Every finding on record at Ivy Creek of Tallapoosa, LLC

A recertification survey was conducted on 4/15/25 to 4/17/25 and Lake Martin Home Health was found to be in substantial compliance with the Conditions of Participation for Emergency Preparedness.

A recertification survey was conducted on 4/15/25 to 4/17/25 at Lake Martin Home Health, a home health agency with one branch. Standard level deficiencies were cited and will require an acceptable Plan of Correction.

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, agency policy and procedure, and interviews, it was determined the agency failed to ensure the medications were reconciled and all current medications were listed on the Medication Summary. This deficient practice did affect two of four home visits (HV) including HV # 2, and HV # 1, and had the potential to affect all patients admitted to the agency. Findings Include: Agency Policy: Medication Profile Policy Number: 2-005 Revised Date : 11/2024 Purpose: To define the use of the medication profile in evaluating a patient's medication regimen, including over-the-counter (OTC) medications, nutrition supplements, herbal remedies, vitamins and minerals. Policy: Patient receiving medications administered by the organization will have a current, accurate medication profile in the clinical record. Medication profiles will be updated for each change to reflect current medications, new and /or discontinued medications. Procedure: ...2. A drug regimen review will be performed at the time of admission, when updates to the comprehensive assessments are performed, when care is resumed after a patient has been placed on hold and with the addition of a new medicine. A. The review will be performed by qualified personnel and will identify drug/food interactions, potential side effects and drug reactions, ineffective drug therapy, significant side effects, significant drug interactions, duplicate drug therapy, and noncompliance with drug therapy. 3. During subsequent home visits, the medication profile will be used as a care planning and teaching guide to ensure that the patient and family/caregiver as well as other clinicians understand the medication regimen. This includes, but is not limited to: A. Using the medication profile to evaluate the use of medications in the home setting, B. Using the medication profile to teach purpose of medication, dosages, routes, administration times, side effects, and contraindications. C. Using the medication profile as a communication tool for other clinicians involved in the care. ...7. Deviations from taking medications as ordered will be documented in clinical notes, and the physician (or allowed practitioner) will be notified. 2. HV # 1 was admitted on 3/11/25 with diagnoses including Emphysema, Unspecified and Essential (Primary) Hypertension. A HV was conducted on 4/15/25 at 11:26 AM to observe care provided by EI # 3, Home Health Aide. A review of the home medications with the patient revealed the following current medications were in the home but not listed in the Medication Summary printed 4/15/25: a) Bupropion Hydrochloride 75 mg one tablet daily. The prescription was filled 3/25/25. b) Acetaminophen 500 mg caplets. HV # 1 stated he/she sometimes takes "some nights to help me sleep, two or three times a week." c) Ibuprofen 200 mg capsules. HV # 1 stated, "I take that when I am aching." An interview was conducted on 4/17/25 at 8:50 AM with EI # 6, Regional Director, who confirmed all medications had not been reconciled and the Medication Summary was not accurate. 1. HV # 2 was admitted to the agency on 12/18/24 and recertified for care from 2/16/25 to 4/16/25 with diagnoses including Hypertensive Heart and Chronic Kidney Disease with Heart Failure, Stage 1-4, Unspecified Chronic Kidney Disease. A HV was conducted on 4/15/25 at 11:35 AM to observe care provided by Employee Identifier (EI) # 5, Physical Therapist. During the HV, medications found in the home were compared to the Medicine Summary (MS) printed on 4/15/25 and verified with the patient. The six medications below were listed on the MS, not found in the home, and verified not in use: a) Amlodipine 10 mg (milligrams), 1 tablet (tab) orally daily. b) Atorvastatin 40 mg 1 tab orally at bedtime. c) Carvedilol 25 mg 1 tab orally two times daily. d) Hydralazine 50 mg 1 tab orally three times daily. e) Potassium Chloride 10 mEq (milliequivalent) 1 tab extended release orally daily. f) Prednisone 10 mg 1 tab orally daily. There were two medications found in the home in use not listed on the MS: a) Hydroxyzine Hydrochloride (HCL) 25 mg 1 tab orally at bedtime as needed, fill date 2/17/25. b) Antifungal 2% powder apply affected area twice daily, fill date 1/20/25. Oxygen 2 liters (L) inhalation (per nasal cannula) continuous was listed on the MS, and found in the home. The patient was not wearing oxygen during the HV physical therapy treatment. An interview was conducted on 4/15/25 at 12:30 PM with HV # 2, who confirmed oxygen use is intermittently, medications not in the home were discontinued about one month ago, and Hydroxyzine Hydrochloride and Antifungal powder are used as needed. An interview was conducted on 4/16/25 at 10:16 AM with EI # 4, Registered Nurse, who confirmed HV # 2's medications had not been reconciled and the current MS was not accurate.

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 observations, agency policy and procedure, interviews, medical record (MR) reviews, and Potter and Perry Fundamentals of Nursing, it was determined the agency failed to ensure the patient and caregiver (pt/cg) were provided oxygen safety signage for the home. This did affect two of three home visit (HV) patients who are using oxygen, including HV # 1 and HV # 3, and had the potential to negatively affect all patients admitted to this agency who use oxygen. Findings Include: Agency Policy: Care Planning Process Policy Number: 1-007 Revised Date: 11/2 Policy ...Definitions 1. Individualized Plan of Care: The patient-specific clinical plan of care includes: ...K. Safety measures to protect against injury ...X. Other appropriate items such as precautions and contraindications... Procedure 1. At the time of the initial assessment, the clinician, along with other involved disciplines, will develop the plan of care based upon the patient's identified needs and will review it with the patient and family/caregiver. 2. All clinicians will consider the conclusions of initial and ongoing assessments in their care planning process, including but not limited to: A. Individualized patient needs and resultant problems related to care... 3. Based on assessment and conclusions, the plan of care will include, but not be limited to: A. Patient specific interventions... D. Specific services to be provided... G. Equipment and supplies ...L. Safety measures to protect against injury... 17. The organization shall provide the patient and caregiver a copy of written instructions outlining: ...C. Any treatments to be administered by the organization's personnel and personnel acting on behalf of the organization... D. Any other pertinent instruction related to the patient's care and treatments that the organization will provide, specific to the patient's care needs. Reference: Perry and Potter Fundamentals of Nursing Fifth Edition Copyright: 2001 ...page 1176... Safety Precautions with Oxygen Therapy... With increasing use of home oxygen therapy, clients...must be aware of the dangers of combustion. The nurse should promote safety by using the following measures: "No Smoking" signs should be placed on the room door and over the bed. The client, visitors and roommates, and all personnel should be informed that smoking is not permitted in areas where oxygen is in use... 1. HV # 1 was admitted to the agency on 3/11/25 with diagnoses including Emphysema, Unspecified and Essential (Primary) Hypertension. A review of the Home Health Certification (HHC) and Plan of Care (POC) dated 3/11/25 revealed: Oxygen: 3 LPM (liters per minute) gas/continuous/inhaled. DME (durable medical equipment): ... oxygen concentrator. Plan developed, …O2 (oxygen) precautions, instructed on medical gas safety-verbalized understanding. Dyspnea and must wear oxygen at all times. Review of Skilled Nurse (SN) visit note dated 3/11/25 revealed: O2 use: 3 lpm continuous nasal cannula. Smokers in home: Family members "No Smoking" signs placed outside doors?: NO, instructed pt/cg to post No Smoking signs... A HV was conducted on 4/15/25 at 11:26 AM to observe care provided by Employee Identifier (EI) # 3, Home Health Aide. Upon entering the HV, it was noted there was no "No Smoking" signage on the door or in the room indicating oxygen was in use. During the HV, oxygen via nasal cannula was observed being used by the patient. The patient stated he/she uses the oxygen continuously. An interview was conducted on 4/17/25 at 8:50 AM with EI # 6, Regional Director, who confirmed there were no signs provided by the agency for the pt/cg to post. EI # 6 stated the DME company was expected to supply the signs and staff failed to ensure signs were received and posted. 2. HV # 3 was admitted on 8/21/24 and recertified for care on 2/12/25 to 4/17/25 with diagnoses including Hypertensive Heart and Chronic Kidney Disease with Heart Failure and Stage 1-4, Unspecified Chronic Kidney Disease and Chronic Obstructive Pulmonary Disease, Unspecified. Review of the HHC and POC revealed: Oxygen: 2 L per minute gas/continuous through CPAP (continuous positive airway pressure)/inhaled. O2 precautions, instructed on medical gas safety-verbalized understanding. A HV was conducted on 4/15/25 at 2:05 PM to observe care provided by EI # 7, Registered Nurse (RN). Upon entering the HV, it was noted there was no "No Smoking" signage posted on the door or in the room indicating oxygen was in use. During the HV, HV # 3 was asked about oxygen use and a "No Smoking" sign. The cg said he/she only uses the oxygen at night with the CPAP mask. The pt/cg stated they had not been provided a sign to post on the door.. An interview was conducted on 4/17/24 at 10:14 AM with EI # 6, who confirmed there were no signs provided by the agency for the pt/cg to post. EI # 6 stated the DME company was expected to provide the signs and staff failed to ensure signs were received and posted.

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 review of the medical record (MR), and staff interview, it was determined the agency failed to ensure staff obtained physician order's for Peripheral Inserted Central Catheter (PICC) dressing changes. This affected MR # 6, one of one records reviewed with a PICC, and had the potential to negatively affect all patients with a PICC. 1. MR # 6 was admitted to the agency on 2/3/25 with diagnoses including Diverticuli of Intestine, Partial/ Unspecified, and Encounter for Adjustment and Management of Vascular Access Device. Review of the Plan of Care dated 2/3/25 to 4/3/25 revealed orders for the Skilled Nurse (SN) to change PICC dressing once a week for two weeks, begin 2/3/25. Review of the SN Visit documentation dated 2/17/25, and 2/24/25, revealed PICC dressing changes were performed. There was no physician order for a PICC dressing after week two. An interview was conducted on 4/17/25 at 9:38 AM with Employee Identifier # 1, Director, who confirmed staff failed to obtain a physician’s order to continue PICC dressing changes.

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 observations, agency policy and procedure, Lake Martin Homecare Clinical Procedure Manual, and interviews, it was determined the agency failed to ensure staff followed agency policy for hand hygiene (HH) and glove changes. This deficient practice did affect one of one home visits (HV) with an aide, including HV # 1, and had the potential to affect all patients served by the agency. Findings Include: Agency Policy: Hand Hygiene Policy Number: 7-009 Revised Date: 11/2024 Purpose: To prevent cross contamination and home care acquired infections Procedure: ...3. Hand decontamination using an alcohol-based hand rub should be performed: D. After contact with body fluids or excretions, mucus membranes... E. When moving from a contaminated body site to a clean body site during patient care. ...G. After removing gloves. Lake Martin Homecare Clinical Procedure Manual: Bath-Bed Bath Purpose: To outline the procedure for bathing the bed bound patient to maintain personal hygiene. Procedure: ...11. Bathe back and buttocks with soap... Take gloves off, wash hands-don new gloves, apply lotion or powder... 1. HV # 1 was admitted on 3/11/25 with diagnoses including Emphysema, Unspecified and Essential (Primary) Hypertension. A HV was conducted on 4/15/25 at 11:26 AM to observe care provided by EI # 3, Home Health Aide. During the bed bath, EI # 3 washed, rinsed, and dried the patient's buttocks with a towel, opened the lid from the patient's lotion, reached into the container of lotion and applied the lotion to the patient's back and legs, all while wearing the same pair of contaminated gloves. EI # 3 failed to remove gloves, perform hand hygiene, and don new gloves before moving from a contaminated body site to a clean body site. An interview was conducted on 4/17/25 at 8:50 AM with EI # 6, Regional Director, who confirmed staff failed to follow agency policy for hand hygiene and glove changes.

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 medical record (MR) review, agency policy, and staff interviews, it was determined the agency failed to ensure nursing staff documented the care provided to a Peripheral Inserted Central Catheter (PICC). This affected MR # 6, one of one patient records with a PICC and had the potential to negatively affect all patients with a PICC. Findings include: Agency Policy: Clinical/Service Data Collection Policy Number: 6-022 Revised Date: 11/24 1. A clinical/service record will be initiated and maintained for each patient receiving care or services...and will include at a minimum: ...E. Dates, times, and types of interventions, assessments, and coordination of care/service. ...7. The clinical service note will include: A. What care/service provided B. Treatment and/or invasive procedures performed. C. Patient response to treatment and/or procedures. D. The date the service was provided... MR # 6 was admitted to the agency on 2/3/25 with diagnoses including Diverticuli of Intestine, Partial/ Unspecified, and Encounter for Adjustment and Management of Vascular Access Device. Review of the Plan of Care (POC) dated 2/3/25 to 4/3/25 revealed orders for Skilled Nurse (SN) weekly visit for five weeks to infuse Ertapenem (intravenous antibiotic for treatment of infection) daily (via PICC), normal saline (NS) flush with 5-10 milliliter (mL) before and after infusion, obtain labs via venipuncture or PICC, 10 mL (NS flush) before labs, after labs 20 mL (NS flush), lock with 5 mL Heparin flush, change PICC injection caps primed with NS. Review of the SN visit notes (VN) dated 2/3/25 and 2/5/25 revealed no documentation of the solution type(s) and amount(s) used to flush the PICC. Further review of the 2/5/25 SN VN revealed no documentation of the care provided during the PICC dressing change. Review of the SN VNs dated 2/10/25 and 2/17/25 revealed no documentation of the solution type(s) and amount(s) used during the PICC flush. There was no documentation PICC injection caps were changed. Review of the SN VN dated 2/24/25 failed to reveal the amount of NS administered during the PICC flush. There was no documentation PICC injection caps were changed. An interview was conducted on 4/17/25 at 9:38 AM with Employee Identifier # 1, Director, who confirmed clinical record documentation did not include all interventions/treatments as ordered on the POC.

Discharge and transfer summaries CFR(s): 484.110(a)(6)(i-iii) (i) A completed discharge summary that is sent to the primary care practitioner or other health care professional who will be responsible for providing care and services to the patient after discharge from the HHA (if any) within 5 business days of the patient's discharge; or (ii) A completed transfer summary that is sent within 2 business days of a planned transfer, if the patient's care will be immediately continued in a health care facility; or (iii) A completed transfer summary that is sent within 2 business days of becoming aware of an unplanned transfer, if the patient is still receiving care in a health care facility at the time when the HHA becomes aware of the transfer. This ELEMENT is not met as evidenced by: Based on medical record (MR) review, agency policy and procedure, and interview with staff, the agency failed to ensure staff provided a copy of the transfer summary to the receiving provider. This affected, MR # 1, in one of two transfers from the home health agency (HHA) to Hospice care, and had the potential to negatively affect all patients transferred from the HHA. Policy/Procedure Title: Transfer/Referral Criteria and Process Policy No. 1-022 Revised November 2024 Purpose …the process for transferring a patient to another service provider. Policy …When a patient’s needs change significantly…a transfer/referral to another service provider will be made. …Procedure …6. The clinician or designee will: …C. Serve as a liaison between the patient, the family/caregiver, and physician…relative to the transfer arrangements. …10. Within 48 hours of transfer, the clinician will complete a transfer summary… 11. Within 72 hours of transfer…send a copy of transfer summary or clinical record to the receiving provider… 1. MR # 1 was admitted to the agency on 12/4/24 with diagnoses including Hemiplegia following Cerebral Infarction, Left Nondominant Side. Record review revealed a physician's order dated 12/31/24, to discontinue physical therapy, patient to transfer to hospice. Further review revealed no documentation a Transfer Summary was sent to the hospice provider. An interview was conducted on 4/17/25 at 9:30 AM, with Employee Identifier # 1, Director, who confirmed the agency failed to provide a Transfer Summary to the receiving hospice agency.

Authentication CFR(s): 484.110(b) Standard: Authentication. All entries must be legible, clear, complete, and appropriately authenticated, dated, and timed. Authentication must include a signature and a title (occupation), or a secured computer entry by a unique identifier, of a primary author who has reviewed and approved the entry. This STANDARD is not met as evidenced by: Based on review of medical records (MR), facility policies and procedures, and staff interviews, it was determined the agency failed to ensure staff completed accurate documentation and authentication of Skilled Nursing (SN) Visits, Home Health Aide (HHA) visits, and physician orders in the electronic medical record within 24 hours per agency policy. This deficient practice affected Home Visit (HV) # 4, MR # 2, MR # 3, MR # 4, MR # 5, HV # 1, HV # 3, HV # 2, MR # 6, in nine of eleven MR reviews and had the potential to affect all patients served by the facility. Findings include: Agency Policy: Clinical/Service Data Collection Policy Number: 6-022 Revision Date: 11/24 Policy: ...Documentation in the clinical/service record will be timely, detailed, accurate, and reflect the care or services provided. Procedure: 1. A clinical/service record will...include at a minimum: ...C. Physician (or allowed practitioner) orders... E. Dates, times, and types of interventions, assessments, and coordination of care/services. ...6. Entries into the clinical/service record will be made on the day care/service is provided to the patient. ...18. Clinicians will have the following timeframe to complete documentation... Other notes including but not not limited to Skilled Nursing Visits, Home Health Aide Visits, Therapy Visit Notes, and re-assessments and therapy discharges: 24 hours. Agency Policy: Home Health Aide Plan of Care Policy Number: 2-003 Revised Date: 11/2024 Policy: Each patient receiving HHA services will have an individualized plan developed by an appropriate professional and utilized to direct the care performed by the assigned aide. Procedure: …2. The HHA plan of care …will include at least: …J. Instructions for completion of documentation …9. HHAs are members of the interdisciplinary team …and shall complete appropriate documentation in compliance with organizational policies and procedures. 8. HV # 2 was admitted to the agency on 12/18/24 and recertified for care from 2/16/25 to 4/16/25 with diagnoses including Hypertensive Heart and Chronic Kidney Disease with Heart Failure, Stage 1-4/Unspecified Chronic Kidney Disease. Review of the POC dated 2/16//25 to 4/16/25 revealed orders for SN visits weekly for five weeks, then every other week for four weeks. Record review revealed four of six SN VN were not completed within 24 hours per agency policy. An interview was conducted on 4/17/25 at 8:58 AM with EI # 6 who confirmed staff failed to complete clinical record documentation within the required 24-hour timeframe. EI # 6 confirmed staff would not have access to HV # 2's complete MR. 9. MR # 6 was admitted to the agency on 2/3/25 with diagnoses including Diverticuli of Intestine, Partial/ Unspecified, and Encounter for Adjustment and Management of Vascular Access Device. Review of the POC dated 2/3/25 to 4/3/25 revealed orders for SN visits weekly visit for five weeks. Review of the MR revealed four of five SN VNs reviewed were not completed within 24 hours per agency policy. An interview was conducted on 4/17/25 at 12:00 PM with EI # 1, who confirmed staff failed to complete clinical VN documentation within the required timeframe. 6. HV # 1 was admitted on 3/11/25 with diagnoses including Emphysema, Unspecified and Essential (Primary) Hypertension. Review of the POC dated 3/11/25 to 5/9/25 revealed orders for SN visits two times a week for week one then once a week for eight weeks. HHA visits effective 4/3/25 once a week for the first week and two times a week for four weeks. Record review revealed five of nine SN VNs were not completed within 24 hours per agency policy. Further record review revealed two of ten HHA VNs were not completed within 24 hours per agency policy. Review of the HHA VNs for the HV observed on 4/15/25 revealed the HHA documented: Ambulation completed-yes Ambulation-transfers completed-yes Hair care completed-yes Oral care completed-yes These four tasks were not observed being completed on the HV by the surveyor. The HHA did not document the visit accurately per agency policy. An interview was conducted on 4/17/25 at 8:50 AM with EI # 6, Regional Director, who confirmed staff failed to complete clinical record documentation within the required 24 hour timeframe and the HHA did not follow agency policy regarding accurate documentation. 7. HV # 3 was admitted on 8/21/24 and recertified for care on 2/12/25 to 4/17/25 with diagnoses including Hypertensive Heart and Chronic Kidney Disease with Heart Failure and Stage 1-4, Unspecified Chronic Kidney Disease and Chronic Obstructive Pulmonary Disease, Unspecified. Review of the POC dated 2/17/25 to 4/17/25 revealed orders for SN visits one time a week for nine weeks then effective 3/17/25, orders for SN visits to increase to two times a week. Record review revealed 12 of 14 SN VNs were not completed within 24 hours per agency policy. An interview conducted on 4/17/25 at 12:00 PM with EI # 1, Director, confirmed staff failed to complete clinical record documentation within the required 24 hour timeframe. 1. HV # 4 was admitted to the agency on 3/26/25 with diagnoses including ST Elevated Myocardial Infarction and Dysphagia. Review of the Plan of Care (POC) dated 3/26/25 to 5/24/25 revealed orders for SN visits one daily for one day and then one weekly for eight weeks. A supplemental order dated 4/8/25 revealed new orders for SN visits to perform wound care four times weekly for 2 weeks and then two SN visits weekly for five weeks. The order was not signed by the Registered Nurse (RN) within 24 hours per agency policy. Five of the nine SN Visit Notes (VN) reviewed were not signed by the RN within 24 hours per the agency policy. An interview was conducted on 4/17/25 at 10:07 AM with Employee Identifier (EI) # 2, Clinical Supervisor, who confirmed staff failed to complete documentation and authentication of orders and SN visit notes within 24 hours per the agency policy. 2. MR # 2 was admitted to the agency on 9/6/24 with a primary diagnosis of Alzheimer's. The patient was discharged to Hospice care on 9/18/24. Review of the POC dated 9/6/24 to 11/4/24 revealed orders for SN visits once weekly for five weeks and then one visit every other week for four weeks. Further review of the POC revealed an order for HHA visits twice weekly for eight weeks. Four of four SN VNs reviewed were not signed by the RN within 24 hours per the agency policy. The Discharge Summary was not signed by the RN within 24 hours per the facility policy. Three of three HHA VNs reviewed were not signed by the HHA within 24 hours per facility policy. Further review of the MR revealed a verbal order dated 9/12/24 for the SN to perform wound care was not signed by the RN within 24 hours per the agency policy. Further review of the MR revealed a verbal order dated 9/18/24 for the SN to discharge the patient was not signed by the RN within 24 hours per agency policy. An interview was conducted on 4/17/25 at 10:34 AM with EI # 2, who confirmed staff failed to complete documentation and authentication of orders, SN visit notes, and HHA visit notes within 24 hours per agency policy. 3. MR # 3 was admitted to the agency on 11/6/24 with a primary diagnosis of Pressure Ulcer of Right Heel. Review of the POC dated 1/5/25 to 3/5/25 revealed orders for SN visits once weekly for nine weeks and HHA visits once weekly for eight weeks. The patient was discharged on 1/14/25 due to goals being met. Two of two SN VNs reviewed were not signed by the RN within 24 hours per agency policy. One of one HHA VNs reviewed were not signed by the HHA within 24 hours per the agency policy. An interview was conducted on 4/17/25 at 10:40 AM with EI # 2, who confirmed staff failed to complete documentation and authentication of SN visit notes, and HHA visit notes within 24 hours per agency policy. 4. MR # 4 was admitted to the agency on 10/15/24 with diagnoses including Gram-negative sepsis and Urinary Tract Infection. Review of the POC dated 2/12/25 to 4/12/25 revealed an order for SN visits once weekly for eight weeks. Review of the Recertification SN visit conducted on 2/11/25 was not signed by the RN within 24 hours per the agency policy. Eight of eight SN VNs reviewed were not signed within 24 hours per the agency policy. An interview was conducted on 4/17/25 at 9:15 AM with EI # 2, who confirmed staff failed to complete documentation and authentication of SN visit notes within 24 hours per agency policy. 5. MR # 5 was admitted to the agency on 4/12/23 with a primary diagnosis of Fitting and Replacement of Urinary Device (Foley Catheter). Review of the POC dated 1/31/25 to 3/31/25 revealed an order for SN visits once monthly for two months. Three of three SN VNs reviewed were not signed within 24 hours per the agency policy. An interview was conducted on 4/17/25 at 10:09 AM with EI # 2, who confirmed staff failed to complete documentation and authentication of SN visit notes within 24 hours per agency policy.

An onsite recertification survey was conducted on 5/17/22 to 5/19/22. Lake Martin Home Health was found to be in substantial compliance with the Centers for Medicare and Medicaid Services requirements for Emergency Preparedness.

A recertification survey was conducted 5/17/22 to 5/19/22 at Lake Martin Home Health with standard level deficiencies cited.

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 observations, review of agency policy and procedure, medical records (MR), and staff interviews, it was determined the agency failed to ensure a current and accurate Medication Profile was maintained on all patients. This affected 4 of 5 Home Visits (HV), including HV # 4, HV # 5, HV # 3, and HV # 2. This had the potential to negatively affect all patients served by the agency. Findings include: Agency Policy: Medication Profile Policy No. 2-005 Reviewed/Approved 01-21-20 Policy Patient receiving medications…will have a current, accurate medication profile in the clinical record. Medication profiles will be updated for each change to reflect current medications, new, and/or discontinued medications. Procedure 1. Upon admission...the admitting clinician will initiate a medication profile to document the current medication regimen. 2. A drug regimen review will be performed at the time of admission, when updates to the comprehensive assessments are performed, when care is resumed after a patient has been placed on hold, and with the addition of a new medication. The review will identify drug/food interactions, potential adverse effects and drug reactions, ineffective drug therapy, duplicative drug therapy, and noncompliance. 3. During subsequent home visits, the medication profile will be used as a care planning teaching guide to ensure that the patient and family/caregiver as well as other clinicians understand the medication regimen. This includes…not limited to: A. Using the medication profile to evaluate the use of medications in the home setting B. Using the medication profile to teach…medications… C. Using the medication profile as a communication tool for other clinicians involved in the care ... 7. Deviations from taking medications as ordered will be documented in clinical notes, and the physician (or other authorized licensed independent practitioner) will be notified. 4. HV # 2 was admitted 4/22/22 with diagnoses including Essential (Primary) Hypertension and Unspecified Atrial Fibrillation. Review of the HHC and POC dated 4/22/22 to 6/20/22 revealed SN visits 1 time per week for 9 weeks. Physical Therapist (PT) 2 times a week for 4 weeks. A HV was conducted on 5/17/22 at 12:10 PM to observe care provided by EI # 3, Physical Therapist Assistant (PTA) and review medications. The medications in the home were compared to the current Medication Summary provided by the agency with EI # 3 and the following discrepancies were found and verified with the patient and EI # 3. Stool Softener Sodium 100 mg, 1 tablet orally 2 times a day was on the Medication Summary. The patient stated, " I have never taken that. I take Miralax. Norco 325 mg/5 mg 1 tablet orally every 6 hours as needed for pain was on the Medication Summary. The patient stated, "I have not used that since last July. That has been discontinued." Zinc 50 mg 1 tablet orally once per day was not on the Medication Summary. The patient stated, "My heart doctor told me to start taking that about a year ago." Iron 28 mg tablet orally once per day was in the home but not on the Medication Summary. The patient stated, " I started taking that about 3 years ago." B-12 500 mcg orally once per day was in the home but not on the Medication Summary. The patient stated, " I have been taking that since January 2021 after I got diagnosed with Covid." Torsemide 20 mg tablet by mouth 2 times per day with meals dated 4/7/22 was in the home but not on the Medication Summary. An interview was conducted on 5/19/22 at 11:14 AM with EI # 1 who confirmed the Medication Summary was not current. 3. HV # 3 was admitted to the agency on 4/29/22 with diagnoses of Unspecified Sequelae of Nontraumatic Intracerebral Hemorrhage and Muscle Weakness (generalized). Review of the HHC and POC dated 4/29/22 to 6/27/22 revealed a SN frequency of once a week for 9 weeks. A HV was conducted on 5/17/22 at 11:55 AM with EI # 4, Speech Therapist, to observe care provided. During the HV, the patients Medication Summary, printed by the agency on 5/17/22 at 11:21 AM and provided to the surveyor, was compared to the medication in home. The following medication discrepancies were found and verified with the patient's caregiver: Ropininole 0.25 mg 1 tablet at night was found in the home with the bottle dated 5/9/22. The caregiver verbalized Ropininole was refilled on 5/9/22 but the patient has been on it "a long time, about 4 years." There was no documentation of Ropininole on the Medication Summary. Ascorbic Acid 1000 mg 1 tablet daily, Ativan 0.5 mg 1 tablet 3 times daily, Calcium 500 plus Vitamin D 600 mg - mcg (micrograms) 1 tablet daily, Vitamin D3 1000 international units 1 tablet daily and Zinc Acetate 50 mg 1 capsule three times a day were on the Medication Summary. The patient caregiver verbalized the patient had not been on Ascorbic Acid, Ativan, Calcium plus Vitamin D, Vitamin D3 or Zinc Acetate since 3/26/22. An interview was conducted on 5/19/22 at 11:08 AM with EI # 1, who confirmed the agency staff failed to ensure there was a current, accurate medication profile in the clinical record. 1. HV # 4 was admitted 12/27/21 and recertified for continued care on 4/26/22 to 6/24/22 with diagnoses including Cutaneous Abscess of the Buttock. MR review revealed the 4/26/22 Home Health Certification (HHC) and Plan Of Care (POC) included orders for HHA (home health aide) 2 times (x) a week and SN (skill nurse) visit 1x a week. Record review revealed SN visit documentation dated 5/12/22 which revealed medications were reviewed with no new/changed medications. A HV was conducted on 5/17/22 at 12:00 PM to observe Employee Identifier (EI) # 5, HHA provide personal care. During the HV, the surveyor compared medications found in the home with the agency Medication Summary (Profile) provided. The following medications found in the home and in use were not documented on the agency Medication Summary: Tramadol 50 mg (milligram) 1 po (by mouth) prn (as needed), filled 4/27/22 and last administered the previous week per the caregiver (CG). Olmesartan 40 mg po bid (twice daily) filled on 4/25/22. Vitamin 50, 000 U po on Monday with 5000 IU (international units) Vitamin D 3 po day filled 4/7/22 . Miconazole 7 2% vaginal anti itch prn rash fill date 2/23/21 in use as needed due to incontinence Multi vitamin Women 50 plus daily for past 4 years per CG. Medications no longer in use per the CG and documented on the agency Medication Summary were: Amiodarone 200 mg orally bid. The CG reported the cardiologist discontinued the medication in April 2022. Guaifenesin 600 mg orally bid. The CG reported not in use within the last 60 days. Losartan 50 mg orally bid. The CG reported not in use since December 2021. In an interview on 5/19/22 at 11:23 AM, EI # 1, Director confirmed the staff failed ensure there was a current, accurate medication profile in the clinical record. 2. HV # 5 was admitted 2/28/22 and recertified for continued care 4/29/22 to 6/27/22 with diagnoses including Acute Embolism and Thrombosis Unspecified Deep Veins of Right Lower Extremity. MR review revealed the 4/29/22 HHC and POC included orders for SN visits 2 x a week and the 5/16/22 SN visit documentation revealed medications were reviewed with no new/changed medications. A HV was conducted on 5/18/22 at 9:05 AM to observe EI # 6, Registered Nurse provide wound care. EI # 6 and the surveyor compared medications found in the home with the agency Medication Summary printed 5/18/22. Irbesartan 75 mg 1 tablet po bid fill date 4/27/22, and Methotrexate 2.5 mg 3 tablets po every week, fill date 5/13/22 were found in the home and not documented on the agency Medication Summary. Also found in the home was Tramadol 50 mg 1 po every 12 hours filled on 5/13/22 Review of the agency Medication Summary documentation printed 5/18/22 failed to include Irbesartan and Methotrexate. Tramadol 50 mg every 6-8 hours prn was documented on the Medication Summary and not Tramadol 50 mg every 12 hours as found in the home on the HV. In an interview on 5/18/22 during the HV, the patient and caregiver confirmed Irbesartan bid use beginning April 2022, Tramadol use every 12 hours prn and not 6-8 hours and Methotrexate is use weekly for "many years". An interview was conducted on 5/18/22 at 9:30 AM and EI # 6 confirmed the Medication Summary was not accurate and current.

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 review of Medical Records (MR) and staff interview it was determined the agency staff failed to ensure physician orders were followed for: 1. Laboratory (lab) testing. 2. Visit frequencies. 3. Insertion of a Foley catheter. 4. Removal of a PICC (peripherally inserted central catheter). This deficient practice did affect 2 of 13 MR reviewed, including MR # 6 and MR # 5 and had the potential to negatively impact all patients served by the agency. Findings Include: 3. MR # 5 was admitted to the agency 9/2/21 to 10/31/21 with diagnosis including Pressure Ulcer of Sacral Region, Stage 4. Review of the HHC and POC dated 9/2/21 included orders for SN visits 1 week 9 and SN to change foley catheter 16 FR (FRENCH) Coude (a type of catheter) with 10 ml (milliliter) balloon 1 month 2. MR review revealed a prn (as needed) SN visit dated 9/24/21 due to foley leaking/bleeding. The SN documented an 18 F (FR) Coude was inserted. MR review failed to reveal a physician’s order to change the foley size from 16 FR to 18 FR. MR review revealed a physician order dated 10/7/21 for SN to discontinue PICC line and after removal inspect and measure catheter length and upper arm circumference. Further MR review revealed the SN Clinical Note dated 10/7/21 with documentation " SN will remove PICC". There was no documentation the SN measured the catheter length and upper arm circumference after PICC removal. In an interview conducted 5/19/22 at 1:35 PM, EI # 7, Clinical Manager, confirmed there was no physician’s order for the 18 FR Coude catheter and no documentation the SN followed the physician's order and measured the PICC catheter length and upper arm circumference following PICC removal. 1. MR # 6 was admitted to the agency on 2/19/22 with diagnoses including, COVID -19 Acute Respiratory Disease and Encephalopathy, Unspecified. Review of the Home Health Certification (HHC) and Plan of Care (POC) dated 2/19/22 to 4/19/22 revealed an order for "Skilled Nurse (SN) to obtain blood via peripheral venipucture for: PT (Protime) with INR (International Normalized Ratio) 1 wk 6 (once a week for 6 weeks)..." with a SN frequency of once a week. Review of the SN Visit Note (VN) dated 2/19/22 revealed no documentation a PT/INR was obtained per the physician order. An interview was conducted on 5/19/22 at 11:48 AM with Employee Identifier (EI) # 1, Director, who confirmed there was no documentation a PT/INR was obtained on 2/19/22.

Discharge plans communication CFR(s): 484.60(c)(3)(ii) (ii) Any revisions related to plans for the patient's discharge must be communicated to the patient, representative, caregiver, all physicians or allowed practitioner's issuing orders for the HHA plan of care, and the patient's primary care practitioner or other health care professional who will be responsible for providing care and services to the patient after discharge from the HHA (if any). This ELEMENT is not met as evidenced by: Based on Medical Record (MR) review, agency policy and procedure and staff interview it was determined the agency failed to ensure the staff provided and documented discharge instructions. This deficient practice did affect 3 of 4 discharged MR's reviewed, including MR # 6, MR # 7 and MR # 5 and had the potential to affect all patients discharged from the agency. Findings Include: Agency Policy: Discharge Criteria and Process Policy Number: 1-024 Date: Not documented Purpose: To outline the process for discharging a patient from service. ...Procedure: ...2. Prior notice will not be necessary when services are discontinued by the patient...however, action taken must be documented in the clinical record... A copy of the discharge instructions will be mailed to the patient. ...4... Discharge instructions will be provided. 2. MR # 7 was admitted to the agency 2/7/22 to 4/17/22 with diagnosis including Hypertensive Heart and Chronic Kidney Disease with Heart Failure. MR review revealed a Communication Note dated 3/16/22 documented by the nurse that the caregiver was requesting D/C (discharge). The nurse documented "...would follow up with patient next week...make sure patient still wants to be discharged..." Review of the record revealed a Non-Visit Discharge Summary dated 3/22/22 with documentation a patient discharge was performed on 3/22/22. Further review of the Discharge Summary revealed "...Copy of Discharge Instructions mailed to patient home". In an interview on 5/19/22 at 11:35 AM with EI # 7, Clinical Manager, the surveyor requested documentation of the discharge instructions mailed to the home. EI # 7 confirmed there was no documentation of the discharge instructions provided to the patient. 3. MR # 5 was admitted to the agency 9/2/21 to 10/31/21 with diagnosis including Pressure Ulcer of Sacral Region, Stage 4. MR review revealed a Communication Note dated 10/12/21 documented by the Home Health Aide that patient refused visit, and caregiver stated they no longer want...services, case nurse notified. MR review revealed a Non-Visit Discharge Summary dated 10/12/21 with documentation a patient discharge was performed on 10/12/21. Further review of the Discharge Summary revealed "..Discharge Instructions mailed to patient." During an interview on 5/19/22 at 1:35 PM with EI # 7, the surveyor requested documentation of the discharge instructions mailed to patient. EI # 7 confirmed there was no documentation of the discharge instructions provided to the patient. 1. MR # 6 was admitted to the agency on 2/19/22 with diagnoses including, COVID -19 Acute Respiratory Disease, Encephalopathy, Unspecified and Chronic Combined Systolic and Diastolic Heart Failure. Review of the Discharge Summary revealed the patient was discharged on 4/12/22 from the agency due to the patient going out of the service area and "discharge instructions mailed to patient." An interview was conducted on 5/19/22 at 11:48 AM with Employee Identifier (EI) # 1, Director, who was asked to provide a copy of the discharge instructions mailed to the patient. EI # 1 verbalized the agency did not have documentation of the discharge instructions mailed to the patient.

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, agency policy and procedure and interview with staff, it was determined the agency failed to ensure staff followed infection control practices for hand hygiene and glove change during wound care. This affected HV (home visit) # 5, in 1 of 2 HV for wound care observation and had the potential to negatively affect all patients and staff. Findings include: Agency Policy Hand Hygiene Policy No. (Number) 7-009 Revised Date: October 2019 Purpose To prevent cross-contamination and home care-acquired infections. Policy ...When hands are visibly dirty, contaminated with proteinaceous material...they should be washed with...a non-antimicrobial or antimicrobial soap and water. When hands are not visibly soiled....using an alcohol-based hand rub... Procedure 3. Hand decontamination...should be performed: C. After contact with a patient's intact skin... D. After contact with...wound dressings... E. When moving from a contaminated body site to a clean body site during patient care. F. After contact with inanimate objects... G. After removing gloves... 1. HV # 5 was admitted to the agency 2/28/22 and recertified for care 4/29/22 to 6/27/22 with diagnoses including Acute Embolism and Thrombosis Unspecified Deep Veins of Right Lower Extremity. A HV was conducted on 5/18/22 at 9:05 AM to observe Employee Identifier (EI) # 6, Registered Nurse provide wound care to three wound sites. EI # 6 performed hand hygiene, donned gloves, and removed the ace wrap and outer gauze dressing from the left lower leg wound site. Next, EI # 6 sprayed wound cleanser on the gauze dressing which had adhered to the wound site. EI # 6 failed to remove gloves, perform hand hygiene, and don clean gloves after removal of the ace wrap and outer gauze dressing, and before accessing clean supplies and applying the wound cleanser. Awaiting physician orders for care to that wound site, EI # 6 allowed the adhered dressing to remain on and continued wound care to another wound site after performing hand hygiene and donning clean gloves. Next EI # 6 completed hand hygiene, donned clean gloves, and removed the dressing from the left middle leg wound site. EI # 6 sprayed wound cleanser onto wound site then removed gloves and performed hand hygiene. EI # 6 failed to perform hand hygiene and don clean gloves after removal of the old dressing and cleansing of the wound site. EI # 6 performed hand hygiene, donned clean gloves, and opened and moistened the Puracol Plus dressing with normal saline. Next EI # 6 cut the Maxasorb dressing, removed his/her gloves and exited the home to the car to obtain supplies and cell phone. EI # 6 failed to perform hand hygiene immediately following glove removal. Upon return to the home, EI # 6 sanitized hands donned gloves, removed the old dressing from the graft site to the left upper leg, applied wound cleanser onto the gauze then cleaned the wound with the gauze. EI # 6 failed to remove gloves, perform hand hygiene, and don clean gloves after removing the old dressing and before accessing clean wound supplies and beginning wound care. In an interview on 5/19/22 at 11:19 AM, EI # 1, Director confirmed staff should perform hand hygiene immediately after glove removal and perform hand hygiene and don clean gloves after removing a wound dressing.

Infection control CFR(s): 484.70(b)(1)(2) Standard: Control. The HHA must maintain a coordinated agency-wide program for the surveillance, identification, prevention, control, and investigation of infectious and communicable diseases that is an integral part of the HHA's quality assessment and performance improvement (QAPI) program. The infection control program must include: (1) A method for identifying infectious and communicable disease problems; and (2) A plan for the appropriate actions that are expected to result in improvement and disease prevention. This STANDARD is not met as evidenced by: Based on review of agency policy, infection control documentation and staff interviews, it was determined the agency failed to investigate, analyze and implement an improvement plan for infectious disease prevention. This had the potential to affect all patients admitted to the agency. Findings include: Agency Policy: Infection Control Plan Policy Number: 7-001 Revised Date: 10/19 Agency Policy: Infection Control Plan Policy Number: 7-001 Revised Date: 10/19 Purpose: To delineate an infection control plan to meet the following goals: 1. Establish the mechanism by which the organization will address surveillance...utilizing scientific methods and epidemiologic principles. ...4. Provide for surveillance systems to track the occurrence and transmission of infections... Policy: Ivy Creek Home Health is committed to reducing the risk of acquisition and transmission of health care associated infections (HAIs). Recognized prevention and control mechanisms will be implemented for planning, surveillance... On 5/19/22 the surveyor was provided the agency Infection Control Program and documentation. During the Infection Control Program review the surveyor requested the agency documentation for infection tracking, trending, analysis and any actions taken for identified opportunities for improvement and disease prevention. The surveyor was provided the Month End Totals Forms, monthly Infection Control Reports and Antibiotic Usage Reports for 2021 and 2022. Review of the Month End Totals Forms, monthly Infection Control Reports and Antibiotic Usage Reports for 2021 and 2022 revealed no documentation agency infections were reviewed/investigated and no root cause analysis was completed to identify patterns/trends of infections . Further review of the agency Infection Control Program and documentation revealed no documentation the parent and branch offices totals were combined into one to report for the agency as a whole. An Interview was conducted on 5/19/22 at 8:30 AM with Employee Identifier (EI) # 7, Clinical Manager and EI # 1, Director, who confirmed the agency infection control program failed to include investigation/root cause analysis and no actions for improvement had been implemented for January 2021 to April 2022.

Patient and caregiver education CFR(s): 484.75(b)(5) Patient and caregiver education; This ELEMENT is not met as evidenced by: Based on Medical Record (MR) review, agency policy and procedures and staff interview it was determined the agency failed to ensure the staff provided education This affected 3 of 13 MRs reviewed, including MR # 6, MR # 3, MR # 5 and had the potential to negatively affect all patient's served by the agency. Findings Include: Agency Policy: Patient Education Process Policy Number: 2-030 Date: Not documented Purpose: To provide guidelines for the provision of health information and instruction to patients and family/caregivers. Policy: Patients and family/caregivers will receive education in verbal, visual, and written format, as appropriate...Education will be the responsibility of each clinician and will focus on: 3. Increasing patient and family/caregiver (cg) potential to follow the plan of care 4. Maximizing care skills of the patient and family/caregiver ...5. Enhancing the patient's and family/caregiver knowledge... ...9. Maintaining the patient's health status... Procedure 1. The clinician will assess, plan, implement, and evaluate the following on each patient and family/caregiver, as appropriate: ...B. The pertinent information needed by the patient and family/caregiver in relation to the care being rendered C. The level of knowledge of the patient...caregiver in relation to the diagnoses, plan of care... ...6. Unless otherwise ordered by the physician...the patient and family/caregiver will receive verbal and, as appropriate, written instructions on: ...b. The medical regimen. c. Medication management and administration. ...E. Nutrition interventions, modified diets... F. Prescribed treatments ...7. Documentation of patient and family/caregiver education will consist of: A. Describing what was taught to the patient... B. Describing the...response to the teaching, including the level of understanding and the ability to repeat or demonstrate what was taught... Agency Procedure: Intravenous (IV) Therapy-Flushing/Heparinizing Venous Catheters Date: Not documented Supportive Data: The peripherally inserted catheter...used for intermittent infusions/medications require flushing after IV therapy...Patients/caregivers (cg) will be taught how to flush their catheter/cannula as part of the...education process... Procedure: ...17. Document procedure in clinical record: Dose/Amount of flush solutions and medication if given. Patency of catheter IV site condition Patient's tolerance of procedure Patient education...Have the patient/cg sign infusion checklist when teaching is completed. 3. MR # 5 was admitted to the agency 9/2/21 to 10/31/21 with diagnosis including Pressure Ulcer of Sacral Region, Stage 4, Pressure Ulcer of Right Upper Back, Stage 4, Pressure Ulcer of Left Hip, Stage 3, Pressure Ulcer of Other Site, Stage 3 and Encounter for Change or Removal of Nonsurgical Wound Dressing. Review of the HHC and POC dated 9/2/21 included physician orders for SN visits 1 week 9 with the following orders: SN to assess skin and pressure ulcers every visit... SN instruct on medication regimen as needed... Caregiver to provide daily wound care to wound # 1, # 2, # 3 and # 4 daily, remove old dressing using aseptic technique, double bag, dispose in trash. Remove gloves, wash hands, don clean gloves, then cleanse wound with soap and water, wound cleanser or NS (normal saline), then pat dry, to wound bed apply Santyl gauze moistened with NS or Dakins, may cover with dry gauze or ABD (abdominal) pad. May wrap with roll gauze. May secure with tape. MR review revealed SN Visit Notes dated 9/2/21, 9/5/21 and 9/8/21 failed to include documentation the SN educated the patient/cg on wound care for wounds # 1-# 4 and infection control procedures to be followed during wound care. There was no documentation a successful demonstration of wound care was performed by the cg. Further MR review revealed a physician's order dated 9/16/21 which revealed new wound orders for care included the following: Wounds # 2, # 4 and # 5 (left distal back) daily wound care, remove old dressing using aseptic technique, double bag, dispose of in trash, remove gloves, wash hands, don clean gloves then cleanse wound with NS, then pat dry, to wound bed apply Drawtex, cover with dry gauze, wrap with (blank) May secure with tape. Wound # 3 provide every other day wound care, remove old dressing using aseptic technique, double bag, and dispose of in trash. Remove gloves, wash hands, don clean gloves, then cleanse wound with NS, then pat dry, to wound bed apply crushed Flagyl, Drawtex, cover with dry gauze, may secure with tape. Apply Allevyn Adhesive Foam Dressing. MR review revealed the SN Visit Note dated 9/16/21 and documentation culture results from wound center showed infection in wounds and new wound care orders. There was no documentation the SN educated the caregiver on the new wound care orders and there was no successful demonstration of wound care documented on 9/16/21. In addition, on 9/16/21 SN Visit, the SN documented MR # 5 will be assessed for PICC line and IV (intravenous) antibiotics on 9/22/21. Review of the physician order dated 9/23/21 found in the MR revealed SN visits 1 week 6, teach patient/cg all aspects of IV medication/solution administration as follows: First flush with 10 ml (milliliter) of NS, then administer Ceftazidme (Ceftazidime) 1 G (gram)/100 ML NS via elastometric (elastomeric) delivery system, After each infusion, flush port with 10 ML NS then lock with 5 ml Heparin. The RN to observe return demonstration of IV infusion and port flush from caregiver on 9/23/21. Review of the SN Visit Note dated 9/23/21 revealed SN assessed the PICC line site, and the "caregiver performed return demonstration of medication administration and flushing PICC Line." There was no documentation of the name of the medication administered, the amount/dosage and the route of administration, the solution(s) used and amount of flush instilled into the PICC line per the agency procedure. There was no documentation of the level of understanding and the ability of the cg to demonstrate the infusion procedure and care of the PICC per the agency policy. In an interview on 5/19/22 at 1:35 PM, EI # 7, Clinical Manager, confirmed the staff failed to follow the agency education policy for patient/cg, document education with ordered treatments and the ability of the cg to provide the ordered care. 1. MR # 6 was admitted to the agency on 2/19/22 with diagnoses including, COVID -19 Acute Respiratory Disease, Encephalopathy, Unspecified and Chronic Combined Systolic and Diastolic Heart Failure. Review of the Home Health Certification (HHC) and Plan of Care (POC) dated 2/19/22 to 4/19/22 revealed orders for "Skilled Nurse (SN) to instruct pt/cg on medication regimen: including name, dosage, side effects, route, frequency, desired action and adverse reactions as needed.." and "SN will instruct pt/cg on teachings: ...CHF (Congestive Heart Failure). Review of the Medication Summary revealed documentation MR # 6 was prescribed Warfarin (Coumadin) 3 mg (milligrams) at bedtime on 2/19/22. Review of the SN Visit Note (VN) dated 2/19/22 revealed documentation of "nutritional requirements...coumadin diet..." Review of the SN VN's from 2/19/22 to 4/19/22 revealed no documentation the agency staff educated the patient on a coumadin, coumadin diet and CHF. Review of the SN VN dated 3/22/22 revealed documentation the following medications were new or changed: Carbidopa-Levodopa 50 mg -200 mg at bedtime documented as a new medication and 25 mg - 250 mg 3 times. Entacapone 200 mg 3 times daily. Entresto 24 mg -26 mg twice daily. Tamsulosin .04 mg daily. Torsemide 10 mg daily. Tramadol 50 mg at bedtime. Baclofen 10 mg 3 times daily. Digoxin 0.25 mg daily. Ropinirole 1 mg 4 times daily. Further review of the SN Visit Note (VN) dated 3/22/22 revealed the agency staff failed to educate the patient on the new/changed medications. An interview was conducted on 5/19/22 at 11:48 AM with Employee Identifier (EI) # 1, Director, who confirmed there was no documentation the pt/cg was provided education on coumadin, coumadin diet, CHF, and the new/changed medications on 3/22/22. 2. MR # 3 was admitted to the agency on 4/20/22 with diagnoses including Traumatic Subdural Hemorrhage with Loss of Consciousness of Unspecified Duration, Subsequent Encounter and Multiple Fractures of Ribs, Left Side, Subsequent Encounter for Fracture with Routine Healing. Review of the HHC and POC dated 4/20/22 to 6/18/22 revealed physician orders for "SN to teach blood thinner med (medication), bleeding precautions, s/s (signs/symptoms) bleeding to report..." and " SN to instruct pt/cg on medication regimen: including name, dosage, side effects, route, frequency, desired action & (and) adverse reactions as needed. " Review of the Medication Summary revealed MR # 3 was prescribed Aspirin 325 mg daily and Plavix 75 mg twice daily as blood thinners with both dated 4/20/22 as the start date. Review of the SN VN dated 4/20/22 revealed documentation of "patient taught on high risk medications complications and interactions..." There was no documentation of the specific high risk medications the patient was taught. Review of the MR revealed no documentation the patient received education on Aspirin and Plavix. An interview was conducted on 5/19/22 at 11:46 AM with EI # 1, who confirmed there was no documentation of the specific high risk medication the patient was taught and the patient received education on Aspirin and Plavix.

Duties of a HH aide CFR(s): 484.80(g)(3) The duties of a home health aide include: (i) The provision of hands-on personal care; (ii) The performance of simple procedures as an extension of therapy or nursing services; (iii) Assistance in ambulation or exercises; and (iv) Assistance in administering medications ordinarily self-administered. This ELEMENT is not met as evidenced by: Based on observation, medical record (MR) review and staff interview it was determined the agency failed to ensure the Home Health Aide ( HHA) followed the written plan of care in 1 of 1 HHA visit observation. This did affect Home Visit (HV) # 4 and had the potential to negatively affect all patients receiving HHA services. 1. HV # 4 was admitted to the agency on 12/21/21 and recertified for the period of 4/26/22 to 6/24/22 with diagnoses including Cutaneous Abscess of the Buttock. A HV was conducted on 5/17/22 at 12:00 PM to observe Employee Identifier (EI) # 5, HHA, provide care. Review of the Aide/Support Care Plan effective 5/17/22 revealed instructions for the HHA to perform hair care every visit. The HHA was not observed performing hair care during the 5/17/22 visit. Review of the HHA Visit Note dated 5/17/22 revealed documentation that hair care was completed. An interview was conducted on 5/19/22 at 11:23 AM with EI # 7, Clinical Manager, who confirmed the HHA should document only care performed and notify the RN when services were not performed as ordered.

Discharge and transfer summaries CFR(s): 484.110(a)(6)(i-iii) (i) A completed discharge summary that is sent to the primary care practitioner or other health care professional who will be responsible for providing care and services to the patient after discharge from the HHA (if any) within 5 business days of the patient's discharge; or (ii) A completed transfer summary that is sent within 2 business days of a planned transfer, if the patient's care will be immediately continued in a health care facility; or (iii) A completed transfer summary that is sent within 2 business days of becoming aware of an unplanned transfer, if the patient is still receiving care in a health care facility at the time when the HHA becomes aware of the transfer. This ELEMENT is not met as evidenced by: Based on review of MR (medical records), agency policy and procedure, and staff interviews, it was determined the agency failed to ensure staff followed their own policy and procedure and submitted the transfer summary to the receiving provider when a patient was transferred to an inpatient facility. This affected MR # 4, 1 of 1 record reviewed with a transfer to another service provider. Findings include: Agency Policy No. (Number) HH: 2-051.1 Subject: Transfer/Referral, Criteria and Process Revised April 2016 Purpose To outline the process for transferring or referring a patient to another service provider. Policy When a patient’s needs change significantly…a transfer/referral to another service provider will be made. Procedure 7. Within 48 hours of transfer, the clinician will complete a transfer summary… 8. Within 72 hours of the transfer, the clinical records clerk will send a copy of the transfer summary or clinical record to the receiving provider… 1. MR # 4 was admitted 12/28/19 and recertified for continued care on 4/16/22 to 6/14/22 with diagnoses including Pressure Ulcer of Left Buttock, Stage 2. MR review revealed a Transfer Summary Non-Visit Document dated 5/5/22 which revealed on 5/5/22 MR # 4 had a transfer to an acute inpatient provider, reasons documented for the transfer were a urinary tract infection and wounds. Further review of the 5/5/22 Transfer Summary documentation revealed the attending physician and RN Case Manager were notified, however there was no documentation the agency provided a copy of the transfer summary/clinical record to the receiving provider. In an interview conducted on 5/19/22 at 11:44 AM, Employee Identifier # 7, Clinical Manager, confirmed the agency staff failed to follow the agency policy and procedure and send the transfer summary to the receiving provider.