Every finding on record at Knox County Health Department Home Health Agency

The Emergency Preparedness regulations were reviewed as part of the Medicare recertification survey completed on 01/11/2024. During the survey it was determined the home health provider is in compliance with the requirements of 42 CFR 484.102 Condition of Participation: Emergency Preparedness for Home Health Providers.

A standard survey for Medicare recertification for the home health provider was completed on 01/11/2024. The provider had 8 current patients.

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 policy review, record review, and interview, the home health provider failed to ensure that the patients received the home health services that were written on their individualized plan of care when the patients did not receive visits according to the visit frequency as ordered on the plan of care in one of five full records reviewed (Record/Patient #1). This deficient practice has the potential to adversely affect the ordered care provided to all the provider’s patients. Findings included: Review of the provider's policy titled, "14 Plan of Treatment/Care," dated reviewed and approved by Governing Board June 16, 2021, showed: - The plan of care shall include frequency of visits for nursing, home health aide, and therapists; - All personnel making home visits must conform to all physician's orders; - Changes in Plan of Treatment- If changes are needed after the initial evaluation/visit, the physician shall be notified, and appropriate modifications or additions obtained and documented in verbal or written orders; and - The Agency staff will promptly notify the physician of any changes at any time that suggest a need to alter the plan of treatment. RECORD/PATIENT #2: Review of the clinical record showed the patient was admitted to the agency on 11/17/2023 with diffuse total brain injury (TBI) with loss of consciousness of unspecified duration, diabetes insipidus (an uncommon problem that causes the fluids in the body to become out of balance), intellectual disabilities, cortical blindness (loss of vision without any ophthalmological causes and with normal pupillary light reflexes due to bilateral lesions of the striate cortex in the occipital lobes), and dysphagia (difficulty swallowing). Review of the plan of care dated 11/17/2023 to 01/15/2024 showed: - Physical therapy (PT) one time a week for one week; - Two times a week for four weeks; - Then two times a week for four weeks; - Occupational therapy (OT) one time a week for one week; - Two times a week for four weeks; - Then two times a week for three weeks; - Speech therapy (ST) one time a week for one week; and - Then three times a week for six weeks. Review of the clinical record showed: - The week of 11/26/2023 only one ST visit (order was for three) was completed. There failed to be any communication note or physician order for the missed visit; - The week of 12/03/2023 only two ST visits (order was for three) and one PT visit (order was for two) was completed. There failed to be any communication notes or physician orders for the missed visits; - The week of 12/17/2023 only one OT visit (order was for two) was completed. There failed to be any communication note or physician order for the missed visit; - The week of 12/24/2023 only two ST visits (order was for three) and one PT visit (order was for two) was completed. There failed to be any communication notes or physician orders for the missed visits; -The week of 12/31/2023 only one ST visit (order was for three) was completed. There failed to be any communication note or physician order for the missed visit. During an interview on 01/11/2024 at 4:15 PM, the administrator stated, missed visits should be made up in the week, and if the visits are not made up the physician is to be notified.

In accordance with current clinical practice CFR(s): 484.105(f)(2) All HHA services must be provided in accordance with current clinical practice guidelines and accepted professional standards of practice. This ELEMENT is not met as evidenced by: Based on state law, the home health provider policy, employee file review, and interview, the provider failed to ensure all staff had the Employee Disqualification List (EDL) checked prior to hire for two contracted staff of four employee files reviewed (Employee #1 and #2). This deficient practice has the potential to affect all patients served by the provider. Findings included:Review of Section 192.2490.12 RSMo: "No person, corporation, organization, or association who received the employee disqualification list under subdivisions (1) and (7) of subsection 11 of this section shall knowingly employ any person who is on the employee disqualification list." Review of the provider’s policy titled “36 Personnel of the Home Health Agency”, dated reviewed and approved by Governing Board June 16, 2021, showed: - All staff hired by the named home health provider will meet the standards as set forth in the "Medicare and Medicaid Programs: Conditions of participation for home health agencies" published January 13, 2017, updated 5/28/2020. EMPLOYEE #1 (E1):Review of the E1's personnel file showed:- Speech therapist (ST):- Date of hire: November 2, 2023; and - Failed to show EDL results prior to hire. EMPLOYEE #2 (E2):Review of the E2's personnel file showed:- Certified occupational therapy assistant (COTA);- Date of hire: December 20,2023; and - Failed to show EDL results prior to hire. During an interview on 01/11/2024 at 4:30 PM, the administrator stated that the EDL should be done prior to hire and both the employees were contracted staff and she would be sure to make sure the EDL results were returned prior to signing the contracts.

The Emergency Preparedness regulations were reviewed as part of the Medicare certification survey completed on 06/09/2021. During the survey it was determined Knox County Health Department Home Health Agency is in compliance with the requirements of 42 CFR 484.102 Condition of Participation: Emergency Preparedness for Home Health Agencies.

A partial extended survey for Medicare certification for Knox County Health Department Home Health Agency was completed on 06/09/2021. The agency had 10 current patients. A COVID-19 Focused Infection Control Survey was completed in conjunction with the survey and no deficiencies were identified related to the Focused Infection Control Survey.

Information to patient CFR(s): 484.50(a)(1) Provide the patient and the patient's legal representative (if any), the following information during the initial evaluation visit, in advance of furnishing care to the patient: This ELEMENT is not met as evidenced by: Based on review of the agency's current patient rights information and interview, the agency failed to update the written notice of patient rights to meet the requirements of the new federal home health regulations effective 01/13/2018 to include that the agency must provide the patient/representative, the notice of rights during the initial evaluation visit, in advance of furnishing care to the patient. This deficient practice has the potential to affect the knowledge and comprehension of the rights and responsibilities of all agency patients. Findings included: The agency administrator provided an admission packet for review on 06/07/2021. The agency notice of patient rights and other information given to a patient during the initial visit contained no written information regarding the patient's right to be informed about the notice of rights during the initial evaluation visit, in advance of furnishing care to the patient. During an interview on 06/09/2021 at 10:00 AM, the administrator stated that: - He/she thought the statement was in another area of the agency's current patient rights information; and - The agency would include the updated federal information in the notice of patient rights included in the admission packet.

Written notice within 4 business days CFR(s): 484.50(a)(4) Provide written notice of the patient's rights and responsibilities under this rule and the HHA's transfer and discharge policies as set forth in paragraph (d) of this section to a patient-selected representative within 4 business days of the initial evaluation visit. This ELEMENT is not met as evidenced by: Based on review of the agency's current patient rights information and interview, the agency failed to update the written notice of patient rights to meet the requirements of the new federal home health regulations effective 01/13/2018 to include that the agency must provide written notice, to a patient-selected representative, of the patient's rights and the agency's transfer and discharge policies with in four business days of the initial evaluation visit. This deficient practice has the potential to affect the knowledge and comprehension of the rights and responsibilities of all agency patients. Findings included: Review of the agency's policy dated 07/15/2020 titled "Home Health Client's Privacy and Rights and Responsibilities" showed: - The client has the right to know the discharge, transfer, and referral policy of this agency, and will receive the policy upon admission to agency services. Signature of the client authorization form is acknowledgement of this receipt and review. The agency administrator provided an admission packet for review on 06/07/2021. The agency notice of patient rights and other information given to a patient during the initial visit contained no information regarding the patient's right; that the agency must provide written notice of the patient's rights under this rule and the agency's transfer and discharge policies to a patient-selected representative within four business days of the initial evaluation visit. During an interview on 06/09/2021 at 10:00 AM, the administrator stated that the agency would include the updated federal information in the notice of patient rights included in the admission packet.

Payment from federally funded programs CFR(s): 484.50(c)(7)(i, ii, iii, iv) Be advised, orally and in writing, of- (i) The extent to which payment for HHA services may be expected from Medicare, Medicaid, or any other federally-funded or federal aid program known to the HHA, (ii) The charges for services that may not be covered by Medicare, Medicaid, or any other federally-funded or federal aid program known to the HHA, (iii) The charges the individual may have to pay before care is initiated; and (iv) Any changes in the information provided in accordance with paragraph (c)(7) of this section when they occur. The HHA must advise the patient and representative (if any), of these changes as soon as possible, in advance of the next home health visit. The HHA must comply with the patient notice requirements at 42 CFR 411.408(d)(2) and 42 CFR 411.408(f). This ELEMENT is not met as evidenced by: Based on record review, home visit observation, and interview, the agency failed to ensure the patient was advised orally and in writing of the extent to which payment for services may be expected from Medicare, Medicaid, or any other federally-funded aid program and the charges of services that may not be covered in two, (Record/Patient #1 and #2), of three home visit observations. This deficient practice has the potential to adversely affect the patient's ability to pay for services for all the agency's patients. Findings included: The agency failed to provide a policy regarding advising the patient orally and in writing about financial liability as outlined by 484.50(c)7 (G440). RECORD/PATIENT #1: Review of the clinical record showed the patient was admitted to home health services on 04/22/2021 with diabetes mellitus type 2 with a foot ulcer (an open sore or wound that occurs in approximately 15 percent of patients with diabetes and is commonly located on the bottom of the foot). During a home visit observation with the skilled nurse on 6/08/2021 starting at 11:00 AM, the home folder/book was reviewed and failed to show written evidence of patient financial liability amounts. The booklet had a section for the patient's financial responsibility to be written in, but the section was blank. During an interview with the patient during the observation visit, he/she stated that there was no written information regarding any payment for services provided but he/she was sure Medicare paid for it all. RECORD/PATIENT #2: Review of the clinical record showed the patient was admitted to home health services on 05/30/2021 with a primary diagnosis of fusion of lumbar spine (surgery to permanently connect two or more vertebrae in the lower spine) and co-morbidities of scoliosis (sideways curve in the backbone) and Parkinson's disease (a progressive disease of the nervous system marked by tremor, muscular rigidity, and slow, imprecise movement). The patient lived at home alone. During a home visit observation with the occupational therapist on 06/08/2021 starting at 9:10 AM, the home folder/book was reviewed and failed to show written evidence of patient financial liability amounts. The booklet had a section for the patient's financial responsibility to be written in, but the section was blank. When the patient was questioned about Medicare payment for services during the observation visit, he/she stated, "They didn't mention it." During an interview on 06/08/2021 at 3:35 PM, the clinical manager stated that he/she had no idea they were supposed to inform the patient in writing about the cost of the home health services.

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, home visit observation, and interview, the agency failed to ensure staff reviewed all of the medications the patients were currently using in order to identify any potential adverse effects and drug interactions in three (Record/Patient #1, #2, and #3) of three home visit observations. This deficient practice has the potential to affect all patients served by the agency. Findings included: Review of the agency's policy dated 07/15/2020 titled, "Policy for Use of Medication and Treatment Profile," showed: - All medications will be reviewed by the skilled nurse; - High risk medications will have documented teaching in the nursing notes as well as the patient's response; - High risk medications include antidiabetic drugs and insulin (to treat high blood glucose (blood sugar) levels or diabetes mellitus); - All drugs will be entered into the medication profile of the electronic health information system used; - Drug interactions and side effects will be reviewed upon admission to home health, resumption of care after inpatient stay, and recertification and shall be updated whenever any changes in medications occur; - Medications and treatments will be reviewed by a skilled nurse at home visits for any changes; - Nurses will update the medication profile as needed and medications that are discontinued or added will be added to the profile upon completion of every visit; and - Patients/caregivers/responsible parties will have a medication profile in the home, and this will be reviewed and updated as needed with each skilled nursing and therapy visit. RECORD/PATIENT #1: Review of the clinical record showed the patient was admitted to the agency on 04/22/2021 with diabetes mellitus type 2 with a foot ulcer (an open sore or wound that occurs in approximately 15 percent of patients with diabetes and is commonly located on the bottom of the foot). During a home visit observation 06/08/2021 starting at 11:00 AM, the medications were reconciled using a current medication profile supplied by the agency and a typed list provided by the patient to the surveyor. Hydrocodone/APAP 5/325 mg (milligram) failed to be listed on either of the supplied lists. There is a physician order dated 05/25/2021 for Hydrocodone/APAP 5/325 mg 1 tablet every four hours as needed for pain greater than 7. During an interview with the patient during the observation visit, he/she stated they were taking the medication as prescribed. During an interview with the clinical manager 06/09/2021 at 10:40 AM, he/she stated that he/she must have left it off of the lists. RECORD/PATIENT #2: Review of the clinical record showed the patient was admitted to home health services on 05/30/2021 with a primary diagnosis of fusion of lumbar spine (surgery to permanently connect two or more vertebrae in the lower spine) and co-morbidities of scoliosis (sideways curve in the backbone) and Parkinson's disease (a progressive disease of the nervous system marked by tremor, muscular rigidity, and slow, imprecise movement). The patient lived at home alone. During a home visit observation on 06/08/2021 starting at 9:10 AM, the home folder/book was reviewed. A list of the patient's current medications failed to be found. During the medication reconciliation, the patient stated he/she did not have a medication list. During the medication reconciliation, the home medication bottles were compared to the current medication profile printed by the agency on 06/07/2021. The following discrepancies were found: - The patient had a bottle of B12 (a vitamin B supplement) and stated he/she takes it sometimes. B12 failed to be on the medication profile; - The patient failed to have vitamin D3 (a vitamin D supplement used for bone health) in the home. Vitamin D3 was listed on the agency medication profile; and - The patient stated vitamin D3 was not in the home and he/she was not aware if the nurse knew he/she was not taking it. RECORD/PATIENT #3: Review of the admission plan of care (POC) dated 05/30/2021 through 07/28/2021 showed: - Diagnoses included but not limited to: Displaced subtrochanteric fracture (hip/femur fracture), chronic obstructive pulmonary disease (COPD, asthma), and insulin dependent diabetes mellitus; - Lispro insulin (Humalog, a fast acting insulin), 100 units/milliliter (ml), four times a day (QID) before meals and at bedtime via insulin sliding scale (amount of insulin determined by the blood glucose/sugar levels); - Pulse oximetry (oxygen (O2) saturation, test to determine the amount of oxygen in the blood stream) every visit and as needed (PRN) for shortness of breath; - Teach oxygen use/precautions; - Contact physician if blood glucose level is less than 60 mg/dl (milligrams/deciliter, unit of measurement) or greater than 150 mg/dl; - Blood glucose monitoring PRN; - Did not address sliding scale blood glucose levels and corresponding insulin dosages; and - Did not address O2 administration, liters per minute (amount of oxygen to be delivered), and delivery system to be used to deliver oxygen (nasal cannula or mask). Review of the initial comprehensive assessment dated 05/30/2021 showed: - An additional diagnosis included dependence upon supplemental oxygen and long term use of insulin; - Diabetic teaching included but not limited to: Checks blood glucose levels QID (four times per day), currently on insulin therapy for blood glucose control, knowledgeable on insulin but needs further education regarding insulin dosage, and educated on sliding scale dosing; and - Oxygen use: 2 liters/minute per nasal cannula, oxygen concentrator for delivery of oxygen, O2 saturation 91% (normal 95-100%). Review of the agency's current Medication Profile dated 06/07/2021 showed: - Lispro (Humalog) insulin, 100 units/ml before meals and at bedtime via insulin sliding scale; - Did not include oxygen use, liters/min, or delivery system. Review of an undated Home Medication List during a home visit observation on 06/08/2021 at 11:30 AM, showed: - Lispro (Humalog) insulin 100 units/ml AC (before meals) if blood sugar is: * 70-139 mg/dl 0 units; * 140-175 mg/dl 3 units; * 176-200 mg/dl 5 units; * 201-250 mg/dl 7 units; * 251-300 mg/dl 9 units; * 301-350 mg/dl 11 units; * 351-400 mg/dl 13 units; and * Greater than 400 mg/dl call the physician; and - Oxygen was not listed on the home medication list. During an interview on 06/09/2021 at 9:15 AM, the clinical manager stated that the sliding scale dosages and O2 liters/minute and delivery system should be listed on the agency medication list and the home medication list for all patients.

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 policy review, record review, and interview, the agency failed to ensure that the patients received the home health services that were written on the individualized plan of care when the patients did not received visits according to the visit frequency ordered on the plan of care in one (Record/Patient #1) of five full record reviews completed. This deficient practice has the potential to adversely affect the ordered care provided to all the agency's patients. Findings included: Review of the agency's policy titled, "14 Plan of Treatment/Care," dated reviewed and approved by Governing Board July 15, 2020, showed: - The plan of care shall include frequency of visits for nursing, home health aide, and therapists; and - All personnel making home visits must conform to all physician's orders. RECORD/PATIENT #1: Review of the clinical record showed the patient was admitted to the agency on 04/22/2021 with diabetes mellitus type 2 with a foot ulcer (an open sore or wound that occurs in approximately 15 percent of patients with diabetes and is commonly located on the bottom of the foot). The agency was, in part, to monitor foot ulcer for healing as well as monitor blood sugars obtained by the patient in the home. Review of the plan of care dated 04/22/2021 to 06/20/2021 showed: - Admit to home health for skilled nurse visits by RN (registered nurse) 2 times a week for 1 week; - 3 times a week for 2 weeks; and - Then 2 times a week for 2 weeks Review of the clinical record showed: - On the third week (week of 05/02/2021) only two skilled nurse visits were completed; and - No communication note or physician order regarding the reason for the missed visit. During an interview on 06/09/2021 at 10:15 AM, the clinical manager stated: - There was no other skilled nursing visit note available for that week; and - The patient had a doctor's appointment but RN A failed to send communication of the missed visit to the doctor or document why there were only two visits that week.

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 interview, the agency failed to ensure that each patient's written individualized plan of care (POC) included all the required elements in four (Record/Patient #1, #2, #3, and #5) of five full records reviewed. This deficient practice has the potential to affect all patients served by the agency. Findings included: Review of the agency's policy dated 07/15/2020 titled, "Plan of Treatment/Care," showed: - The POC used for all patients should include: * Pertinent diagnosis; * Current mental/psychosocial/cognitive status; * Prognosis; * Rehabilitation potential; * Functional and physical limitations; * Activities performed: * Nutritional requirements; * Medications and treatments ordered; * Any safety measures required to prevent injury; * Types of services and equipment required; * Frequency of visits for nursing, home health aide, and therapists; * Discharge plan including expected date of referral or discharge; * Patient risk level for rehospitalization and/or emergency department visits and necessary interventions to address underlying conditions; * Patient and caregiver education and training to facilitate timely discharge; * Patient specific interventions and goal identified by the agency and patient; * Information related to advanced directives; and * Any additional items the agency or physician may choose to include; - Therapists and other agency personnel shall participate in developing the POC; - The registered nurse or therapist records and signs all verbal orders and obtains the physician's signature; - The POC is considered a verbal order to start care; - If changes are needed after the initial visit/evaluation, the physician will be notified and appropriate modifications or additions obtained and documented in verbal or written orders; - Agency staff will promptly notify the physician of any changes at any time that suggest a need to alter the plan of treatment; - Any revision to the POC, including changes in discharge plan, due to a change in patient health status must be communicated to the patient, representative (if any) caregiver, and all physicians issuing orders for the POC; - Therapy orders will include the specific procedures and modalities to be used and the amount; verbal orders will be obtained and documented for any change in therapy services before the change is implemented; and - Medications shall be reviewed for possible ineffective drug therapy, adverse reactions, significant side effects, drug interactions, allergies, contraindications, and report any concerns/problems to the physician. RECORD/PATIENT #1: Review of the comprehensive start of care assessment dated 4/22/2021 showed the patient was admitted with a primary diagnosis of Type 2 diabetes mellitus (a disease characterized by unstable blood sugars) with a foot ulcer. Other diagnoses included but not limited to: -Acquired absence of right great toe (amputated toe); -Personal history of diabetic foot ulcer (an open sore or wound that occurs in approximately 15 percent of patients with diabetes and is commonly located on the bottom of the foot); and -Peripheral vascular disease (a circulatory condition in which narrowed blood vessels reduce blood flow to the limbs). Review of the patient's plan of care (POC) dated 4/22/2021 showed DME (durable medical equipment) and supplies with surgical sandals (a medical shoe used to protect the foot and toes after an injury or surgery) and Prevalon boot (a protective boot designed to keep the heel off the mattress to relieve pressure for individuals when in bed) listed. The POC failed to show further directions for their use. Review of skilled nursing visit notes dated 04/23/2021, 05/04/2021 and 05/17/2021 showed the patient wearing surgical sandals during the day and pressure relief boot on left lower extremity at night. This information was not limited to the above dated skilled nurse visit notes but also found on other notes. During a home visit observation on 06/08/21 beginning at 11:00 AM, showed: - The patient was wearing surgical sandals upon arrival to the home; - The nurse removed the surgical sandals to perform dressing change; - After the patient requested instructions on the use of the pressure relief boot, the nurse applied and removed a pressure relief boot and told the patient to wear that boot when in bed; and - The nurse replaced the surgical sandals after completing the dressing change. During an interview on 06/09/2021 at 10:40 AM, the clinical manager stated that: - He/she was unable to locate the directions for use of the surgical sandals or the pressure relief boot on the plan of care dated 04/22/2021; - The sandals were worn when up and the boot to his/her left lower extremity when he/she was in bed; and - He/she would add these orders to the plan of care. RECORD/PATIENT #2: Review of the clinical record showed the patient was admitted to home health services on 05/30/2021 with a primary diagnosis of fusion of lumbar spine (surgery to permanently connect two or more vertebrae in the lower spine) and co-morbidities of scoliosis (sideways curve in the backbone) and Parkinson's disease (a progressive disease of the nervous system marked by tremor, muscular rigidity, and slow, imprecise movement). The patient lives at home alone. Review of the skilled nursing visit notes dated 05/30/2021 and 06/02/2021 showed the patient: - Wore an abdominal binder during the day; and - Used ice to help relieve pain. Review of the plan of care dated 05/30/21 to 07/28/2021 failed to show orders or instructions for use of the abdominal binder or ice treatments. During a home visit observation on 06/08/2021 at 9:10 AM, the patient was observed wearing a lumbar back brace during the whole visit. During an interview on 06/08/2021 at 3:30 PM, the clinical manager stated that orders for the use of the abdominal binder and the ice treatment should have been on the plan of care. RECORD/PATIENT #3: Review of the initial comprehensive assessment dated 05/30/2021 showed: - An additional diagnosis included dependence upon supplemental oxygen and long term use of insulin; - Diabetic teaching included but not limited to: Checks blood glucose levels QID, currently on insulin therapy for blood glucose control, knowledgeable on insulin but needs further education regarding insulin dosage, and educated on sliding scale dosing; - Oxygen use: 2 liters/minute per nasal cannula, oxygen concentrator for delivery of oxygen, O2 saturation 91% (normal 95-100%); - Dressing to right knee clean, dry, and intact and covered with ace bandages and wearing compression stockings; and - Patient using ice machine as needed to relieve pain. Review of the admission plan of care (POC) dated 05/30/2021 through 07/28/2021 showed: - Diagnoses included but not limited to: Displaced subtrochanteric fracture (hip/femur fracture), chronic obstructive pulmonary disease (COPD, asthma), and insulin dependent diabetes mellitus; - Lispro insulin (Humalog, a fast acting insulin), 100 units/milliliter (ml), four times a day (QID) before meals and at bedtime via insulin sliding scale (amount of insulin determined by the blood glucose/sugar levels); - Blood glucose monitoring PRN; - Did not address sliding scale blood glucose levels and corresponding insulin dosages; - Did not address O2 administration, liters per minute (amount of oxygen to be delivered), and delivery system to be used to deliver oxygen (nasal cannula or mask); - Did not address length of time and how often Polar Cooler Ice Machine to be applied to the right knee; and - Did not address how often and how long ace wraps and compression stockings were to be worn/applied. During an interview on 06/09/2021 at 9:15 AM, the clinical manager stated that the sliding scale dosages, O2 liters/minute and delivery system, ace bandages and compression stockings and ice machine instructions should be listed on the POC. RECORD/PATIENT #5: Review of the initial comprehensive assessment dated 05/21/2021 showed: - Patient currently self-administering Lovenox injections; and - Lovenox (a blood thinning medication to help prevent deep vein thrombosis (blood clots) following joint replacement surgery) injections to be administered daily for seven days. Review of the POC dated 05/21/2021 through 07/19/2021 showed: - Diagnosis included but not limited to: Aftercare following joint replacement (total right knee replacement); - Enoxaparin (Lovenox), solution 40 milligrams (mg)/0.4 milliliters (ml), 40 mg daily SQ (subcutaneous, beneath the skin) injectable; and - Did not include how many doses/days the Lovenox was to be administered, who was to administer the injection or if it was to be self-administered, or an end date for the Lovenox. During an interview on 06/09/2021 at 9:15 AM, the clinical manager stated that: - The skilled nurse should list the end date and other information about Lovenox injectable on the POC; and - The nurse caring for the patient was new to home health and needed more training.

Visit schedule CFR(s): 484.60(e)(1) Visit schedule, including frequency of visits by HHA personnel and personnel acting on behalf of the HHA. This ELEMENT is not met as evidenced by: Based on record review, home visit observation, and interview, the agency failed to ensure written instructions were provided to the patient/caregiver outlining the visit schedule, including the frequency of visits in three (Record/Patients #1, #2, and #3) of three home visit observations. This deficient practice has the potential to adversely affect the patient involvement with the plan of care for all the agency's patients. Findings included: A policy failed to be provided by the agency. RECORD/PATIENT #1: Review of the clinical record showed the patient was admitted to home health services on 04/22/2021 with diabetes mellitus type 2 with a foot ulcer (an open sore or wound that occurs in approximately 15 percent of patients with diabetes and is commonly located on the bottom of the foot). During a home visit observation with the skilled nurse on 6/08/2021 starting at 11:00 AM, the home folder/book was reviewed and failed to show a written frequency of visits for the skilled nurse or the physical therapist. The calendar in the folder failed to be completed with a schedule for any disciplines. During an interview with the patient during the observation visit, he/she stated that there was no schedule left due to the frequency of his/her doctor's appointments. RECORD/PATIENT #2: Review of the clinical record showed the patient was admitted to home health services on 05/30/2021 with a primary diagnosis of fusion of lumbar spine (surgery to permanently connect two or more vertebrae in the lower spine). The patient had co-morbidities of scoliosis (sideways curve in the backbone) and Parkinson's disease (a progressive disease of the nervous system marked by tremor, muscular rigidity, and slow, imprecise movement). The patient lived at home alone. During a home visit observation with the occupational therapist on 06/08/2021 starting at 9:10 AM, the home folder/book was reviewed and failed to show a written frequency of visits for the skilled nurse, physical therapist, or occupational therapist. The calendar in the folder failed to be completed with a schedule for any disciplines. During an interview with the patient during the observation visit, he/she stated that he/she did not know when the nurse would be coming back. RECORD/PATIENT #3: Observation during a home visit on 06/08/2021 at 11:30 AM showed: - The physical therapist (PT) provided the patient's home folder to the surveyor; and - A blank copy of a visit schedule was found in the home folder. During an interview on 06/08/2021 at 11:30 AM, the PT stated that: - He/she normally told patients when he/she would make a visit; - If the patient wants the visit written down, he/she would write it on a calendar; and - He/she just fits in a visit when he/she can because his/her schedule is so busy. During an interview on 06/09/2021 at 9:40 AM, the clinical manager stated that there is a copy of a printed visit schedule in the home folder and all disciplines should record their visits for the patients.

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 policy review, record review, home visit observation, and interview, the agency failed to ensure written instructions were provided to the patient/caregiver outlining the patient medication schedule/instructions in one (Record/Patient #2) of three home visit observations. This deficient practice has the potential to adversely affect the patient involvement with the plan of care for all the agency's patients. Findings included: Review of an untitled policy dated reviewed and approved by the governing board July 15, 2020 showed patients/caregivers/responsible parties will have a medication profile in the home. RECORD/PATIENT #2: Review of the clinical record showed the patient was admitted to home health services on 05/30/2021 with a primary diagnosis of fusion of lumbar spine (surgery to permanently connect two or more vertebrae in the lower spine) and co-morbidities of scoliosis (sideways curve in the backbone) and Parkinson's disease (a progressive disease of the nervous system marked by tremor, muscular rigidity, and slow, imprecise movement). The patient lived at home alone. During a home visit observation with the occupational therapist on 06/08/2021 starting at 9:10 AM, the home folder/book was reviewed and failed to show a written medication schedule. When the medications were reviewed with the patient, he/she stated that there was no written medication schedule in the home. During an interview on 06/08/2021 at 3:35 PM, the clinical manager stated that RN A (admitting nurse) must have forgotten to take a medication profile to the home.

Treatments and therapy services CFR(s): 484.60(e)(3) Any treatments to be administered by HHA personnel and personnel acting on behalf of the HHA, including therapy services. This ELEMENT is not met as evidenced by: Based on home visit observation and interview, the agency failed to provide the patient/caregiver with a copy of written instructions of any treatments being administered by the agency in two (Record/Patient #2 and #3) of three home visit observations. This deficient practice has the potential to affect the patient's knowledge of self-care and agency expectations in all patients served by the agency. Findings included: The agency did not have a policy related to providing written instructions for treatments to be left in the patients homes. RECORD/PATIENT #2: Review of the clinical record showed the patient was admitted to home health services on 05/30/2021 with a primary diagnosis of fusion of lumbar spine (surgery to permanently connect two or more vertebrae in the lower spine) and co-morbidities of scoliosis (sideways curve in the backbone) and Parkinson's disease (a progressive disease of the nervous system marked by tremor, muscular rigidity, and slow, imprecise movement). The patient lived at home alone. Review of the physical therapy (PT) evaluation visit note dated 06/02/2021 showed the PT evaluated the patient and was only making the one visit. A home exercise program was given to the patient. During a home visit observation with the occupational therapist on 06/08/2021 starting at 9:10 AM, the home folder/book was reviewed and failed to show a written instructions for the physical therapy home exercise program. The patient stated that there was no written therapy instructions in the home, he/she was doing the exercises he/she was instructed on at the in-patient facility prior to discharge. During an interview on 06/08/2021 at 3:35 PM, the clinical manager stated that written instructions should have been left in the home. RECORD/PATIENT #3: During a home visit observation on 06/08/2021 at 11:30 AM with physical therapist (PT) C, the surveyor observed the patient's home admission folder. The agency failed to provide written instructions for therapy exercises or any other treatments/therapy administered by the agency staff. During an interview on 06/08/2021 at 11:30 AM PT C stated that: - He/she saw the patient only one time previous to today's visit; - The physical therapy assistant (PTA) visits the patients routinely and should bring copies of exercises for the patient to leave in the home; - He/she would text the PTA and tell him/her to bring printed exercises to the patient and leave in the home folder. During an interview on 06/09/2021 at 10:00 AM, the clinical manager stated that staff should leave therapy instructions or other treatment information in the patient's home.

Infection Prevention CFR(s): 484.70(a) Standard: Infection Prevention. The HHA must follow accepted standards of practice, including the use of standard precautions, to prevent the transmission of infections and communicable diseases. This STANDARD is not met as evidenced by: Based on policy review, home visit observation, and interview, the agency staff failed to follow accepted standards of practice for one (Record/Patient #2) of three patients observed during home visits. This deficient practice has the potential to adversely affect the health and safety of all the patients receiving care from the agency. Findings included: Review of the agency's policy titled, "Infection Control Plan for Home Care Agency," dated July 15, 2020, showed that homecare activities that require hand decontamination include but are not limited to: - After contact with a patient's intact skin (e.g. (example) when taking a pulse or a blood pressure, and lifting a patient); and - After contact with an inanimate object (including medical equipment) in the patient's immediate vicinity. RECORD/PATIENT #2: A home visit observation on 06/08/2021 starting at 9:10 AM showed: - The occupational therapist (OT) re-entering her bag on multiple occasions after patient contact and failed to decontaminate her hands; - The OT set up a pegboard on a barrier on the kitchen counter to utilize as an activity for fine motor dexterity; - He/she then dropped a peg on the kitchen floor; - He/she proceeded to pick it up and lay it on the barrier with the peg board for the patient to utilize during the therapy session and failed to decontaminate the peg; and - The patient on two more occasions dropped a peg to the floor during the activity, each time the OT picked them up and failed to decontaminate them before allowing the patient to utilize them. During an interview on 06/09/2021 at 10:40 AM, the clinical manager stated that: - The therapist should have gotten all of his/her needed items out of the bag at one time; - The therapist should have decontaminated his/her hands before re-entering the bag after patient contact; and - It would be not be appropriate to utilize the pegs without first cleaning them after they fell on the floor.

Provide services in the plan of care CFR(s): 484.75(b)(3) Providing services that are ordered by the physician or allowed practitioner as indicated in the plan of care; This ELEMENT is not met as evidenced by: Based on policy review, clinical record review, and interview, the agency failed to ensure that the registered nurse followed the physician's orders as indicated on the patient's individualized plan of care related to wound care orders in one (Record/Patient #1) of one patient observed for wound care. This deficient practice has the potential to adversely affect the care of all the patients served by the agency. Findings included: Review of the agency's policy titled, "Plan of Treatment/Care," dated July 15, 2020, showed in part, that the plan of treatment used for all clients shall include: - The medications and treatments ordered; - All personnel making home visits must conform to all physician's orders; and - The agency staff administers medications and treatments only as ordered. RECORD/PATIENT #1: Review of the clinical record showed the patient was admitted to home health services on 04/22/2021 with diabetes mellitus type 2 with a foot ulcer (an open sore or wound that occurs in approximately 15 percent of patients with diabetes and is commonly located on the bottom of the foot). Review of the most recent wound care order in the clinical record dated 5/25/2021 showed: - Dressing change, 1 application, wound #4, right foot - cleanse daily with normal saline, apply calcium alginate (a highly absorbent, biodegradable alginate dressing derived from seaweed), gauze 4x4, kerlix (a brand of rolled gauze bandage) secure with paper tape, change daily; and - Dressing change, 1 application, wound #3, left calcaneous (heel) - cleanse daily with normal saline, apply calcium alginate, gauze 4x4, kerlix secure with paper tape, change daily. During a home visit observation on 06/08/21 beginning at 11:00 AM, RN A completed each dressing change utilizing Algicell AG ( a calcium alginate dressing with antimicrobial silver) and failed to use calcium alginate as ordered. During an interview 06/09/2021 at 10:40 AM, the clinical manager stated, "Oh, I didn't write the AG (abbreviation for silver) on the end? I will go clarify that order."

Communication with physicians CFR(s): 484.75(b)(7) Communication with all physicians involved in the plan of care and other health care practitioners (as appropriate) related to the current plan of care; This ELEMENT is not met as evidenced by: Based on agency policy review, clinical record review, home visit observation, and interview, the agency failed to assure agency clinicians effectively communicated with all physicians or other health care practitioners related to the patient's current plan of care (POC) in, but not limited to, two (Record/Patient #2 and #5) of five full record reviews. This deficient practice has the potential to affect all patients served by the agency. Findings included: Review of the agency's policy dated 07/15/2020 titled, "Plan of Treatment/Care," showed: - If changes are needed after the initial evaluation/visit, the physician will be notified and appropriate modifications or additions obtained and documented in verbal and written orders; and - The agency staff will promptly notify the physician of any changes at any time that suggest a need to alter the plan of treatment. RECORD/PATIENT #2: Review of the clinical record showed the patient was admitted to home health services on 05/30/2021 with a primary diagnosis of fusion of lumbar spine (surgery to permanently connect two or more vertebrae in the lower spine) and co-morbidities of scoliosis (sideways curve in the backbone) and Parkinson's disease (a progressive disease of the nervous system marked by tremor, muscular rigidity, and slow, imprecise movement). The patient lived at home alone. Review of the referral information from the hospital showed: - CarePort (electronic system for communication of referrals from facilities) New Home Care Referral for the patient showed comments from the referral source as follows: Discharge expected for 05/28/2021. Can you accept for PT/OT (physical therapy/occupational therapy), nursing and bath aide; and - Faxed communication from the hospital sent on 05/28/2021 showed the following: * Primary disciplines requested: Physical therapy and skilled nursing; and * Secondary disciplines requested: Occupational therapy and aide. Review of the plan of care dated 05/30/2021 to 07/28/2021 showed orders for: - PT one time per week for one week to evaluate and treat; - OT to evaluate and treat; and - Failed to show orders for home health aide visits. Review of the start of care comprehensive nursing assessment dated 05/30/2021 failed to show documentation of: - The patient's bathing and grooming needs and if the services of a home health aide would be beneficial; - If the patient declined home health aide services: and - Communication with the physician regarding discontinuation of home health aide services. Review of the physical therapy evaluation visit dated 06/02/2021 showed an evaluation of the patient was completed and the patient declined further PT visits. The clinical record failed to show communication with the physician regarding a one time only PT visit and the patient declining therapy care. During an interview on 06/08/2021 at 3:30 PM, the clinical manager stated that: - The PT should have faxed the physician to let them know that only a PT evaluation was completed and no further visits were planned; and - The patient probably refused bathing and it should have been documented on the nursing visit note. RECORD/PATIENT #5: Review of the POC dated 05/21/2021 through 07/19/2021 showed: - Aftercare joint replacement surgery (right total knee). Review of a skilled nursing note dated 05/27/2021 showed: - Patient complained of a new reddened area on the right lower extremity (RLE), anterior (front) shin, painful to touch; - Physician contacted, left message for nurse to call back about reddened area; and - No further documentation of follow up with physician concerning reddened area to RLE anterior shin. Review of skilled nursing notes dated 06/01/2021 and 06/04/2021 did not show documentation related to follow up with the physician concerning the reddened area on the RLE anterior shin. During an interview on 06/09/2021 the clinical manager stated that: - There was no documentation for follow up with the physician related to the reddened area to the patient's shin until a late entry for 05/27/2021 was entered into the electronic record during the survey on 06/08/2021; and - The registered nurse caring for the patient was new to home health and needed more training in how to document in the clinical record.

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 agency policy review, clinical record review, and interview, the agency failed to ensure a completed transfer summary was sent within two business days of an unplanned transfer to the receiving facility in one (Record/Patient #6) of two discharge records reviewed. This deficient practice has the potential to affect all discharged or transferred patients served by the agency. Findings included: Review of the agency's policy dated 07/15/2020 titled, "Home Health Discharge, Transfer, and Referral Policy," showed: - Discharge or transfer from this agency may occur if your physician who is responsible for your home health plan of care (POC) and the agency agree that measurable outcomes and goals of your POC have been achieved and you no longer need home health services; - Your physician who is responsible for your home health plan of care and the agency agree they can no longer meet your needs based on your acuity (the level of attention or service a patient needs from professional staff) level; the agency will arrange transfer to another care provider when the patient's needs exceed the agency's capabilities; - Discharge summaries will be sent to the primary care physician or other physicians who will be responsible for providing care and services to the patient after discharge from the agency within five business days of the patient's discharge; and - Transfer summaries will be completed and sent within two 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 agency becomes aware of the transfer. RECORD/PATIENT #6: Review of the POC dated 04/22/2021 through 06/20/2021 showed: - Diagnoses included but not limited to: Parkinson's disease (a brain disorder that leads to shaking, stiffness, and difficulty with walking, balance, and coordination), dehydration, weakness, chronic kidney disease (a condition characterized by a gradual loss of kidney function over time), and lymphedema (swelling that generally occurs in the arms or legs). Review of the clinical record showed: - A physical therapy (PT) evaluation performed on 04/23/2021, further visits to be performed; and - An occupational therapy (OT) evaluation performed on 04/26/2021, no further OT visits to be performed. Review of a skilled nursing (SN) visit dated 05/03/2021 at 10:00 AM showed: - 4+ pitting edema (severe swelling of the extremities from fluid buildup in the tissue causing a large indentation when pressed, arising from congestive heart failure) in the BLE (bilateral lower extremities), right lower leg reddened and tender to touch, increased weakness, nosebleed, "hurts all over", numbness of 4th digit right hand, did not want to seek emergent care, but wanted to return to skilled nursing facility; family member planned to take patient to the facility this after noon (05/03/2021); - Primary care physician's office notified of edema and weight increase; - Spoke with SN facility; informed a bed was available for the patient; and - Family member notified; to transport the patient to the SN facility this afternoon. Review of a physical therapy assistant (PTA) visit note dated 05/03/2021 at 12:24 PM did not show documentation related to discharge on this date to a skilled facility. Review of a Case Communication note dated 05/03/2021 showed: - 4+ pitting edema (severe swelling of the extremities from fluid buildup in the tissue causing a large indentation when pressed, arising from congestive heart failure) in the BLE (bilateral lower extremities), right lower leg reddened and tender to touch, increased weakness, nosebleed, "hurts all over", numbness of 4th digit right hand, did not want to seek emergent care, but wanted to return to skilled nursing facility; family member planned to take patient to the facility this after noon (05/03/2021). Review of a nursing discharge summary dated 05/04/2021 showed: - Diagnoses included but not limited to: Dehydration, Parkinson's disease, chronic kidney disease, and weakness; - On 04/27/2021, 3+ pitting edema to BLEs; - Right lower leg with redness and tender to touch; - Patient declined emergent care and patient requested admission to skilled nursing facility; - Did not include summary for physical or occupational therapies; and - Faxed/sent to primary care physician on 05/04/2021 at 11:51 AM. During an interview on 06/09/2021 at 9:15 AM, the clinical manager stated that: - A SN transfer summary was sent to the primary care physician on 05/04/2021 one day after the patient's transfer to the skilled nursing facility; - The SN transfer did not include a summary from physical therapy (PT) or occupational therapy (OT), who performed evaluation assessments on the patient; - The SN transfer summary was not sent to the skilled nursing facility; and - PT nor OT sent a transfer summary to the SN facility when the patient was transferred.