Every finding on record at Kah Development 4, LLC

On 06/10/2024 at 11:00 AM, an entrance conference was conducted with Agency Representatives. The Agency was informed the purpose of the visit was to conduct a Medicare recertification survey for compliance with 42 CFR Part 484 Conditions of Participation for Home Health Agencies. On 06/13/2024 at 11:30 AM, an exit conference was conducted with Agency Representatives. Preliminary findings of the survey were discussed.

Encoding and transmitting OASIS CFR(s): 484.45(a) Standard: An HHA must encode and electronically transmit each completed OASIS assessment to the CMS system, regarding each beneficiary with respect to which information is required to be transmitted (as determined by the Secretary), within 30 days of completing the assessment of the beneficiary. This STANDARD is not met as evidenced by: Based on pre-survey review of the Agency's reports, it was determined the agency failed to transmit all comprehensive assessments within the 30 day timeframe as required by CMS Conditions of Participation (CoP). This failed practice, if not corrected, could result in more late records submissions. A review of the HHA Error Summary report showed there were 31 comprehensive records that had been submitted past 30 days after completion of the record as of 06/03/2024.

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 record review and interview, it was determined the Agency failed to ensure there was a documented complete review of the medication side effects and possible drug interactions for 1 (# 11) of 17 (#1-#17) client records reviewed. This failed practice had the potential to negatively impact all patients as there was a potential for adverse reactions or interactions without a comprehensive review completed. Findings follow: Clinical record review of #11 revealed a patient with a start of care date of 11/19/22 and diagnosis of Pressure Ulcer Stage III and IV. a. A Home Health Certification and Plan of Care with certification period of 05/12/24 – 07/10/24 documented, “…Medications…Gentamicin 30mg [milligrams]/ 60 [milliliters] monthly instill into bladder monthly during catheter change…” b. On 06/12/24, during record review, there was no evidence of medication interaction review of Gentamicin. c. On 06/13/24 at 9:45 a.m., the Branch Director and Clinical Manager were asked to provide any documentation regarding the Gentamicin interaction review for clinical record #11 and none was provided by the end of the survey.

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 it was determined the Agency failed to ensure the Physician’s order was followed for 2 (#11 and #12) of 5 (#11 -#15) patient wound treatments observed. This failed practice had the potential to affect all patients with pressure ulcers on the current census. Findings follow: 1. Clinical record review of #11 revealed a patient with a start of care date of 11/19/22 and diagnosis of Pressure Ulcer Stage III and IV. a. A Home Health Certification and Plan of Care with certification period of 05/12/24 – 07/10/24 documented, “… Sacrum cleanse with ¼ strength Dakin's (a liquid cleanser) and pat dry. Apply Medi-honey (a Manuka honey gel for wounds) to wound bed until necrotic (affected with or characterized by death of a usually localized area of living tissue) tissue is gone. Cover with Saline moistened hydrafera blue ( hydrafera blue is an antibacterial and infection killing wound dressing) and foam dressing using clean technique. Right buttock cleanse with ¼ strength Dakins and pat dry. Apply Medi-honey to wound bed. Apply ¼ Dakin's wet to dry dressing. Cover with foam bandage or ABD pad…” b. On 06/12/24 at 11:04 a.m., Employee #4 was observed providing wound care. The licensed nurse did not moisten the hydrafera blue before applying it to the wound. (the instructions indicate the material should be moistened prior to placing over the wound) better In addition, hydrafera blue was applied to the buttock wound although it was not in the current wound care orders. c. On 06/13/24 at 9:45 a.m., the Branch Director and Clinical Manager were informed the nurse had not moistened the hydrafera blue before applying in the wound. The Branch Director looked in the computer to determine the last supply that was sent to the home, and it was Hydrafera blue classic which requires it to be moistened before application in the wound. 2. Clinical record review of #12 revealed a patient with a start of care date of 12/12/23 and a diagnosis of Pressure Ulcer right heel, unstageable. a. A Home Visit Encounter document dated 06/10/24 included an order which read, “…. Care Plan R [right]heel: HH [Home Health] to cleanse wound with wound cleanser and pat dry. Apply topical antibiotic, then silver alginate to wound bed. Cover with ABD pad. Wrap with rolled gauze and secure with paper tape. Change three times per week and prn [as needed] for soiling….” b. On 06/12/24 at 9:00 a.m., Employee #3 was observed providing wound care. The licensed nurse did not apply silver alginate to the wound. c. On 06/13/24 at 9:45 a.m., the Home Health Director and Case Manager were informed that the nurse did not apply silver alginate in the wound as ordered on 06/10/24.

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 Clinical Record review and staff interview, the Agency failed to ensure a complete Discharge/Transfer Summary completed and sent to the Physician after Transfer in 1 (#1) of 17 Clinical Records Reviewed (#1-#17). This failed practice had the potential to place all transferred patients at risk by preventing effective and efficient coordination of care among health care team members and providers. Findings: Review of Clinical Record #1 revealed the Patient was last scheduled and seen on 05/01/2024. The patient had a one time weekly visit with physical therapy each week until 06/13/2024. There were missed visits for weeks of 5/5/24 and 5/12/24. A Resumption of Care (ROC) scheduled for 5/14/24 but the patient was still hospitalized although no hospital transfer had been completed. According to a clinical comment in the record, the patients son was spoken to on 05/20/2024 and the son revealed the patient expired while in hospital. The Agency continued to attempt to contact the patient to schedule visits after 5/20/24. There was no recorded transfer/discharge summary in the patient clinical record. Agency staff were given the opportunity to provide additional information. None was forthcoming.

Plan of care CFR(s): 484.60(a)(1) Each patient must receive the home health services that are written in an individualized plan of care that identifies patient-specific measurable outcomes and goals, and which is established, periodically reviewed, and signed by a doctor of medicine, osteopathy, or podiatry acting within the scope of his or her state license, certification, or registration. If a physician or allowed practitioner refers a patient under a plan of care that cannot be completed until after an evaluation visit, the physician or allowed practitioner is consulted to approve additions or modifications to the original plan. This STANDARD is not met as evidenced by:

. On 10/06/2021 at 10:30 AM, an entrance conference was conducted with Agency Representatives. The Agency was informed the purpose of the visit was to conduct a Medicare Recertification survey for compliance with the Conditions of Participation for Home Health. On 10/08/2021 at 10:20 AM an exit conference was conducted with Agency Representatives. Preliminary findings of the survey were discussed. .

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 Clinical Record review and staff interviews, it was determined the Skilled Nurse (SN) failed to include all medications Patient is taking during the review of the patients medications in 1 (#5) of 10 (#1 - #10) Clinical Records reviewed. This failed practice by the SN posed a risk of potential harm for patients on census receiving O2 therapy by inhibiting the Nurse and Physician's ability to make informed decisions regarding the patients medication regimen related to potential adverse effects, drug reactions, significant side effects or significant drug interactions. Findings follow: 1. A document titled, "Home Health Care Certification and Plan of Care" (POC) listed a diagnosis of "Dependence on supplemental oxygen". Review of a document titled "Visit Note Report dated 09/01/2021" showed the SN assessment and documentation of "O2 use PRN [as needed] at night." Review of a document titled "Client Medication Report" dated 09/15/2021 did not list O2 on the medication list . 2. During an interview on 10/08/2021 at 9:15 AM, Agency Representatives were provided an opportunity to present additional documentation. With no additional documentation presented, Agency Personnel #1 and #2 confirmed the Agency staff did not include all medications the patients were currently using during a review of medications. Agency Personnel #1 stated "Oxygen was not on the medications list."

Plan of care CFR(s): 484.60(a)(1) Each patient must receive the home health services that are written in an individualized plan of care that identifies patient-specific measurable outcomes and goals, and which is established, periodically reviewed, and signed by a doctor of medicine, osteopathy, or podiatry acting within the scope of his or her state license, certification, or registration. If a physician or allowed practitioner refers a patient under a plan of care that cannot be completed until after an evaluation visit, the physician or allowed practitioner is consulted to approve additions or modifications to the original plan. This STANDARD is not met as evidenced by: Based on Clinical Record review, Patient interview, and staff interview, it was determined the Agency failed to provide care in accordance with the written Plan of Care (POC) in 1 (#2) of 10 (#1 - #10) Clinical Records reviewed. This failed practice had the potential to affect the quality of care received by all 90 patients currently on census, in that, there was a risk of adverse outcomes, potential to affect the attainment of the patients individual goals and a risk of hospitalizations due to unrecognized signs/symptoms of disease exacerbation. Findings follow: 1. Review of Clinical Record #2 showed a Patient with a primary diagnosis of "Aftercare following Surgery for Neoplasm". Review of a document titled, "Home Health Certification and Plan of Care" with a certification date of 09/23/2021 to 11/21/2021" contained an order for "Physical Therapist to evaluate to determine condition......Eliminate structural barriers and improve safety to increase functional independence (Ramps, Adaptive Wheelchair, Bathroom aides". There was no evidence of PT evaluation being completed from 09/23/2021 to 10/07/2021. 2. During an interview with Patient #2, Patient's spouse reported Patient needed grab bars in the bathroom and asked if Physical therapy would be coming to assess the patient's needs . 3. During an interview on 10/08/2021 at 9:15 AM with Agency staff, Personnel #2 stated "There were no frequencies on the 485[POC] for PT and was missed for scheduling." Agency Personnel #1 and #2 verified PT failed to care for Patient #2 as ordered on the POC.