Every finding on record at Intensive Home Health Care, Inc.

Intensive Home Health Care, Inc is in compliance with 42 CFR 484, Conditions of Participation for Home Health Agencies.

Recertification Survey

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 the patient's written POC (plan of care) was followed by failing to collect and document the patient's weight or measure arm girth for 4 (#2, #4, #5, and #6) of 7 sampled patients. Findings: Review of the Agencies undated policy titled “Plan of Care/485 policy” read in part... Implementation of the plan of care: All services shall be delivered in accordance with the authorized plan of care. Patient #2 Review of Patient #2’s clinical record for the certification period of 12/20/2025- 02/17/2026 revealed the following diagnoses in part…Age related Fracture to Left Femur, Acute Embolism, Type 2 Diabetes Mellitus, and Anemia. Review of the Patient #2’s plan of care for the certification period of 12/20/2025- 02/17/2026 revealed an order for skilled nurse visits 1wk 9 (1 visit a week for 9 weeks). The POC revealed an order for weights every skilled nurse visit, and if unable to obtain weight to obtain arm girth in centimeters. Review of Patient #2’s vital sign log and nurse’s notes for the certification period of 12/20/2025- 02/17/2026 revealed no weights or arm girth documented. Patient #4 Review of Patient #4’s clinical record for the certification period of 11/27/2025-01/25/2026 revealed the following diagnoses, included in part…, Type 2 Diabetes Mellitus, Congestive Heart Failure, Hypertensive Heart Disease, and Depression. Review of the Patient #4’s plan of care for the certification period of 11/27/2025-01/25/2026 revealed an order for skilled nurse visits 1wk6 and 1wk2 (1 visit a week for 6 weeks and 1 visit a week for 2 weeks). The POC revealed an order for weights every skilled nurse visit and if unable to obtain weight to obtain arm girth in centimeters. Review of Patient #4’s vital sign log and nurse’s notes for the certification period of 11/27/2025-01/25/2026 revealed no weights or arm girth documented for the following nursing visits: 12/4/2025, 12/18/2025, and 01/02/2026. Patient #5 Review of Patient #5’s clinical record for the certification period of 11/29/2025-01/27/2025 revealed the following diagnoses included in part… Type 2 Diabetes Mellitus, Non Pressure Chronic Ulcer, Hypertensive Heart Disease, and Atrial Fibrillation. Review of the Patient #5’s plan of care for the certification period of 11/29/2025-01/27/2025 revealed an order for skilled nurse visits 1wk8 (1 visit a week for 8 weeks). The POC revealed an order for weights every skilled nurse visit and if unable to obtain weight to obtain arm girth in centimeters. Review of Patient 5’s vital sign log and nurse’s notes for the certification period of 11/29/2025-01/27/2026 revealed no weights or arm girth documented. Patient #6 Review of Patient #6’s clinical record for the certification period of 10/17/025-12/10/2025 revealed the following diagnoses included in part…Orthopedic Aftercare of Surgical Amputation to Right above the Knee Amputation, Peripheral Vascular Disease, and Hypertension. Review of the Patient #6’s plan of care for the certification period of 10/17/2025-12/10/2025 revealed an order for skilled nurse visits 1wk9 (1 visit a week for 9 weeks). The POC revealed an order for weights every skilled nurse visit and if unable to obtain weight to obtain arm girth in centimeters. Review of Patient #6’s vital sign log and nurse’s notes for the certification period of 10/17/2025-12/10/2025 revealed no weights or arm girth documented for the following nursing visits: 10/17/2025, 10/21/2025, 11/04/2025, 11/18/2025, 11/25/2025, and 12/02/2025. An interview on 01/21/2026 at 9:15 a.m. with S2LPN confirmed that she does not collect weight or arm girth every visit because at times she forgets. An interview on 01/22/2026 at 10:49 a.m. with S1DON confirmed the above weights/arm girth were not documented as collected in the patient’s charts, but should have been.

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 observation and interview the agency failed to ensure the skilled nurse followed accepted standards of practice for infection control for 1 (#1) of 3 patients observed during home visits as evidenced by failing to ensure the skilled nurse changed gloves and perform hand hygiene appropriately during wound care. Findings: Review of the Agency’s undated policy titled, “Infection Control Policy” read in part…Standard Transmission: All personnel will use standard precautions at all times to prevent the spread of infectious agents; this includes not limited to, hand hygiene, use of personal protective equipment, and proper disposal of sharps. Review of Patient #1's plan of care for certification period of 12/15/2025-2/12/2026 revealed Patient #1 had a pressure ulcer to right and left foot with the following orders in place: Wound #3 Left Medial distal foot-cleanse with wound cleanser, pat dry, apply moisturizer lotion to surrounding tissue, mix and apply topical antibiotics, apply alginate, cover with dry gauze, apply abdominal pad and wrap with kerlix. Wound #7- Right foot-cleanse with wound cleanser, pat dry, apply moisturizer lotion to surrounding tissue, mix and apply topical antibiotics, apply alginate, cover with dry gauze, apply abdominal pad and wrap with kerlix. An observation on 01/21/2026 at 9:15 a.m. of S2LPN performing wound care on Patient #1’s bilateral feet revealed that S2LPN applied gloves prior to wound care on the right foot wound. S2LPN was observed removing the right foot wound dressing, discarding the old dressing, reaching over in clean the field and removing 4x4 gauze from original packaging, cleaning the wound, discarding 4x4 gauze, reaching over into clean field, grabbing clean dressing, and then appling the clean dressing to the wound bed. S2LPN at this time removed the old gloves and discarded them. S2LPN then applied new gloves and provided wound care as above to the left foot wound. S2LPN failed to change out gloves and sanitize hands between each step during wound care for both wounds. At the end of wound care, S2LPN was observed wrapping the package of gauze that she reached into with soiled gloves and placed them back with the clean wound care supplies. An interview on 01/21/2026 at 9:35 a.m. S2LPN confirmed that she did not sanitized her hands in-between gloves changes and did not change gloves more than 1 time for each wound. S2LPN stated that she was unsure how many times her gloves needed to be changed. S2LPN confirmed that she did plan to use the 4x4 gauze that she placed in her bag after reaching into them with soiled gloves, but will now throw them out.

Emergency Preparedness Survey

EP Testing Requirements CFR(s): 484.102(d)(2) §416.54(d)(2), §418.113(d)(2), §441.184(d)(2), §460.84(d)(2), §482.15(d)(2), §483.73(d)(2), §483.475(d)(2), §484.102(d)(2), §485.68(d)(2), §485.542(d)(2), §485.625(d)(2), §485.727(d)(2), §485.920(d)(2), §491.12(d)(2), §494.62(d)(2). *[For ASCs at §416.54, CORFs at §485.68, REHs at §485.542, OPO, "Organizations" under §485.727, CMHCs at §485.920, RHCs/FQHCs at §491.12, and ESRD Facilities at §494.62]: (2) Testing. The [facility] must conduct exercises to test the emergency plan annually. The [facility] must do all of the following: (i) Participate in a full-scale exercise that is community-based every 2 years; or (A) When a community-based exercise is not accessible, conduct a facility-based functional exercise every 2 years; or (B) If the [facility] experiences an actual natural or man-made emergency that requires activation of the emergency plan, the [facility] is exempt from engaging in its next required community-based or individual, facility-based functional exercise following the onset of the actual event. (ii) Conduct an additional exercise at least every 2 years, opposite the year the full-scale or functional exercise under paragraph (d)(2)(i) of this section is conducted, that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or individual, facility-based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the [facility's] response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the [facility's] emergency plan, as needed. *[For Hospices at 418.113(d):] (2) Testing for hospices that provide care in the patient's home. The hospice must conduct exercises to test the emergency plan at least annually. The hospice must do the following: (i) Participate in a full-scale exercise that is community based every 2 years; or (A) When a community based exercise is not accessible, conduct an individual facility based functional exercise every 2 years; or (B) If the hospice experiences a natural or man-made emergency that requires activation of the emergency plan, the hospital is exempt from engaging in its next required full scale community-based exercise or individual facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional exercise every 2 years, opposite the year the full-scale or functional exercise under paragraph (d)(2)(i) of this section is conducted, that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or a facility based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (3) Testing for hospices that provide inpatient care directly. The hospice must conduct exercises to test the emergency plan twice per year. The hospice must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual facility-based functional exercise; or (B) If the hospice experiences a natural or man-made emergency that requires activation of the emergency plan, the hospice is exempt from engaging in its next required full-scale community based or facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional annual exercise that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or a facility based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop led by a facilitator that includes a group discussion using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the hospice's response to and maintain documentation of all drills, tabletop exercises, and emergency events and revise the hospice's emergency plan, as needed. *[For PRFTs at §441.184(d), Hospitals at §482.15(d), CAHs at §485.625(d):] (2) Testing. The [PRTF, Hospital, CAH] must conduct exercises to test the emergency plan twice per year. The [PRTF, Hospital, CAH] must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise; or (B) If the [PRTF, Hospital, CAH] experiences an actual natural or man-made emergency that requires activation of the emergency plan, the [facility] is exempt from engaging in its next required full-scale community based or individual, facility-based functional exercise following the onset of the emergency event. (ii) Conduct an [additional] annual exercise or and that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or individual, a facility-based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the [facility's] response to and maintain documentation of all drills, tabletop exercises, and emergency events and revise the [facility's] emergency plan, as needed. *[For PACE at §460.84(d):] (2) Testing. The PACE organization must conduct exercises to test the emergency plan at least annually. The PACE organization must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise; or (B) If the PACE experiences an actual natural or man-made emergency that requires activation of the emergency plan, the PACE is exempt from engaging in its next required full-scale community based or individual, facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional exercise every 2 years opposite the year the full-scale or functional exercise under paragraph (d)(2)(i) of this section is conducted that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or individual, a facility based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the PACE's response to and maintain documentation of all drills, tabletop exercises, and emergency events and revise the PACE's emergency plan, as needed. *[For LTC Facilities at §483.73(d):] (2) The [LTC facility] must conduct exercises to test the emergency plan at least twice per year, including unannounced staff drills using the emergency procedures. The [LTC facility, ICF/IID] must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise. (B) If the [LTC facility] facility experiences an actual natural or man-made emergency that requires activation of the emergency plan, the LTC facility is exempt from engaging its next required a full-scale community-based or individual, facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional annual exercise that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or an individual, facility based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the [LTC facility] facility's response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the [LTC facility] facility's emergency plan, as needed. *[For ICF/IIDs at §483.475(d)]: (2) Testing. The ICF/IID must conduct exercises to test the emergency plan at least twice per year. The ICF/IID must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise; or. (B) If the ICF/IID experiences an actual natural or man-made emergency that requires activation of the emergency plan, the ICF/IID is exempt from engaging in its next required full-scale community-based or individual, facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional annual exercise that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or an individual, facility-based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the ICF/IID's response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the ICF/IID's emergency plan, as needed. *[For HHAs at §484.102] (d)(2) Testing. The HHA must conduct exercises to test the emergency plan at least annually. The HHA must do the following: (i) Participate in a full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise every 2 years; or. (B) If the HHA experiences an actual natural or man-made emergency that requires activation of the emergency plan, the HHA is exempt from engaging in its next required full-scale community-based or individual, facility based functional exercise following the onset of the emergency event. (ii) Conduct an additional exercise every 2 years, opposite the year the full-scale or functional exercise under paragraph (d)(2)(i) of this section is conducted, that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or an individual, facility-based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the HHA's response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the HHA's emergency plan, as needed. *[For OPOs at §486.360] (d)(2) Testing. The OPO must conduct exercises to test the emergency plan. The OPO must do the following: (i) Conduct a paper-based, tabletop exercise or workshop at least annually. A tabletop exercise is led by a facilitator and includes a group discussion, using a narrated, clinically relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. If the OPO experiences an actual natural or man-made emergency that requires activation of the emergency plan, the OPO is exempt from engaging in its next required testing exercise following the onset of the emergency event. (ii) Analyze the OPO's response to and maintain documentation of all tabletop exercises, and emergency events, and revise the [RNHCI's and OPO's] emergency plan, as needed. *[ RNCHIs at §403.748]: (d)(2) Testing. The RNHCI must conduct exercises to test the emergency plan. The RNHCI must do the following: (i) Conduct a paper-based, tabletop exercise at least annually. A tabletop exercise is a group discussion led by a facilitator, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (ii) Analyze the RNHCI's response to and maintain documentation of all tabletop exercises, and emergency events, and revise the RNHCI's emergency plan, as needed. This STANDARD is not met as evidenced by: Based on interview and record review the agency failed to ensure exercises to test the Emergency Plan were conducted at least annually by having a full-scale exercise that is community-based; or an annual individual, facility-based functional exercise and an additional exercise that may include, a second full-scale exercise that is community or facility-based or a tabletop exercise that includes group discussion, as evidenced by failure to have documented evidence that two such exercises had been conducted annually. Findings: Review of the agency’s emergency preparedness documentation revealed table top exercises dated 03/26/2020, 08/2021, and 05/04/2022. Further review revealed there was no documentation of full-scale community or facility based functional exercises for 2020, 2021, or 2022. Interview on 01/31/2023 at 1:30 p.m. with S1 Administrator/DON (Director of Nursing) revealed there were no full scale exercises conducted for 2020, 2021, or 2022. S1 Administrator/DON stated she was unaware of the requirements.

Recertification Survey Abbreviations: DON-Director of Nursing BMI- Body Mass Index GM-Gram mg-milligram BID-twice a day po-by mouth ml-milliliter XR-extended release

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 observation, interview and record review, the agency failed to ensure the patient’s medication profile accurately listed the correct medications the patient was taking for 1 (Patient #1) of 2 (Patient #1 and Patient #2) medications reviewed during home visits. Findings: Review of Patient #1’s CPOC with an admission date of 12/14/2022 and a certification date of 12/14/2022 – 02/11/2023 revealed Patient #1 had a primary diagnosis of Aftercare following joint replacement surgery and secondary diagnosis of Presence of right artificial knee. Review of Patient #1’s home medications during a home visit conducted on 01/31/2023 at 9:00 a.m. with S2 LPN and Patient #1 revealed Patient #1 was taking the following medications: 1. Mounjaro Subcutaneous 5 mg/0.5 mls, inject 5 mg into skin every 7 days 2. Rayadlee 30 mcg one cap every day 3. Latanoprost Ophthalmic 0.005% one drop in each eye at bedtime 4. Furosemide 80 mg one daily 5. Clotrimazole-Betamethasone 0.05% one application topically twice a day 6. Albuterol 2.5 mg/3 ml (0.083%) nebulizer solution, take 3 mls by nebulizer every 4 hours daily 7. Symbicort Inhalation 160-4.5 mcg/act 2 puffs twice daily 8. Losartan Potassium 50 mg one daily 9. Lyrica 200 mg one daily 10. Eliquis 5 mg twice daily 11. Amiodarone HCL 200 mg one starting 12/23/2022 12. Novolog Flex pen Subcutaneous 100 unit/ml 3 ml vial per sliding scale 13. Tresiba Flex touch Subcutaneous 100 unit/ml Administer 70 mg SC daily 14. Allopurinol 300 mg one tab daily 15. Jardiance 10 mg one tab daily 16. Singulair 10 mg one tab daily 17. Pantoprazole Sodium 40 mg one daily 18. Potassium Chloride ER 20 meq one tab twice daily Review of the Medication Profile and interview with Patient #1 revealed the following the discrepancies which included additional medications Patient #1 revealed she was taking. 1. Tramadol 50 mg one every 4-6 hours as needed for pain – filled 12/31/2022 and was currently taking. 2. Zofran 4 mg one by mouth every 6 hours as needed – Patient #1 revealed she was taking with her pain medication daily and was not on Medication Profile. 3. Linzess 145 mcg one daily – Patient #1 revealed she was taking instead of the Docusate Sodium 100 mg one daily that was listed on the Medication Profile. 4. Meloxicam 7.5 mg one twice a day with meals – Patient #1 revealed she had never filled the prescription and was not taking. Interview with S2 LPN on 01/31/2023 at 9:15 a.m. confirmed the above discrepancies and revealed she was unaware them. Interview with S1 ADM/DON on 01/31/2023 at 2:00 p.m. revealed Patient #1 had received Skilled Nurse Visits weekly and the medication discrepancies should not have occurred if the staff were reviewing the patient’s medications each visit.

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 patient's Individualized Plan of Care included all medications and treatments for 1 (#7) of 7 sampled patients. Findings: Review of the closed record revealed Patient #7 admitted to the agency on 12/05/2021 with diagnoses of Cutaneous abscess of abdominal wall, Gastrostomy malfunction, Down syndrome, Morbid (severe) obesity due to excess calories, and BMI 50.0-59.9, adult. Review of the Plan of Care for service period 12/05/2021-02/02/2022 revealed the medication area was blank. Review of the admit narrative nursing note revealed in part…patient received the following medication changes: Risperdal, Nyastatin, Bactroban. Review of the Medication Profile for Patient #7 revealed it was blank. Review of Patient #7's Physician Referral documentation revealed it contained a medication list that included the following medications: Nyastatin 100,000 unit/GM powder. Apply to groin area twice a day. Scopolamine 1.5mg/3day patch-Apply one patch topically every 3 days. Rotate sites. Pantoprazole 40mg granule packet. Empty one packet of oral suspension granules into pudding or applesauce and give by mouth. Xarelto 20mg one po every evening. Peridex 0.12% oral rinse-15ml po BID. Flonase allergy relief 50mcg spray-one spray to each nostril twice a day. Multivitamin with minerals tab-one tab po daily. Claritin 10mg one po daily. Microgestin 21 one po daily. Risperidone 0.5mg tablet one po daily at bedtime. Adderall XR 15mg capsule one capsule po in the morning. Ipratropium-Albuterol 0.5-3(2.5mg)/3ml one unit dose as needed. Interview on 01/31/2023 at 12:16 p.m. with S1 Administrator/DON revealed the admitting nurse was responsible for entering medications on admission. S1 Administrator/DON stated she was responsible for reviewing the admit assessment information and approving the plan of care. S1 Administrator/DON confirmed she had approved Patient #7’s admission Plan of Care, that Patient #7's medications had not been entered into her medication profile and that Patient #7's medications had not been added to her plan of care and should have been.

Program scope CFR(s): 484.65(a)(1),(2) Standard: Program scope. (1) The program must at least be capable of showing measurable improvement in indicators for which there is evidence that improvement in those indicators will improve health outcomes, patient safety, and quality of care. (2) The HHA must measure, analyze, and track quality indicators, including adverse patient events, and other aspects of performance that enable the HHA to assess processes of care, HHA services, and operations. This STANDARD is not met as evidenced by: Based on interview and record review, the agency failed to have a QAPI program that showed measurable improvements in indicators for which there is evidence that improvement in those indicators that would improve health outcomes, patient safety and quality of care. Findings: Review of the QAPI reports presented by S1 ADM/DON on 01/31/2023 at 2:30 p.m. revealed falls were the only indicator the agency was following/monitoring. Review of the Potentially Avoidable Event outcome reports for 12/2021 to 10/2022 revealed the facility had four list indicators which included Emergent Care for Hypo/Hyperglycemia, Development of UTIs, increased numbers of Pressure Ulcers and Discharge to the community with Stage 2 Pressure Ulcers. Interview with S1 ADM/DON on 01/31/2023 at 2:30 p.m. revealed falls were chosen because she knew that it effected most of her population and was something she felt would be good to track. S1 ADM/DON revealed she had not used the Potentially Avoidable Event outcome reports to guide QAPI for the agency.

Responsibilities of skilled professionals CFR(s): 484.75(b) Standard: Responsibilities of skilled professionals. Skilled professionals must assume responsibility for, but not be restricted to, the following: This STANDARD is not met as evidenced by: Based on interview and record review the agency failed to ensure the RN re-assessed a patient’s Stage 2 Pressure Ulcer weekly for 1 (Patient #5) of 3 patient’s (Patient #4, Patient #5, and Patient #7) reviewed for wounds/pressure ulcers. Findings: Review of Patient #5’s Plan of Care dated 12/27/2022 to 02/24/2023 revealed the primary diagnosis was Pressure Ulcer of Sacral Region and secondary diagnosis of Hypertension. Review of the OASIS recertification dated 12/22/2022 revealed Patient #5 had a Stage 2 Pressure Ulcer to her sacral region that was 1.0 cm X 2.0 cm X 0.1 cm and had serosanguinous drainage. Review of Patient #5’s Nurses’ notes dated 01/02/2023, 01/10/2023, 01/17/2023, 01/24/2023 and 01/31/2023 revealed the patient had not been seen by an RN to re-assess the wound. Interview with S1 ADM/DON on 01/31/2023 at 3:30 p.m. revealed according to the agency policy, an RN should conduct a weekly wound assessment for all wounds and document findings. S1 ADM/DON confirmed Patient #5 had not had a RN skilled nurse visit since 12/22/2022 to re-assess the Stage 2 Pressure Ulcer but should have.

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 record review and interview the agency failed to ensure the SN (Skilled Nurse) provided services as ordered by the Physician and as indicated in the Plan of Care by failing to perform wound care for 1 (#7) of 7 sampled patients. Findings: Review of the Plan of Care for period 12/05/2021-02/02/2021 revealed the SN (Skilled Nurse) was to provide wound care each SNV (Skilled Nurse Visit). Review of Patient #7's Admission Narrative Notes revealed in part.......Patient has the following wounds: healing lesions where old peg tube was removed and became infected and scattered dry rash to abdomen below tube site. Wound Care: Cleanse daily with mild soap/water, rinse and pat dry. Apply Bactroban and Bordergauze to old peg site and dust Nyastatin powder on dry abdominal rash. SN to assess sites and provide wound care each SNV. Review a of SN visit narrative note dated 12/08/2021 revealed there was a small amount of purulent drainage coming from wound on abdomen. There was no documentation that the SN performed wound care. Review a of SN visit narrative note dated 12/13/2021 revealed Patient #7 had scratched the wound on her abdomen. SN reinforced the bandage. There was no documentation that the SN performed wound care. Review a of SN visit note dated 12/28/2021 revealed Patient #7's mother reported the wound was intact and no longer required wound care. There was no documentation that the SN assessed the wound during the visit. Interview on 01/31/2023 at 12:00 p.m. with S1 Administrator/DON confirmed there was no documentation the SN had performed wound care on 12/08/2021 and 12/13/2021. S1 Administrator also confirmed the SN should have assessed the wound and documented the findings after Patient #7's mother reported the wound was healed and the SN had not.

Nursing services supervised by RN CFR(s): 484.75(c)(1) Nursing services are provided under the supervision of a registered nurse that meets the requirements of §484.115(k). This ELEMENT is not met as evidenced by: Based on interview and record review the agency failed to ensure nursing services were provided under the supervision of a Registered Nurse for 2 (#2 and #7) of 7 sampled patients. #2 Review of the visit schedule for Patient #2 revealed Patient #2 had no RN Supervisory visits for services provided by the agency LPN for dates 12/19/2022-01/13/2023. Interview on 01/30/2023 at 12:12 p.m. with S1 Administrator/DON confirmed the above findings. S1 Administrator/DON stated she was responsible for making LPN and RN visit schedules and must have overlooked the required visit. #7 Review of the visit schedule for Patient #7 revealed Patient #7 had no RN Supervisory visits for services provided by the agency LPN for dates 12/13/2021-12/30/2021. Interview on 01/31/2023 at 12:16 p.m. with S1 Administrator/DON confirmed the visit findings for Patient #7. S1 Administrator/DON stated RN Supervisory visits had not been performed every 14 days and should have been.

Rehab services supervised by PT, OT CFR(s): 484.75(c)(2) Rehabilitative therapy services are provided under the supervision of an occupational therapist or physical therapist that meets the requirements of §484.115(f) or (h), respectively. This ELEMENT is not met as evidenced by: Based on record review and interview, the agency failed to ensure the Physical Therapist (PT) conducted PTA supervisory visits no less than every sixth visit for 1 (Patient #1) of 3 (Patient #1, Patient #3 and Patient #5) sampled patients who received Physical Therapy services. Findings: Observation during a home visit conducted on 01/31/2023 at 9:00 a.m. revealed Patient #1 had a completely healed scar area to her right knee. Interview with Patient #1 during the home visit revealed Patient #1 was currently receiving Physical Therapy services. Review of Patient #1’s CPOC with an admission date of 12/14/2022 and a certification date of 12/14/2022 – 02/11/2023 revealed Patient #1 had a primary diagnosis of Aftercare following joint replacement surgery and secondary diagnosis of Presence of right artificial knee. Review of Patient #1’s Therapy Notes’ revealed on 12/14/2022 the PT conducted a re-evaluation visit. Further review of the Therapy Notes’ revealed PTA visits were conducted on 12/16/2022, 12/21/2022, 12/23/2022, 12/26/2022, 12/28/2022, and 12/30/2022. The next PT supervisory visit was not conducted until 01/02/2023.

Onsite supervisory visit every 14 days CFR(s): 484.80(h)(1)(i) If home health aide services are provided to a patient who is receiving skilled nursing, physical or occupational therapy, or speech-language pathology services, a registered nurse or other appropriate skilled professional who is familiar with the patient, the patient's plan of care, and the written patient care instructions described in §484.80(g), must make an onsite visit to the patient's home no less frequently than every 14 days. The home health aide does not have to be present during this visit. This ELEMENT is not met as evidenced by: Based on record review and interview the agency failed to ensure a Registered Nurse (RN), who was familiar with the patient and the patient's Plan of Care, made an onsite visit to the patient's home no less than every 14 days for aide supervisory visits for 2 (Patient #2 and Patient #3) of 2 sampled patients with Home Health Aide services. Findings: 1. Review of the clinical record revealed Patient #3 was admitted to the agency on 09/13/2022, with a principal diagnosis of Fracture unspecified part of clavicle and Emphysema. Review of the Home Health Certification and Plan of Care for certification period of 11/12/2022 to 01/10/2023 revealed orders that included the following: Home Health Aides 2w8. Review of the Home Health Aide visit notes revealed documentation that an Aide Supervisory visit was conducted by the RN on 12/06/2022, however there was no documentation that reflected that Patient #3 had received an Aide Supervisory Visit from 12/06/2022 thru 12/27/2022. Interview with S1 DON on 01/30/2023 at 2:55 p.m. revealed the RN failed to conduct an Aide Supervisory visit from 12/06/2022 – 12/27/2022. #2 Review of the visit calendar for Patient #2 revealed the patient was seen by the HHA (Home Health Aide) twice a week starting on 12/06/2022. Further review revealed a HHA supervisory visit by an agency RN had not been conducted for dates 12/19/2022 through 01/13/2023. Findings confirmed with S1 Administrator/DON on 01/30/2023 at 12:20 p.m.

Goals in the patient's plans of care CFR(s): 484.110(a)(3) Goals in the patient's plans of care and the patient's progress toward achieving them; This ELEMENT is not met as evidenced by: Based on observation, interview and record review, the agency failed to ensure patient goals in the patient's plans of care were achievable and the patient could progress toward achieving the goals for 1 (Patient #1) of 3 (Patient #1, Patient #2, and Patient #3) home visits conducted. Findings: Observation during a home visit conducted on 01/31/2023 at 9:00 a.m. revealed Patient #1 had a completely healed scar area to her right knee. Review of Patient #1’s CPOC with an admission date of 12/14/2022 and a certification date of 12/14/2022 – 02/11/2023 revealed Patient #1 had a primary diagnosis of Aftercare following joint replacement surgery and secondary diagnosis of Presence of right artificial knee. Review of Patient #1’s CPOC revealed a patient goal of: The patient’s wound will decrease in size by 2 cm by 01/20/2023. Review of Patient #1’s Admission Assessment of Wounds revealed the wound was 0.0 cm X 0.0 cm X 0.0 cm, closed. Review of Patient #1’s Nurse Notes conducted by the LPN’s dated 12/28/2022, 01/03/2023, 01/10/2023, and 01/17/2023 revealed the goal that Patient #1’s wound would decrease in size by 2 cm was continued each visit. Interview with S1 ADM/DON on 01/31/2023 at 1:30 p.m. revealed the goals for Patient #1 should not have included the wound would heal by 01/20/2023 because the wound had been assessed upon admission that it was closed and measured 0.0 cm X 0.0 cm 0.0 cm. S1 ADM/DON also revealed staff should not have continued to use the wound would heal by 2 cm each visit in the nurse notes.