Every finding on record at Interim Healthcare of the Triad Inc.

An onsite recertification survey was conducted 06/09/2026 thru 06/11/2026. No deficencies to the Emergency Preparedness Conditions of Participation were identified.

An onsite recertification survey was conducted 06/09/2026 thru 06/11/2026. A deficiency to the Medicare Conditions of Participation was identified.

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 policy and procedure review, clinical record review, and staff interview the agency failed to follow the plan of care for assessing vital signs for 2 of 22 records reviewed (#17 and #20). Findings included: A policy, “Developing a Plan to Meet Patient/Client Needs”, revised 04/02/2021 was received from the Clinical Director on 06/11/2026 at 1006. The policy stated, “…a patient’s plan of care plan at a minimum includes, but is not limited to the following elements…all treatments…” 1.Patient #17 had a SOC (start of care) of 05/14/2026 and included diagnoses of other chondrocalcinosis (calcium deposits in the joints), essential hypertension, and type 2 diabetes. The plan of care had orders for physical therapy 2 times a week for 4 weeks. Orders included all skills to assess vital signs every visit. Review of physical therapy visit notes for 05/20/2026, 05/26/2026,05/29/2026,06/03/2026 and 06/04/2026 revealed no vital signs were documented in the clinical record. 2.Patient #20 had a SOC of 05/19/2026 and included diagnoses of encounter for removal of surgical dressing, aftercare following joint replacement surgery and presence of right artificial knee joint. The plan of care had orders for physical therapy 2 times a week for 4 weeks. Orders included all skills to assess vital signs every visit. Review of physical therapy visit notes for 05/22/2026 and 05/25/2026 revealed no vital signs were documented in the clinical record. Interview with the clinical director on 06/10/2026 at 1454 revealed, “I don’t see the vital signs documented anywhere.”

An onsite recertification survey was conducted June 12, 2023-June 15, 2023. No deficiencies to Emergency Preparedness Program were identified.

An onsite complaint investigation and recertification survey was conducted June 12, 2023-June 15, 2023. The complaint allegations were unsubstantiated. There were standard level deficiencies identified with the recertification survey. Complaint intake 98175

Accuracy of encoded OASIS data CFR(s): 484.45(b) Standard: The encoded OASIS data must accurately reflect the patient's status at the time of assessment. This STANDARD is not met as evidenced by: Based on clinical record review, and staff interview, the agency failed to accurately assess patients’ medications on the OASIS (Outcome and Assessment Information Set—standardized assessment) for 4 of 18 patients (#2, 11, 3 and 14). Findings included: 3. Patient # 3 had a Start of Care [SOC] date of 3/7/23 and an admitting diagnosis of aftercare following joint replacement surgery. Review of the Plan of Care [POC] for the certification period 3/7/23 to 5/5/23 included orders for SN [skilled nursing] 1 visit per week for 2 weeks. Review of the clinical record revealed RN # 5 completed the OASIS [ The Outcome and Assessment Information Set-comprehensive assessment at the SOC] on 3/7/23. Review of the OASIS question N0415 was answered incorrectly. The patient was taking Doxycycline 100 mg daily. N0415 did not capture the use of the antibiotic. RN #5 was not available for interview. An interview was conducted the clinical manager on 6/15/23 at approximately 12:30 pm. During the interview, the clinical manager confirmed the OASIS was answered incorrectly. 4. Patient # 14 had a Start of Care [SOC] date of 4/13/23 and an admitting diagnosis of encounter for surgical aftercare following surgery on following surgery on the digestive system. Review of the clinical record revealed RN # 12 completed the SOC OASIS [The Outcome and Assessment Information Set-comprehensive assessment] on 4/13/23. Review of the OASIS question N0415 was answered incorrectly. The patient was taking Amoxicillin-Clavulanate [antibiotic] at the time of the SOC. N0415 did not capture the antibiotic. During an interview with the regional director on 6/15/23 at approximately 12:30 pm, the regional director confirmed the OASIS question was answered incorrectly. 1. Patient #2 was admitted on 11/15/22 with a diagnosis of encounter for surgical aftercare and type 2 diabetes. The Plan of Care (POC) for 11/15/22 included an order for skilled nursing weekly for four weeks. The patient was hospitalized on 12/29/22. A resumption of care assessment (comprehensive assessment conducted after a hospitalization during the home health episode of care) was conducted on 1/3/23. The patient was not identified as taking an antipsychotic (used to treat psychosis, delusions, hallucinations, paranoia, or disordered thought) or antidiabetic (used to treat diabetes) medications in the OASIS (Outcome and Assessment Information Set—standardized assessment). The updated Plan of Care for 11/15/2-1/13/23 included orders for olanzapine (an antipsychotic medication) 10 mg nightly and glipizide (medication used to lower blood sugar levels) 10 mg twice daily before meals. An interview with the clinical manager on 6/15/23 at 11:18 a.m. confirmed the OASIS was not coded accurately. 2. Patient #11 was admitted on 5/26/23 with diagnoses of aftercare following joint replacement surgery and presence of a right artificial hip joint. The initial assessment was conducted on 5/26/23. The patient was not identified as taking an antiplatelet medication in the OASIS (Outcome and Assessment Information Set—standardized assessment). The Plan of Care (POC) for 5/26/23-7/24/23 included orders for aspirin 81 mg twice daily. An interview with the clinical manager on 6/15/23 at 11:33 a.m. confirmed the OASIS was not coded accurately.

5 calendar days after start of care CFR(s): 484.55(b)(1) The comprehensive assessment must be completed in a timely manner, consistent with the patient's immediate needs, but no later than 5 calendar days after the start of care. This ELEMENT is not met as evidenced by: Based on agency policy, clinical record review and staff interviews the agency failed to complete the comprehensive assessment within 5 days for 1 of 2 patients with order for ST [speech therapy] [#13]; and failed to conduct MSW [medical social work] evaluation for 1 of 1 patient with orders for MSW evaluation [#18]. The findings included: The policy, Developing a Plan to Meet Patient/Client Needs [no date], was provided by the agency director on 6/14/23 at 3:47 pm. The policy stated, “…A qualified designated employee obtains orders for care/service…” 1. Patient # 13 had a Start of Care date of 4/29/23 and admitting diagnoses of heart failure and diabetes mellitus. Review of the Plan of Care for the certification period 4/29/23 to 6/27/23 included orders for OT [occupational therapy] 2 times a week for 4 weeks. Review of OT # 9 documentation dated 5/2/23 revealed OT obtained an order for ST [speech therapy] due to patient’s “brain fog” and difficulty reading. Review of the clinical record revealed ST had not completed an evaluation visit as of 5/11/23 when the patient was admitted to the hospital. ST # 10 was not available for interview. During an interview with the clinical manager on 6/15/23 at approximately 11:30 am, the clinical manager stated, “Maybe the speech therapist didn’t have enough time to see the patient before she went back to the hospital.” 2. Patient # 18 had a Start of Care date of 5/7/23 and admitting diagnoses of acute and chronic respiratory failure and chronic obstructive pulmonary disease [COPD-lung disease]. Review of the referral from _____ [name of hospital] dated 5/5/23 revealed orders for SN [skilled nursing], PT [physical therapy], OT [occupational therapy], HHA [home health aide] and MSW [medical social worker]. Review of the clinical record revealed there was no evaluation by the MSW. During an interview with the regional director on 6/15/23 at 12:30 pm, the regional director confirmed the comprehensive assessment was not completed within 5 days.

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, clinical record review, observation, and staff interview, the agency failed to conduct a comprehensive medication review for 8 of 18 patients (#1, 2, 11, 17, 12, 13, 14, and 16). Findings included: A policy, “Content of the Patient/Client Record” (no date), was received on 6/14/23 at 4:39 p.m. by Employee #31. The policy stated, “The following information is included in each patient/client record when applicable to the care/service the patient/client is receiving…Medication list including prescription and over-the-counter medications…Ongoing updates to the medication list…” A policy, “Medications” (no date), was provided by Employee #31 on 6/12/23 at 2:55 p.m. The policy stated, “The designated qualified nurse provides the patient/caregiver with medication instructions that include at a minimum…Name and description of the medication…Dosage, route of administration, and duration of drug therapy..." 5. Patient # 12 had a Start of Care date of 6/2/23 and admitting diagnosis of aftercare following joint replacement surgery. Review of the Plan of Care [POC] for the certification period 6/2/23 to 7/31/23 included orders for PT [physical therapy] 1 time a week for 1 week then 3 times a week for 3 weeks. On 6/13/23, a joint visit was made with PT # 28. During the visit a medication review was conducted using a medication profile provided by the agency. The medication profile did not list the following drugs: Valsartan [blood pressure] 12.5 mg daily, Mounjaro [diabetic medication] 7.5 mg [injection] each week. During an interview with the patient, the patient reported she had been taking these medications since before admission to home health. An interview was conducted with PT # 28 directly after the visit. During the interview PT # 28 confirmed the medications had not been reviewed for changes. 6. Patient # 13 had a Start of Care date of 4/29/23 and an admitting diagnoses of heart failure and type 2 diabetes mellitus with chronic kidney disease [high blood sugar levels damage the filtering units of the kidneys]. The patient had an inpatient hospital stay from 5/11/23 to 5/20/23. Review of the Resumption of Care [ROC-comprehensive assessment completed after an inpatient stay] Plan of Care [POC] for the certification period 4/29/23 to 6/27/23 included orders for OT [occupational therapy] 2 times a week for 4 weeks. A joint visit was made with OT # 9 on 6/13/23 at approximately 9 am. 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 melatonin [sleep] 1 mg at 9 am [sic] and B 12 [supplement] [no dosage] take 1 tablet each day. During an interview with the caregiver on 6/13/23, the caregiver stated, “she hasn’t taken melatonin since she came home from the hospital and I gave it to her at bedtime, not in the morning. The strength of the B 12 is 100 mcg per day. She does take 1 of those each day.” During an interview with OT # 9 on 6/15/23 at approximately 9:35 am. During the interview the OT confirmed the medications on the medication profile were not correct. “I don’t look at the medicines each visit. I ask if the patient has had any changes in her medications.” 7. Patient # 14 had a Start of Care date of 4/13/23. Review of the Plan of Care [POC] for the certification period 6/12/23 to 8/10/23 included a diagnosis of encounter for surgical aftercare following surgery on following surgery on the digestive system. The POC included orders for SN [skilled nursing] 3 times a week for 9 weeks. A joint visit was made with RN # 29 on 6/14/23 at approximately 10:15 am. During the visit a medication review was conducted using a medication profile provided by the agency. The following medications were listed on the medication profile: Amlodipine [blood pressure] 5 mg 1 tablet at bedtime and Ondansetron [nausea] 4 mg tablet. Take 1 tablet every 8 hours as needed for nausea. During an interview with the patient, the patient stated, “I don’t take those pills anymore.” During an interview with RN # 29 on 6/14/23 the RN confirmed the medications had not been reviewed. 8. Patient # 16 had a Start of Care date of 5/24/23 and an admitting diagnosis of nondisplaced fracture of lateral malleolus [ankle] of right fibula [outer and usually smaller of the two bones between the knee and ankle]. Review of the Plan of Care [POC] for the certification period 5/24/23 to 7/22/23 included orders for PT [physical therapy] 1 time a week for 1 week then 2 times a week for 4 weeks. On 6/14/23 at approximately 9 am a joint visit was made with PT # 30 using a medication profile provided by the agency. During the visit, a medication review was conducted. The following discrepancies were noted: The medication profile did not include Tylenol [over the counter pain relief] 325 mg 2 tablets every 6 hours as needed or Albuterol Sulfate Inhaler 90 mcg, 8.5 gm [used for shortness of breath]. An interview was conducted with the caregiver during the visit. The caregiver reported the patient had been using Tylenol since “before she broke her ankle”. The caregiver reported the inhaler was ordered while the patient was “at rehab, before coming home.” An interview was conducted with PT # 8 during the visit. PT # 8 confirmed the medications on the POC had not been reviewed. 1. Patient #1 was admitted on 12/5/22 with a diagnosis of type 1 diabetes mellitus with hyperglycemia (high blood sugar). The Plan of Care (POC) for 12/8/22-2/2/23 included skilled nursing visits twice weekly for nine weeks. The POC for 2/3/23-4/3/23 included orders for skilled nursing visits weekly for four weeks. Both POCs included an order for insulin lispro 100 units/ml taken in the morning, noon, and evening. The medication dosage stated, “does not know ss [sliding scale—dose varies based on blood sugar].” There was no evidence until 2/8/23 that the physician was contacted for clarification of the sliding scale. An interview was conducted RN #19 on 6/15/23 at 10:30 a.m. The RN stated, “She is a brittle diabetic. ____ [another nurse] and I both tried to call the endocrinologist (a healthcare provider who specialized in the study of hormones, endocrine glands, and organs).” An interview with the clinical manager on 6/15/23 at 10:48 a.m. confirmed there was no evidence the nurse attempted clarification until 2/8/23. 2. Patient #2 was admitted on 11/15/22 with a diagnosis of encounter for surgical aftercare. The Plan of Care (POC) for 11/15/22 included an order for skilled nursing weekly for four weeks. The POC included Ropinirole (a medication used to treat restless leg syndrome) 0.5 mg twice daily for 14 days. The POC for 1/14/23-3/14/23 included orders for physical therapy visits twice weekly for two weeks. Medications included Ropinirole (a medication used to treat restless leg syndrome) 0.5 mg twice daily for 14 days. There was no evidence of a comprehensive medication review during the recertification. An interview with the regional director on 6/15/23 at 11:13 a.m. confirmed the medication was discontinued from the medication profile after 14 days. 3. Patient #11 was admitted on 5/26/23 with diagnoses of aftercare following joint replacement survey and presence of a right artificial hip joint. The Plan of Care for 5/26/23-7/24/23 included orders for skilled nursing visits weekly for three weeks; and physical therapy to evaluate and treat. A joint home visit was made with PT #30 on 6/13/23 at 10:45 a.m. A medication review was conducted with the patient. The POC included Colchicine 0.6 mg daily for gout. The patient stated that he was told not to take Colchicine after surgery. The medication list included famotidine 20 mg twice daily (stomach medicine). The patient stated that he does not take that. Maxitrol ophthalmic solution (eye drop used for inflammation of the eyes) was on the medication list to use one drop in the left eye four times daily. The patient stated that he used the drops three times daily. There was no evidence that a comprehensive medication assessment was conducted. An interview with the clinical manager on 6/14/23 at 11:00 a.m. revealed the admitting staff should conduct a comprehensive medication assessment at the time of admission. 4. Patient #17 was admitted on5/17/23 with a diagnosis of diverticula (small bulging pouch) of large intestines with perforation (a hole or a break in the wall of the membrane) and abscess (collection of pus). The Plan of Care (POC) for 5/17/23-7/15/23 included orders for skilled nursing visits two times for one week, then weekly for two weeks. The POC also included orders for metronidazole (an antibiotic and antiprotozoal medication) 500 mg three times daily. A joint home visit was made with LPN #32 on 6/14/23 at 10:30 a.m. A medication review was conducted with the patient during the home visit. The patient stated that he never had a prescription for metronidazole. An interview with RN #13 (RN that completed the initial assessment) on 6/15/23 at 9:52 a.m. revealed the patient was not taking the medication and should have been removed from the POC.

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, clinical record review and staff interviews the plan of care failed to include complete medication orders [#3, 9, 14, and 18]; failed to provide accurate primary diagnosis for 1 of 4 discharged patients [#9]. The findings included: The policy, Developing a Plan to Meet Patient/Client Needs [no date], was provided by the agency administrator on 6/14/23 at 3:47 pm. The policy stated, “…Ensures a patient’s individualized home health plan of care includes the following… all pertinent diagnoses…All medications and treatments…” 1.Patient # 3 had a Start of Care date of 3/7/23 and an admitting diagnosis of aftercare following joint replacement surgery. Review of the Plan of Care [POC] for the certification period 3/7/23 to 5/5/23 included orders for SN [skilled nursing] 1 visit per week for 2 weeks and “SN to assess response to and compliance with medications, teach/instruct medication administration, purpose, side effects…” Review of the POC the following entries: Desonide [topical anti-inflammatory] 0.05% apply topically as needed. Desonide did not include the frequency or the indications for its use; Flonase Allergy Relief 50 mcg/inhalation nasal spray use 1 spray in each nostril as needed. Flonase did not include the frequency. Nitroglycerin [used for chest pain] 0.4 mg sublingual [under the tongue]-place 1 tablet under the tongue every 5 minutes for chest pain, as needed. The entry did not include how many times to repeat the medication before activating 911. During an interview with the clinical manager on 6/15/23 at approximately 11:30 am, the clinical manager confirmed the medication entries on the POC were not complete. 2. Patient # 9 had a Start of Care date of 5/5/23 and an admitting diagnosis of encounter for adjustment and management of VAD [vascular access device – devices that are inserted into the body through a vein to enable the administration of fluids, blood products, medications or other therapies to bloodstream]. Review of the Plan of Care [POC] for the certification period 5/7/23 to 7/3/23 included orders for PT [physical therapy] 1 time a week for 1 week then 2 times a week for 3 weeks then 1 time a week for 3 weeks. The POC included nitroglycerin [chest pain] 0.4 mg sublingual [under the tongue]. Take 1 tablet every 5 minutes as needed for chest pain. The entry lacked how many times nitroglycerin could be taken before activating 911. During an interview with the clinical manager on 6/15/23 at approximately 11:30 am, the clinical manager confirmed the medication entry was not complete. 3. Patient # 14 had a Start of Care date of 4/13/23 and an admitting diagnosis of encounter for surgical aftercare following surgery on following surgery on the digestive system. Review of the Plan of Care [POC] for the certification period 4/13/23 to 6/11/23 revealed no medications. During an interview with the regional director on 6/15/23 at approximately 12:40 pm, it was stated that the patient was on medications when the POC was developed. “I don’t know how that happened.” 4. Patient # 18 had a Start of Care [SOC] date of 5/7/23 and admitting diagnoses of acute and chronic respiratory failure and chronic obstructive pulmonary disease [COPD-lung disease]. Review of the Plan of Care [POC] for the certification period 5/7/23 to 7/5/23 included orders for SN [skilled nursing] 2 times a week for 1 week then 1 time a week for 8 weeks; PT [physical therapy] 1 time a week for 1 week then 2 times a week for 3 weeks; OT [occupational therapy] 2 times a week for 4 weeks. Review of the SOC documentation by the RN # 27 revealed the following information, “…female with past medical history of atrial flutter [a heart dysrhythmia] …congestive heart failure…on 3 liters of oxygen…” PT # 15 documented, “…patient is on 3 liters of oxygen…” OT # 18 “…has respiratory failure and is on 3 liters of oxygen. Review of the POC revealed oxygen was not listed. During an interview with the clinical manager on 6/15/23 at approximately 11:35 am, the clinical manager confirmed the POC should have included oxygen. 5. Patient # 9 had a Start of Care [SOC] date of 5/5/23 and an admitting diagnosis of encounter for adjustment and management of VAD [vascular access device – devices that are inserted into the body through a vein to enable the administration of fluids, blood products, medications or other therapies to bloodstream]. Review of the referral revealed physician’s orders for PT [physical therapy] and OT [occupational therapy] only. Review of the Plan of Care [POC] for the certification period 5/5/23 to 7/3/23 included orders for PT 1 time a week for 1 week then 2 times a week for 3 weeks then 1 time a week for 3 weeks. PT # 31 completed the SOC visit on 5/5/23. Review of the POC revealed the primary diagnosis was encounter for adjustment and management of VAD. During an interview with the clinical manager on 6/15/23 at approximately 11:30 am, it was confirmed the primary diagnosis on the POC was incorrect.

Conformance with physician orders CFR(s): 484.60(b) Standard: Conformance with physician or allowed practitioner orders. This STANDARD is not met as evidenced by: Based on clinical record review and staff interviews the agency failed to obtain vital signs in accordance with physician's orders for 2 of 18 patients [#6 and 18]. The findings included: 1. Patient # 6 had a Start of Care date of 2/1/23. Review of the Plan of Care for the certification period 5/2/23 to 6/30/23 revealed a diagnosis of pressure ulcer of right buttock, stage 4 [ulcer penetrates all three layers of skin, exposing muscles, tendons and bones]. The POC included orders for PT [physical therapy] 2 times a week for 3 weeks effective the week of 5/9/23 and “PT to assess BP [blood pressure], P [pulse], Resp [respirations] q [every] visit…” Review of the PT visit completed on 5/12/23 by PT # 6 revealed no vital signs were obtained. PT # 6 was not available for interview. During an interview with the clinical manager on 6/15/23 at approximately 11:20 am, it was confirmed vital signs were not obtained in accordance with the POC. 2. Patient # 18 had a Start of Care date of 5/7/23 and admitting diagnoses of acute and chronic respiratory failure and chronic obstructive pulmonary disease [COPD-lung disease]. Review of the Plan of Care [POC] for the certification period 5/7/23 to 7/5/23 included orders for PT [physical therapy] 1 time a week for 1 week then 2 times a week for 3 weeks and “PT to assess BP [blood pressure], P [pulse], Resp [respirations] every visit. Review of the clinical record revealed PT # 6 conducted a routine visit on 5/23/23. Further review of the clinical record revealed no documented vital signs. PT # 6 was not available for interview. During an interview with the clinical manager on 6/15/23 at approximately 11:35 am, it was confirmed PT # 6 did not obtain vital signs in accordance with the physician’s order.

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 staff interview, the agency provided surgical site care without an order for 1 of 5 patients with a surgical site (#5); and failed to follow the plan of care for obtaining blood via a PICC (peripherally inserted central catheter—IV access to large central veins) line for 1 of 3 patients with a PICC line (#15). Findings included: A policy, “Developing a Plan to Meet Patient/Client Needs” (no date), was provided by Employee #31 on 6/14/23 at 3:47 p.m. The policy stated, “A qualified designated employee obtains order for care/service prior to delivery of such and…Ensures a patient’s individualized home health plan of care includes…All medication and treatments…” 1. Patient #5 was admitted on 2/14/23 with a diagnosis of aftercare following joint replacement surgery, presence of artificial knee joint, and encounter for change or removal of surgical wound dressing. The Plan of Care for 2/14/23-4/14/23 included orders for physical therapy twice for one week, three times per week for two weeks, then one time for one week. On 2/17/23, the physical therapist removed the Aquacel dressing from the knee. There was no evidence of an order to remove the dressing. An interview with the clinical manager on 6/15/213 at 11:00 a.m. confirmed there was no order to remove the dressing. 2. Patient #15 was admitted on 5/11/23 with diagnoses of osteomyelitis (infection of the bone) right ankle, type 2 diabetes, and peripheral vascular disease. The Plan of Care (POC) for 5/11/23-7/9/23 included orders for skilled nursing one time for one week, then twice weekly for five weeks. The POC also included orders to “Draw labs via PICC (peripherally inserted central catheter—IV access to large central veins), flush PICC with 10 cc 0.9% NaCl, waste 8 cc blood, obtain specimen, flush with 20 cc 0.9% NaCl, followed by 5 cc Heparin…” On 5/18/23, the PICC was flushed with 5 cc NS, then 6 cc of blood was discarded, and flushed with 10 cc NS after blood was obtained. On 5/25/23, the PICC was flushed with 6 cc NS, then 7 cc of blood was discarded, and flushed with 10 cc NS after blood was obtained. On 6/8/23, the PICC was flushed with 5 cc NS, then 6 cc of blood was discarded, and flushed with 10 cc NS after blood was obtained. An interview with the clinical manager on 6/15/23 at 11:50 confirmed the PICC flushes and the amount of blood discarded was not done as ordered in 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, document review, clinical record review and staff interview the agency failed to notify the physician of vital signs outside of parameters for 2 of 18 patients (#1 and 18); blood sugars outside of parameters for 2 of 3 diabetic patients (#1 and 15); a delay in physical therapy for 1 of 11 patients that received physical therapy (#1); and to alert the physician of changes in 1 of 4 discharged patients (#4). Findings included: A policy, “Coordination of Care/Services” (no date), was provided by Employee #31 on 6/12/23 at 2:55 p.m. The policy stated, “The designated employee contacts the physician or allowed practitioner…when…The patient’s/client’s condition changes…The patient’s/client’s response to care/treatments or medications is not as expected…” A document, “Addendum A Examples of Standards of Practice” (no date), was provided by Employee #31 on 6/14/23 at 3:47 p.m. The policy stated, “…The clinician monitors/reviews blood glucose readings each encounter. The clinician notifies the health care practitioner of blood glucose results outside of established parameters…” 3. Patient # 4 had a Start of Care date of 12/29/22. Review of the Plan of Care [POC] for the certification period 2/27/23 to 4/27/23 included a diagnosis of chronic combined systolic and diastolic heart failure [heart doesn’t pump effectively]. The POC included orders for SN [skilled nursing] 2 times a week for 2 weeks then 1 visit a week for 1 week. Review of the clinical record revealed RN # 4 documented the following information: 3/6/23 “…patient stated he has been experiencing with [sic] shortness of breath when walking, patient stated he has not been wearing his oxygen [order was for oxygen at 3 liters continuously]. SN instructed patient on wearing oxygen, patient stated he refused to wear outside…” 3/23/23 “Pt sitting at kitchen table…has at least 10 pills out which he stated he is going to take …SN discussed with pt if he continues to be non-compliant with meds and MD appointments SN will dc [discharge].” 4/12/23 “Pt lying in bed c/o [complaints of] experiencing some shortness of breath and has oxygen on…instructed to notify MD if condition does not improve or get [sic] worse…”There is no evidence the RN contacted the physician to report these findings. During an interview with the RN on 6/15/23 at 9 am, the RN stated, “I called the doctor all the time about this patient.” 4. Patient # 8 had a Start of Care date of 4/15/23 and an admitting diagnosis of lobar pneumonia. Review of the Plan of Care [POC] for the certification period 4/15/23 to 6/13/23 included orders for ST [speech therapy] 1 time a week for 1 week then 2 times a week for 4 weeks and “…All skills to report systolic [top number] blood pressure greater than 150… pulse rate greater than 100 or less than 60 to MD [physician]…” Review of the clinical records revealed ST # 10 documented the following vital signs 4/25/23 – pulse: 102, 5/2/23 – pulse: 110, 5/4/23 – pulse: 122, 5/9/23 –blood pressure: 152/72 , 5/11/23 - pulse: 112, 5/16/23 – blood pressure: 152/92, 5/18/23 – blood pressure: 168/97, 5/23/23 – blood pressure: 176/116, 5/25/23 – pulse: 103, 5/29/23 – blood pressure: 165/91. There was no evidence ST # 10 contacted the physician of the vital signs outside the given parameters. ST was not available for interview. An interview was conducted with the regional director on 6/15/23 at approximately 12:45 pm. During the interview, it was confirmed the physician was not notified. 1A. Patient #1 was admitted on 12/5/22 with a diagnosis of type 1 diabetes mellitus with hyperglycemia (high blood sugar). The Plan of Care (POC) for 12/8/22-2/2/23 included skilled nursing visits twice weekly for nine weeks. The POC for 2/3/23-4/3/23 included orders for skilled nursing visits weekly for four weeks. Both POCs included an order to notify the physician of a heart rate greater than 100. Between 12/5/22-2/14/23, the patient’s heart rate was greater than 100 with no physician notification for 5 of 13 nursing visits. An interview with the clinical director on 6/15/23 at 10:57 a.m. confirmed there was no evidence of physician notification. 1B. Patient #1 was admitted on 12/5/22 with a diagnosis of type 1 diabetes mellitus with hyperglycemia (high blood sugar). The Plan of Care (POC) for 12/8/22-2/2/23 included skilled nursing visits twice weekly for nine weeks. The POC for 2/3/23-4/3/23 included orders for skilled nursing visits weekly for four weeks. Both POCs included an order to notify the physician of a blood sugar greater than 200. Between 12/5/22-2/14/23, the patient’s blood sugar was greater than 200 with no physician notification for 5 of 13 nursing visits. An interview with the clinical manager on 6/15/23 at 10:57 a.m. confirmed there was no evidence of physician notification. 1C. Patient #1 was admitted on 12/5/22 with a diagnosis of type 1 diabetes mellitus with hyperglycemia (high blood sugar). The Plan of Care (POC) for 12/8/22-2/2/23 included orders for physical therapy one time for one week, then twice weekly for four weeks. There was no evidence physical therapy attempted to conduct a visit until 12/30/22. An interview with the clinical manager on 6/15/23 at 10:48 a.m. revealed therapy was put on hold due to no Medicaid authorization. The interview confirmed there was no evidence the physician was notified that therapy was not provided based on the POC. 2. Patient #15 was admitted on 5/11/23 with diagnoses of osteomyelitis (infection of the bone) right ankle, type 2 diabetes, and peripheral vascular disease. The Plan of Care (POC) for 5/11/23-7/9/23 included orders for skilled nursing one time for one week, then twice weekly for five weeks. The POC also included to report blood sugar greater than 200 or less than 60. On 5/11/23, RN #13 documented the blood sugar as 241. There was no evidence the physician was notified of the blood sugar outside parameters. An interview with the clinical on 6/15/23 at 11:44 a.m. confirmed there was no evidence of physician notification.

Communication with all physicians CFR(s): 484.60(d)(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 agency policy, clinical record review and staff interviews the agency failed to communicate with the physician when SN and PT visits were not made in accordance with the POC for 2 of 18 patients [#6, 18]. The findings included: The policy, Variances from the Plan of Care/Service Plan [no date], was provided by the agency administrator on 6/14/23 at 3:47 pm. The policy stated, “…or designee notifies all parties including any ordering physician or allowed practitioner…” 1. Patient # 6 had a Start of Care date of 2/1/23. Review of the Plan of Care for the certification period 5/2/23 to 6/30/23 revealed a diagnosis of pressure ulcer of right buttock, stage 4 [ulcer penetrates all three layers of skin, exposing muscles, tendons and bones]. The POC included orders for SN [skilled nursing] 1 time a week for 9 weeks. Review of the clinical record revealed no nursing visit was made after the recertification visit on 5/1/23. [No SN visit was made the 1st week of the new episode]. There was no evidence the physician was notified of the missed SN visit. During an interview with the clinical manager on 6/15/23 at approximately 11:45 am, it was confirmed the physician was not notified of the missed visit. 2. Patient # 18 had a Start of Care [SOC] date of 5/7/23 and admitting diagnoses of acute and chronic respiratory failure and chronic obstructive pulmonary disease [COPD-lung disease]. Review of the Plan of Care [POC] for the certification period 5/7/23 to 7/5/23 included orders for PT [physical therapy] 1 time a week for 1 week then 2 times a week for 3 weeks. Review of the clinical record revealed PT # 15 documented a missed visit on 5/30/23 and 6/1/23. There was no evidence PT # 15 notified the physician of the missed visits. PT # 15 was not available for interview. During an interview with the regional director on 6/15/23 at approximately 12:15 pm, it was confirmed the physician was not notified of the missed visits.

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 clinical record review and staff interview, the RN failed to document external catheter length and arm circumference on 2 of 3 patients with a PICC line (#7 and 15); and to measure wounds for 1 of 8 patients with a wound (#6). Findings included: The policy, Examples of Standard of Practice [no date], was provided by the agency administrator on 6/14/23 at 3:47 pm. The policy stated, “…Wound-The clinician measures the wound(s) weekly and documents the results…” 3. Patient # 6 had a Start of Care date of 2/1/23. Review of the Plan of Care for the certification period 5/2/23 to 6/30/23 revealed a diagnosis of pressure ulcer of right buttock, stage 4 [ulcer penetrates all three layers of skin, exposing muscles, tendons and bones]. The POC included orders for SN [skilled nursing] 1 time a week for 9 weeks and “Clean wound with antibiotic solution. Apply prisma [type of wound dressing]. Apply gauze that is folded in half. Covered [sic] with bordered foam dressing…” Review of the clinical record revealed no wound measurements were obtained the weeks of 5/20/23 and 6/3/23. During an interview LPN # 7 on 6/15/23 at approximately 9:15 am, LPN # 7 confirmed the wound was not measured for those 2 weeks. 1. Patient #7 was admitted on 5/23/23 with a diagnosis of encounter for surgical aftercare following surgery and encounter for adjustment and management of a vascular access device. The Plan of Care (POC) for 5/23/23-7/21/23 included orders for skilled nursing visits weekly for nine weeks. RN #23 conducted the initial assessment on 5/23/23 and a routine visit on 5/29/23. There was no evidence of external catheter length or arm circumference on either visit. An interview with RN #23 on 6/15/23 at 10:40 a.m. confirmed there was no documentation of the measurements. 2. Patient #15 was admitted on 5/11/23 with diagnoses of osteomyelitis (infection of the bone) right ankle, type 2 diabetes, and peripheral vascular disease. The Plan of Care (POC) for 5/11/23-7/9/23 included orders for skilled nursing one time for one week, then twice weekly for five weeks. The patient had a PICC (peripherally inserted central catheter—IV access to large central veins) line for administration of IV antibiotics. The initial assessment was conducted on 5/11/23 by RN #13. There was no evidence the RN measured the arm circumference. An interview with the clinical manager on 6/15/23 at 11:44 a.m. confirmed there was no evidence of arm circumference on 5/11/23.

Patient and caregiver education CFR(s): 484.75(b)(5) Patient and caregiver education; This ELEMENT is not met as evidenced by: Based on clinical record review, and staff interview, the agency failed conduct a visit as requested by the patient for 1 of 3 patients with a vascular access device (#15). Findings included: Patient #15 was admitted with diagnoses of osteomyelitis (infection of the bone) right ankle, type 2 diabetes, and peripheral vascular disease. The Plan of Care (POC) for 5/11/23-7/9/23 included orders for skilled nursing one time for one week, then twice weekly for five weeks. The patient had a PICC (peripherally inserted central catheter—IV access to large central veins) line for administration of IV antibiotics. The initial assessment was conducted on 5/11/23 by RN #13. The nurse noted that the patient would like another visit the next day to review antibiotic administration with the patient’s caregiver. There was no evidence of a visit until 5/15/23. An interview was conducted with the clinical manager on 6/15/23 at 11:44 a.m. The clinical manager confirmed there was no follow-up visit or documentation for a visit on 5/12/23.

Home health aide assignments and duties CFR(s): 484.80(g)(1) Standard: Home health aide assignments and duties. Home health aides are assigned to a specific patient by a registered nurse or other appropriate skilled professional, with written patient care instructions for a home health aide prepared by that registered nurse or other appropriate skilled professional (that is, physical therapist, speech-language pathologist, or occupational therapist). This STANDARD is not met as evidenced by: Based on clinical record review and staff interviews the patient care instructions for the home health aide failed to give clear instructions on the type of bath the patient should receive for 1 of 1 patient with home health aide services [#18]. The findings included: Patient # 18 had a Start of Care date of 5/7/23 and admitting diagnoses of acute and chronic respiratory failure and chronic obstructive pulmonary disease [COPD-lung disease]. Review of the Plan of Care [POC] for the certification period 5/7/23 to 7/5/23 included orders for SN [skilled nursing] 2 times a week for 1 week then 1 time a week for 8 weeks; HHA [home health aide] 3 times a week for 9 weeks. Review of the aide plan of care revealed the following tasks “complete bed bath on Tuesday, Thursday and Saturday and partial bath shower/tub on Tuesday, Thursday and Saturday.” During an interview with the regional director 6/15/23 at 12:30 pm, it was confirmed the assigned tasks were not clear.

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 clinical record review and staff interviews the agency failed to conduct home health aide supervisory visits at least every 14 days for 1 of 1 patient receiving home health aide services [#18]. The findings included: Patient # 18 had a Start of Care date of 5/7/23 and admitting diagnoses of acute and chronic respiratory failure and chronic obstructive pulmonary disease [COPD-lung disease]. Review of the Plan of Care [POC] for the certification period 5/7/23 to 7/5/23 included orders for SN [skilled nursing] 2 times a week for 1 week then 1 time a week for 8 weeks; HHA [home health aide] 3 times a week for 9 weeks. Review of the clinical record revealed the aide made 9 visits from 5/11/23-6/12/23. Further review of the clinical record revealed no aide supervisory visits were completed. During an interview with the regional director on 6/15/23 at 12:30 pm, she confirmed no aide supervisory visits were performed.

Required items in clinical record CFR(s): 484.110(a)(1) The patient's current comprehensive assessment, including all of the assessments from the most recent home health admission, clinical notes, plans of care, and physician or allowed practitioner orders; This ELEMENT is not met as evidenced by: Based on agency policy, clinical record review and staff interviews the agency failed to ensure interventions/goals were correct for 1 of 4 discharged patients [#4]; failed to ensure laboratory results were placed on the clinical record for 1 of 2 patients with lab work ordered [#8]; and failed to ensure the clinical record contained accurate information related to patient diagnosis for of 3 of 18 patients [#10, 13,18]. The policy, Content of the Patient/Client Record [4/2/21], was provided by the agency administrator on 6/14/23 at 4:39 pm. The policy stated, “…The following information is included in each patient/client record when applicable to the care/service the patient/client is receiving…Relevant diagnostic and therapeutic procedures, treatments, tests and their results…” 1. Patient # 4 had a Start of Care date of 12/29/22. Review of the Plan of Care [POC] for the certification period 2/27/23 to 4/27/23 included a diagnosis of chronic combined systolic and diastolic heart failure [heart doesn’t pump effectively]. The POC included orders for SN [skilled nursing] 2 times a week for 2 weeks then 1 visit a week for 1 week. Further review of the POC revealed PT [physical therapy] interventions. Review of the clinical record revealed there were no orders for PT for the episode 2/27/23-4/27/23. During an interview with RN # 4 on 6/15/23 at 9:15 am, the RN stated, “I don’t know how those interventions/goals got on the POC. I don’t mess with PT’s stuff.” RN # 4 confirmed the PT interventions/goals should not have been on the POC. 2. Patient # 8 had a Start of Care date of 4/15/23 and an admitting diagnosis of lobar pneumonia. Review of the Plan of Care [POC] for the certification period 4/15/23 to 6/13/23. Review of the clinical record revealed orders for SN [skilled nursing] 1 time a week for 3 weeks. A supplemental order was written on 5/22/23 for SN visit 1 time to obtain lab work. The lab work was obtained on 5/24/23. Review of the clinical record revealed the lab work results were not placed on the clinical record until 6/15/23. During an interview with the regional director at 12:45 pm, she stated, “The lab work is usually linked to the chart within a day or so after the results.” 3. Patient # 10 had a Start of Care date of 4/21/23 and admitting diagnoses of non-pressure chronic ulcer of left heel and midfoot, diabetes mellitus due to underlying conditions and type 2 diabetes mellitus with diabetic polyneuropathy [complication of diabetes characterized by death of nerve fibers, which leads to loss of nerves]. Review of the Plan of Care [POC] for the certification period 4/21/23 to 6/19/23 included orders for SN [skilled nursing] 1 time a week for 1 week then 3 times a week for 5 weeks. Review of the clinical record revealed the patient received 21 SN visits from 4/21/23 to 6/12/23. Review of the SN clinical notes revealed for 8 of the 21 visits the SN answered “NA” to the question related to diabetes. During an interview with RN # 4 on 6/15/23 at approximately 9 am, RN # 4 confirmed the patient was a diabetic and the question related to diabetes should have not been marked with “NA”. 4. Patient # 13 had a Start of Care date of 4/29/23 and admitting diagnoses of heart failure and diabetes mellitus. Review of the Plan of Care for the certification period 4/29/23 to 6/27/23 included orders for PT [physical therapy] 2 times a week for 3 weeks. Review of the clinical record revealed PT # Nicole made visits on 5/2/23 and 5/9/23. Review of the PT visit note for those dates revealed PT # Nicole answered “No” to the question related to a diagnosis of heart failure. The patient was hospitalized from 5/11/23-5/20/23. Supplemental orders for SN visits were written on 5/21/23 for SN visits 3 times a week for 1 week then 2 times a week for 2 weeks then 1 time a week for 1 week. Supplemental orders for PT, OT and ST were written on 5/23/23 for the following frequencies: PT 2 times a week for 5 weeks; OT 2 times a week for 4 weeks; ST 1 time a week for 4 weeks. Review of the clinical record revealed the patient received 16 visits [SN, PT, OT] visits from 5/21/23-6/13/23. Further review of the clinical record revealed 10 of the 16 visits had “No” marked related to the CHF diagnosis. During an interview with PTA # 6 on 6/15/23 at approximately 10 am, the PTA stated, “I didn’t know she had CHF.” During an interview with the clinical manager on 6/15/23 at approximately 11:35 am, the clinical manager confirmed the clinical record was not accurate. 5. Patient # 18 had a Start of Care [SOC] date of 5/7/23 and admitting diagnoses of acute and chronic respiratory failure and chronic obstructive pulmonary disease [COPD-lung disease]. Review of the Plan of Care [POC] for the certification period 5/7/23 to 7/5/23 included orders for SN [skilled nursing] 2 times a week for 1 week then 1 time a week for 8 weeks; PT [physical therapy] 1 time a week for 1 week then 2 times a week for 3 weeks; OT [occupational therapy] 2 times a week for 4 weeks. Review of the clinical record revealed 17 visits [SN, PT, OT] were made from 5/7/23 to 6/12/23. Further review of the clinical record revealed for 9 of the 17 visits the clinicians had marked “NA” to the question related to the patient having CHF [congestive heart failure]. During an interview with the regional director on 6/15/23 at approximately 12:35 pm, the regional director confirmed the documentation related to CHF was not accurate.

Interventions and patient response CFR(s): 484.110(a)(2) All interventions, including medication administration, treatments, and services, and responses to those interventions; This ELEMENT is not met as evidenced by: Based on policy review, clinical record review and staff interview, the nurse failed to complete documentation for 1 of 5 patients with lab orders (#2); document PICC (peripherally inserted central catheter—IV access to large central veins) line dressing changes/cap changes for 1 of 3 patients with a PICC line (#7); and the visit notes had inconsistent documentation related to integumentary status and medication for 1 of 2 patients that received IV antibiotics (#15). Findings include: A policy, “Content of the Patient/Client Record” (no date), was received on 6/14/23 at 4:39 p.m. by Employee #31. The policy stated, “The following information is included in each patient/client record when applicable to the care/service the patient/client is receiving…Appropriate information on each does of medication administered by employees…All interventions, including treatments, and services, and responses to those interventions…Relevant diagnostic and therapeutic procedures, treatments, tests, and their results…The patient’s/client’s response to care/service provided…” 1. Patient #2 was admitted on 11/15/22 with a diagnosis of encounter for surgical aftercare. The Plan of Care (POC) for 11/15/22 included an order for skilled nursing weekly for four weeks. The POC also included orders for lab draw on 11/15/22. There was no documentation of the venipuncture site, type of needle use, number of attempts, and how the patient tolerated it. An interview with the regional director on 6/15/23 at 11:30 confirmed the venipuncture documentation only included that the lab was collected. 2. Patient #7 was admitted on 5/23/23 with a diagnosis of encounter for surgical aftercare following surgery and encounter for adjustment and management of a vascular access device. The Plan of Care (POC) for 5/23/23-7/21/23 included orders for skilled nursing visits weekly for nine weeks. The POC also included orders to change the injection caps weekly and after blood draws. RN #23 conducted a home visit on 5/29/23. Labs were obtained and PICC (peripherally inserted central catheter—IV access to large central veins) line dressing was changed. There was no evidence the injections caps were changed. An interview with RN #23 on 6/15/23 at 10:40 a.m. revealed the nurse changed the caps but failed to document the cap changes. 3A. Patient #15 was admitted on 5/11/23 with diagnoses of osteomyelitis (infection of the bone) right ankle, type 2 diabetes, and peripheral vascular disease. The Plan of Care (POC) for 5/11/23-7/9/23 included orders for skilled nursing one time for one week, then twice weekly for five weeks. The patient had a PICC (peripherally inserted central catheter—IV access to large central veins) line for administration of IV Vancomycin (antibiotic) 1.75 grams every 12 hours. On 5/15/23, Vancomycin was decreased to 1.25 grams every 12 hours. Between 5/18/23-6/14/23, for 13 of 13 visits the interventions stated that Vancomycin 1.75 mg was “ongoing.” An interview with the clinical manager on 6/15/23 at 11:44 a.m. revealed the intervention was not updated with the change in medication dosage. 3B. Patient #15 was admitted on 5/11/23 with diagnoses of osteomyelitis (infection of the bone) right ankle, type 2 diabetes, and peripheral vascular disease. The Plan of Care (POC) for 5/11/23-7/9/23 included orders for skilled nursing one time for one week, then twice weekly for five weeks. The patient had a PICC (peripherally inserted central catheter—IV access to large central veins) line for administration of IV Vancomycin (antibiotic) 1.75 grams every 12 hours. Between 5/11/23-6/14/23, for 11 of 15 visits, the integumentary status did not include diabetes, peripheral vascular disease, and/or vascular access device. An interview with the clinical manager on 6/15/23 at 11:44 a.m. revealed there were inconsistencies.

An onsite recetification survey was conducted 03/01/21 to 03/03/21. No deficiencies to the Emergency Prepardeness Program were identifed.

An onsite recertification survey was conducted 03/01/21 to 03/03/21. Deficiencies to the Medicare Conditions of Participation were identified.

Development and evaluation of plan of care CFR(s): 484.75(b)(2) Development and evaluation of the plan of care in partnership with the patient, representative (if any), and caregiver(s); This ELEMENT is not met as evidenced by: Based on agency policy review, clinical record review and staff interviews the agency failed to include the patient/caregiver in developing the plan of care for 1 of 1 patient receiving occupational therapy services who requested " a change in staff " [#21]. The findings included: The policy, Developing a Plan to Meet Patient/Client Needs, was provided on 3/2/21 by the Regional Director. The policy stated, " ...The designated employee collaborates with the patient/client, representative, and caregiver as well as the health care practitioner ...to develop a plan of care/service plan ..." Patient # 21 had a Start of Care [SOC] date of 1/5/21 and an admitting diagnosis of Pneumonia. A review of the Plan of Care [POC] for the certification period 1/5/21 to 3/5/21 revealed a supplemental order dated 1/18/21 for OT [occupational therapy] 2 times a week for 3 weeks. A review of the clinical record revealed on 2/3/21 OT # 15 documented the following, "per grand- daughter family is requesting a different occupational therapist." During a phone interview with occupational therapist #15 on 3/3/21 at approximately 10:00 am the OT reported, "the family was upset with me because I was concerned about the patient ' s cognition and I requested a neurological consult ...I didn ' t include the patient ' s family in the decision making before I asked for the consult." An interview was conducted with RN # 16 on 3/3/21 at approximately 9:30 am. During the interview RN # 16 confirmed the OT failed to include the patient/family when developing the plan of care related to occupational therapy.

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 interviews the agency failed to provide services as ordered by the physician for 2 of 4 patients with wounds (#6), and physical therapy services for 1 of 5 discharged records (#4). Findings include: A policy, "Developing a Plan to Meet Patient/Client Needs" (dated 8/18), was provided by the regional director on 03/02/21 at 8:30 a.m. The policy stated, " ensures a patient's individualized home health plan of care includes the following: types of services, frequency and duration of visits to be made, all medications and treatments ...the clinician measures the wound(s) weekly and documents the results" 1.Patient #6 was admitted on 1/15/21 with diagnoses of encounter for change or removal of surgical wound, complication of surgical and medical care, unspecified, and personal history of malignant neoplasm of the breast. The Plan of Care (POC) for 1/15/21-3/15/21 included skilled nursing (SN) 3 time per week for 9 weeks to assess wound for size, color, granulation, epithelization, exudate (amount/type), odor, pain, condition of surrounding skin, for s/s/ of infection. SN to instruct patient/caregiver on wound care procedure. SN to perform wound care 3 times a week and prn - apply drape to peri wound, apply black foam to wound bed, cover with transparent dressing, apply dime size hole and apply track pad, negative pressure wound therapy at 125 mm hg (millimeters of mercury) continuous. Review of skilled nursing visits for the week of 01/18/21 revealed no wound measurements were obtained on visits 1/18/21, 1/20/21, or 1/22/21. Further review of record revealed a skilled nurse visit was not in the record for 2/19/21. An interview with Employee #2 was conducted on 3/3/21 at 11:04 a.m. revealed " I didn't document some of the measurements, the nurse that saw the patient on 2/15/21 should have done a missed visit for 2/19/21 since the patient went to the hyperbaric chamber and the dressing was changed there, I was on vacation that week". 2. Patient #4 was admitted on 12/17 /20 with a diagnosis of pneumonia, essential hypertension, unspecified dementia, and chronic kidney disease. The Plan of Care (POC) for 12/17/20-2/14/21 included orders for physical therapy 2 times a week for 4 weeks physical therapy to instruct patient/caregiver on safety issues regarding transfer techniques, gait training, fall precautions and home exercise program for strengthening/balance/endurance. Review of the clinical record revealed physical therapy visits were conducted 1 time a week on 12/21/20, 12/28/20, 01/06/21, 01/11/21, 01/18/21, and 01/25/21. An interview with Employee #4 on 3/3/21 at 10:27 a.m. revealed " I thought I wrote the order 1-2 times a week and I saw her just 1 time a week" " I am new to the setting and didn't realize I couldn't write range orders".

Preparing clinical notes CFR(s): 484.75(b)(6) Preparing clinical notes; This ELEMENT is not met as evidenced by: Based on clinical record review and staff interviews the agency failed to include wound measurements in the clinical record for 1 of 7 patients with wounds [#13]. The findings included: Patient # 13 had a Start of Care date of 1/1/20 and diagnoses of Pressure Ulcer of Right Ankle [stage 4], Diabetes Mellitus with other Skin Ulcerations and Diabetes Mellitus with Foot Ulcer. A review of the Plan of Care [POC] for the certification period from 12/26/20 to 2/23/21 revealed orders for SN [skilled nursing] 3 visits per week for 9 weeks; 3 Visits PRN [as needed] for change in condition, new wound care orders, labs and "SN to perform wound care 3 days per week and prn soiling/dislodgement; apply alginate ag cover with dry gauze and or abd pad and wrap with three layer compression wrap-lateral left foot and right lateral foot". A review of the clinical record revealed RN # 3 made routine visits on 12/28/20, 1/1/21, 1/18/21, 1/20/21, 2/1/21, 2/8/21, 2/10/21 and 2/12/21 and LPN # 10 made routine visits on 12/20/20 and 2/5/21. Further review of the clinical record revealed no weekly wound measurements were documented for any of the visits from 12/28/21-12/12/21. A telephone interview was conducted with RN # 3 on 3/3/21 at approximately 12 noon. During the interview RN # 3 reported, "I am not sure what happened, I am usually pretty good about measuring wounds the first visit of each week. I may have written the measurements on a sheet of paper and failed to enter the information in the computer." On 3/3/21 at approximately 8:30 am a phone interview was conducted with LPN # 10 . LPN # 10 stated, "I may have measured the wounds and just forgot to put the information in." On 3/3/21 at approximately 12:30 pm an interview was conducted with RN #16. RN # 16 reported, "it is the agency policy that wounds are to be measured each week."