Every finding on record at Jhs Operations, LLC

A recertification survey entrance conference was conducted on 09/06/23. Census: 194 Mt. Vernon: Licensed & Certified – 88, Licensed Home Health – 29 Longview: Licensed & Certified – 62, Licensed Home Health – 15 The agency is in compliance with 42 CFR, Part 484.102, Emergency Preparedness Requirements for Home Health Agencies.

A recertification and follow-up (9KHU11 exit 03/24/21) survey entrance conference was conducted on 09/06/23. Follow-up re-cited. Census: 194 Mt. Vernon: Licensed & Certified – 88, Licensed Home Health – 29 Longview: Licensed & Certified – 62, Licensed Home Health – 15 Acronyms: RN- Registered Nurse LVN- Licensed Vocational Nurse POC- plan of care mg - milligram SOC- Start of care SN- Skilled Nurse lab- laboratory UTI- urinary tract infection p.m. - post meridiem a.m. - ante meridiem O/A- observation/assessment mcg- micrograms ml- milliliters

A review of all current medications CFR(s): 484.55(c)(5) A review of all medications the patient is currently using in order to identify any potential adverse effects and drug reactions, including ineffective drug therapy, significant side effects, significant drug interactions, duplicate drug therapy, and noncompliance with drug therapy. This ELEMENT is not met as evidenced by: Based on observation, interview, and record review, the agency failed to have a current medication list in each patient record for 2 of 7 patients with whom a home visit was conducted. (Patient #6 & #7) This failure could place patients at risk of medication errors or adverse reactions. Findings included: Record review of Patient #7’s POC dated 08/05/23 to 10/03/23 indicated a SOC date of 06/06/23, and indicated she was 63 years old with diagnoses including hypertensive heart disease (heart problems that occur because of high blood pressure that is present over a long time) with heart failure, type 2 diabetes (body either doesn't produce enough insulin, or it resists insulin) with diabetic neuropathy (nerve damage), venous insufficiency (leg veins don't allow blood to flow back up to your heart), long term use of aspirin, long term use of insulin (controls blood sugar levels), and history of falls. The POC indicated Patient #7 was ordered skilled nursing visits one time a week for eight weeks. The POC included orders for SN to review patient medications. During a home visit observation and interview on 09/07/23 at 8:26 a.m., Patient #7 said she took 40units of Novolin 70/30 insulin in the morning, not 30units, and had been taking 40units for a while. Patient #7 said the insulin was increased to 40units when she had a heart catheterization July 28th, 2023, but she forgot to tell the SN. Record review of Patient #7’s Medication Profile dated 07/31/23 revealed an order for 30units of Novolin 70/30 insulin every a.m. and 20units every p.m. starting 03/28/23. Record review of Patient #6’s POC dated 09/01/23 to 10/30/23 indicated a SOC date of 09/01/23 and indicated she was 83 years old with diagnosis including congestive heart failure (heart can't pump blood well enough to meet your body's needs). The POC indicated Patient #6 was ordered skilled nursing once a week for two weeks, then once a week for six weeks. The POC included orders for SN to review patient medications. During a home visit observation and interview on 09/07/23 at 9:41 a.m., Patient #6 was wearing Oxygen. Patient #6 said she wore 5 Liters of Oxygen all the time and had been using it since 2014. Patient #6 said she had a history of chronic obstructive pulmonary disorder (causes airflow blockage and breathing). LVN C said Oxygen was not on Patient #6’s medication list and Patient #6 was admitted to the agency last Friday (09/01/23). LVN C said the SN that admitted the patient may have went off the medication list from the hospital. Record review of Patient #6’s Medication Profile dated 09/04/23 did not indicate Patient #6 had any orders for Oxygen. During an interview on 09/08/23 at 11:34 a.m., the RN Alternate Administrator said if a patient was on Oxygen, it would be listed on the medication list. The RN Alternate Administrator said a medication reconciliation was done at every SN visit, and if there were any medication changes the SN would write an order to update the medication record. During an interview on 09/08/23 at 12:23 p.m., the RN Administrator said medication reconciliations were done every start of care, every SN visit, and when there were any changes. Record review of a Medication Report policy dated 03/03/21 indicated “1. Purpose: To provide a complete list of all medications the patient is taking and an evaluation of the patient’s knowledge of the effects of these medications… 2… The profile will be reviewed and updated as needed to reflect current medications the patient is taking… 5… the Nurse must add newly ordered drugs or medication changes to the patient medication report…”

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 interview and record review, the agency failed to ensure the plan of care contained the required elements to cover all supplies and equipment required, patient specific interventions and education, and safety measures to protect against injury for 9 of 12 patients reviewed for plans of care. (Patient #’s 3, 4, 5, 6, 7, 9, 10, 11, & 12) This failure could place patients at risk of not recognizing symptoms of bleeding, and not receiving proper care/instruction leading to complications and hospitalization. Findings included: Record review of Patient #3’s POC dated 08/26/23 to 10/24/23 indicated a SOC date of 04/28/23 and indicated she was 64 years old with diagnosis including type 2 diabetes mellitus (body either doesn't produce enough insulin, or it resists insulin) with chronic kidney disease (kidneys are damaged and cannot filter blood as well as they should), congestive heart failure (heart can't pump blood well enough to meet your body's needs), anxiety (feeling of fear, dread, and uneasiness), chronic pain syndrome (symptoms beyond pain alone, like depression and anxiety, which interfere with their daily lives), obstructive sleep apnea (collapse of the airway with decease in oxygen or arousal from sleep), and long term use of Aspirin. The POC indicated Patient #3 was ordered skilled nursing visits one time a week for eight weeks. The POC medication list indicated Patient #3 took Aspirin 325mg, one tablet daily. The POC included orders for SN to perform and record blood sugar reading every visit, and as needed. The POC did not include bleeding safety precautions and safety measures for sharps precautions. Record review of Patient #4’s POC dated 07/22/23 to 09/19/23 indicated a SOC date of 07/22/23 and indicated he was 70 years old with diagnosis including cellulitis (bacterial skin infection) of right lower limb, atherosclerotic heart disease (build-up of fats, cholesterol, and other substances in and on the artery walls), hypertensive chronic kidney disease (high blood pressure caused by damage to the kidneys), depression (loss of pleasure or interest in activities for long periods of time), peripheral vascular disease (narrowing of peripheral blood vessels), paroxysmal atrial fibrillation (irregular heartbeat), long term use of anticoagulants (blood thinners), and long term use of antiplatelets (stop blood cells (called platelets) from sticking together and forming a blood clot). The POC indicated Patient #4 was ordered skilled nursing visits one time a week for one week, then twice a week for three weeks, then once a week for six weeks. The POC medication list indicated Patient #4 took Eliquis (blood thinner) 5mg, one tablet, two times daily and Clopidogrel (Plavix) 75mg, one tablet, one time daily. The POC did not include bleeding safety precautions. Record review of Patient #5’s POC dated 08/19/23 to 10/17/23 indicated a SOC date of 04/26/22 and indicated she was 84 years old with diagnosis including type 2 diabetes mellitus (body either doesn't produce enough insulin, or it resists insulin), vitamin B12 deficiency anemia (body can't make enough healthy red blood cells), Alzheimer’s disease (problems with memory, thinking and behavior), hypertensive heart disease (heart problems that occur because of high blood pressure that is present over a long time) with heart failure, long term use of insulin, and history of falling. The POC indicated Patient #5 was ordered skilled nursing visits one time a week for three weeks, then once every 4 weeks for 4 weeks. The POC medication list indicated Patient #5 took Toujeo Solostar U-300 insulin, 300units/ml subcutaneous (under the skin), 10units daily, and Vitamin B12 1000 mcg/ml, inject 1ml intramuscular once weekly for weakness. The POC did not include safety measures for sharps precautions. Record review of Patient #6’s POC dated 09/01/23 to 10/30/23 indicated a SOC date of 09/01/23 and indicated she was 83 years old with diagnosis including congestive heart failure (heart can't pump blood well enough to meet your body's needs). The POC indicated Patient #6 was ordered skilled nursing once a week for two weeks, then once a week for six weeks. The POC indicated under orders Oxygen via nasal cannula (device used to deliver supplemental oxygen) at 2 liters continuous, and SN for O/A and skilled teaching of safe oxygen use in the home. Oxygen was not listed under the medications in the POC, and the POC did not include supplies and equipment required for Oxygen therapy. Record review of Patient #7’s POC dated 08/05/23 to 10/03/23 indicated a SOC date of 06/06/23, and indicated she was 63 years old with diagnoses including hypertensive heart disease (heart problems that occur because of high blood pressure that is present over a long time) with heart failure, type 2 diabetes mellitus (body either doesn't produce enough insulin, or it resists insulin) with diabetic neuropathy (nerve damage), venous insufficiency (leg veins don't allow blood to flow back up to your heart), long term use of aspirin, long term use of insulin (controls blood sugar levels), and history of falls. The POC indicated Patient #7 was ordered skilled nursing visits one time a week for eight weeks. The POC medication list indicated Patient #7 took 30units of Novolin 70/30 insulin subcutaneous (under the skin) every a.m. and 20units every p.m. The POC did not include safety measures for sharps precautions. Record review of Patient #9’s POC dated 07/28/23 to 09/25/23 indicated a SOC date of 01/29/23 and indicated she was 28 years old with diagnosis including chronic congestive heart failure (heart can't pump blood well enough to meet your body's needs), type 2 diabetes mellitus (body either doesn't produce enough insulin, or it resists insulin), end stage renal disease (kidneys are no longer able to work at a level needed for day-to-day life), paroxysmal atrial fibrillation (irregular heartbeat), chronic obstructive pulmonary disorder (cause airflow blockage and breathing-related problems), long term use of Aspirin, long term use of antiplatelets (stop blood cells (called platelets) from sticking together and forming a blood clot), dependance on supplemental Oxygen, and dependance on renal dialysis (a treatment to clean your blood when your kidneys are not able to). The POC indicated Patient #9 was ordered skilled nursing visits one time a week for four weeks, then once every three weeks for 3 weeks, then once a week for one week. The POC also included orders for SN to perform and record blood sugar reading every visit, and as needed. The POC did not include safety measures for sharps precautions and did not include supplies and equipment required for blood sugar checks. The POC medication list indicated Patient #9 took Aspirin 81mg, one tablet, daily, and Clopidogrel (Plavix) 75mg, one tablet, daily. The POC did not include bleeding safety precautions. Record review of Patient #10’s POC dated 08/09/23 to 10/07/23 indicated a SOC date of 02/10/23 and indicated she was 86 years old with diagnosis including wound to left lower leg, pressure ulcer of sacral region (the portion of your spine between your lower back and tailbone), type 2 diabetes mellitus (body either doesn't produce enough insulin, or it resists insulin), hypertensive heart disease (long-term condition that develops over many years in people who have high blood pressure) with heart failure, chronic obstructive pulmonary disorder (cause airflow blockage and breathing-related problems), long term use of Aspirin, long term use of antiplatelets (stop blood cells (called platelets) from sticking together and forming a blood clot), and history of falling. The POC indicated Patient #10 was ordered skilled nursing visits twice a week for one week, then once a week for seven weeks. The POC also included orders for SN to perform and record blood sugar reading. The POC did not include safety measures for sharps precautions and did not include supplies and equipment required for blood sugar checks. The POC medication list indicated Patient #10 took Aspirin 81mg, one tablet every p.m., and Clopidogrel (Plavix) 75mg, one tablet, daily. The POC did not include bleeding safety precautions. Record review of Patient #11’s POC dated 08/23/23 to 10/21/23 indicated a SOC date of 04/25/23 and indicated she was 80 years old with diagnosis including congestive heart failure (heart can't pump blood well enough to meet your body's needs), type 2 diabetes mellitus (body either doesn't produce enough insulin, or it resists insulin), end stage renal disease (kidneys are no longer able to work at a level needed for day-to-day life), atrial fibrillation (irregular heartbeat), dependance on renal dialysis (a treatment to clean your blood when your kidneys are not able to), long term use of insulin (controls blood sugar levels), dependance on supplemental Oxygen, and presence of automatic cardiac defibrillator (small battery-powered device placed in the chest that detects and stops irregular heartbeats). The POC indicated Patient #11 was ordered skilled nursing visits once a week for two weeks, then once every two weeks for six weeks, then once a week for one week. The POC medication list indicated Patient #11 took Insulin Lispro 100 units/ml subcutaneous (under the skin), three times daily per sliding scale. The POC did not include safety measures for sharps precautions. The medication list also indicated Patient #11 was ordered Oxygen 2 to 4liters continuous. The POC did not include supplies and equipment required for Oxygen therapy or Oxygen safety precautions. Record review of Patient #12’s POC dated 08/29/23 to 10/27/23 indicated a SOC date of 06/30/23 and indicated he was 86 years old with diagnosis including congestive heart failure (heart can't pump blood well enough to meet your body's needs), chronic kidney disease stage 3 (kidneys are damaged and cannot filter blood as well as they should), cellulitis (bacterial skin infection) of right lower limb, paroxysmal atrial fibrillation (irregular heartbeat, cardiomyopathy (disease of the heart muscle that makes it harder for the heart to pump blood to the rest of the body), depression (loss of pleasure or interest in activities for long periods of time), long term use of anticoagulants (blood thinners), and presence of automatic cardiac defibrillator (small battery-powered device placed in the chest that detects and stops irregular heartbeats). The POC indicated Patient #12 was ordered skilled nursing visits once a week for one weeks, then once every three weeks for three weeks. The POC medication list indicated Patient #12 took Xarelto (blood thinner) 20mg, one tablet, one time daily. The POC did not include bleeding safety precautions. During an interview on 09/07/23 at 10:18 a.m., LVN C said the POC was updated by the case managers and the RN Alternate Administrator had been checking over them. She said the POC should include all medications and goals. LVN C said a patient on Oxygen POC should include safety measures with Oxygen. LVN C said the POC should include sharps precautions if a patient was on Insulin. LVN C said a patient’s POC on blood thinners should include fall precautions, bleeding safety precautions, and instructions on who to call and when to go to the emergency room. During an interview on 09/08/23 at 11:34 a.m., the RN Alternate Administrator said a POC for a patient on blood thinners should include monitoring and education of signs and symptoms of bleeding to report. She said bleeding safety precautions should be on the POC. The RN Alternate Administrator said a POC for a diabetic patient and a patient on insulin should include safety measures for sharps precautions and diabetic supplies under durable medical equipment. The RN Alternate Administrator said a patient’s POC on Oxygen should include what type of Oxygen, Oxygen precautions under safety measures, and Oxygen supplies under durable medical equipment and Oxygen would be on the medication list. The RN Alternate Administrator said the POC was updated as needed by the SN that took the order. She said otherwise the POC was updated at recertification. During an interview on 09/08/23 at 12:23 p.m., the RN Administrator said the POC was updated by the RN case manager for the patient at SOC, recertification, and with order changes. The RN Administrator said if a patient was on Eliquis or a blood thinner the POC should include signs and symptoms of bleeding and adverse reactions. He said a diabetic patient on Insulin POC should include blood sugar checks, education on high and low blood sugar, and safety precautions for sharps. Review of Aspirin (oral route) precautions dated 09/01/23 and accessed at https://www.mayoclinic.org/drugs-supplements/aspirin-oral-route/precautions/drg-20152665 indicated “...this medicine may increase risk for bleeding problems, including stomach ulcers or bleeding. This usually occurs if you are taking aspirin with certain medicines. Check with your doctor right away if you have black, tarry stools, severe or continuing stomach pain, unusual bleeding, bruising, or weakness, or vomiting of blood or material that looks like coffee grounds…” Review of Plavix (Clopidogrel) Precautions revised on 09/10/23 and accessed at https://www.drugs.com/plavix.html indicated “…Clopidogrel increases your risk of bleeding, which can be severe or life-threatening. Call your doctor or seek emergency medical attention if you have bleeding that will not stop, if you have blood in your urine, black or bloody stools, or if you cough up blood or vomit that looks like coffee grounds…” Review of Eliquis instructions dated 09/10/23 and accessed at https://www.drugs.com/eliquis.html on 09/13/23 indicated “...Eliquis is used to lower the risk of stroke or a blood clot… Eliquis increases your risk of severe or fatal bleeding, especially if you take certain medicines at the same time (including some over-the-counter medicines)… Call your doctor at once if you have signs of bleeding such as: swelling, pain, feeling very weak or dizzy, bleeding gums, nosebleeds, heavy menstrual periods or abnormal vaginal bleeding, blood in your urine, bloody or tarry stools, coughing up blood or vomit that looks like coffee grounds, or any bleeding that will not stop. Eliquis should be stopped 24-48 hours prior to any surgery, invasive procedure, or dental work. Tell your surgeon if you are taking Eliquis… Do not stop taking Eliquis unless your doctor tells you to. Stopping suddenly can increase your risk of blood clot or stroke. Review of Xarelto instructions dated 08/22/23 and accessed at https://www.drugs.com/xarelto.html on 09/13/23 indicated “...Xarelto is used to treat or prevent blood clots… Rivaroxaban (Xarelto) can cause you to bleed more easily. Call your doctor at once if you have signs of bleeding such as: bruising or bleeding that will not stop (nosebleeds, bleeding gums, heavy menstrual bleeding); pain, swelling, new drainage, or excessive bleeding from a wound; headaches, dizziness, weakness, feeling like you might pass out; urine that looks red, pink, or brown; or bloody or tarry stools, coughing up blood or vomit that looks like coffee grounds…” Review of Oxygen Therapy and Safety Precautions dated 2023 and accessed at https://www.mjhs.org/resource/oxygen-therapy-and-safety/ on 09/13/23 indicated “…Always use oxygen carefully. Oxygen is a safe gas when appropriately used. Although it does not burn, it does support combustion. Follow these safety precautions when using oxygen from any source (oxygen tank, oxygen concentrator, portable oxygen, etc.) Notify the fire department and the electric company that you are using oxygen. Place “Oxygen in Use” signs in visible areas. Never place the tank or machine near an open flame (e.g., matches, lit candles, a stove in use). Keep the oxygen tank at least six feet away. Always turn your oxygen off when not in use. Always check the oxygen levels on your oxygen tank… The oxygen backup tank should be stored lying flat (or upright and secured) and in a safe, well-ventilated place. Check the oxygen tubing for cracks and leaks. Clean the nasal prongs to keep them open. Check the prongs daily. Never smoke when the oxygen source is in your residence. Do not allow anyone else to smoke. Always have a “No Smoking” sign posted in a visible spot. Do not use your oxygen within six feet of electrical appliances, especially stoves, heaters, toasters, or hair dryers. Do not use your oxygen in an area where combustible materials, such as oils, greases, aerosol sprays, lotions, or solvents, are present. Do not use petroleum-based products while oxygen is in use. Avoid the use of products that contain alcohol (e.g., skin products). Get into the habit of checking the batteries of your smoke detector every month and change batteries as needed. Call the Durable Medical Equipment (DME) company for service or any questions you might have. Have fire extinguishers on hand…” Record review of a Plan of Care policy dated 09/09/20 indicated “… Planning for care is a dynamic process that address the care, treatment, and services to be provided. The plan will be consistently reviewed to ensure that client needs are met, and will be updated as necessary, but at least every sixty (60) days… 3. The Plan of Care shall be completed in full to include… L. Medications, treatments, and procedures. M. Medical supplies and equipment required. N. Any safety measures to protect against injury. O. Instructions to client/caregiver, as applicable… W. All of the above items must always be addressed on the Plan of Care…

Only as ordered by a physician CFR(s): 484.60(b)(1) Drugs, services, and treatments are administered only as ordered by a physician or allowed practitioner. This ELEMENT is not met as evidenced by: Based on observation, record review, and interview, the agency failed to ensure that services and treatments were administered only as ordered by a physician for 1 of 7 patients (Patient #7) in which home visits were conducted, in that: The SN collected a urine specimen (sample for medical testing) on Patient #7 without an order. This failure could place patients at risk of receiving incorrect and/or unnecessary services/treatments not approved by a physician. Findings included: Record review of Patient #7’s POC dated 08/05/23 to 10/03/23 indicated a SOC date of 06/06/23, and indicated she was 63 years old with diagnoses including hypertensive heart disease (heart problems that occur because of high blood pressure that is present over a long time) with heart failure, type 2 diabetes (body either doesn't produce enough insulin, or it resists insulin) with diabetic neuropathy (nerve damage), venous insufficiency (leg veins don't allow blood to flow back up to your heart), long term use of aspirin, long term use of insulin (controls blood sugar levels), and history of falls. The POC indicated Patient #7 was ordered skilled nursing visits one time a week for eight weeks. During a home visit observation and interview on 09/07/23 at 8:26 a.m., Patient #7 reported to LVN C she was burning “down there” even when not “peeing” and indicated maybe she had a urinary tract infection (infection in the urinary system). LVN C then went to her car to obtain a urine specimen cup and brought it back inside and instructed Patient #7 to urinate in the cup for a sample to send to the lab. Patient #7 went to the bathroom and once finished LVN C collected the sample. LVN C said Patient #7 had a standing order for urine sample collection. Record review of a Coordination Note for Patient #7 by LVN C dated 09/07/23 indicated Patient #7 reported she was having burning in her peri area off and on, even when not urinating. The note indicated the SN obtained a urinalysis using aseptic (preventing infection) technique and standard precautions with clean catch method per standing orders. During an interview on 09/08/23 at 10:47 a.m., the RN Alternate Administrator said standing orders for a urinalysis (used to screen for urinary tract infections) would be on the 485/POC. She said if a patient reported symptoms of a UTI, the SN would review the patient’s POC to make sure there was a standing order for a urinalysis. She said if the POC did not have a standing order for a urinalysis, the SN would contact the physician from the patient’s home and obtain an order. The RN Alternate Administrator reviewed Patient #7’s clinical record and said there was no standing order for a urine specimen. She said the SN should have contacted the doctor and received an ordered to collect urine. During an interview on 09/08/23 at 12:23 p.m., the RN Administrator said standing orders were in the patient’s chart under orders and on the 485/POC. He said the SN was okay to collect a urine sample but would need to call the doctor to get an order. Review of Patient #7’s clinical record did not reveal an order for the SN to obtain a urine specimen. Record review of a Physician’s Orders policy dated 06/21/21 indicated “…2. All medications, treatments, and services provided to patients must be ordered by a physician or allowed practitioner… 9. All signed physician or allowed practitioner orders shall be maintained in the electronic medical record…”

Patient medication schedule/instructions CFR(s): 484.60(e)(2) Patient medication schedule/instructions, including: medication name, dosage and frequency and which medications will be administered by HHA personnel and personnel acting on behalf of the HHA. This ELEMENT is not met as evidenced by: Based on observation, interview, and record review the agency failed to provide the patient and caregiver with a copy of written instructions of the patient medication schedule / instructions for 4 of 4 patients (Patient #’s 3, 5, 6, & 7) reviewed for medication schedule, in that: There was no patient medication schedule or instructions, written in plain language, in the home folders of Patient #3, #5, #6, and #7. This failure could place patients at risk of medication errors or adverse reactions. Findings included: Record review of Patient #7’s POC dated 08/05/23 to 10/03/23 indicated a SOC date of 06/06/23, and indicated she was 63 years old with diagnoses including hypertensive heart disease (heart problems that occur because of high blood pressure that is present over a long time) with heart failure, type 2 diabetes (body either doesn't produce enough insulin, or it resists insulin) with diabetic neuropathy (nerve damage), venous insufficiency (leg veins don't allow blood to flow back up to your heart), long term use of aspirin, long term use of insulin (controls blood sugar levels), and history of falls. The POC indicated Patient #7 was ordered skilled nursing visits one time a week for eight weeks. During a home visit observation and interview on 09/07/23 at 8:26 a.m., there was not a medication list in Patient #7’s home folder. LVN C said most patients lose their home folder. Patient #7 said she kept her home folder in the same place all the time. Record review of Patient #5’s POC dated 08/19/23 to 10/17/23 indicated a SOC date of 04/26/22 and indicated she was 84 years old with diagnosis including type 2 diabetes mellitus (body either doesn't produce enough insulin, or it resists insulin), vitamin B12 deficiency anemia (body can't make enough healthy red blood cells), Alzheimer’s disease (problems with memory, thinking and behavior), hypertensive heart disease (heart problems that occur because of high blood pressure that is present over a long time) with heart failure, long term use of insulin, and history of falling. The POC indicated Patient #5 was ordered skilled nursing visits one time a week for three weeks, then once every 4 weeks for 4 weeks. During a home visit observation and interview on 09/07/23 at 9:02 a.m., there was not a home folder or medication list in Patient #5’s room (patient lived in a facility). LVN C said there was no home folder in Patient #5’s room and the facility staff moved stuff around, and home folders got thrown away. LVN C said she did not see the home folder and did not want to go through Patient #5’s belongings. Surveyor was unable to interview Patient #5. Record review of Patient #6’s POC dated 09/01/23 to 10/30/23 indicated a SOC date of 09/01/23 and indicated she was 83 years old with diagnosis including congestive heart failure (heart can't pump blood well enough to meet your body's needs). The POC indicated Patient #6 was ordered skilled nursing once a week for two weeks, then once a week for six weeks. During a home visit observation and interview on 09/07/23 at 9:41 a.m., there was not a medication list in Patient #6’s home folder. Patient #6 said she thought everything the agency gave her was in her home folder. Record review of Patient #3’s POC dated 08/26/23 to 10/24/23 indicated a SOC date of 04/28/23 and indicated she was 64 years old with diagnosis including type 2 diabetes mellitus (body either doesn't produce enough insulin, or it resists insulin) with chronic kidney disease (kidneys are damaged and cannot filter blood as well as they should), congestive heart failure (heart can't pump blood well enough to meet your body's needs), anxiety (feeling of fear, dread, and uneasiness), chronic pain syndrome (symptoms beyond pain alone, like depression and anxiety, which interfere with their daily lives), obstructive sleep apnea (collapse of the airway with decease in oxygen or arousal from sleep), and long term use of aspirin. The POC indicated Patient #3 was ordered skilled nursing visits one time a week for eight weeks. During a home visit observation and interview on 09/07/23 at 12:09 p.m., there was not a medication list in Patient #3’s home folder. Patient #3 said she did not have a medication list from the agency. LVN D said she had not brought a medication list or POC to the patient in a long time because nothing had changed since admission. During an interview on 09/08/23 at 11:39 a.m., the RN Alternate Administrator said once a SOC visit was completed it generated a workflow which consisted of a schedule and medication list. She said the SN took this to the patient at the next SN visit. During an interview on 09/08/23 at 12:23 p.m., the RN Administrator said after the SOC and once the medication list was locked and verified, the list was taken to the patient’s home at the subsequent (following) visit. Record review of the agency’s policies and procedures did not reveal a policy related to providing the patient with written instructions of the patient medication schedule.

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 observation, interview and record review, the agency failed to ensure the skilled professional provided services that were ordered by the physician or allowed practitioner as indicated in the plan of care for 2 of 7 (Patient #’s 5 & 7) patients reviewed for plans of care in which home visits were conducted, in that: The agency did not ensure Patient #’s 5 & 7 skin was assessed during every SN visit. This failure could place patients at risk of improper skin/foot care and could lead to wounds and further complications. Findings included: Record review of Patient #7’s POC dated 08/05/23 to 10/03/23 indicated a SOC date of 06/06/23, and indicated she was 63 years old with diagnoses including hypertensive heart disease (heart problems that occur because of high blood pressure that is present over a long time) with heart failure, type 2 diabetes (body either doesn't produce enough insulin, or it resists insulin) with diabetic neuropathy (nerve damage), venous insufficiency (leg veins don't allow blood to flow back up to your heart), long term use of aspirin, long term use of insulin (controls blood sugar levels), and history of falls. The POC indicated Patient #7 was ordered skilled nursing visits one time a week for eight weeks. The POC orders included SN to assess patient’s skin integrity and instruct patient/caregiver on measures to prevent pressure ulcers. The POC orders also included SN for O/A and teaching of lower extremity skin inspection and proper skin/foot care. During a home visit observation on 09/07/23 at 8:26 a.m., Patient #7 was ambulating (walking) in the home with no shoes on. The SN did not assess Patient # 7’s feet and did not teach on proper diabetic skin/foot care. Record review of Patient #5’s POC dated 08/19/23 to 10/17/23 indicated a SOC date of 04/26/22 and indicated she was 84 years old with diagnosis including type 2 diabetes mellitus (body either doesn't produce enough insulin, or it resists insulin), vitamin B12 deficiency anemia (body can't make enough healthy red blood cells), Alzheimer’s disease (problems with memory, thinking and behavior), hypertensive heart disease (heart problems that occur because of high blood pressure that is present over a long time) with heart failure, long term use of insulin, and history of falling. The POC indicated Patient #5 was ordered skilled nursing visits one time a week for three weeks, then once every 4 weeks for 4 weeks. The POC orders also included SN for O/A and teaching of lower extremity skin inspection and proper skin/foot care. During a home visit observation on 09/07/23 at 9:02 a.m., Patient #5 was asleep in a recliner and had on house shoes. The SN did not remove Patient #5’s shoes to assess her feet. During an interview on 09/07/23 at 10:18 a.m., LVN C said she glanced at Patient #7’s feet but did not look at the bottom of her feet. LVN C said she did not remove Patient #5’s shoes to assess her feet because she did not want to wake her up, and the facility would let her know if Patient #5 had any skin issues. During an interview on 09/08/23 at 11:34 a.m., the RN Alternate Administrator said if a patient with diabetes had on socks and shoes during a SN visit, she would expect the SN to take off the socks and shoes and assess the patient’s feet. During an interview on 09/08/23 at 12:23 p.m., the RN Administrator said a diabetic assessment included a skin assessment to check for wounds. He said if a patient had diabetes and had on socks and shoes, the SN should remove the shoes and complete a skin assessment. Record review of a signed job description dated 09/12/14 by LVN C indicated… "Duties and responsibilities ...4. Performs and documents nursing service delivery…” Record review of a Plan of Care policy dated 09/09/20 indicated “… Planning for care is a dynamic process that address the care, treatment, and services to be provided. The plan will be consistently reviewed to ensure that patient needs are met, and will be updated as necessary, but at least every sixty (60) days… Record review of a Licensed Professional Services policy dated 01/10/20 indicated “…Licensed professionals actively participate in the coordination of all aspects of the patient’s care, in accordance with professional standards and practices…” Record review of a Standards of Practice policy dated 11/12/20 indicated “…1… staff will practice within the guidelines of their state discipline… 3. Patient care will be provided under the Plan of Care… 5. The national patient safety standards and other accreditation standards (if applicable) will be incorporated into standards, performance expectations, orientations, and policy and procedure where applicable.” Review of Diabetic Foot Exam dated 05/09/23 and accessed at https://medlineplus.gov/lab-tests/diabetic-foot-exam/ on 09/13/23 indicated “…People with diabetes have a high risk for many types of foot health problems. A diabetic foot exam can help find problems that can lead to serious infection and amputation (surgery to remove all or part of your foot) if they're not found and treated early. Diabetic foot problems can happen over time if high blood glucose (blood sugar) damages the nerves and blood vessels in your feet… If you don't feel pain in your feet, you may not notice a callus, blister, or cut on your foot. Without treatment, these types of common foot wounds can become ulcers (open sores) that can get infected. If you have diabetes, a foot sore or infection may not heal well, even with treatment. That's because diabetes can damage blood vessels and cause poor blood flow in your feet. If an infection doesn't get better, tissue in your foot may die. This is called gangrene. If you have gangrene or an infection that won't heal, your toe, foot, or part of your leg may need to be amputated to prevent infection from spreading and to save your life… A diabetic foot exam is used to find foot health problems in people with diabetes before they cause serious infection…”