175 mg take 1 daily, Cetirizine [antihistamine] 10 mg daily, Divalproex [antiseizure] 125 mg 3 times a day, Carbidopa-levodopa [used for Parkinson’s] 25 mg 1 at bedtime, and Mucinex [expectorant] 10 mg 3 times daily. A comparison to the medication profile to the current medication administration record at the assisted living facility revealed the patient was no longer taking those medications. During an interview with the agency administrator on 2/12/25 at approximately 11 am, the director confirmed the POC did not include the current/correct medications the patient was taking. 4. Patient # 18 had a Start of Care date of 2/13/24 with an admitting diagnosis of Crohn’s Disease [inflammatory bowel disease]. Review of the Plan of Care [POC] for the certification period 12/9/24-2/6/25 included orders for SN [skilled nursing] 1 time a week for 9 weeks. Further review of the POC revealed the Patient’s Expressed Goal was “To keep my TPN [total parenteral nutrition-medical treatment where all necessary nutrients are provided directly into the bloodstream] going.” The POC did not include the TPN; the rate of the TPN or any other necessary directions. During an interview with the agency director on 2/12/25 at approximately 10 am, the director confirmed the POC lacked all the required components. G0574, Section 484.60 (a)(2) The individualized plan of care must include the following: All medications and treatments Patient #7 had a Start of Care date of 1/9/2025 with an admitting diagnosis of Chronic Kidney Disease (causes progressive damage and loss of function in the kidneys) and Type 2 Diabetes (condition in which the body has trouble controlling blood sugar levels). Review of the Plan of care for the certification period 1/9/2025 to 3/23/2025 included orders for PT (physical therapy) 1 time a week for 5 weeks and OT (occupational therapy) 1 time a week for 7 weeks. Review of the plan of care revealed Potassium (an essential mineral that supports heart, bone, kidney health, helps to balance fluid in the body, and helps muscles contract), was listed twice – once as Potassium Chloride ER (extended release)10 milliequivalents 1 pill daily and once as Klor-Con ER (a name brand of potassium) 10 milliequivalents 1 pill daily. Further review of the POC revealed the following entry: Humalog Insulin Tempo pen 100 units per milliliter (a prefilled, disposable insulin pen with a dial that is used to adjust dose to administer pre-meal insulin) based on a sliding scale (the insulin dose based on the blood sugar level before the meal). The POC did not include the physician-ordered sliding scale. During an interview with RN # 3 she confirmed the POC listed the potassium twice and there was no sliding scale for the insulin.

All orders recorded in plan of care CFR(s): 484.60(a)(3) All patient care orders, including verbal orders, must be recorded in the plan of care. This ELEMENT is not met as evidenced by: Based on agency policy, clinical record review, and staff interviews the plan of care failed to include all orders for 1 of 1 patient who resided in an ALF [assisted living facility] [#3]. The findings included: The policy, “Physician Orders”, revised 10/1/23, was received from the agency director on 2/11/25 at 2:26 PM. The policy stated”, …services are provided according to the most recent orders updating the patient’s plan of care…” Patient #3 had a Start of care date of 9/16/2024 with an admitting diagnoses of Essential primary hypertension (high blood pressure) and Dermatitis (skin inflammation). Review of the plan of care for the certification period 9/16/2024 to 10/3/2024 included orders for SN (skilled nurse) 2 times a week for 3 weeks. Review of the clinical record revealed the following documentation by RN # 9 9/23/24 “zinc applied to groin and buttocks.” On 9/26/2024 RN # 9 documented, “…SN cleansed buttocks and perineum and applied zinc.” Further review of the clinical record revealed no physician’s order for zinc. The agency director phoned RN #9 and it was confirmed during an interview on 2/12/2025 at approximately 11:05 am, that while the order to apply Zinc is listed on the ALF orders, the order to apply Zinc was not added to the agency plan of care.

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 agency policy, clinical record review, and staff interviews the agency failed to follow the physician's order for discarding blood for 1 of 1 patient with a CVAD [central venous access device-thin tube inserted into a vein to deliver fluids and/or medications etc.] [#18]. The findings included: The policy, Physician's Orders [10/1/23], was provided by the agency director on 2/11/25 at 10:46 am. The policy stated, " ...No medications, treatments...will be administered without the order of a qualified physician or authorized practitioner..." Patient # 18 had a Start of Care date of 2/13/24 with an admitting diagnosis of Crohn’s Disease [inflammatory bowel disease]. Review of the Plan of Care [POC] for the certification period 12/9/24-2/6/25 included orders for SN [skilled nursing] 1 time a week for 9 weeks and “skilled nurse to perform lab draw from CVAD [central venous access device-thin tube inserted into a vein to deliver fluids and/or medications etc.] ...Discard 5 ml of blood...”Review of the clinical record revealed RN # 7 conducted a infusion SN visit on 1/14/24 and documented “Blood Discarded-10 ml”. During an interview with the agency director on 2/12/25 at approximately 10 am, the director confirmed the amount of discarded blood was not in accordance with the physician’s order.

Communication with all physicians CFR(s): 484.60(d)(1) Standard: Coordination of Care. The HHA must: (1) Assure communication with all physicians or allowed practitioners involved in the plan of care. This ELEMENT is not met as evidenced by: Based on clinical record review and staff interviews the agency failed to notify the physician when unable to obtain blood for labwork due to an occulsion of CVAD [central venous access device-thin tube inserted into a vein to deliver fluids and/or medications etc.] line for 1 of 1 patient receiving TPN [total parenteral nutrition-medical treatment where all necessary nutrients are provided directly into the bloodstream] [#18]. The findings included: Patient # 18 had a Start of Care date of 2/13/24 with an admitting diagnosis of Crohn’s Disease [inflammatory bowel disease]. Review of the Plan of Care [POC] for the certification period 12/9/24-2/6/25 included orders for SN [skilled nursing] 1 time a week for 9 weeks and “skilled nurse to perform lab draw from CVAD [central venous access device-thin tube inserted into a vein to deliver fluids and/or medications etc.]. Draw CBC [complete blood count] with diff [differential] and CMP [complete metabolic panel] every week...” Review of the clinical record revealed RN # 7 conducted an infusion RN visit on 1/22/25 and documented the following information, “Unable to get labs. PICC [peripherally inserted central catheter] occluded. Patient is going to send a message to ______ [name of nurse practitioner] ...” There was no evidence that the RN followed up and notified the nurse practitioner or physician of the inability to obtain the labs due to the line being occluded. During an interview with the agency director on 2/12/25 at approximately 10 am, the director confirmed the RN failed to notify the physician of the line occlusion.

Provide services in the plan of care CFR(s): 484.75(b)(3) Providing services that are ordered by the physician or allowed practitioner as indicated in the plan of care; This ELEMENT is not met as evidenced by: Based on policy review, clinical record review, and staff interview, the agency failed to follow the physicians order for home health aide visits as ordered by the physician for 1 of 2 records reviewed with aide services (#2); failed to provide physical therapy visits in accordance with physician's orders for 1 of 15 patients receiving physical therapy (#15). Findings included: 2. Patient #15 was admitted on 1/10/2025 with diagnoses of L pleural effusion (a buildup of fluid between the tissues that line the lungs and the chest). The plan of care for 1/10/2025 to 3/10/2025 had orders for PT 1 time a week for 1 week, 2 times a week for 1 week, and 1 time a week for 5 weeks. Review of the clinical record on 2/11/2025 revealed no PT visits were completed the week of 1/26/2025-2/1/2025 as ordered. Interview with agency director confirmed that no additional documentation was in the record as to why the visits were not made and no notification was in the record that the physician was notified. Review of policy, “Physician Orders”, revised 10/1/23, was received from the agency director on 2/11/25 at 2:26 PM. The policy stated”, …services are provided according to the most recent orders updating the patient’s plan of care…” 1.Patient #2 was admitted was admitted on6/6/2024 with diagnoses of moderate protein calorie intake, prolonged grief disorder, pain in right knee, and repeated falls. The plan of care for 6/6/24 to 8/4/24 had orders for home health aide 1 time a week for 1 week, 2 times a week for 1 week. Review of the clinical record on 2/10/25 revealed no home health aide visits were completed the week of 6/17/24 as ordered. No additional documentation was in the record as to why the visits were not made. Interview with the agency administrator on 2/12/25 at 10:17 AM revealed, “I talked to the nurse she thought she put in both orders, but didn’t there are 2 missed visits for the aide, no notification is in the record that the physician was notified”.