Every finding on record at Kismet Rdk, LLC

A Recertification Survey was conducted by the Iowa Department of Inspections, Appeals & Licensing from 2/3/25 to 2/6/25 and the home health agency was found to be operating in compliance with the Establishment of Emergency Preparedness.

The Iowa Department of Inspections, Appeals & Licensing conducted a Recertification Survey from 2/3/25 to 2/6/25. The recertification survey identified the home health agency was operating out of compliance with the following standard level home health regulations. The agency reported a current census of 82 patients at the time of the survey.

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, patient interviews, staff interview, clinical record reviews and agency policy review, the agency failed to complete an accurate drug regimen review with each comprehensive assessment for 3 of 3 sampled patients with home observation visits (Patients #1, #2 and #3). Failure to ensure medications reviewed at the time of each drug regimen review are current and accurate placed the patients at risk for increased potential unidentified medication interactions, side effects and duplication of medications. Findings include: According to the agency policy titled Drug Regimen Review, dated December 2020, the patient's clinical record should reflect all medications, including times of administration and route, that the patient is taking both prescription and non-prescription, The documentation in the clinical record should confirm that the agency nurse considered each medication the patient is currently taking for possible side effects and the list, in its entirety, for possible drug interactions. During an interview on 2/4/25 at 8:28 AM the Administrator stated the drug regimen review (DRR) process is completed by the Registered Nurse (RN) on admission, recertification and discharge. 1.Patient #1 had a start of care date of 11/7/24. Clinical record review revealed the following: a. The Plan of Care (POC), dated 1/6/25 to 3/6/25, identified the patient had a diagnosis of Encounter for urinary device and included physician orders for medication and skilled nursing services. Medications included the following bowel medications for constipation: Dulcolax 10 mg rectal suppository, every 24 hours as needed, Milk of Magnesia 400 mg/5ml oral every 24 hours as needed, Miralax 17 gram/dose oral every 24 hours as needed and senna plus 8.6 mg-50 mg tablet every 12 hours as needed. b. The recertification comprehensive assessment, dated 1/3/24, completed by Staff D, RN, included documentation a DRR was completed and no discrepancies identified. c. During a home observation visit on 1/23/25 at 9:00 AM with Staff B, LPN, set up the patient's medications. During the same home observation visit the patient stated he/she did not have any of the laxative medications in the home and had not needed laxatives for several years. The DRR failed to include an accurate review of all medications taken by the patient. 2. Patient #2 had a start of care date of 9/27/22. Clinical record review revealed the following: a. The POC, dated 1/14/25 to 3/14/25, identified the patient had a diagnosis of Encounter for anxiety and included physician orders for medication and skilled nursing services. b. The recertification comprehensive assessment, dated 1/9/24, completed by the Administrator, included documentation a DRR was completed and no discrepancies identified. c. During a home observation visit on 1/23/25 at 9:15 AM with Staff C, LPN, set up the patient's medications. During the same home observation visit the patient stated he/she had the following medicated ointments in the home for pain: Biofreeze and Salonpas. The DRR failed to include an accurate review of all medications taken by the patient. 3. Patient #3 had a start of care date of 1/18/22. Clinical record review revealed the following: a. The POC, dated 1/2/25 to 3/2/25, identified the patient had a diagnosis of Encounter for vascular device and included physician orders for medication and skilled nursing services. b. The group home medication list, dated 2/4/25 to 2/5/25, included the medication cetirizine (allergy medication) 1 mg/1ml give 1 mg as needed. The agency medications list failed to include the medication. c. The undated agency medication list included the following medications: Diazepam 7.5 mg-10 mg give 10 mg rectal as needed for seizure lasting 5 minutes, Acetaminophen 325 mg give 2 tablets every 6 ours as needed for pain/fever and Ibuprophen 200 mg every 8 hours as needed for pain./fever. The medications not included on the group home medication list. The DRR failed to include an accurate review of all medications taken by the patient.

Competency evaluation CFR(s): 484.80(c)(1)(2)(3) Standard: Competency evaluation. An individual may furnish home health services on behalf of an HHA only after that individual has successfully completed a competency evaluation program as described in this section. (1) The competency evaluation must address each of the subjects listed in paragraph (b)(3) of this section. Subject areas specified under paragraphs (b)(3)(i), (iii), (ix), (x), and (xi) of this section must be evaluated by observing an aide's performance of the task with a patient or pseudo-patient. The remaining subject areas may be evaluated through written examination, oral examination, or after observation of a home health aide with a patient, or with a pseudo-patient as part of a simulation. (2) A home health aide competency evaluation program may be offered by any organization, except as specified in paragraph (f) of this section. (3) The competency evaluation must be performed by a registered nurse in consultation with other skilled professionals, as appropriate. This STANDARD is not met as evidenced by: Based on personnel file review, agency policy review and clinical record review, the agency failed to ensure 3 of 3 sampled home health aides (Staff E, F and G), demonstrated completion of all of the assigned extra skills while observed by a registered nurse to determine competency in each task prior to being allowed to care for agency patients independently for 2 patients (Patient #1 and #4). Failure to ensure that home health aides demonstrated completion of all of the assigned extra skills while observed by a registered nurse (RN) to determine competency in each task prior to being allowed to care for agency patients independently, increased the potential risk of harm to the patient. Findings include: According to the undated agency policy, titled Home Health Aide Assignments, the initial assessment for need shall be determined by the home health coordinator or designated Registered Nurse (RN). Factors to be considered shall include, but not be limited to experience and competency of the home health aide. 1.Patient #1 had a start of care date of 11/7/24. Clinical record review revealed the following: a. The Plans of Care, dated 11/7/24 to 1/5/25 and 1/6/25 to 3/6/25, identified the patient had the diagnosis of urinary device and included physician orders for skilled nursing and home health aide services. The POC included orders for the medication Eliquis (blood thinner). b. The home health aide care plan, dated 1/3/25, directed the aide to perform the task of skin care, nail care, assist with dressing every visit, bed bath-partial/complete, per patient request every visit, denture care every visit, hair care -brush every visit, nail care every visit, oral care every visit, shampoo in sink per patient request every visit, skin care every visit, check pressure areas every visit, assist shower every visit, shampoo every visit, deodorant every visit, catheter care. c. The task of bleeding precautions require extra skills competency testing prior to assigning the aide to perform the tasks as an extension of nursing services. d. The home care aide nates, dated 12/3, 12/6, 12/10, 12/13, 12/17, 12/20, 12/24, 12/27, 12/31/24 and 1/3, 1/7, 1/10, 1/24, 1/17, 1/21, 1/28 and 1/31/25, included documentation the aide assigned and performed the task of bleeding precautions. The clinical record documented Staff E and Staff F, Home Health Aide, provided care to Patient #1. Personnel file review revealed the following: e. Staff E, Home Health Aide, had a hire date of 6/15/17. Staff E had never been competency tested to perform the task of bleeding precautions. f. Staff F, Home Health Aide, had a hire dated of 1/30/20. Staff F had never been competency tested to perform the task of bleeding precautions. 2. Patient #4 had a start of care date of 1/23/25. Clinical record review revealed the following: a. The POC, dated 1/23/25 to 3/23/25, identified the patient had a diagnosis of pneumonia and included physician orders for skilled nursing and home health aide services. The POC also included the order for the medication Eliquis. b. The home health aide care plan, dated 1/s3/25, directed the aide to perform the task of bleeding precautions. c. The task of bleeding precautions require extra skills competency testing prior to assigning the aide to perform the tasks as an extension of nursing services. d. The home care aide nates, dated 1/29/25, included documentation the aide assigned and performed the task of bleeding precautions. The clinical record documented Staff G, Home Health Aide, provided care to Patient #4. Personnel file review revealed the following: e. Staff G, Home Health Aide, had a hire date of 5/10/22. Staff G had never been competency tested to perform the task of bleeding precautions. The above findings reviewed with the Administrator.

Home health aide assignments and duties CFR(s): 484.80(g)(1) Standard: Home health aide assignments and duties. Home health aides are assigned to a specific patient by a registered nurse or other appropriate skilled professional, with written patient care instructions for a home health aide prepared by that registered nurse or other appropriate skilled professional (that is, physical therapist, speech-language pathologist, or occupational therapist). This STANDARD is not met as evidenced by: Based on clinical record review, agency policy review, and agency staff interview, the agency failed to provide individualized and specific written patient care instructions from a registered nurse (RN) to agency home health aides for 2 of 2 sampled patients receiving home health aide services (Patients #1 and #4). Failure to ensure agency registered nurses provided patient specific written instructions directing the care provided by the agency's home health aides for each patient increased the risk agency patients would receive inappropriate or inconsistent home health aide services. Findings include: According to the undated agency policy, titled Home Health Aide Assignments, the initial assessment for need shall be determined by the home health coordinator or designated Registered Nurse (RN) and developed through the Plan of Care construction. 1. Patient #1 had a start of date of 11/7/24. Clinical record review revealed: a. The Plan of care (POC), dated 1/6/25 to 3/6/25, identified the patient had a diagnosis of encounter for urinary device and included orders for skilled nursing and home health aide services. The POC also included physician orders for the medication Eliquis (blood thinner). b. The home health aide care plan, dated 1/3/25, included the task of nail care assigned to the aide. c. Review of the home health aide notes, dated 1/3, 1/7, 1/10, 1/14, 1/17, 1/21, 1/28, 1/31 and 2/4/25, included documentation aide services provided nail care to the patient. 2. Patient #4 had a start of date of 1/23/25. Clinical record review revealed: a. The POC, dated 1/23/25 to 3/23/25, identified the patient had a diagnosis of encounter for pneumonia and included orders for skilled nursing and home health aide services. The POC also included physician orders for the medication Eliquis (blood thinner). b. The home health aide care plan, dated 1/23/25, included the task of nail care assigned to the aide. c. Review of the home health aide notes, dated 1/27/25, included documentation aide services provided nail care to the patient. The agency failed to provide written individual patient instruction for nail care. The above findings reviewed with the Administrator.

HH aide supervision elements CFR(s): 484.80(h)(4)(i-vi) Home health aide supervision must ensure that aides furnish care in a safe and effective manner, including, but not limited to, the following elements: (i) Following the patient's plan of care for completion of tasks assigned to a home health aide by the registered nurse or other appropriate skilled professional; (ii) Maintaining an open communication process with the patient, representative (if any), caregivers, and family; (iii) Demonstrating competency with assigned tasks; (iv) Complying with infection prevention and control policies and procedures; (v) Reporting changes in the patient's condition; and (vi) Honoring patient rights. This ELEMENT is not met as evidenced by: Based on clinical record review, agency policy review and staff interview, the agency failed to ensure registered nurses supervising home health aides maintained documentation of a review of all required supervisory elements including following the patient plan of care, maintaining open communication with patient/caregiver, demonstrating competency of all assigned tasks, complying with infection prevention and control policies, reporting changes in the patient condition and honoring patient rights for 1 of 1 sampled patients receiving home health aide services requiring home health aide supervision (Patient #1). A total of 21 patients received home health aide services and the agency employed 4 home health aides at the time of the survey. Failure to ensure the supervision of home health aides by registered nurses maintained documentation of a review of all required supervisory elements increased the risk of agency staff not meeting the patients' personal care needs. The agency's policy, titled Home Health Aide Supervision, revised February 2022, home health aide supervision must ensure that aides furnish care in a safe and effective manner, including, but not limited to, the following elements: following the patient's plan of care, Maintaining an open communication process with the patient, representative or caregiver and family, demonstrating competency with assigned tasks, complying with infection prevention and control policies and procedures, reporting changes in the patient's condition and honoring patient rights. 1. Patient #1 had a start of care date of 11/7/24. Clinical record review revealed the following: a. The Plans of Care, 11/7/24 to 1/5/25 and 1/6/25 to 3/6/25, included orders for skilled nursing and home health aide services. b. Skilled nursing visit notes, dated 12/6, 12/20, 12/27/24, 1/3, 1/17 and 1/31/25, included documentation home health aide supervision was completed and the aide followed the care plan. The notes lacked documentation the nurse assessed the aide’s ability to meet the following required supervisory elements: maintaining open communication with patient/caregiver, demonstrating competency of all assigned tasks, reporting changes in the patient condition and honoring patient rights. The agency failed to supervise the home health aide on all of the required supervisory elements. The above findings were reviewed with the Administrator.

Required items in clinical record CFR(s): 484.110(a)(1) The patient's current comprehensive assessment, including all of the assessments from the most recent home health admission, clinical notes, plans of care, and physician or allowed practitioner orders; This ELEMENT is not met as evidenced by: Based on clinical record review, agency policy review, and agency staff interview, the agency failed to complete provide wound assessments on a weekly basis per agency policy for 1 of 1 sampled patients with wounds (Patient #5). Failure to accurately and thoroughly complete wound assessments put patients at an increased risk of unidentified condition changes. Findings include: According to the agency policy titled Wound Care in the Home Care Setting, dated December 2020, pressure ulcers and other wounds will be measured at least weekly (every 7 days). During an interview on 2/4/25 at 8:28 AM the Administrator stated wound measurements expected to include length, width and depth weekly and are documented on the wound visit sheet. 1.Patient #5 had a Start of Care date of 12/29/22. Clinical record review revealed the following: a. The Plan of Care, dated 12/18/24 to 2/15/25, identified the patient had a diagnosis of infection following surgical procedure. The POC included orders for skilled nursing services weekly. b. The skilled nurse note, dated 12/8/24, Staff R, Registered Nurse (RN) included documentation of a wound to the anterior left subclavian due to trauma. The measurements included 2 centimeters (cm) length, by 1 cm width by 0.01 cm depth. c. The skilled nurse visit notes, dated 12/6/24, Staff , Licensed Practical Nurse (LPN) identified a wound of the right medial leg but failed to include documentation of measurements of the wound. d. The skilled nurse visit note, dated 12/10/24, Staff B, LPN identified a wound of the right medial leg and right heel, but failed to include documentation of measurements of the wounds. e. The skilled nurse visit notes, dated 12/18/24, Staff D, RN identified a wound of the right medial leg but failed to include documentation of measurements of the wound. The agency nurse failed to obtain complete wound assessment and measurements weekly per agency policy. The above findings reviewed with the Administrator.

The recertification survey, conducted from 6/6/22 through 6/8/22, identified the following deficiencies related to Appendix Z Establishment of Emergency Preparedness. The agency reported a current census of 104 patients at the time of the recertification survey.

EP Training Program CFR(s): 484.102(d)(1) §403.748(d)(1), §416.54(d)(1), §418.113(d)(1), §441.184(d)(1), §460.84(d)(1), §482.15(d)(1), §483.73(d)(1), §483.475(d)(1), §484.102(d)(1), §485.68(d)(1), §485.625(d)(1), §485.727(d)(1), §485.920(d)(1), §486.360(d)(1), §491.12(d)(1). *[For RNCHIs at §403.748, ASCs at §416.54, Hospitals at §482.15, ICF/IIDs at §483.475, HHAs at §484.102, "Organizations" under §485.727, OPOs at §486.360, RHC/FQHCs at §491.12:] (1) Training program. The [facility] must do all of the following: (i) Initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles. (ii) Provide emergency preparedness training at least every 2 years. (iii) Maintain documentation of all emergency preparedness training. (iv) Demonstrate staff knowledge of emergency procedures. (v) If the emergency preparedness policies and procedures are significantly updated, the [facility] must conduct training on the updated policies and procedures. *[For Hospices at §418.113(d):] (1) Training. The hospice must do all of the following: (i) Initial training in emergency preparedness policies and procedures to all new and existing hospice employees, and individuals providing services under arrangement, consistent with their expected roles. (ii) Demonstrate staff knowledge of emergency procedures. (iii) Provide emergency preparedness training at least every 2 years. (iv) Periodically review and rehearse its emergency preparedness plan with hospice employees (including nonemployee staff), with special emphasis placed on carrying out the procedures necessary to protect patients and others. (v) Maintain documentation of all emergency preparedness training. (vi) If the emergency preparedness policies and procedures are significantly updated, the hospice must conduct training on the updated policies and procedures. *[For PRTFs at §441.184(d):] (1) Training program. The PRTF must do all of the following: (i) Initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles. (ii) After initial training, provide emergency preparedness training every 2 years. (iii) Demonstrate staff knowledge of emergency procedures. (iv) Maintain documentation of all emergency preparedness training. (v) If the emergency preparedness policies and procedures are significantly updated, the PRTF must conduct training on the updated policies and procedures. *[For PACE at §460.84(d):] (1) The PACE organization must do all of the following: (i) Initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing on-site services under arrangement, contractors, participants, and volunteers, consistent with their expected roles. (ii) Provide emergency preparedness training at least every 2 years. (iii) Demonstrate staff knowledge of emergency procedures, including informing participants of what to do, where to go, and whom to contact in case of an emergency. (iv) Maintain documentation of all training. (v) If the emergency preparedness policies and procedures are significantly updated, the PACE must conduct training on the updated policies and procedures. *[For LTC Facilities at §483.73(d):] (1) Training Program. The LTC facility must do all of the following: (i) Initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected role. (ii) Provide emergency preparedness training at least annually. (iii) Maintain documentation of all emergency preparedness training. (iv) Demonstrate staff knowledge of emergency procedures. *[For CORFs at §485.68(d):](1) Training. The CORF must do all of the following: (i) Provide initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles. (ii) Provide emergency preparedness training at least every 2 years. (iii) Maintain documentation of the training. (iv) Demonstrate staff knowledge of emergency procedures. All new personnel must be oriented and assigned specific responsibilities regarding the CORF's emergency plan within 2 weeks of their first workday. The training program must include instruction in the location and use of alarm systems and signals and firefighting equipment. (v) If the emergency preparedness policies and procedures are significantly updated, the CORF must conduct training on the updated policies and procedures. *[For CAHs at §485.625(d):] (1) Training program. The CAH must do all of the following: (i) Initial training in emergency preparedness policies and procedures, including prompt reporting and extinguishing of fires, protection, and where necessary, evacuation of patients, personnel, and guests, fire prevention, and cooperation with firefighting and disaster authorities, to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles. (ii) Provide emergency preparedness training at least every 2 years. (iii) Maintain documentation of the training. (iv) Demonstrate staff knowledge of emergency procedures. (v) If the emergency preparedness policies and procedures are significantly updated, the CAH must conduct training on the updated policies and procedures. *[For CMHCs at §485.920(d):] (1) Training. The CMHC must provide initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles, and maintain documentation of the training. The CMHC must demonstrate staff knowledge of emergency procedures. Thereafter, the CMHC must provide emergency preparedness training at least every 2 years. This STANDARD is not met as evidenced by: Based on review of the agency's emergency preparedness plan, personnel file review and agency staff interview, the agency failed to ensure training in emergency preparedness for 3 of 3 sampled contracted therapists consistent with their expected roles (Staff D, F and G). Lack of emergency preparedness training for staff puts patients at risk should an emergency situation arise and staff would be needed to assist patients to ensure patient safety. Findings include: According to the agencies policy titled Emergency Operations Plan Training Program, dated February, 2022, the agency will provide initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement and volunteers (if applicable) consistent with their expected roles. Provide emergency preparedness training at least every two years. Training should be modified, incorporating any lessons learned from the most recent exercises, real-life emergencies that occurred in the last two years and during review of the emergency operations plan every two years. During an interview on 6/8/22 at 12:40 PM, the Administrator, reported she did not have any written documentation of training for the contracted staff for emergency preparedness. Review of the agency's emergency preparedness training revealed the following: 1. Staff D, Speech Therapist, had a hire date of 5/5/22 and worked for the agency as a contracted employee. The agency was unable to provide documentation of any emergency preparedness training. 2. Staff F, Physical Therapist, had a hire date of 12/11/19 and worked for the agency as a contracted employee. The agency was unable to provide documentation of any emergency preparedness training. 3. Staff G, Physical Therapist Assistant, had a hire date of 4/18/22 and worked for the agency as a contracted employee. The agency was unable to provide documentation of any emergency preparedness training. The agency failed to ensure all staff completed annual training in emergency preparedness as required by agency policy and regulation. The above stated findings were reviewed for Staff D, F and G with the Administrator and Clinical Manager. The agency provided no further information prior to the end of the survey.

The recertification survey for 42CFR 484 Home Health Conditions of Participation, conducted 6/4/22 through 6/8/22, found the agency operating out of compliance with the following standard level deficient practices. The agency reported a current census of 104 patients at the time of the recertification survey.

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 agency policy review, clinical record review and agency staff and caregiver interview, the agency failed to assess each patients medications for duplication, side effects, ineffectiveness, actual or potential interactions and non-compliance within the required time frames, identifying medication discrepancies, as part of the initial comprehensive assessment at admission and as part of the updates to the comprehensive assessment at the time of recertification, resumption of care and discharge for 2 of 7 sampled patients (Patients #1 and #2). Failure to identify actual/ potential issues at the time of each comprehensive assessment increased the potential for unidentified medication interactions and side effect risks to the patient. Findings Include: 2. Patient #1 had a start of care date of 7/13/2021. Clinical record review revealed the following: The Plans of Care, dated 3/10/2022 to 5/8/2022 and 5/9/2022 to 7/7/2022, documented the patient's primary diagnosis of hypertensive heart disease with associated chronic kidney disease. a. The Plan of Care, dated 3/10/2022 to 5/8/2022, included the medications metoprolol, lisinopril and furosemide, all medications taken to lower the blood pressure. The drug regimen review, collected in conjunction with the update to the comprehensive assessment at the time of recertification on 3/8/2022, lacked the registered nurse's identification of the 3 blood pressure medications taken by the patient as duplicate medications. The registered nurse also failed to identify the potential for potentiation of the medications when combined, potentially resulting in hypotension with change from lying to sitting to standing. b. The Plan of Care, dated 5/9/2022 to 7/7/2022, included the medications metoprolol, lisinopril and furosemide, all medications taken to lower the blood pressure. The drug regimen review, collected in conjunction with the update to the comprehensive assessment at the time of recertification on 5/4/2022, lacked the registered nurse's identification of the 3 blood pressure medications taken by the patient as duplicate medications. The registered nurse also failed to identify the potential for potentiation of the medications when combined, potentially resulting in hypotension with change from lying to sitting to standing. c. The Plan of Care, dated 5/9/2022 to 7/7/2022, included the medication Claritin (loratadine) 10 mg one tablet for allergies. During surveyor observation on 6/7/2022 at 8:30 AM while accompanied by Staff B, Licensed Practical Nurse (LPN), the surveyor noted the LPN placed Zyrtec (cetirizine) 10 mg into the patient's weekly medication planner. The cetirizine was ordered by the physician and was delivered to the patient's home via prescription from the pharmacy. Cetirizine is an allergy medication. The patient did not use Claritin for allergies, instead used Cetirizine. The Plan of Care did not include the correct medication taken by the patient. The registered nurse completed the drug regimen review on 5/4/2022 without noting the discrepancy between the two allergy medications and what the physician had prescribed for the patient's use. The surveyors reviewed the above stated findings for Patients #1 and #2 with the Administrator and the Clinical Manager. The agency provided no additional information prior to the end of the survey. According to the agency policy titled Medication Reconciliation, dated December, 2020, the agency will reconcile patient's medications at time of admission and on an ongoing basis 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 non-compliance with drug therapy. At time of admission, the admitting RN, PT or SLP will create and document a complete list of medications that the patient is taking at home, including dose, strength, route and frequency. Any concerns or discrepancies will be reconciled by a RN with the patient's physician. Discrepancies include duplications, omissions, changes, contraindications and/or unclear information. During an interview on 6/8/22 at 9:30 AM, the Clinical Manager stated the drug regimen review completed by the RN at start of care, recertification, resumption of care and on discharge. 1. Patient #2 had a start of care date of 4/12/22. Clinical record review revealed the following: The Plan of Care (POC), dated 4/12/22 to 6/10/22, documented the patient's primary diagnosis of hypertensive heart disease with heart failure and atrial fibrillation. a. The Plan of Care included orders for skilled nursing 1 time a seek to fill medication planners with patient medications ordered by the physician. The POC included the medication myrbetriq (bladder muscle relaxer) for treatment of urinary incontinence. The drug regimen review, collected in conjunction with the update to the comprehensive assessment at the time of start of care on 4/12/22, lacked a discrepancy noted in the patient's medications. During surveyor observation on 6/7/2022 at 8:45 AM while accompanied by Staff A, Registered Nurse (RN), the surveyor and RN compared the patients physician orders and current medications in the home. The patient did not have the medication myrbetriq available. During an interview with the patient's caregiver during the same home observation visit, he/she stated the patient had not been taking myrbetriq since at least February, 2022 due to the ill effects with the diagnoses of atrial fibrillation. The Plan of Care did not include the correct medication taken by the patient. The registered nurse completed the drug regimen review on 4/12/22 without noting the discrepancy between the patient's medications and what the physician had prescribed for the patient's use.

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 agency policy review, clinical record review and agency staff interview, the agency failed to follow a Plan of Care established and periodically reviewed by a physician or notify the physician of the need to vary frequency of visits or inability to perform treatments/services as originally ordered on the Plan for Care for 3 of 7 sampled patients (Patients #1, #2 and #6). Failure to follow a Plan of Care established by a physician placed patients at risk of not receiving safe, individualized and consistent care designed to meet each patient's health care needs. 3. Patient #2 had a start of care date of 4/12/22. Clinical record review revealed the following: The Plan of Care, dated 4/12/22 to 6/10/22, documented the patient's diagnoses of hypertensive heart disease with heart failure and atrial fibrillation. The Plan included orders for the skilled nurse visits 1 time a week. The physician prescribed interventions included assessment of the patient's weight weekly and report an increase of 2 pounds or more in 24 hours or a 5 pound gain or loss in 1 week. The skilled nurse visit notes, dated 4/20, 4/27/22, 5/11 and 5/18/22, lacked documentation of an assessment of the patient's weight. The nurse failed to assess Patient #2's weight as ordered by the physician on the Plan of Care. The nurse could not report readings outside of the physician ordered parameters for reporting without assessing the patient's weight. The surveyors reviewed the above stated findings for patient # 1, #2 and #6 with the Administrator and Clinical Manager. The agency provided no further information prior to the end of the survey. Findings include: According to the agency policy, titled Plan of Care- CMS 485 and Physician Orders and dated 12/2020, each patient must receive an individualized written Plan of Care specifying the care and services necessary to meet the needs of the patient as identified in the comprehensive assessment. Each patient must receive the home health services written in the individualized Plan of Care and according to physician orders. If the agency provides fewer visits than the physician orders or it has altered the Plan of Care, the physician must be notified. The agency must maintain documentation in the clinical record of the physician notification. During agency staff interview on 6/6/2022 at 10:15 AM, the Administrator reported the agency sends a missed visit note to the physician if the frequency of visits is varied from the Plan of Care at least monthly. If the Plan of Care needs vary in tasks/interventions performed, the clinician contacts the physician at the time to obtain direction/orders. 1. Patient #1 had a start of care date of 7/13/2021. Clinical record review revealed the following: a. The Plan of Care, dated 3/10/2022 to 5/8/2022, included physician orders for home health aide visits once weekly. The home health aide care plan, dated 3/10/2022, directed the home health aide to visit the patient once weekly to assist with showering, shampooing and dressing of the patient. The clinical record included documentation of only 1 homemaking visit to clean the patient's home during the week of 4/10-16/2022. The clinical record lacked documentation of any home health aide visits to assist with bathing and personal care during the week of 4/10-16/2022. The clinical record lacked documentation of communication with the physician related to the need to vary from the physician ordered frequency of home health aide visits. The clinical record lacked documentation of any missed visit notification to the physician of the variance in home health aide visit frequency. 2. Patient #6 had a start of care date of 3/25/2022 and was discharged from agency services on 5/24/2022 following a transfer to a nursing home. Clinical record review revealed the following: The Plan of Care, dated 3/25/2022 to 5/23/2022, documented the patient's diagnoses of hypertensive heart disease, chronic kidney disease and diabetes. The Plan included orders for the skilled nurse to visit the patient once weekly. The physician prescribed interventions included assessment of the patient's blood sugars, reporting any blood sugars less than 60 or above 400 to the physician. The skilled nurse visit notes, dated 4/7/2022 and 4/14/2022, lacked documentation of an assessment of the patient's blood sugar. The nurse failed to assess Patient #6's blood sugars as ordered by the physician on the Plan of Care. The nurse could not report readings outside of the physician ordered parameters for reporting without assessing the blood sugar readings.

Plan of care must include the following CFR(s): 484.60(a)(2)(i-xvi) The individualized plan of care must include the following: (i) All pertinent diagnoses; (ii) The patient's mental, psychosocial, and cognitive status; (iii) The types of services, supplies, and equipment required; (iv) The frequency and duration of visits to be made; (v) Prognosis; (vi) Rehabilitation potential; (vii) Functional limitations; (viii) Activities permitted; (ix) Nutritional requirements; (x) All medications and treatments; (xi) Safety measures to protect against injury; (xii) A description of the patient's risk for emergency department visits and hospital re-admission, and all necessary interventions to address the underlying risk factors. (xiii) Patient and caregiver education and training to facilitate timely discharge; (xiv) Patient-specific interventions and education; measurable outcomes and goals identified by the HHA and the patient; (xv) Information related to any advanced directives; and (xvi) Any additional items the HHA or physician or allowed practitioner may choose to include. This ELEMENT is not met as evidenced by: Based on agency policy review, clinical record review and surveyor observation, the agency failed to ensure the accurate completion of all components comprising the Plan of Care, including all supplies and equipment used to meet the needs of the patient for 4 of 7 sampled patients (Patients #1, #2, #3 and #7). Failure to maintain complete and accurate Plans of Care with current orders placed the patients at risk to not receive services, medications and/or treatments according to assessed needs and physician orders. 4. Patient #2 had a start of care date of 4/12/22. Clinical record review revealed the following: The Plan of Care, dated 4/12/22 to 6/10/22, identified the following as medical equipment and supplies used by the patient: fingerless compression gloves, quad cane, cane, alcohol swabs, lancets, shower chair, gloves, walker, automatic blood pressure cuff, medication planner box, incontinent pads, dentures-partial, INR machine, sharps container, commode, pill splitter, lift chair, edema wear and thumb immobilizer. Surveyor observation during a home visit on 6/7/2022 at 8:45 AM while accompanied by Staff A, Registered Nurse (RN), revealed the following: a. The surveyor observed a reacher propped against the front of the lift chair. b. The patient's caregiver stated the patient used the reacher to pick items up out of his/her reach and had the device prior to the start of home health services. The Plan of Care, dated 5/9/2022 to 7/7/2022, lacked inclusion of the reacher as equipment used by the patient to meet his/her needs. 4. Patient #7 had a start of care date of 1/7/22 and discharge date of 5/6/22. Clinical record review revealed the following: a. The Plans of Care, dated 1/7/22 to 3/7/22 and 3/8/22 to 5/6/22, identified the following as medical equipment and supplies used by the patient: built in shower bench, handheld shower, grab bars and walker. b. The comprehensive assessment at start of care, dated 1/7/22 identified the patient incontinent of urine. c. The home health aide visit notes, dated 3/11, 3/25/22, 4/1, 4/8, 4/14, 4/22, 4/29/22 and 5/6/22, included documentation the aide performed perineal care, incontinence care and incontinence skin care. d. During an interview on 6/8/22 at 8:50 AM, Staff C, Home Care Aide stated the patient incontinent of urine and wore incontinent products which included incontinent pads. The Plans of Care, dated 1/7/22 to 3/7/22 and 3/8/22 to 5/6/22, lacked inclusion of the incontinent products as equipment used by the patient to meet his/her needs. The surveyors reviewed the above stated findings for patient # 1, #2, #3 and #7 with the Administrator and Clinical Manager. The agency provided no further information prior to the end of the survey. Findings include: According to agency policy, titled Plan of Care- CMS 485 and Physician Orders and dated 12/2020, the Plan of Care must include any supplies and equipment required to meet the needs of the patient. 1. Patient #1 had a start of care date of 7/13/2021. Clinical record review revealed the following: The Plan of Care, dated 5/9/2022 to 7/7/2022, identified the following as medical equipment and supplies used by the patient: bath bench, grab bars, medication planner, 4 wheeled walker, incontinence pads and briefs and an emergency response system. Surveyor observation during a home visit on 6/7/2022 at 8:30 AM while accompanied by Staff B, Licensed Practical Nurse (LPN), revealed the following: a. The surveyor observed a toilet riser on the patient's toilet in the only bathroom in the apartment. The patient resided alone. The Plan of Care, dated 5/9/2022 to 7/7/2022, lacked inclusion of the toilet riser as equipment used by the patient to meet his/her needs. b. The surveyor observed a metal u-shaped 1/4 upper side rail on the right side of the bed. During the home visit, patient interview revealed the patient used the side rail to get in an out of bed. The Plan of Care, dated 5/9/2022 to 7/7/2022, lacked inclusion of the u-shaped bed side rail as equipment used by the patient to meet his/her needs. 2. Patient #3 had a start of care date of 4/15/2022. Clinical record review revealed the following: The Plan of Care, dated 4/15/2022 to 6/13/2022, identified the following as medical equipment and supplies used by the patient: cane, grab bars, scale and automatic blood pressure machine. a. The physical therapy visit note, dated 5/20/2022, documented the patient had a new 4 wheeled walker, using the walker instead of the cane for ambulation due to a recent fall that resulted in a laceration to the scalp requiring stapling. The physical therapy visit notes, dated 5/23/2022, 5/25/2022, 5/31/2022 and 6/1/2022, documented the patient's use of the 4 wheeled walker. b. The skilled nurse visit note, dated 5/31/2022, documented the nurse observed the patient using a 4 wheeled walker for ambulation. c. Surveyor observation during a home visit on 6/7/2022 at 10:40 AM while accompanied by Staff D, Speech Therapist, revealed Patient #3 had a 4 wheeled walker and used the walker during the home visit. The Plan of Care, dated 4/15/2022 to 6/13/2022, did not included a 4 wheeled walker as equipment used by the patient to meet his/her needs. The clinical record lacked any update to the Plan of Care that included the 4 wheeled walker as equipment used by the patient to meet his/her needs.

Interdisciplinary assessment of the patient CFR(s): 484.75(b)(1) Ongoing interdisciplinary assessment of the patient; This ELEMENT is not met as evidenced by: Based on clinical record review, agency policy review, and staff interview, the agency failed to perform ongoing interdisciplinary assessments of the patient for 2 of 2 sampled patients with alteration of skin integrity (Patient #4 and #6). Failure to ensure staff obtain physician orders for administration of treatments provided by agency staff placed agency patients at risk for inconsistent care/treatment and possible harm. Findings include: 2. Patient #6 had a start of care date of 3/25/22 and was discharged from agency services on 5/24/2022 following a transfer to a nursing home. Clinical record review revealed the following: a. The Plans of Care dated 3/25/2022 to 5/23/2022, included orders for skilled nursing visits once weekly. The Plan included physician orders for treatment of a wound on the right upper leg and wrapping of both lower legs with compression wraps (ACE bandages). b. The skilled nursing visit note, dated 4/7/2022, documented the nurse performed wound care and wrapped the lower extremities with compression wraps. The note lacked any wound measurements, including length, width or depth of the right leg wound. The clinical record lacked documentation of any wound measurements by an agency clinician during the week of 4/3-9/2022 as required by agency policy. The surveyor reviewed the above stated findings for Patients #4 and #6 with the Administrator and Clinical Manager. The agency provided no additional information prior to the end of the survey. According to the agency policy titled Wound Care in the Home Care Setting, dated December, 2020, pressure ulcers and other wounds will be measured at least weekly (every 7 days). During an interview on 6/9/22 at 9:20 AM, the Clinical Manager stated the expectation for wound measurements to be completed weekly. The measurements to include the length, width and depth of each wound. 1. Patient #4 had a start of care date of 4/15/22. Clinical record review revealed the following: a. The Plans of Care dated 4/15/22 to 6/13/22, included orders for skilled nursing visits 4 times a week times 1 week and 3 times a week times 6 weeks. The Plan included physician orders for treatment of a surgical wound on the abdomen with a wound vac (vacuum) and pressure wounds to the left and right buttock to be washed daily and apply calmoseptine to the open areas. b. The skilled nursing visit notes, dated 4/17, 4/18, 4/19 and 4/21/22, documented the nurse performed wound care to the surgical wound and 2 pressure wounds. The notes lacked any wound measurements, including length, width or depth of the abdominal or right and left buttock wounds. c. The skilled nursing visit notes, dated 5/9, 5/11 and 5/13/22, documented the nurse performed wound care to the surgical wound and identified the pressure wounds to the right and left buttock healed. The notes lacked any wound measurements, including length, width or depth of the abdominal wound. The clinical record lacked documentation of any wound measurements by an agency clinician during the weeks of 4/17-22/22 and 5/8-5/14/22 as required by agency policy.

Competency evaluation CFR(s): 484.80(c)(1)(2)(3) Standard: Competency evaluation. An individual may furnish home health services on behalf of an HHA only after that individual has successfully completed a competency evaluation program as described in this section. (1) The competency evaluation must address each of the subjects listed in paragraph (b)(3) of this section. Subject areas specified under paragraphs (b)(3)(i), (iii), (ix), (x), and (xi) of this section must be evaluated by observing an aide's performance of the task with a patient or pseudo-patient. The remaining subject areas may be evaluated through written examination, oral examination, or after observation of a home health aide with a patient, or with a pseudo-patient as part of a simulation. (2) A home health aide competency evaluation program may be offered by any organization, except as specified in paragraph (f) of this section. (3) The competency evaluation must be performed by a registered nurse in consultation with other skilled professionals, as appropriate. This STANDARD is not met as evidenced by: Based on personnel file review, clinical record review and agency staff interview, the agency failed to ensure the home health aides successfully completed competencies in all home health aide skills that exceed basic skills, which require a registered nurse or other appropriate skilled professional in consultation with a registered nurse, to evaluate the competency of the aide by direct observation for 2 of 2 sampled home health aides who were assigned to perform extra skills (Staff C and E) while caring for one patient (Patient #6). The agency employed 5 home health aides at the time of the survey. Failure to ensure home health aides were competent in any assigned skill which exceed the level of basic home health aide skills placed agency patients at risk to receive inadequate or unsafe home health aide services. Findings include: Patient #6 had a start of care date of 3/25/2022 and was discharged from agency services on 5/24/2022 following a transfer to a nursing home. Clinical record review revealed the following: The Plan of Care, dated 3/25/2022 to 5/23/2022, included physician orders for home health aide services twice weekly. The home health aide care plan, dated 3/25/2022, directed the aides to assist the patient with a sponge bath, dressing assistance and ambulation with a walker twice weekly. The home health aide visit notes, dated 4/7/2022, 4/14/2022, 4/18/2022, 4/25/2022 and 4/29/2022, documented the home health aides wrapped the patient's legs with a compression wrap (ACE bandage). The clinical record included documentation completed by Staff C and Staff E, both home health aides. During agency staff interview on 6/8/2022 at 8:55 AM, Staff C, Home Health Aide, reported she had cared for Patient #6 prior to the patient's discharge. The aide reported she had wrapped the patient's legs with an ACE bandage when the bandage came off and the patient would allow the aide to put it back on. During agency staff interview on 6/8/2022 at 10:00 AM, Staff E, Home Health Aide, reported she had cared for Patient #6 prior to the patient's discharge. The aide reported she had wrapped the patient's legs with an ACE bandage when the bandage came off and the patient would allow the aide to put it back on. During agency staff interview on 6/8/2022 at 10:20 AM, the Clinical Manager reported she was aware the aides were wrapping the patient's lower extremities with compression wraps "when the wraps applied by the nurse came off and the patient would allow the aide to put the wraps back on". Personnel file review revealed the following: Staff C, Home Health Aide, had a hire date of 6/15/2017. The aide's personnel file lacked documentation of RN observation and determination of competency for application of a compression wrap. Staff E, Home Health Aide, had a hire date of 5/12/2021. The aide's personnel file lacked documentation of RN observation and determination of competency for application of a compression wrap. During agency staff interview on 6/8/2022 at 12:50 PM, the Administrator reported she looked for documentation of competency determination for compression wraps for Staff C and E, Home Health Aides, and was unable to locate any evidence to support competency was completed. The above findings were reviewed with the Administrator and the Clinical Manager. No further information was provided prior to the end of the survey.

Services provided by HH aide CFR(s): 484.80(g)(2) A home health aide provides services that are: (i) Ordered by the physician or allowed practitioner; (ii) Included in the plan of care; (iii) Permitted to be performed under state law; and (iv) Consistent with the home health aide training. This ELEMENT is not met as evidenced by: Based on agency policy review, clinical record review and agency staff interview, the agency failed to ensure home health aides provided care to agency patients only as ordered by the physician, permitted under state law and/or as directed by the skilled professional assigning the home health aide to the patient for 4 of 4 sampled patients receiving home health aide services (Patients #1, #5, #6 and #7). The agency reported providing home health aide services to 25 patients at the time of the survey. Failure to ensure that home health aide services are provided only as ordered by the physician, permitted under state law and/or as directed by the skilled professional assigning the home health aide to the patient and according to the home health aide care plan increased the risk that patients' personal care needs were not adequately met. 4. Patient #7 had a start of care date of 1/7/22 and discharge date of 5/6/22. Review of the clinical record revealed the following: a. The POC, dated 3/8/22 to 5/6/22, included physician orders for skilled nursing and home health aide services. b. The home health aide care plan, dated 3/8/2, included RN instructions to the home health aide to complete the following tasks: shower, shampoo, lotion, assist with dressing, brush/comb hair and clean the bathroom. c. The home health aide visit notes, dated 3/11, 3/25/22, 4/1, 4/8, 4/14, 4/22, 4/29/22 and 5/6/22, included documentation the aide performed perineal care, incontinence care and incontinence skin care. The tasks performed were not included in the home health aide care plan. During an interview on 6/8/22 at 8:50 AM Staff C, HCA, stated the patient incontinent of urine. She ensured the patient's perineal area cleansed well with bathing due to incontinence. The surveyors reviewed the above stated findings for patient # 1, #5, #6 and #7 with the Administrator and Clinical Manager. The agency provided no further information prior to the end of the survey. Findings including: According to the undated agency policy, titled Home Health Aide/HCBS Assignments, the Home Health Director or designee registered nurse will assign a home health aide when services are ordered by the physician. Any changes in the assignment to the aide will be communicated to the home health aide and will be documented on a new Care Plan. Changes must reflect physician orders and be documented in the patient's clinical record. According to the agency policy, titled Care Planning Process and dated 12/2020, the home health aide assignment sheet will be developed by a registered nurse or therapist if nursing services are not ordered. The assignment will be reviewed at least every 14 days during the supervisory visit and based on the patient's health status and environment. Revisions will be completed in writing by the nurse or therapist with any changes in health status, environment and/or physician orders. 1. Patient #1 had a start of care date of 7/13/2022. The Plans of Care, dated 3/10/2022 to 5/8/2022 and 5/9/2022 to 7/7/22, included physician orders for skilled nursing services once weekly and home health aide services once weekly to assist with bathing and personal care. Clinical record review revealed the following: The aide care plan, dated 3/10/2022, directed the aides to assist the patient with showering, shampooing and dressing weekly and perform trimming of the patient's fingernails at the patient's request. Home health aide visit notes revealed the following: a. 4/5/2022- The aide documented applying lotion to the patient and brushing/combing the patient's hair in addition to all of the assigned tasks. The care plan did not include either applying lotion or hair care as assigned tasks. b. 4/20/2022- The aide omitted the assigned task of assistance with dressing. The aide failed to document the reason for the omission. The aide documented applying lotion to the patient and brushing/combing the patient's hair in addition to all of the assigned tasks. The care plan did not include either applying lotion or hair care as assigned tasks. c. 5/4/2022- The aide documented applying lotion to the patient and brushing/combing the patient's hair in addition to all of the assigned tasks. The care plan did not include either applying lotion or hair care as assigned tasks. d. 5/11/2022- The aide documented applying lotion to the patient, brushing/combing the patient's hair and providing incontinence care in addition to all of the assigned tasks. The care plan did not include either applying lotion, hair care or incontinence care as assigned tasks. e. 5/18/2022- The aide omitted the assigned task of assistance with shower and shampoo. The aide failed to document the reason for the omission. The aide documented performing a sponge bath instead of a shower, brushing/combing the patient's hair and incontinence care in addition to all of the assigned tasks. The care plan did not include either sponge bath, hair care or incontinence care as assigned tasks. f. 5/25/2022- The aide documented brushing/combing the patient's hair and providing incontinence care in addition to all of the assigned tasks. The care plan did not include either hair care or incontinence care as assigned tasks. g. 6/1/2022- The aide documented applying lotion to the patient, brushing/combing the patient's hair and providing incontinence care in addition to all of the assigned tasks. The care plan did not include either applying lotion, hair care or incontinence care as assigned tasks. 2. Patient #5 had a start of care date of 2/11/2022. The Plans of Care, dated 2/11/2022 to 4/11/2022 and 4/12/2022 to 6/10/2022, included physician orders for home health aide services three times weekly to assist with bathing and personal care with no skilled service provision. Clinical record review revealed the following: The aide care plans, dated 2/11/2022 and 4/12/2022, directed the aides to assist the patient with showering, shampooing, application of lotion, dressing assistance, brush/comb the patient's hair and shaving three times weekly. The plan directed the aides to perform trimming of the patient's fingernails once weekly. Home health aide visit notes revealed the following: a. 4/4/2022- The aide documented omitting shampooing the patient's hair, brushing/combing the patient's hair, applying lotion and shaving the patient. The aide failed to document the reason for omission. b. 4/8/2022- The aide documented omitting shampooing the patient's hair, brushing/combing the patient's hair, applying lotion and shaving the patient. The aide failed to document the reason for omission. c. 4/12/2022- The aide documented omitting shampooing the patient's hair, brushing/combing the patient's hair, applying lotion and shaving the patient. The aide failed to document the reason for omission. d. 4/13/2022- The aide documented omitting shampooing the patient's hair, brushing/combing the patient's hair, applying lotion and shaving the patient. The aide failed to document the reason for omission. e. 4/18/2022- The aide documented omitting shampooing the patient's hair, brushing/combing the patient's hair, applying lotion and shaving the patient. The aide failed to document the reason for omission. f. 4/20/2022- The aide documented omitting shampooing the patient's hair, brushing/combing the patient's hair, applying lotion and shaving the patient. The aide failed to document the reason for omission. g. 4/27/2022- The aide documented omitting the shower, shampooing the patient's hair, brushing/combing the patient's hair and shaving the patient. The aide The aide documented omitting shampooing the patient's hair, brushing/combing the patient's hair, applying lotion and shaving the patient. The aide failed to document the reason for omission of the other omitted tasks. h. 4/29/2022- The aide documented omitting shampooing the patient's hair, brushing/combing the patient's hair and shaving the patient. The aide failed to document the reason for omission. i. 5/2/2022- The aide documented omitting shampooing the patient's hair, brushing/combing the patient's hair, applying lotion and shaving the patient. The aide failed to document the reason for omission. j. 5/9/2022- The aide documented omitting shampooing the patient's hair, brushing/combing the patient's hair and shaving the patient. The aide failed to document the reason for omission. k. 5/11/2022- The aide documented omitting shampooing the patient's hair, brushing/combing the patient's hair, applying lotion and shaving the patient. The aide failed to document the reason for omission. l. 5/13/2022- The aide documented omitting shampooing the patient's hair, brushing/combing the patient's hair, applying lotion and shaving the patient. The aide failed to document the reason for omission. m. 5/18/2022- The aide documented omitting assistance with dressing, brushing/combing the patient's hair, and shaving the patient. The aide failed to document the reason for omission. n. 5/27/2022- The aide documented omitting shaving the patient. The aide failed to document the reason for omission. o. 5/31/2022- The aide documented omitting shaving the patient. The aide failed to document the reason for omission. The aide documented applying the patient's compression stockings. Application of compression stockings requires physician approval for the aide to perform the task as an extension of nursing services. The clinical record lacked a physician order to apply compression stockings and the task had not been assigned by the nurse for the aide to perform. p. 6/6/2022- The aide documented applying the patient's compression stockings. Application of compression stockings requires physician approval for the aide to perform the task as an extension of nursing services. The clinical record lacked a physician order to apply compression stockings and the task had not been assigned by the nurse for the aide to perform. During agency staff interview on 6/8/2022 at 8:55 AM, Staff C, Home Health Aide, reported she had applied compression stockings for the patient after he/she obtained them approximately one week ago at the patient's request. q. The home health aide visit notes, dated from 4/4/2022 through 6/6/2022 lacked documentation of the aide trimming the patient's fingernails as directed by the registered nurse. 3. Patient #6 had a start of care date of 3/25/2022 and was discharged from agency care on 5/24/2022 following a transfer to a nursing home. Clinical record review revealed the following: The Plan of Care, dated 3/25/2022 to 5/23/2022, included physician orders for skilled nursing services once weekly and home health aide services twice weekly. The Plan included physician orders for the skilled nurse to apply compression wraps to both patient's legs. The Plan included the medication Nystatin powder applied under the breasts and abdominal folds. The aide care plan, dated 3/25/2022, directed the aides to assist the patient with a sponge bath, dressing, and ambulation using a walker twice weekly. a. Home health aide visit notes, dated 4/4/2022; 4/8/2022; 4/11/2022; 4/20/2022; 4/25/2022; and 5/13/2022, documented the home health aide applied the Nystatin powder under the patient's breasts and abdominal folds. Application of a medicated powder requires physician approval for the aide to perform the task as an extension of nursing services. The clinical record lacked a physician order to apply the Nystatin powder and the task had not been assigned by the nurse for the aide to perform. b. Home health aide visit notes, dated 4/8/2022; 4/11/2022; 4/25/2022; and 4/29/2022, documented the home health aide applied compression wraps (ACE bandages) to both of the patient's lower legs. Application of compression wraps requires physician approval for the aide to perform the task as an extension of nursing services. The clinical record lacked a physician order to apply the compression wraps and the task had not been assigned by the nurse for the aide to perform. (See G768 for associated information)

HH aide supervision elements CFR(s): 484.80(h)(4)(i-vi) Home health aide supervision must ensure that aides furnish care in a safe and effective manner, including, but not limited to, the following elements: (i) Following the patient's plan of care for completion of tasks assigned to a home health aide by the registered nurse or other appropriate skilled professional; (ii) Maintaining an open communication process with the patient, representative (if any), caregivers, and family; (iii) Demonstrating competency with assigned tasks; (iv) Complying with infection prevention and control policies and procedures; (v) Reporting changes in the patient's condition; and (vi) Honoring patient rights. This ELEMENT is not met as evidenced by: Based on clinical record review, agency policy review and agency staff interview, the agency failed to ensure registered nurses supervising home health aides maintained documentation of a review of all required supervisory elements including following the patient plan of care, maintaining open communication with patient/caregiver, demonstrating competency of all assigned tasks, complying with infection prevention and control policies, reporting changes in the patient condition and honoring patient rights for 2 of 4 sampled patients receiving home health aide services (Patients #1 and #6). The agency reported providing home health aide services to 25 patients at the time of the survey. Failure to ensure the supervision of home health aides by registered nurses maintained documentation of a review of all required supervisory elements increased the risk of agency staff not meeting the patients' personal care needs. Findings include: According to the agency's policy, titled Home Health Aide Supervision and dated 2/2022, home health aide supervision must ensure that aides furnish care in a safe and effective manner, including but not limited to, the following elements: Following the patient's plan of care for completion of tasks assigned to a home health aide; Maintaining open communication with the patient, caregivers, family or representatives; Demonstrating competency with assigned tasks; Complying with infection prevention and control policies and procedures; Reporting changes in patient condition; and Honoring patient rights. 1. Patient #1 had a start of care date of 7/13/2021. The Plans of Care, dated 3/10/2022 to 5/8/2022 and 5/9/2022 to 7/7/2022, included physician orders for skilled nurse and home health aide services once weekly. Clinical record review revealed the following: The Plans of Care, dated 3/10/2022 to 5/8/2022 and 5/9/2022 to 7/7/22, included physician orders for skilled nursing services once weekly and home health aide services once weekly to assist with bathing and personal care. Clinical record review revealed the following: The home health aide supervisory visit notes, dated 4/6/2022, 4/20/2022, 5/4/2022, 5/11/2022 and 5/25/2022, documented the registered nurse's assessment to determine the aide follows the plan of care; documents and reports thoroughly; practices universal precautions; notifies supervisor of changes; maintains open communication with the patient; demonstrates competency on assigned tasks; and honors patient rights were marked "not applicable". The notes documented the aide completes all tasks. The aide care plan, dated 3/10/2022, directed the aides to assist the patient with showering, shampooing and dressing weekly and perform trimming of the patient's fingernails at the patient's request. Home health aide visit notes revealed the following: a. 4/5/2022- The aide documented applying lotion to the patient and brushing/combing the patient's hair in addition to all of the assigned tasks. The care plan did not include either applying lotion or hair care as assigned tasks. b. 4/20/2022- The aide omitted the assigned task of assistance with dressing. The aide failed to document the reason for the omission. The aide documented applying lotion to the patient and brushing/combing the patient's hair in addition to all of the assigned tasks. The care plan did not include either applying lotion or hair care as assigned tasks. c. 5/4/2022- The aide documented applying lotion to the patient and brushing/combing the patient's hair in addition to all of the assigned tasks. The care plan did not include either applying lotion or hair care as assigned tasks. d. 5/11/2022- The aide documented applying lotion to the patient, brushing/combing the patient's hair and providing incontinence care in addition to all of the assigned tasks. The care plan did not include either applying lotion, hair care or incontinence care as assigned tasks. e. 5/18/2022- The aide omitted the assigned task of assistance with shower and shampoo. The aide failed to document the reason for the omission. The aide documented performing a sponge bath instead of a shower, brushing/combing the patient's hair and incontinence care in addition to all of the assigned tasks. The care plan did not include either sponge bath, hair care or incontinence care as assigned tasks. f. 5/25/2022- The aide documented brushing/combing the patient's hair and providing incontinence care in addition to all of the assigned tasks. The care plan did not include either hair care or incontinence care as assigned tasks. g. 6/1/2022- The aide documented applying lotion to the patient, brushing/combing the patient's hair and providing incontinence care in addition to all of the assigned tasks. The care plan did not include either applying lotion, hair care or incontinence care as assigned tasks. The nurse failed to complete all required elements of supervision. the nurse documented the aides completed all tasks in general; however, the aides omitted assigned tasks without identifying the reason and completed tasks that had never been assigned. 2. Patient #6 had a start of care date of 3/25/2022 and was discharged from agency care on 5/24/2022 following a transfer to a nursing home. Clinical record review revealed the following: The Plan of Care, dated 3/25/2022 to 5/23/2022, included physician orders for skilled nursing services once weekly and home health aide services twice weekly. The Plan included physician orders for the skilled nurse to apply compression wraps to both patient's legs. The Plan included the medication Nystatin powder applied under the breasts and abdominal folds. The aide care plan, dated 3/25/2022, directed the aides to assist the patient with a sponge bath, dressing, and ambulation using a walker twice weekly. The home health aide supervisory visit notes, dated 4/7/2022, 4/20/2022, 5/3/2022, 5/10/2022 and 5/19/2022, documented the registered nurse's assessment to determine the aide follows the plan of care; documents and reports thoroughly; practices universal precautions; notifies supervisor of changes; maintains open communication with the patient; demonstrates competency on assigned tasks; and honors patient rights were marked "not applicable". The notes documented the aide completes all tasks. a. Home health aide visit notes, dated 4/4/2022; 4/8/2022; 4/11/2022; 4/20/2022; 4/25/2022; and 5/13/2022, documented the home health aide applied the Nystatin powder under the patient's breasts and abdominal folds. Application of a medicated powder requires physician approval for the aide to perform the task as an extension of nursing services. The clinical record lacked a physician order to apply the Nystatin powder and the task had not been assigned by the nurse for the aide to perform. b. Home health aide visit notes, dated 4/8/2022; 4/11/2022; 4/25/2022; and 4/29/2022, documented the home health aide applied compression wraps (ACE bandages) to both of the patient's lower legs. Application of compression wraps requires physician approval for the aide to perform the task as an extension of nursing services. The clinical record lacked a physician order to apply the compression wraps and the task had not been assigned by the nurse for the aide to perform. (See G768 for associated information) c. During agency staff interview on 6/8/2022 at 8:55 AM, Staff C, Home Health Aide, reported she had previously cared for Patient #6 prior to the patient's discharge. The aide reported applying Nystatin powder under the patient's breasts and in the abdominal folds and applied ACE bandages to the patients lower legs when the patient would allow. d. During agency staff interview on 6/8/2022 at 10:00 AM, Staff E, Home Health Aide, reported she had previously cared for Patient #6 prior to the patient's discharge. The aide reported applying Nystatin powder under the patient's breasts and in the abdominal folds and applied ACE bandages to the patient's lower legs when the patient would allow. e. During agency staff interview on 6/8/2022 at 10:20 AM, the Clinical Manager reported she was the primary nurse for Patient #6 prior to the patient's discharge. The Clinical Manager reported she was aware the aides were wrapping the patient's lower extremities with ACE bandages but had neglected to add the task to the assignment. The Clinical Manager reported she was not aware the aides were applying Nystatin powder under the patient's breasts and abdominal folds. The nurse failed to complete all required elements of supervision. The nurse documented the aides completed all tasks in general; however, the aides omitted assigned tasks without identifying the reason and documented completion of tasks that had never been assigned. The above stated findings for Patients #1 and #6 were reviewed with the Administrator and the Clinical Manager. The agency provided no additional information prior to the end of the survey.

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 agency staff completed and sent a transfer summary to the health care professionals responsible for providing care to the patient while in a health care facility within 2 business days of the planned transfer for 3 of 3 sampled patients requiring transmission of a transfer summary (Patient #4, #6 and #8). Failure to send the physician and other health care professionals a summary of the patient's care while receiving services from the agency in a timely manner may result in inadequate or inappropriate follow-up and care. Findings include: 3. Patient #6 had a start of care date of 3/25/2022 and was discharged from agency services on 5/24/2022 following transfer to a nursing home. Clinical record review included the following: The update to the comprehensive assessment at the time of transfer to an inpatient facility, dated 5/24/2022, documented the patient was transferred to the hospital. The patient's clinical record lacked documentation of a completed transfer summary. The clinical record lacked documentation indicating the agency sent a medication list or transfer summary to the admitting inpatient facility. The patient did not return to home health services upon discharge from the hospital due to transfer from the hospital to a nursing home. During agency staff interview on 6/8/2022 at 9:55 AM, the Administrator reported she reviewed the patient's clinical record and was unable to find a completed transfer summary. The surveyors reviewed the above stated findings with the Administrator and the Clinical Manager. The agency provided no additional information prior to the end of the survey. During an interview on 6/18/22 at 9:50 AM the Administrator stated the agency had not been sending transfer summaries to the hospitals upon patients transfer but did send them to the physician. 1. Patient #4, had a start of care date of 4/15/22. Review of the clinical record revealed the following: a. The Plan of Care, dated 4/25/22 to 6/13/22, included a physician order for skilled nursing services. b. A transfer/discharge summary, dated 6/1/22, included documentation the patient transferred to the hospital on 5/31/22 and included documentation the form faxed to the physician on 6/1/22. The transfer/discharge summary not documented it had been sent to the receiving hospital. The clinical record lacked documentation agency staff sent a transfer summary to the hospital within 2 business of the planned transfer. 2. Patient #8, had a start of care date of 9/1/19 and discharge date of 9/10/21. Review of the clinical record revealed the following: a. The Plan of Care, dated 8/26/21 to 10/24/21, included a physician order for skilled nursing services. b. A transfer/discharge summary, dated 8/31/21, included documentation the patient transferred to the hospital on 8/28/21 and included documentation the form faxed to the physician on 8/31/22. The transfer/discharge summary not documented it had been sent to the receiving hospital. c. A transfer/discharge summary, dated 9/13/21, included documentation the patient transferred to the hospital on 9/10/21 and included documentation the form faxed to the physician on 9/13/21. The transfer/discharge summary not documented it had been sent to the receiving hospital. The clinical record lacked documentation agency staff sent a transfer summary to the hospital within 2 business of the planned transfer.