Every finding on record at L. Woerner, Inc.

Investigate complaints made by patient CFR(s): 484.50(e)(1)(i) (i) Investigate complaints made by a patient, the patient's representative (if any), and the patient's caregivers and family, including, but not limited to, the following topics: This ELEMENT is not met as evidenced by: Based on a review of 6 patient records, the agency's complaint log, and interviews with the Chief Nursing Officer and Regional Director of Patient Services (DPS), it was determined in 1 patient record (patient #5) the agency failed to have an effective process in place to ensure that all complaints related to patient care are documented, investigated, and resolved. Evidence as follows: Patient #5 was admitted to the agency on 04/22/24 with diagnoses that included surgical aftercare following surgery of the circulation system, type 1 diabetes, heart failure, chronic obstructive pulmonary disease, and atrial fibrillation. An agency Client Episode Coordination note dated 05/06/24, indicated the agency received call from a hospital case manager that stated the patient had voiced "some concerns" about not hearing from agency nursing staff "on visits." The note continues as follows: - 05/07/24, 8:57 a.m., telephone call to patient's cell number. Left voice mail "that we received information that they were unhappy with some of the home care, left VM to call back regarding issues." - On 05/07/24, 9:30 a.m. "I called the patient's hospital room but no answer." - On 05/07/24, 10:35 a.m., telephone call to the the spouse's cell phone and left a voice mail to call back regarding issues. - 05/07/24 2:17 p.m., called patient's cell phone again, left voice mail. A note dated 05/08/24 included more attempts to reach the patient: - 05/08/24 9:57 a.m., telephone call to the patient's cell phone, and left another message. - 05/08/24 11:32 a.m., telephone call to spouse, and left voice mail to return call. - 05/08/24, 1:55 p.m., received a call from patient's relative. Discussed issues with home care and expectations. Reviewed the services to be provided and what a home care visit looks like. The relative felt that the patient and caregiver "didn't really know what home care was, and their expectations of what it was." The relative stated they would be speaking to the patient and caregiver to explain. On 06/21/24, the Complaint Log for the past 4 months was requested and received during the entrance conference. A review of the Complaint Log from 2/1/24-6/13/24 revealed that patient #6's complaint was not entered in the log. The agency's "Patient Concerns/Grievances" policy, revised 01/2021, included: - All HCR staff are responsible for notifying the Clinical Manager or his/her designee. - The Clinical Manager or his/her designee is responsible for investigating all patient complaints - A summary log will be retained by the Director of Patient Services. The agency failed to log, investigate, and follow policy when the complaint was received. On 06/21/24 at 2:15 p.m., the surveyor reviewed the above records with the Chief Nursing Officer, Director of Patient Services, and Clinical Managers. They acknowledged the findings and provided no additional information. Failure to track, investigate and resolve complaints has the potential for unmet patient needs and possible negative patient outcomes.

This statement of deficiencies report is the result of a review of the agency's emergency preparedness during the recertification survey conducted 11/06/23 through 11/15/23. The following information was reviewed on 11/04/23 during the pre-survey preparation: accuracy of contact information in the Health Commerce System. The following information was reviewed during the survey: the agency's emergency preparedness policies and procedures, communication plan, the emergency patient roster and current listing of agency staff. Interviews were conducted with the Administrator, Director of Patient Services and Clinical Managers. The following deficiency was cited: J 1156 Governing Authority

The following statement of deficiencies represents the results of a partial extended recertification survey of HCR / HCR Home Care Certified Home Health Agency (Liverpool) conducted 11/06/2023 through 11/15/2023 and included complaint investigation #NY0099057. The allegations in complaint #NY0099057 were determined unsubstantiated. A standard recertification survey was initiated on 11/06/2023. Deficient practices were identified within Level 1 standards in Condition 484.60 (Care planning, coordination of services, and quality of care), resulting in a partial extended survey. The survey consisted of a review of 18 clinical records, including 5 discharge records, 10 personnel records, and 7 observational home visits. The survey included a review of pertinent policies and procedures, Quality Improvement meeting minutes for the past 12 months, the agency's Admission Packet, the Emergency Preparedness Plan, 2 contracts, and the Complaint Log were reviewed. Pre-survey activities consisted of a review on 11/02/23 of the agency’s Health Commerce System account, internet Quality Improvement and Evaluation System (iQIES) reports for the period 08/01/2022 through 07/31/2023, and the agency’s compliance with report submission for the 2022 statistical report. The Administrator, Director of Patient Services, Clinical Managers, and nursing staff were interviewed. Findings were reviewed at the exit conference on 11/15/23. The following deficiencies were identified as a result of the survey: Federal: G526 Content of the comprehensive assessment; G536 A review of all current medications; G548 Within 48 hours of the patient's return; G 574 Plan of care must include the following: G578 Conformance with physician's orders; G 606 Integration of all services; G 682 Infection prevention and G798 Home Health Aide assignments and duties. State: J1156 Governing Authority and J1420 Personnel.

Content of the comprehensive assessment CFR(s): 484.55(c) Standard: Content of the comprehensive assessment. The comprehensive assessment must accurately reflect the patient's status, and must include, at a minimum, the following information: This STANDARD is not met as evidenced by: Based on clinical record review, observational home visits, and interviews with the Administrator, Director of Patient Services (DPS) and Clinical Managers (CM), it was determined for 5 of 18 patients (patients #1, 3, 12, 13, and 17) the agency failed to ensure initial comprehensive nursing assessments were of sufficient scope to ensure all patient needs were identified. Evidence as follows: Patient #12 was admitted to the agency on 10/04/23 with diagnoses of urinary symptoms, hyperkalemia, chronic kidney disease, benign prostatic hypertrophy, and congestive heart failure. On 10/04/23 the skilled nurse (SN) visited the patient for the initial assessment and failed to perform a comprehensive assessment of pain management. The 10/04/23 to 12/02/23 Home Health Certification and Plan of Care included the following: -Acetaminophen 500 mg three times a day as needed (PRN) for pain. -Lidocaine 4% patch every 12 hours PRN for back pain, on 12 hours off 12 hours. The SN documented the patient currently had 4 out of 10 aching pain to the right hip. The SN failed to assess pain throughout the day, what worsened pain and what relieved pain. The SN documented the patient was taking acetaminophen three times a day and failed to document the dosage of the medication and effectiveness. The SN failed to assess if the patient was using the lidocaine patch, the location of use and effectiveness of the intervention. On 11/14/23 at 2:45 p.m. the record was reviewed with the Administrator, DPS and Clinical Managers. They acknowledged the findings and provided no additional information. Patient #17 was admitted to the agency 04/27/23 with diagnoses including type 2 diabetes with foot ulcer, non-pressure chronic ulcer of left heel and mid-foot, and osteomyelitis. The patient was selected from the internet Quality Improvement Evaluation System (iQIES) Potentially Avoidable Event Reports for Increase in Number of Pressure Ulcers and Discharged to the Community with an Unhealed Stage II Pressure Ulcer. The 04/27/23 Certification and Plan of Care, and subsequent orders, included skilled nurse (SN) visits 2-3 times weekly to provide wound care and assessment. On 05/01/23 the SN documented wound measurements as 13 cm (length) x 12.2 cm (width) x 0.8 (depth). On 05/08, 05/19, 05/22, and 05/31/23 the SN documented in the Wound Record Report the reason wound measurements were not taken as “Worldview” (a software program to capture wound photos and measurements). On 05/08 wound photos were taken that did not capture measurements; there were no wound photos or measurements present in the record from 05/19 or 05/22/23. On 05/31/23 wound photos included measurements as 16 cm x 12.4 cm x 0.1 cm. On 06/05/23 the SN documented the wound measured 14 cm x 13 cm x 2.5 cm, there was no documentation related to the significant increase in depth. On 11/13/23 the surveyor reviewed the undated agency policy “WOUNDS” which stated, “Wounds should be measured a minimum of once per week or if there is a significant change in wound status.” From 05/01/23 through 05/31/23 the SN failed to assess wound measurements per agency policy. On 11/13/23 at 1 p.m. the above record was reviewed with Administrator, DPS and Clinical Managers. They acknowledged the findings and provided no additional information. Patient #13 was admitted to the agency on 04/12/23 with diagnoses including type 2 diabetes, end-stage renal disease, retinopathy, depression, and cerebral vascular accident (stroke). The patient was selected from the internet Quality Improvement Evaluation System (iQIES) Potentially Avoidable Event Reports for Hyper/Hypoglycemia. Nursing The Home Health Certification and Plan of Care (POC) dated 04/18/23 included the following: - skilled nurse (SN) for instruction/reinforcement of diabetes management, including diet, skincare, foot care, and medications to manage blood sugar. Patient/Caregiver blood glucose testing. The patient's primary care provider's office notes dated 04/06/23 included the patient was having problems managing diabetes due to poor fine motor skills and retinopathy (poor vision) and will try to use a sensor to monitor blood sugar but will have to evaluate whether the screen of the phone is able to be seen consistently. The patient stated the screen of the glucometer is not able to be consistently seen. Medications included: - lantus insulin 100u/ml, 14 units at bedtime - Humalog kwikpen (U-100) insulin, use 2 times daily with breakfast and dinner 70 - 90 6u, 91 - 130 8u, 131 - 150 10u, 151- 200 12u, ...351 - 400 20u. - Baqsimi 3mg/actuation nasal spray 1 spray in nostril as needed for low blood sugar. Maximum daily dose of one spray. On 04/18/23, the SN visited for the initial assessment of the patient and documented the patient lived alone and had decreased vision, which made blood sugar testing difficult. A note indicated the patient was to be assessed on 04/20/23 for a talking glucometer. The SN documented that blood sugar was elevated during the visit and also spoke to the physician's office staff to obtain the Humalog sliding scale for twice-daily use. The SN failed to assess if the patient could test the blood sugar independently with limited vision and to assess the availability of the caregiver. There was no evidence the SN ensured the patient could see the sliding scale, use the Humalog pen, and interpret the sliding scale with impaired vision. On 04/21/23, the SN visited and found the range of blood sugar readings from the glucometer 216 - 455. The SN documented that " the 455 is after not taking the insulin as prescribed because the patient stated they were too tired." The SN documented the patient's remarks from the visit as, sometimes I get tired and don't take the Lantus, and also documented the patient hadn't tested the blood glucose that day; no reason for not testing was noted. The SN failed to assess if the patient was capable of testing the blood sugar independently or if the caregiver had been available to assist the patient with testing and medications. On 04/28/23, the SN visited and determined the patient was now testing and using the sliding scale 3 times daily instead of the previously ordered 2 times daily. The SN notified the physician's office and updated the order. There was no evidence the SN discussed with the physician's office or patient the amount of Humalog insulin on hand or the increased amount that would be required to ensure the patient would have enough insulin for the new, 3 times per day order. The discharge note dated 06/09/23 included the patient sought emergent care for hyperglycemia without hospital admission and that the patient had "run out of insulin." Social Work The patient's primary care provider's office notes dated 04/06/23 included in the agency referral indicated "Home Care referral to be initiated. SW assessment would be helpful d/t current social situation and depression." On 04/18/23, the SW included in the start of care narrative note social work to evaluate for life alert services in the home. The 04/18/23 POC included the referral for medical social services, effective 04/23/23, once a week for 2 weeks to evaluate and assess social and emotional factors related to the client's illness, need for care, response to treatment and adjustment to care to be followed by collaboration with the physician and nurse to develop a plan of care. The POC also included an antidepressant, duloxetine 30mg capsule daily. The reason for the referral listed on the POC was an evaluation of additional resources that may be available in the home, long-term care, and blister packs. On 04/25/23, the social worker (SW) visited the patient and documented emotional findings that the patient had anxiety, a pre-existing psychiatric diagnosis. In the narrative note from the visit, neither the patient's emotional findings, anxiety, or depression were documented. The SW failed to assess the patient's anxiety, depression, or need for life alert. On 11/13/23 at 1 p.m., the above record was reviewed with the Administrator, DPS, and Clinical Managers. They acknowledged the findings and provided no additional information. Failure of the agency staff to perform a comprehensive assessment of the patients may result in unmet patient needs and negative patient outcomes.

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 a review of clinical records, observational home visits and interviews with the Administrator, Director of Patient Services (DPS) and Clinical Managers (CM), it was determined in 2 of 18 records, (patients #5 and 10) the skilled nurse (SN) failed to perform comprehensive medication reviews. Evidence as follows: Patient #10 was admitted to the agency on 03/21/23 with diagnoses of kidney failure, congested heart failure, chronic obstructive pulmonary disease, and anemia. The 10/13/23 hospital discharge instruction documented the patient had been admitted to the hospital on 10/08/23 with the diagnosis of hematochezia (rectal bleeding) and was discharged on 10/13/23 with an indwelling catheter. The 10/13/23 discharge instructions for the medication spironolactone (a diuretic, or fluid reducer) 1- 25mg tablet on Monday, Wednesday, and Friday and was a change from daily administration. The 10/20/23 resumption of care order documented spironolactone 1- 25mg tablet daily. There was no evidence of a supplemental order with a medication change after the patient had been discharged from the hospital. The skilled nurse failed to accurately update the plan of care and reconcile the medications. On 11/13/23 at 1:00 p.m., the surveyor reviewed the above records with the Administrator, DPS, and CM. They acknowledged the findings and provided no additional information. Home Visit (HV) Patient #5 was admitted to the agency on 09/15/23 with diagnoses of surgical amputation of the toes, type 2 diabetes with peripheral angiopathy, atherosclerosis, paroxysmal atrial fibrillation, coronary heart disease, congestive heart failure, and anemia. The Home Health Certification and Plan of Care (POC) dated 09/15/23 included furosemide (a diuretic) 1 - 40mg tablet twice daily. On 11/08/23 at 12:00 p.m., the surveyor conducted an observational HV with the skilled nurse (SN). During the visit, the SN reviewed the patient's medication bottles and compared them to the physician's orders on the POC. The patient's furosemide bottle label ordered 1- 40mg tablet daily. The patient stated, "I take that one once daily, just like it says." The patient's weight had increased by 18 pounds from the start of care on 09/15/23 to the date of the HV. The SN called the physician's office during the visit to report the weight gain, clarify the order, and schedule a visit with the patient's physician. The SN had also reported a 10# weight gain to the physician on 10/23/23. The agency Medication Reconciliation Protocol dated 01/2022 included: - medication reconciliation is required at every in-home patient visit - compare the current medication orders and medication labels in the home and patient report of how medications are taken The POC included an order for Baqsimi (a fast-acting blood sugar elevator) 3mg/actuation nasal spray, 1 spray, as needed, into each nostril as needed for hypoglycemia. The patient stated that medication was "out in my truck, I think," and was never reconciled before the completion of the visit. The SN failed to reconcile the medications between the start of care and the HV. On 11/13/23 at 1 p.m., the above record was reviewed with the Administrator, DPS, and CM. They acknowledged the findings and provided no additional information. Home Visit (HV) Patient # 3 was admitted to the agency on 10/27/23 with diagnoses of acute kidney failure, type 1 diabetes, osteomyelitis, sepsis, congestive heart failure (CHF), and cellulitis of the left lower limb. On 11/07/23, the surveyor conducted an observational HV and reviewed the medications with the patient and caregiver afterward. The Home Health Certification and Plan of Care (POC) included: - multivitamin 1 tablet daily - nitroglycerin 0.4 mg sublingual tab every 5 minutes as needed for chest pain, maximum daily dose 3 tablets - senna plus 8.6mg - 50mg capsule, 2 caps at bedtime A review of the patient's medication and an interview with the patient and caregiver revealed the following: - the patient took women's multivitamin gummies, 2 pieces daily - the Senna Plus was PRN or as-needed only - the nitroglycerin vial was stored in the refrigerator and, after examination, found to have expired 02/2020 and, per the caregiver, had not been checked On 11/13/23 at 1 p.m., the above record was reviewed with the Administrator, DPS, and Clinical Managers. They acknowledged the findings and provided no additional information. Failure to perform complete and accurate medication reviews could lead to patients potentially taking medications inconsistent with the physician's intentions and possible negative patient outcomes.

Within 48 hours of the patient's return CFR(s): 484.55(d)(2) Within 48 hours of the patient's return to the home from a hospital admission of 24 hours or more for any reason other than diagnostic tests, or on physician or allowed practitioner - ordered resumption date; This ELEMENT is not met as evidenced by: Based on a review of clinical records, observational home visits, and interviews with the Administrator, Director of Patient Services (DPS) and Clinical Managers (CM), it was determined in 1 out of 18 records (patient #10) the skilled nurse (SN) failed to assess the patient within 48 hours of the patient's return to the home from a hospital admission of 24 hours or more. Evidence as follows: Patient #10 was admitted to the agency on 03/21/23 with diagnoses of kidney failure, congestive heart failure, chronic obstructive pulmonary disease, and anemia. On 10/08/23 the patient was admitted to the hospital with the diagnosis of hematochezia (blood in the stool) and was discharged on 10/13/23 (a Friday) with an indwelling urinary catheter. On 10/14/23 at 10:25 a.m., the on-call RN documented on the Patient Information Report the patient’s caregiver called the agency to report the patient was home from the hospital and the patient’s catheter was leaking. The on-call RN documented the resumption of care (ROC) visit was scheduled to occur 10/17/23 and directed the caregiver to take the patient to the emergency room if they were having problems with the catheter. The agency failed to appropriately address the patient’s acute need, and failed to complete the ROC assessment within 48 hours of the patient's return home from the hospital. There was no evidence the physician was notified and approved of the delayed resumption of care. On 11/13/23 at 1 p.m. the above findings were reviewed with the Administrator, DPS and CM. The CM stated it was agency practice not to make a visit for acute issues until after the ROC was complete, and that ROCs are not scheduled during the weekend because nursing staff work Monday through Friday. The Administrator later told the surveyor there are nursing staff on-call who can visit a patient and complete the ROC during the weekend. Failure to perform a resumption of care assessment within the required time frame has the potential to result in unmet patient needs and negative patient outcomes, and left this patient without needed home care services resulting in an unnecessary emergency room visit.

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 a review of clinical records, observational home visits, and interviews with the Director of Patient Services (DPS) and Clinical Manager, it was determined in 3 of 18 records (patients #1, 4 and 14) the agency failed to develop complete and accurate plans of care that were individualized to address the total needs of the patients. Evidence as follows: Patient #14 was admitted to the agency on 01/06/23 with diagnoses including type 2 diabetes and end stage renal disease. The patient was selected from the internet Quality Improvement Evaluation System (iQIES) Potentially Avoidable Event Reports for Emergent Care for Hypo/Hyperglycemia and Development of Urinary Tract Infection. The 01/06/23 Certification and Plan of Care (POC) included patient/caregiver check blood sugars 4 times daily and as needed using Dexcom scanner. On 01/06/23 the skilled nurse documented in the comprehensive assessment a random blood glucose of 252, with a range of 100 to 450. -The POC failed to include the acceptable range of blood glucose including parameters for when to notify the physician. On 11/13/23 at 1 p.m. the above record was reviewed with Administrator, DPS and Clinical Managers. They acknowledged the findings and provided no additional information. Home Visit (HV) Patient #4 was admitted to the agency on 02/24/23 with diagnoses of stage 4 pressure ulcers to gluteal and sacral sites, multiple sclerosis, paraplegia and cystostomy. The 10/16/23 certification period had ordered for the skilled nurse to administer bladder irrigation with 60 ml sterile water as needed for occlusion to the supra pubic catheter. On 11/08/23 at 10 a.m. the surveyor conducted an observational HV with skilled nurse and caregiver present. During the HV, the caregiver reported to the nurse they needed to irrigate the patient's supra-pubic catheter more frequently due to more frequent blockages. On 11/09/23 the agency provided a policy Standard of Care Documentation Protocol, dated 3/2022 included; plan of care must include an order to allow patient or caregiver to perform the intervention and to indicate the nurse is to teach as well as perform the intervention as needed. The SN failed to: - Report finding of increased need for irrigation in the home to the physician. - Teach caregiver supra-pubic irrigation treatment including use of equipment. - Establish if caregiver is correctly performing the treatment by a return demonstration. - Provide evidence that written directives were left in the home for reference when skilled nurse in not present. On 11/13/23 at 1:00 p.m., the surveyor reviewed the above records with the Administrator, DPS and Clinical Managers. They acknowledged the findings and provided no additional information. Failure to perform adequate assessments for changes in patient condition, notify the physician, and update the plan of care as needed, has the potential for unmet patient needs, and possible negative patient outcomes. Failure to ensure the development of complete and accurate plans of care to meet the needs of the patients may result in negative patients outcomes.

Conformance with physician orders CFR(s): 484.60(b) Standard: Conformance with physician or allowed practitioner orders. This STANDARD is not met as evidenced by: Based on review of patient records, observational home visits and interviews with the Administrator, Director of Patient Services (DPS) and Clinical Managers, it was determined in 4 of 18 patient records, (patients #3, 8, 14, and 17) that clinical staff failed to provide care as ordered by the physician. Evidence as follows: Patient #17 was admitted to the agency 04/27/23 with diagnoses including type 2 diabetes with foot ulcer, non-pressure chronic ulcer of left heel and mid foot, and osteomyelitis. The patient was selected from the internet Quality Improvement Evaluation System (iQIES) Potentially Avoidable Event Reports for Increase in Number of Pressure Ulcers and Discharged to the Community with an Unhealed Stage II Pressure Ulcer. On 05/18/23 the physician ordered “Skilled nurse to change Blastix cream with Adaptic, gauze, abdominal pad and secure with Kerlix on Monday, Wednesday and Friday.” The SN visited to provide wound care on Friday 5/19 and Monday 5/22; the patient was scheduled to be seen in the wound clinic on 05/24/23. On Friday 05/26/23 the skilled nurse visited the patient, documented wound care performed per physician orders, and the wound had a faint odor. On 05/31/23 the on-call RN documented the patient called and stated he received no visit that day and his dressing was saturated; the SN visited to complete wound care that evening 9:25-10:11 p.m. On 11/13/23 at 1 P.M., during record review, the surveyor asked why no visit occurred between 05/26 and 05/31/23. On 11/15/23 the DPS provided the surveyor a verbal order, dated 05/23/23, to reduce nursing visits to 2 times for the week of 05/28/23 due to the holiday. The DPS stated it was common practice for the agency to contact the physician to reduce frequency of visits to accommodate holidays. Review of the order revealed the LPN who wrote the order documented they left a detailed message for the nurse at physician’s office. There was no evidence the writer received authorization in advance for the verbal order, the order was signed by the physician on 06/01/23. Frequency of home health services should be based upon clinical need, and the physician ordered plan of care, not on the availability of agency staff. Patient #14 was admitted to the agency on 01/06/23 with diagnoses including type 2 diabetes and end stage renal disease. The patient was selected from the internet Quality Improvement Evaluation System (iQIES) Potentially Avoidable Event Reports for Emergent Care for Hypo/Hyperglycemia and Development of Urinary Tract Infection. On 01/06/23 the skilled nurse documented in the comprehensive assessment the patient had an AV fistula (access for dialysis) in left arm. The 01/06/23 Certification and Plan of Care (POC) included no blood pressure left arm. -On 01/06/23 and 01/20/23, the physical therapist documented BP in left arm. -On 01/13/23 and 01/16/23 the occupational therapist documented BP in left arm. The 01/06/23 POC included patient/caregiver check blood sugars 4 times daily and as needed using Dexcom scanner. -On 01/11/23 the physical therapist visited the patient and documented physician orders do not include blood glucose testing On 11/13/23 at 1 p.m. the record was reviewed with Administrator, DPS and Clinical Managers. They acknowledged the findings and provided no additional information. Patient #10 was admitted to the agency on 03/21/23 with diagnoses of kidney failure, congested heart failure, chronic obstructive pulmonary disease, and anemia. Home Health Certification and Plan of Care (POC) dated 09/17/23 ordered the patient to demonstrate proficiency switching from daytime catheter leg bag to large drainage bag. SN failed to: - Ensure demonstration and observe return demonstration by patient and CG. -Ensure infection control practices were followed correctly. - Ensure written instructions were left in the home. On 11/13/23 at 1:00 p.m. the surveyor reviewed the above records with the Administrator, DPS and Clinical Managers. They acknowledged the findings and provided no additional information. Patient #4 was admitted to the agency on 02/24/23 with diagnoses of stage 4 pressure ulcers to gluteal and sacral areas, sclerosis, paraplegia and cystostomy. The 10/16/23 certification period had ordered for the skilled nurse to administer bladder irrigation with 60 ml sterile water as needed for occlusion to the supra pubic catheter. On 11/08/23 at 10 a.m. the surveyor conducted a home visit with skilled nurse and caregiver present. During the visit the caregiver reported to the nurse that he had increased the frequency with supra pubic irrigation from 2 times a day to 3 times a day due to frequent blockages. On 11/09/23 the agency provided a policy tilted Standard of Care Documentation Protocol dated 3/2022. The plan of care must include an order to allow patient/ or caregiver to perform the intervention and to indicate the nurse is to teach as well as perform the intervention as needed, this included Foley/suprapubic catheters. The SN failed to: - obtain an order for the caregiver to perform task On 11/13/23 at 1:00 p.m. the surveyor reviewed the above records with the Administrator, DPS and Clinical Managers. They acknowledged the findings and provided no additional information. Failure to perform adequate assessments for changes in patient condition, notify the physician, and update the plan of care as needed, has the potential for unmet patient needs, and possible negative patient outcomes. Home Visit (HV) 1. Patient #3 was admitted to the agency on 10/27/23 with diagnoses that included acute kidney failure, type 1 diabetes, osteomyelitis, sepsis, congestive heart failure (CHF), and cellulitis of the left lower limb. Wound Care The Home Health Certification and Plan of Care (POC) dated 10/27/23 included wound care orders as follows: - wound care to left great toe and 2nd toe surgical wound; cleanse area with normal saline and pat dry. Apply wet to dry dressing and secure with kerlix (stretchy gauze); change daily. On 11/07/23 at 10:30 a.m., the surveyor conducted an HV and observed the skilled nurse (SN) perform wound care to the left great toe and 2nd toe as follows: - the wound was cleansed with Hibiclens - sterile packing was moistened with saline and packed into the wounds with a sterile cotton-tipped applicator - covered with gauze pad - wrapped with kerlix and secured The SN failed to follow the wound care orders. Daily Weight The POC included an order to check weight daily and call physician for weight gain greater than or equal to 3 pounds in a day or 5 pounds in a week. During the HV, the SN asked the patient's caregiver (CG) how the weights had been. The CG responded that they could not obtain the weight as the patient was "too unsteady" to stand safely on the scale, even with the walker and assistance. The patient had returned home from the hospital on 10/27/23 and missed 10 daily weights. The patient was unsteady, and the caregiver voiced concern about the patient falling. The SN assisted the patient to get onto the scale and logged the weight. On 11/13/23 at 1:00 p.m., the findings were reviewed with the Administrator, DPS, and CM, who acknowledged the findings and provided no additional information. 2. Patient #10 was admitted to the agency on 03/21/23 with diagnoses of kidney failure, congested heart failure, chronic obstructive pulmonary disease, and anemia. The 10/13/23 hospital discharge instruction documented the patient had been admitted to the hospital on 10/08/23 with the diagnosis of hematochezia (rectal bleeding) and was discharged on 10/13/23 with an indwelling catheter. The 10/13/23 discharge instructions for the medication spironolactone (a diuretic, or fluid reducer) 1- 25mg tablet on Monday, Wednesday, and Friday and was a change from daily administration. The 10/20/23 resumption of care order documented spironolactone 1- 25mg tablet daily. There was no evidence of a supplemental order with a medication change after the patient had been discharged from the hospital. The skilled nurse failed to accurately update the plan of care and reconcile the medications. On 11/13/23 at 1:00 p.m., the surveyor reviewed the above records with the Administrator, DPS, and CM. They acknowledged the findings and provided no additional information. 3. Patient #8 was admitted to the agency on 11/03/23 with diagnoses of fracture of the right pubis/orthopedic aftercare, pressure ulcer of the right buttock, fracture of the first lumbar vertebrae, history of falls, type 2 diabetes, and rheumatoid arthritis. On 11/03/23, the skilled nurse (SN) visited and documented the patient had a pain level of "7". The Home Health Certification and Plan of Care (POC) included parameters for pain to notify the physician if the pain was greater than 6 on a 1- 10 scale. There was no evidence the SN notified the physician the patient's pain was greater than 6. On 11/14/23 at 2:00 p.m., the findings were reviewed with the Administrator, DPS, and CM, who acknowledged the findings and provided no additional information. Failure to provide care as outlined in the physician's orders has the potential for unmet patient needs and negative outcomes for the patient population.

Integrate all services CFR(s): 484.60(d)(3) Integrate services, whether services are provided directly or under arrangement, to assure the identification of patient needs and factors that could affect patient safety and treatment effectiveness and the coordination of care provided by all disciplines. This ELEMENT is not met as evidenced by: Based on review of patient records, observational home visits, and interviews with the Administrator, Director of Patient Services (DPS) and Clinical Managers (CM), it was determined for 2 out of 18 patients (patients #9 and 14) agency staff failed to provide coordinated care to meet the needs of the patients. Evidence as follows: Patient #14 was admitted to the agency on 01/06/23 with diagnoses including type 2 diabetes and end stage renal disease. The patient was selected from the internet Quality Improvement Evaluation System (iQIES) Potentially Avoidable Event Reports for Emergent Care for Hypo/Hyperglycemia and Development of Urinary Tract Infection. The agency staff failed to coordinate care as follows: NURSING SERVICES/DIABETES MANAGEMENT The 01/06/23 Certification and Plan of Care (POC) included: -patient/caregiver check blood sugars 4 times daily and as needed using Dexcom scanner -NovoLog FlexPen (rapid acting insulin) 3 times daily per sliding scale (insulin dosage dependent on blood glucose readings) and size of meals On 01/06/23 the skilled nurse (SN) documented the patient’s caregiver/spouse provided 24/7 care, checked blood glucose (BG), injected insulin, and administered medications. On 01/12/23 the SN documented in “coordination notes” they called the physician to inform them the 01/13/23 SN visit would be by phone and normal in-home scheduled visits would resume going forward. On 01/13/23 the SN documented they left a message on the patient’s machine with callback information. -There was no evidence the 01/13/23 telephone visit occurred. The SN failed to coordinate with the case manager or patient to reschedule and failed to notify the physician the visit did not occur. On 01/16/23 the occupational therapist (OT) documented regarding BG “patient declines taking today”, and on 01/18 “refuses to take today.” The OT did not document when BG was last checked or range of recent BGs. On 01/18/23 the OT documented they communicated with the social worker (SW) and SN, however there was no evidence the above information regarding BG testing was communicated to the case manager or physician. On 01/20/23 the SN visited, and documented patient’s son was present during visit and the primary caregiver remained in hospital. The son stated he didn’t know if anyone had checked the patient’s blood sugars, the patient stated they checked them at dialysis. The son demonstrated proficiency and independence, blood sugar was 346, the patient hadn’t been getting correct insulin dosages. The SN reviewed the sliding scale with caregiver, notified MD office, and set up the Dexcom sensor and showed caregiver how to use it. -The SN failed to coordinate with the family to determine whether the CG instructed during the visit was available for monitoring BG 4 times daily and administering insulin 3 times daily as ordered. On 01/23/23 the OT documented regarding BG, “patient does not remember but took 6 units meaning blood sugar between 201 and 250.” The OT did not document who (patient or what CG) checked the BG and administered insulin. On 01/25 and 01/26/23 the SN documented leaving a message for the patient and receiving a call back stating client was unavailable due to scheduled dialysis that day and medical appointments the following day. -The SN failed to coordinate a rescheduled visit. -On 01/27/23 the OT documented patient declined BG testing and failed to communicate this information to the case manager or physician. On 02/01/23 the OT visited and documented “Patient speech more slurred/difficult to understand than normal and patient appears with increased confusion and increased lethargy. Patient reports not taking blood sugar today. After bringing patient diabetic supplies patient reports not knowing how to do on own as wife, who is currently hospitalized, usually does it. Patient son present midway through session and was able to take blood sugar with sugars running very high at 543. Call made to (physician) office who recommend patient goes to ER for follow up due to dangerously high level.” INTERDISCIPLINARY COMMUNICATION/24/7 SUPERVISION On 01/06/23 the skilled nurse (SN) documented that the patient “requires 24 hour care and supervision”, and that the caregiver / wife was overwhelmed and requested a social work referral for more help. On 01/18/23 the OT documented in client coordination notes to call son at (telephone number) for scheduling if unable to reach patient. On 01/18/23 the SW documented a missed visit due to “patient states that his wife has been in the hospital since Sunday and that he is unable/not willing to come to the door today. Moving visit to next week.” -The SW failed to communicate this information to agency team members or coordinate with the family to ensure that the patient was safe at home given the need for 24/7 supervision. -The social worker documented that the MD office was notified, however the corresponding “order” reflected only notification of a missed /rescheduled visit. Coordination notes documented case conferences occurred on 01/16/23 and 01/27/23, both documented “no concerns/complaints identified at this time” and failed to address/coordinate: -whether the patient had 24/7 supervision -whether there was a caregiver available to monitor BG 4 times daily and administer insulin per sliding scale -need for and lack of aide services SCHEDULE COORDINATION/COORDINATION WITH DIALYSIS CLINIC On 01/06/23 the skilled nurse (SN) documented that the patient had dialysis every Tuesday, Thursday, and Saturday. On 01/18 the patient declined a physical therapy visit, and on 01/19/23 declined visits from PT and nursing who documented he had dialysis that day (Tuesday). On 01/25 and 01/26/23 the SN documented leaving a message for the patient and receiving a call back stating client was unavailable due to scheduled dialysis that day and medical appointments the following day. -The team failed to coordinate their visits according to the patient’s scheduled dialysis appointments. On 01/20/23 the SN visited, and documented patient’s son stated he didn’t know if anyone had checked the patient’s blood sugars, the patient stated they checked them at dialysis. -The SN failed to coordinate with the providers at the dialysis clinic to obtain information regarding their blood glucose monitoring. AIDE SERVICES On 01/13/23 the OT documented a request for aide services beginning as soon as possible three days per week. A “coordination notes-follow-up comment” dated 01/17/23 documented “aide schedule to follow once available” and “clinician notified of denial via e-mail. -There was no evidence of any additional agency coordination to secure aide services. On 11/13/23 at 1 p.m. the record was reviewed with Administrator, DPS and Clinical Managers. They acknowledged the findings and provided no additional information. On 11/15/23 the surveyor interviewed the DPS regarding the frequency of scheduled SN visits and missed visits. The DPS stated that SN visits after the start of care were intended/scheduled to occur twice weekly for 2 weeks, then once weekly for 4 weeks, and that the agency did not document them as missed visits because the scheduler deleted the visits rather than noting them as missed. The surveyor requested any interagency documentation regarding attempts to secure aide service for the patient, no further information was provided. Patient #9 was admitted to the agency on 10/12/23 with diagnoses of urinary tract infection, sepsis, history of kidney transplant, presence of suprapubic urinary catheter, hypertension with orthostatic hypotension, squamous cell carcinoma of the right temple and eye, blindness to left eye and sleep apnea. The agency failed to coordinate care to meet needs. Urinary Catheter The 10/10/23 hospital summary revealed the patient was hospitalized for sepsis with acute encephalopathy due to complicated urinary tract infection and orbital cellulitis. On 10/12/23 the SN visited the patient for the start of care assessment and documented the patient had a suprapubic catheter. On 11/05/23 the SN documented in the resumption of care (ROC) note the catheter was draining light yellow urine with a small amount of mucous. On 11/07/23 at 8:20 a.m. the on-call SN documented the caregiver reported the patient was not passing urine through the catheter and the adult briefs were wet. The caregiver reported the tube was untwisted and urine began flowing into the bag and was cloudy. The on-call nurse encouraged extra fluids and documented informing the case manager via email. On 11/07/23 at 2:49 p.m. the SN visited the patient and documented the catheter was draining and urine was clear. There was no mention of previous issue with the urine being blocked and any education regarding prevention of further issues. On 11/08/23 at 8:28 a.m. the on-call nurse documented receiving a call from the caregiver reporting the catheter was clogged, some urine was leaking into the bag, but most was draining into the adult briefs. On 11/08/23 at 12:50 p.m. the supervisor documented in a late entry note calling the caregiver that morning and informing the caregiver they were working on finding a nurse to make a prn visit and had not been able to yet. The supervisor documented the caregiver stated, “I need someone sooner than later”, the patient could hardly stay awake, and the caregiver needed help. The agency failed to coordinate to ensure the patient, who had a history of a kidney transplant, was seen timely to address urinary retention and prevent a visit to the hospital. Over 4 hours passed until the patient was advised to go to the hospital. On 11/08/23 at 12:51 p.m. the DPS documented the caregiver reported the patient was lethargic, not eating and drinking, and had gotten worse over the last few days and requesting a nurse come out and see the patient. Urine output was low and the DPS instructed the caregiver to go to the emergency department (ED) for evaluation. The 11/08/23 ED report revealed the patient had presented to the department with weakness, the suprapubic catheter was found to be kinked and once corrected, the patient had 900 cc of urine from the catheter. The patient returned home on 11/09/23 with an order for an antibiotic. Personal Care On 10/12/23 the SN visited the patient for the start of care assessment and documented the patient was dependent for activities of daily living (ADLs) including with bathing, dressing and toileting and was unable to transfer, stand or walk without assistance of two people. The SN documented the caregiver was available 24 hours a day 7 days a week but had become overwhelmed and another family member assisted as needed on evenings and weekends, and a home health aide was needed. The SN documented the patient was looking for private paid assistance with ADLs. The 10/12/23 to 12/10/23 Home Health Certification and Plan of Care orders included home health aide (HHA) effective 10/22/23 to provide personal care 2 times a week for one week. The 11/05/23 ROC orders included HHA 2 times weekly for two weeks. On 11/07/23 the social worker (MSW) documented the patient was paying privately for aide service a couple of days a week to assist with personal care and the MSW referred the patient to the office of aging for personal care services. There was no evidence of coordination to initiate HHA services through the agency. On 11/13/23 the surveyor requested aide documentation, and none was provided. On 11/14/23 at 2:45 p.m. the record was reviewed with the Administrator, DPS and Clinical Managers. They acknowledged the findings and provided no additional information. Failure to coordinate patient care has the potential for unmet patient needs, and possible negative patient outcomes.

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 7 observational home visits, review of agency policies and procedures, and interviews with the Administrator, Director of Patient Services (DPS), and Clinical Managers (CM), it was determined during 1 of 7 visits (patient #3), the skilled nurse (SN) failed to follow accepted standards of infection control practices. Evidence as follows: Home Visit (HV) Patient #3 was admitted to the agency on 10/27/23 with diagnoses of acute kidney failure, type 1 diabetes, osteomyelitis, sepsis, congestive heart failure (CHF), and cellulitis of the left lower limb. On 11/07/23 at 10:30 a.m., the surveyor conducted an observational HV and observed the SN violate infection control as follows: Peripherally Inserted Central Catheter (PICC) During the HV, the skilled nurse (SN) performed a PICC dressing change. The surveyor observed the following: - The SN failed to perform hand hygiene after removing the soiled dressing and doffing gloves. - The SN dropped items on the floor and balanced on the carpet with an ungloved hand to pick them up. No hand hygiene was performed after touching the floor. - The SN lifted the chlorhexidine swab pack from the dressing change kit and placed it on the sterile field with the same ungloved hand that had touched the floor, thus contaminating the outside of the swab package and the sterile field. - The SN donned the sterile gloves without performing hand hygiene. The pack of chlorhexidine swabs was then handled with the sterile gloved hands, thus contaminating the sterile gloves. - With the PICC open and unsecured, the SN obtained the sterile measuring tape and measured the circumference of the patient's upper arm, contaminating the measuring tape. When measuring complete, the SN ran a sterile glove down the length of the tape, re-contaminating the sterile glove. - The patient's masked face was turned toward the insertion site during the procedure. The surveyor reviewed the agency's undated PICC policy which included: - instruct patient to turn the head away from the site during the procedure and have the patient don a mask - after discarding the soiled dressing and securement device, remove gloves, perform hand hygiene, and don sterile gloves Wound Care The patient's wound care orders indicated daily dressing changes to the left great toe and 2nd toe. The surveyor observed the following: - After using a mobile device to photograph the wound, the SN doffed gloves and donned gloves without hand hygiene in between; this procedure was completed twice when the photograph was repeated. The agency's undated Wounds policy and procedure included performing hand hygiene after doffing soiled gloves and prior to donning clean gloves. The agency's policies were consistent with the Centers for Disease Control Hand Hygiene Guidance, which states: The Core Infection Prevention and Control Practices for Safe Care Delivery in All Healthcare Settings recommendations of the Healthcare Infection Control Practices Advisory Committee (HICPAC) include the following strong recommendations for hand hygiene in healthcare settings. Healthcare personnel should use an alcohol-based hand rub or wash with soap and water for the following clinical indications: - immediately before touching a patient - before performing an aseptic task (e.g., placing an indwelling device) or handling invasive medical devices - before moving from work on a soiled body site to a clean body site on the same patient - after touching a patient or the patient's immediate environment - after contact with blood, body fluids, or contaminated surfaces - immediately after glove removal Reference: https://www.cdc.gov/handhygiene/providers/guideline.html On 11/13/23 at 1:00 p.m., the findings were reviewed with the Administrator, DPS, and CM, who acknowledged the findings and provided no additional information. Failure to ensure the SN is oriented to agency policies and procedures regarding standard precautions for the prevention and transmission of infectious agents has the potential for unmet patient needs and possible negative patient outcomes.

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 review of 2 clinical records for patients receiving home health aide (HHA) service (patients #9 and 11) and interviews with the Administrator, Director of Patient Service (DPS), and Clinical Managers CM), it was determined in both records, the skilled nurse (SN) failed to develop complete and accurate aide written instructions. Evidence as follows: Patient #11 was admitted to the agency on 06/12/23 with diagnoses of lymphedema, chronic wounds to lower legs, and congestive heart failure. On 10/06/23 the SN visited the patient for the recertification assessment and documented the patient had nonpitting edema and chronic wounds to both lower legs. The SN performed wound care including Aquacel AG to the wound beds and two layers of Coban (compression) wrap. The SN documented the patient was encouraged to elevate legs, The 10/10/23-12/08/23 Home Health Certification and Plan of Care included orders for dressing change weekly and home health aide twice weekly to assist with personal care. Medications included ammonium lactate 12% lotion topically daily to legs. The 10/10/23 home health aide care plan was incomplete as follows: -The aide instructions included assist with Bath/Shower as needed every visit, and shampoo hair in shower every visit. -The care plan failed to include instructions regarding the lower leg dressings to include removing or covering for showers and changes to report to the nurse such as increased drainage or dislodgement. -The care plan failed to include instructions for management of edema including elevation of legs. -The care plan instructions included lotion to arms, legs, back every visit and failed to identify the type of lotion, such as the lotion listed in the medications. On 11/14/23 at 2:45 p.m. the surveyor reviewed the record with the Administrator, DPS and Clinical Managers. They acknowledged the findings and provided no additional information. Patient #9 was admitted to the agency on 10/12/23 with diagnoses of urinary tract infection, sepsis, history of kidney transplant, presence of suprapubic urinary catheter, hypertension with orthostatic hypotension, squamous cell carcinoma of the right temple and eye, blindness to left eye and sleep apnea. On 10/12/23 the SN visited the patient for the start of care assessment and documented the patient was dependent for activities of daily living (ADLs) including with bathing, dressing and toileting and was unable to transfer, stand or walk without assistance of two people and the patient had a suprapubic catheter. The 11/05/23 aide care plan included complete assistance with a sponge bath at every visit and failed to include any instructions regarding care of the urinary catheter. On 11/14/23 at 2:45 p.m. the surveyor reviewed the record with the Administrator, DPS and Clinical Managers. They acknowledged the findings and provided no additional information. Failure to ensure that home health aide care plans are complete has the potential for unmet patient needs.

This revised statement of deficiencies is being issued to provide the results of the complaint investigation survey (Complaint # 62301) initiated on 03/08/22, which developed into findings of Immediate Jeopardy, for two separate patients (patients # 1 and # 3), on two different dates 03/14/2022 and 03/17/2022 as follows: On 03/14/2022, at 12:00 pm the Immediate Jeopardy (IJ) template was provided to the Administrator for the Immediate Jeopardy finding identified within the Level 1 Standard 484.60 (b) G 578, Conformance with Physician's Orders. The Director of Patient Services and Administrator were advised of the need for an abatement plan for both Immediate Jeopardy situations. On 03/17/22 at 2:00 pm, the IJ template was provided to the Director of Patient Services in person, and to the Administrator via video conference for the Immediate Jeopardy finding identified within the Level 1 Standard 484.55 (c) G 526, Content of the Comprehensive Assessment. The Director of Patient Services and Administrator were advised of the need for an abatement plan for both Immediate Jeopardy situations. On 03/16/22, the Administrator provided the survey team with an Abatement plan for the 03/14/22 IJ. The plan required revisions and was not accepted. The agency submitted abatement plans for both Immediate Jeopardy findings on 03/23/22 and both were accepted on 03/24/22. On 04/01/22, the complaint survey was completed and the survey team verified implementation of the interventions outlined in the Abatement plans including and not limited to: - caseload reassignment - focused audits and then re-audits of all patients receiving wound care - audits of records managed by the nurse involved in the IJ identified on 03/14/22 - education and training of all Supervisory and field staff - for the 2 involved patients: immediate review and update of assessments and physician's orders - root cause analyses to determine the areas of weakness Both approved Abatement plans were found to be satisfactorily implemented on 04/01/22. The determination of Immediate Jeopardy was resolved however, Condition Level Non-Compliance continues : 484.55 Comprehensive Assessment of Patients; 484.60 Care Planning, Coordination of Services, and Quality of Care. The complaint survey consisted of 8 clinical record reviews, 2 home visits, a review of an agency complaint log, policy and procedure reviews, and interviews with agency staff including the Administrator and Director of Patient Services. The supervision and training were reviewed for one employee (employee # 1) and recent education and training were reviewed for all employees related to IJ abatement. The complaint allegations were substantiated. The following standard level deficiencies are being cited: G 526 Comprehensive Assessment of Patients; G 536 Comprehensive Medications; G 574 Plan of Care must Include the following: G 578 Conformance with physician's orders; G 580 Only as ordered by the physician; G 590 Promptly alerts the physician; G 606 Integration of all services; G 682 Infection Control. The agency census on 03/08/22 was 733. NOTE: The following are repeat deficiencies cited at the Re-Certification Survey: event ID K40D11, completed 12/17/20. G 526 Comprehensive Assessment of Patients; G 536 Comprehensive Medications; G 574 Plan of Care must Include the following: G 590 Promptly alerts the physician; G 606 Integration of all services and G 682 Infection Control.

Comprehensive Assessment of Patients CFR(s): 484.55 Condition of participation: Comprehensive assessment of patients. Each patient must receive, and an HHA must provide, a patient-specific, comprehensive assessment. For Medicare beneficiaries, the HHA must verify the patient's eligibility for the Medicare home health benefit including homebound status, both at the time of the initial assessment visit and at the time of the comprehensive assessment. This CONDITION is not met as evidenced by: Based on review of clinical records, policies and procedures, interviews with the Administrator, Director of Patient Services, agency staff, and observational home visits, it was determined the agency: Failed to ensure assessments were comprehensive, accurate, patient-specific, and reflected the patient's current status and needs. See G 526 Failed to ensure that comprehensive medication reviews identified discrepancies; physicians were notified of issues and follow-ups occurred to ensure discrepancies were corrected. See G 536 The cumulative effect of the agency's systemic failure to ensure assessments are comprehensive, accurate, patient-specific, and identify changes in the patient's condition resulted in a determination of Immediate Jeopardy for patient # 3 and the potential for negative outcomes for the entire patient population. Additionally, the agency failed to ensure that all staff understood their role to assess and ensure the caregiver's ability to manage necessary care, treatment, mobility, and transportation needs, and notify the authorized practitioner when changes occurred.

Content of the comprehensive assessment CFR(s): 484.55(c) Standard: Content of the comprehensive assessment. The comprehensive assessment must accurately reflect the patient's status, and must include, at a minimum, the following information: This STANDARD is not met as evidenced by: Based on review of clinical records, policies and procedures, 2 observational home visits and interviews with Administrator and Director of Patient Services, it was determined in 6 of 8 patients (patient # 1, 2, 3, 4, 6, and 8) the comprehensive assessments were incomplete, inaccurate and failed to identify the patient's current status. A finding of Immediate Jeopardy was identified on 03/17/2022 within the Level 1 Standard 484.55 Content of the Comprehensive Assessment and the IJ Template was provided to the Administrator in person. (patient # 3) Evidence as follows: Patient # 1 was admitted to the agency on 02/04/22 with diagnoses of an open wound to the top of the right foot, type 1 diabetes with diabetic chronic kidney disease, and metabolic encephalopathy. The SN failed to perform a comprehensive assessment as follows: The SN visited the patient on 02/04/22 and documented wound measurements of 3.2 x 5.3 x 0.2 (length x width x depth). The 02/04/22 physician orders directed the SN to perform dressing changes until the wound was healed; to cleanse the wound (right dorsum, top of foot) with soap and water and apply xeroform as primary dressing and apply foam pad. If foam not available, cover with dry gauze and wrap with kerlix and secure with tape and change dressing 3 times a week. On 02/04/22, the SN copied the physician's orders for wound care into the visit note section "wound care provided". The documentation included "SN to provide teaching related to wound healing principles..." The next paragraph "SN to perform wound care to the dorsum of the right foot trauma until healed: cleanse wound with soap and water and apply xeroform as primary dressing and apply foam pad. If foam padnoy (not) available, cover with dry gauze and wrap with kerlix secure with tape as the secondary dressing. Change 3 times weekly and PRN (as needed) for strike through drainage or dressing dislodgement using clean technique" "Caregiver may be taught to perform wound care" The SN failed to assess the patient/caregiver's competency or willingness to provide wound care; document the type of secondary dressing applied (foam pad versus kerlix); how the patient/caregiver competency was demonstrated if the SN completed wound care. Subsequent wound care visits were provided approximately once a week on 02/09/22, 02/15/22, 02/21/22, 02/25/22 (LPN visit), 03/01/22 and 03/08/22. (Not 3 times a week as ordered) During each visit the SN failed to: - recognize that the physician ordered wound care 3 times a week and the dressing applied once a week by the SN was the same dressing in place at the next visit (5 to 8 days later). - document the type of outer dressing applied to the wound. - assess the patient or caregiver’s willingness and/or competence in providing wound care. - contact the physician to discuss changes in wound care frequency. On 03/11/22, at 1:30 pm an interview was conducted with the SN and the DPS. The surveyor asked if the SN if she ever observed the caregiver provide wound care? The SN stated, “no she (the caregiver) refused to provide the wound care”. The surveyor: so wound care hasn’t been completed 3 times a week? SN: “No, but that’s why I got orders to increase my frequency, because the wife won’t do the wound care.” Diabetes/Diabetic Management On 02/04/22, the SN documented in the start of care note "visit details:" "patient was hospitalized partly in reason due to his diabetic management." “Patient has been prescribed Lantus and does not have any.” The SN contacted the physician’s office and spoke to the nurse practitioner later in the day on 02/04/22 "who will call a prescription into the pharmacy." The SN documented a blood glucose range of 100 to 230. The SN documented the blood glucose is monitored through a glucose meter. The SN failed to assess the type of meter or document that it was a continuous sensor. The the next nursing assessment visit was completed on 02/09/22, 5 days later. During the visit the SN documented a fasting blood sugar of 243 and that the patient reported eating candy last night. The SN failed to assess the patient's use of all diabetic medications including if the patient obtained and used his Lantus insulin missing at the start of care. The SN documented the patient was able to self administer injectable medications, but failed to assess the patient's use of Humalog (short acting) insulin and failed to document if the patient self-administered 14 units of Humalog KWIKPEN (U100) insulin subcutaneously ordered "as directed/PRN" for a blood sugar of 201 – 250 per the sliding scale. The admission nurse documented the patient was unable to self administer injectable medications due to fine motor/dexterity impairments. On 02/15/22, the SN documented the “patient” is providing injectable medications and the patient had a fasting blood sugar of 95. There was no evidence the patient was observed providing insulin injections. On 02/21/22, the SN visited the patient and documented a fasting blood sugar of 236 and the caregiver manages the injectable medications. There was no assessment of the change in patient's ability to self administer injectable medications or if the patient/caregiver administered Humalog sliding scale insulin coverage of 14 units for a fasting blood sugar of 236 as ordered in the sliding scale. On 02/25/22, a licensed practical nurse (LPN) visited the patient and documented the patient’s glucometer wasn’t functional and the LPN contacted the physician. On 03/01/22, 4 days later, the SN visited the patient and identified the patient’s random blood sugar was 336, 30 minutes after a meal, the client was able to self-administer injectable medications, and the blood glucose ranges were 87 to 487. The SN documented the "blood sugar readings have remained stable". The SN failed to recognize that a blood glucose reading of 487 was not "stable", was abnormally high, and required physician notification. The SN reviewed with the patient the need to take insulin as directed, however, failed to assess the patient’s ability to self-administer Humalog insulin including the correct dose and with the limited hand dexterity. On 03/08/22, 7 days later, the SN visited the patient and documented a random blood sugar of 278, after eating 30 minutes earlier. The SN again reviewed the need to take insulin as directed but failed to assess if the patient had been taking insulin as ordered in the plan of care. On 03/11/22, the surveyor interviewed the SN and DPS regarding assessment of patient taking Humalog insulin and reporting elevated blood sugar readings over 400 (487) to the physician. The SN stated that she didn’t report the blood sugar readings and that she should probably have. The surveyor asked if the patient was ever observed self-administering Humalog insulin per the sliding scale for elevated blood sugars. The SN stated “No, the patient wasn’t due to eat, but that he told the nurse he could listen for the pen clicks”. On 03/11/22 at 2 pm the findings of this record were reviewed with the DPS. The entire record was reviewed with the DPS and Administrator. Patient #2 was admitted to the agency on 02/14/22 with diagnoses closed fracture of the left femur, hypertensive heart failure, acute systolic (congestive) heart failure, cardiomyopathy, lymphedema (extremity swelling). On 02/14/22, the SN visited the patient and documented the patient had no lower extremity edema and a weight of 241 pounds. On 02/15/22, the physical therapist visited the patient and documented the patient had 1 + (mild pitting slight indentation that disappears rapidly) edema of both lower extremities. On 02/18, 02/22 and 02/24/22, the physical therapist visited and documented bilateral 1+ lower extremity edema. On 02/23/22, the SN visited the patient and identified the patient gained 8.5 pounds in one week and weighed 249.5 pounds. The SN failed to document the presence or absence of edema. The physical therapist visited the patient on 02/22 and on 02/24/22 and identified 1+ edema. On 02/24/22, the PT documented the lower extremity redness in addition to the 1+ edema. On 03/02/22, at 09:42 am, the SN visited the patient for a discharge assessment from skilled nursing services. The SN documented the patient’s weight was 250.5 pounds, but failed to assess if the patient was checking his weight every day; the SN documented no problems with the patient’s integumentary system or cardiovascular system, yet the PT assessment visit completed on 02/24/22 7 days earlier noted the patient’s lower extremities were edematous and red. On 03/02/22 at 11:30 am, the PT visited the patient and documented a weight gain of 4.5 pounds in less than 2 hours; another weight increase to 255 pounds but failed to document an assessment of edema. On 03/15/22, the above findings were reviewed with the Administrator and DPS, the acknowledged the information and provided no additional information. Patient # 4 was admitted to the agency on 02/25/22 with a primary diagnosis of Type 1 Diabetes mellitus with ketoacidosis without coma. The SN failed to perform a complete assessment of the patient's Diabetes and Diabetic Management. On 02/25/22 the SN visited the patient and documented a fasting blood sugar of 377, the patient lives alone, had a blood glucose range of 377 to 401 patient /caregiver monitor via BG meter advised the physician of an elevated blood glucose. The SN documented in the start of care narrative note that an assessment of the insulin pen used to administer 8 units of short acting insulin prior to her arrival and discovered the needle was bent sideways. Yet in the endocrine section of the assessment, the SN documented: "no issues identified, patient takes medications from a mediset filled by a caregiver that is accurately filled" In another section of the assessment the SN documented the patient requires reminders to take medications reliably. The SN failed to assess who would consistently provide reminders for this patient who lived alone. Another section of the Medication assessment asks if there are any concerns that may impact medication safety, independence and or compliance? The SN documented that there were no concerns observed, however failed to address the patient's non-compliance to the prescribed sliding scale insulin order, using a single use insulin needle more than once, and the needle was bent. The SN also documented "no issues found during medication review" Yet all of the above issues are medication concerns. During subsequent SN visits completed on 03/04/22 and 03/09/22 the SN failed to assess the patient use of sliding scale insulin. On 03/09/22, the SN documented review of the patient's BG record, but failed to document the range of blood glucose readings or if the patient was following the correct sliding scale insulin range. On 03/15/22, the above findings were reviewed with the Administrator and DPS, they acknowledged the findings and provided no additional information. HV 1. Patient #3 was admitted to the agency on 02/10/22 with a primary diagnosis of pressure ulcers and secondary diagnoses of type II diabetes, hypertension, kidney disease, depression, myoneural disorder (unspecified), post-laminectomy syndrome, and bed-confinement status. The skilled nurse (SN) failed to perform a comprehensive assessment of the patient's needs; communicate abnormal findings to the physician and ensure a coordinated plan of care was developed. As a result, within 20 days of admission to the agency, the patient was hospitalized with new and increased osteomyelitis and sepsis due to infected wounds. Wounds On 02/10/22, the SN visited to complete the comprehensive assessment and documented “the caregiver will be taught to provide care”. There was no evidence the SN demonstrated wound care procedure, provided written instructions, or observed a return demonstration to verify the caregiver's proficiency and understanding to provide wound care to all 4 wounds. The following 4 pressure ulcers were documented at the start of care: #7 – stage II to the left upper back #8 – stage IV coccyx/sacrum #6 - unstageable Right heel #2 – unstageable Left heel On 02/10/22, the SN documented performing wound care on 4 wounds. The SN failed to identify: - the patient failed to attend the wound care clinic (WCC) appointment on 02/09/22, the day prior - when the dressings had last been changed and by whom The dressings had been changed on 02/02/22, 8 days prior, by the physician at the WCC who documented the left heel wound had a moderate amount of tan serosanguinous drainage. The SN documented drainage for the left heel: A scant amount of purulent drainage. The left heel had developed purulent drainage since being seen in the WCC on 02/02/22. The referral for care was faxed from the wound care clinic on 02/03/22. The physician wrote on the fax cover sheet On Monday, 02/14/22 the SN case manager visited and performed wound care. Another wound was identified as follows: #9 – Mid-calf right: the SN assessed the wound, applied an ABD pad, and wrapped the leg with gauze. The SN attempted to obtain orders for the wound but documented a message was left at the physician’s office. The SN failed to identify the name of the physician's office notified. On 02/17/22, the SN visited and performed wound care. The SN failed to document the drainage type and amount from the wounds and that orders had not yet been obtained for wound #9 identified at the last visit. The SN also failed to identify what type of care had been provided to the wound, how often, and by whom. The SN failed to identify the patient had not attended the WCC appointment on 02/16/22, the day prior to the visit. On Monday 02/21/22, the SN visited and performed wound care. The SN failed to document orders had not yet been obtained for wound #9, what type of care had been provided to the wound, how often, and by whom. On Friday 02/25/22, the SN visited and performed wound care. The SN failed to document the drainage type, and amount, from the wounds and failed to identify the patient did not go to the wound care clinic on Wednesday, 2 days prior. The SN failed to identify that orders had not been obtained for wound #9, what type of care had been provided to the wound, how often, and by whom. On Monday 02/28/22, the SN case manager visited and performed wound care. The SN failed to obtain measurements of the right heel wound and documented “unable” for the reason why. The SN failed to explain why the measurements were unable to be obtained. The heel wounds had been measurable at all prior visits. The SN documented a scant amount of serosanguinous drainage with a “faint” odor. The SN failed to document if orders had been obtained for wound #9, the care given to wound #9, and by whom. The SN failed to identify the patient had not been attending the wound care clinic. On 03/14/22, the surveyor requested the agency's wound care policy and was provided, the "Wound Care Standards of Practice" policy and protocol which was undated. The protocol states if someone other than HCR staff is performing wound care, HCR staff must observe the person(s) changing the dressing at least once (more if appropriate) and performing the wound care as ordered. documentation must include what the patient /caregiver was observed performing, any teaching and observation of correct infection control practices (i.e. hand washing, universal precautions), and a review of signs and symptoms of wound infections. Written instructions must be left in the patient's home clearly documenting steps to provide wound care as ordered. The SN failed to follow agency policy when the demonstration and observed the return demonstration of wound care to all of the patient's wounds and failed to provide written instructions for wound care, including directions for each specific wound. On 03/17/22, the administrator stated the patient’s son did not need to know how to perform wound care. The agency had an “on-call” nurse for emergency wound care, the agency visited 2 times weekly, and the patient was seen in the WCC on Wednesdays. On 03/21/22 the surveyor conducted an observational home visit with the SN. During the visit, the SN removed the dressing and assessed wound #9 on the right mid-lateral to posterior calf. The SN was unsuccessful in attempting to obtain orders for care. The WCC would not give orders for care until the patient was seen, and the patient had not been to the clinic since 02/02/22. The SN informed the caregiver “you’ll have to put it on after I leave, I’m not allowed to do it without orders”. The SN cleared away the drape beneath the calf and set the patient's leg down onto the sheet without any dressing in place. The wound remained open until the time the surveyor left. See G682 Infection Control At the completion of the visit, the surveyor interviewed the patient and the patient’s caregiver. The patient’s caregiver stated that he was shown how to do the bandage changes; “last week a nurse came out and went through everything with me. I have watched the bandage being changed at the hospital…also, I have to change it almost every time I change the Attends because it gets soaked (with urine), you know.” When asked if written instructions had ever been provided for any of the various wounds, the caregiver replied, "no, not from the nurses". The surveyor asked how often the caregiver changes the heel and leg bandages? “I don’t change those. I let the nurses; the nurses do a better job with them.” On 03/22/22, the SOC SN was interviewed and admitted the caregiver was not given a demonstration or taught wound care at the start of the care visit. On 03/25/22, the SN that performed the visit 03/17/22 was interviewed by the surveyor. The surveyor asked the SN, how was wound care demonstrated/return demonstrated to the caregiver when there were no orders from a physician for that wound (#9)? The SN replied that "applying any dressing is better than applying no dressing at all" and that the caregiver had just elected dressing supplies to place on the wound because of having no orders. Off-loading On 02/02/22 the WCC physician referral documented off-loading equipment orders of Roho cushion (for use while sitting), hospital bed with air mattress, and waffle boots. The physician indicated the patient “has and is using all of the above”. On 02/10/22, during the start of care (SOC) visit, the SN documented the “patient requesting waffle boots”. The SN documented the physician’s office was called to obtain a prescription. On 03/16/22, during the record review, the surveyor requested the date the waffle boots were ordered during the SOC visit and the date they became available to the patient. On 03/17/22, the administrator followed up and stated the patient currently had waffle boots, although no date of arrival of the boots ordered at the SOC was provided. The SN failed to assess the patient and caregiver’s knowledge of off-loading, the use of the equipment, and turning and positioning skills. Edema On 03/11/22, the SN documented edema in the lower extremities’ limits ambulation but failed to assess the edema. On 03/21/22 while at the home visit, the surveyor observed bilateral edema to the lower extremities. The SN assessed the edema and asked the patient and caregiver about it. The patient responded her legs were always like that. The SN documented in the narrative note from the visit, plus one edema noted in lower extremities, and the patient reports this is a baseline for her. From 02/10/22 to 03/11/22, the SN failed to assess edema. The record was reviewed initially on 03/16/22 and updated on 03/22/22 with the Administrator, Director of Patient Services (DPS), Quality Assurance Director, and Compliance Director. They acknowledged the findings and produced a document directing the surveyor to review specific areas of the record. 2. Patient #6 was admitted to the agency on 02/28/22 with a primary diagnosis of cellulitis of the left lower limb and secondary diagnoses of type II diabetes, subacute osteomyelitis of the left foot and ankle, COPD, asthma, hypertension, lumbago, and bipolar disorder. The skilled nurse failed to perform a comprehensive assessment as follows: On 02/28/22 the skilled nurse (SN) visited the patient to complete the comprehensive assessment. The SN documented the patient lives alone, was discharged from the hospital on 02/27/22, has a peripherally inserted central catheter (PICC) with twice-daily antibiotic infusions, and a full-thickness wound with 2 times daily dressing change orders. Wounds On 02/28/22, the SN documented wound care had not been completed during the visit as the patient insisted on performing the care. The SN documented the patient was proficient at wound care since September, however, failed to: - ensure the patient was observed correctly performing wound care - understood the orders and was given the written instructions - had the correct supplies on hand On 03/01/22 the SN visited and documented the wound was not assessed and wound care was not provided as the patient had completed the care. The SN also documented the patient had no history of diabetes. The SN failed to: - ensure the patient was observed (or verbalized the correct steps and technique) for correctly performing wound care - understood the orders and was given the written instructions - had the correct supplies on hand On 03/07/22, the SN visited and performed wound care on the left foot. The SN failed to: - ensure the patient was observed (or verbalized the correct steps and technique) for correctly performing wound care - understood the orders and was given the written instructions - had the correct supplies on hand On 03/08/22, the SN reported to the office of the nurse practitioner the WAT score had increased from 21 to 27 yesterday after completing the wound care. The SN failed to educate, demonstrate and verify the proficiency of the patient to perform wound care according to physician orders and using the appropriate techniques, twice daily. PICC The SN noted the PICC was in the right upper extremity and documented: - the purple lumen is used for Vancomycin infusions, flushes easily, and, is “aspiration occluded”. - the red lumen is completely occluded. The SN failed to assess if the patient: - had taken the Vancomycin 1.5 Gm over 90 minutes mixed with normal saline, every 12 hours since discharge from the hospital - could infuse IV antibiotics twice daily safely and correctly - had the ordered IV medications, diluent, and flushing supplies on hand - was using the correct procedure and solutions to flush the catheter lumens - when the red lumen had become occluded, and when the patient had last flushed the occluded lumen. Respiratory On 02/28/22, the SN documented the patient had COPD and asthma. The patient had an albuterol rescue inhaler ordered, 2 puffs every 4 hours as needed for shortness of breath, and a long-acting steroidal inhaler, Symbicort 160mcg-4.5mcg per actuation, ordered 2 puffs 2 times daily. The SN failed to assess if the patient had the inhalers in the home, if the patient understood the directions for use, and had the manual dexterity and coordination to use the inhalers correctly. On 03/16/22, the record was reviewed with the Administrator, Director of Patient Services (DPS) Quality Director, and Compliance Director. They acknowledged the findings, and no further information was provided. 3. Patient # 8 was admitted to the agency on 02/17/22 with a diagnosis of surgical amputation left great toe, type 2 diabetes, chronic ulcer bilateral feet, and hypertension. The patient had a peripheral inserted central catheter (PICC) line for intravenous antibiotics. The skilled nurse failed to perform a comprehensive assessment as follows: IV ANTIBIOTICS The 02/17/22 Certification and Plan of Care included “skilled nurse/patient/caregiver may infuse ertapenem (antibiotic to be administered intravenously) 1 gram mixed with normal saline via gravity pump/gravity.” On 02/17/22 the SN visited the patient for a comprehensive initial assessment. There was no documented evidence the SN assessed the patient’s / caregiver’s ability to administer the medication intravenously (IV). The SN documented in the interventions section of the assessment “review patient/caregiver competency in providing treatments as ordered by the MD (EX – wound care, IV, injection, BGs, oxygen, ostomy and other medical treatments)” was “NA” (not applicable). The SN documented in the cognitive/behavioral section of the assessment the patient was alert and oriented, able to focus and shift attention, comprehends, and recalls task directions independently. On 02/21/22, 4 days later, another SN visited the patient and documented one of the lumens (tube to insert medication or draw blood from the PICC) was left open and was occluded, and the patient was “unsure how to administer IV antibiotic.” The patient required significant teaching regarding how to administer using SASH (saline, antibiotics, saline, heparin) and aseptic technique. On 03/22/22 at approximately 12:15 PM the surveyor interviewed the SN and asked what she meant when she documented the patient was “unsure” how to administer the antibiotic on 02/21/22. The SN stated she was concerned because one of the claves (closure devices) was off which left the PICC open for infection, and it was occluded. She also said the patient needed to be taken through instructions step by step and seemed to have trouble comprehending. When asked whether the patient missed any doses of antibiotics, she stated it was "hard to say because he had a bunch of half-empty bags (of the antibiotic solution) in the box,” but that the patient said he had been doing it. On 03/22/22 at approximately 1:15 PM the surveyor interviewed the admission nurse who stated she provided education to the patient and the patient’s father and had them practice with hands-on demonstration, but did not document doing so. She said she thought the patient may have some intellectual disability issues. During the initial assessment, the SN failed to document any teaching or the patient’s understanding of the procedure. The SN failed to revisit/reassess the patient until 4 days later at which time 1 of the 2 lumens was occluded, and it was unclear if the patient received all doses of IV medication.

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 a review of clinical records and interviews with the Administrator Director of Patient Services (DPS) and skilled nurses, it was determined in 2 of 8 records (patients #3 and 6) the skilled nurse (SN) failed to perform comprehensive medication reviews. Evidence as follows: Based on a review of clinical records and interviews with the Administrator Director of Patient Services (DPS) and skilled nurses, it was determined in X of 8 records (patients #) the skilled nurse (SN) failed to perform comprehensive medication reviews. 1. Patient #3 was admitted to the agency on 02/10/22 with a primary diagnosis of pressure ulcers and secondary diagnoses of type II diabetes, hypertension, kidney disease, depression, unspecified myoneural disorder, post-laminectomy syndrome, and bed-confinement status. The skilled nurse (SN) failed to perform a comprehensive review of the patient's medications as follows: The 02/02/22 Wound Care Clinic (WCC) referral information included: - the patient’s current medications list included clonidine 0.1mg - 1 tablet twice daily On 02/10/22, the SN documented, the patient only has clonidine 0.3 mg and will pick up clonidine 0.1mg at the pharmacy. There is no evidence the SN verified the patient’s caregivers had picked up the 0.1 mg clonidine tablets. On 03/09/22, the patient was discharged from the hospital. While hospitalized, the patient had hypotension (low blood pressure) and the clonidine was discontinued. The discharge instructions included “Key Information: Your medications have changed, stop taking clonidine, Lasix, hydrochlorothiazide, lisinopril, and vancomycin solution.” On 03/11/22, the SN performed the resumption of care visit and documented the medications were present in the home. There is no evidence the SN reviewed the discharge instructions with the patient and the caregiver or updated the medications in the record. On 03/17/22, the SN visited and reconciled the medications “directly from the bottles”, and clonidine 0.3 mg was noted in the home. On 03/21/22, during the observational home visit, the SN reconciled the medications and determined the patient was taking clonidine 0.3mg twice daily. The clonidine order at the SOC was for 0.1 mg twice daily, and that had been discontinued while the patient was hospitalized. No new orders for clonidine were present in the record and the patient had not visited the primary care physician's office. On 03/21/22, the medical record was reviewed with the DPS and Clinical Manager who acknowledged the findings and provided no additional information. On 03/25/22 the surveyor verified the clonidine dosage on record with the hospital pharmacist. The clonidine dosage was 0.1 mg twice daily at the last hospital discharge in 12/2021 until the clonidine was discontinued on 03/09/22 at discharge from the hospital. The 02/02/22 Initial Agency referral medications included Vancomycin 125 mg capsule 4 times daily, disp. #48 with no refills, for 12 days. (to discontinue on or around 02/14/22) On 03/15/22, the patient's medication list indicated the medication was active without a stop date. The 03/09/22 Hospital discharge instructions included Vancomycin 125mg capsule, 1 capsule 2 times daily for 5 doses. The resumption of care medication order failed to include the instructions for the medication that included it was for 5 doses only and should have terminated several days after the patient's discharge from the hospital, on or around 03/11/22 - 03/12/22. As of 03/15/22, the medication remained current on the profile. On 04/01/22, the medication profile was again reviewed. The 02/10/22 Vancomycin 125mg 4 times daily order was noted as discontinued by the resumption of care nurse on 03/11/22, and the 03/11/22 resumption of care hospital discharge instructions Vancomycin 125mg capsule, 1 capsule 2 times daily for 5 doses remained current on the profile. On 03/15/22, the above findings were reviewed with the Administrator and DPS, they acknowledged the findings but provided no additional information. 2. Patient #6 was admitted to the agency on 02/28/22 with a primary diagnosis of cellulitis of the left lower limb and secondary diagnoses of type II diabetes, subacute osteomyelitis of the left foot and ankle, COPD, asthma, hypertension, lumbago, and bipolar disorder. The skilled nurse failed to perform a comprehensive assessment as follows: The patient was ordered Vancomycin 1.5 GM intravenously every 12 hours for osteomyelitis. The hospital discharge instructions indicate the next dose was due on 02/28/22 by 08:00 am as the last dose was given in the hospital at 07:00 pm on 02/27/22. The SN documented in the 02/28/22 start of care narrative note, "the patient has osteomyelitis with a large wound on the lateral side of the foot". The patient became tearful when told an amputation may be needed. The SN failed to arrive at the patient's home until 2:33 PM on 02/28/22, > 6.5 hours after the medication was due. The SN failed to instruct the patient on IV medication administration and the use of the Curlin pump, and there is no evidence the patient received a 12 hour dose between 02:00 am and 04:00 am on 03/01/22. The SN arrived at the patient's home the following day, 03/01/22 at 10:40 am, stayed for 20 minutes, and documented "patient was demonstrated and provided a return demonstration on IV administration. Patient is using a Curlin pump to administer Vancomycin". The SN failed to ensure the patient received Vancomycin every 12 hours when one dose was provided on 02/28/22 between 02:00 pm and 04:00 pm and another dose on 03/01/22 at 10:40 am. Failure to perform deliver intravenous antibiotics on time and complete and accurate medication reviews could lead to increased bacterial growth and worsening wound infections and patients potentially taking medications inconsistent with the physician's intentions, and negative patient outcomes.

Care planning, coordination, quality of care CFR(s): 484.60 Condition of participation: Care planning, coordination of services, and quality of care. Patients are accepted for treatment on the reasonable expectation that an HHA can meet the patient's medical, nursing, rehabilitative, and social needs in his or her place of residence. Each patient must receive an individualized written plan of care, including any revisions or additions. The individualized plan of care must specify the care and services necessary to meet the patient-specific needs as identified in the comprehensive assessment, including identification of the responsible discipline(s), and the measurable outcomes that the HHA anticipates will occur as a result of implementing and coordinating the plan of care. The individualized plan of care must also specify the patient and caregiver education and training. Services must be furnished in accordance with accepted standards of practice. This CONDITION is not met as evidenced by: Based on record reviews, policies and procedures, interviews with the Administrator, Director of Patient Services and agency staff it was determined the condition was not met: As evidenced by: Failure to develop comprehensive plans of care which address each patient's individual needs. See G 574. Failure to follow physician orders or contact physician when unable to comply. G 578. Failure to ensure care provided is ordered by a physician. G 580. Failure to promptly alert relevant physician of changes. G 590. Failure to communicate with all physicians. See G 602. Failure to integrate all services. See G 606. The cumulative effect of the systemic issues identified in the failure to conform with the physician's orders resulted in an Immediate Jeopardy finding for patient # 1 related to the failure to provide wound care and assessments 3 times a week as ordered by the physician. Failure to develop comprehensive plans of care; communicate with all physicians; promptly alert the physician of changes in condition; and integrate all services has the potential for negative outcomes for the entire patient population.

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 clinical record review, observational home visits, interviews with agency staff and the Administrator and Director of Patient Services (DPS), it was determined in 4 of 8 records (patients # 1, 2, 3, and 8) that the plan of care developed failed to contain all relevant information necessary to meet the patient's needs. Evidence as follows: Patient # 1 was admitted to the agency on 02/04/22 with diagnoses of an open wound to the top of the right foot, type 1 diabetes mellitus with diabetic chronic kidney disease, metabolic encephalopathy. The 02/04/22 – 04/04/22 Home Health Certification and Plan of Care failed to include the following: Diabetes and Diabetic Management The plan of care included skilled nurse for instruction/reinforcement of diabetes management including: medications to manage blood sugar, patient/caregiver blood glucose testing as ordered by the physician. The patient/caregiver independent with BG checks, patient has sensor 3 to 4 times a day. There is no plan for the SN to assess the patient's compliance with BG testing and insulin administration. The plan of care failed to include specific frequency for blood sugar testing such as before meals, and failed to include a plan for the SN to assess compliance with BG testing and insulin administration. - The medication list includes Humalog Kwik pen (U-100) insulin 100 unit/ml subcutaneous as directed/PRN (as needed) with a sliding scale: There is no frequency for administration sliding scale insulin coverage and no specificity to when the patient should test BG. 15 grams of carbohydrates for a blood sugar of less than 70, 70 - 90 6 units; 91 – 130 8 units; 131 – 150 10 units; 151 – 200 12 units; 201 – 250 14 units; 251 – 300 units 16 units; 301 - 350 18 units; 351 – 400 20 units; > 400 Call MD. Wound Care The wound care orders included SN to perform wound care 3 times a week until healed this order was inconsistent with the SN frequency of SN visits ordered. The SN frequency/Duration of Visits – 1 week 1, 2 week 3, 1 week 5. The initial assessment was completed on a Friday, there was no explanation of how the wound care ordered 3 times a week would be completed when the SN visit schedule was only 2 visits a week. This record was reviewed with the Administrator and DPS on 03/11/22, they acknowledged the findings and provided no additional information. Patient #2 was admitted to the agency on 02/14/22 with diagnoses closed fracture of the left femur, hypertensive heart failure, acute systolic (congestive) heart failure, cardiomyopathy, lymphedema (extremity swelling). The plan of care failed to include: Congestive Heart Failure - plan to assess lower extremity edema. The plan of care included direction for the SN to assess/evaluate co-morbid conditions including congestive heart failure. The plan failed to include direction for the SN to assess and monitor lower extremity edema. - plan to assess weight changes greater than 2 pounds per day or greater than 5 pounds per week. The plan directs the SN to teach the patient to report signs and symptoms, however, there was no plan for the SN to review the assess the patient’s compliance with daily weight monitoring. On 03/15/22, the findings were reviewed with the Administrator and Director of Patient Services. They acknowledged the findings and provided no additional information. Patient #3 was admitted to the agency on 02/10/22 with a primary diagnosis of pressure ulcers and secondary diagnoses of type II diabetes, kidney disease, depression, unspecified myoneural disorder, post-laminectomy syndrome, and bed-confinement status. The 02/10/22 Home Health Certification and Plan of Care (POC) was incomplete/inaccurate as follows: Wound Care On 02/14/22, 4 days after the start of care, an additional wound was identified as follows: #9 – Mid-calf right 02/14/22 documentation included the wound was assessed, it was partial-thickness, and measurements were not taken. The reason given for no measurements was “unable” with no further explanation. The narrative note included the SN case manager covered it with an ABD pad and rolled gauze then notified the MD office of the new wound and left a message on the office nurse line. The SN case manager failed to identify the name of the office where the message was left. On 03/02/22, the patient was seen in the wound care clinic at which time the physician determined the wounds had worsened with purulent drainage and the patient had hypotension, both signs of acute sepsis, and sent the patient emergently to the emergency room for care. On 03/09/22 the patient was discharged from the hospital with the following orders for the bilateral heel wounds which had recently been debrided: cleanse with Vashe, apply with Adaptic touch to wound base then Aquacel AG, cover with 4x4 gauze, ABD pad, wrap with Kling and secure with tape. Change every 2 days and PRN (as needed). On 03/17/22, the SN visited for a re-assessment of the patient. The SN asked the caregiver to perform wound care to wound #9 located on the right lateral calf as the SN had not yet obtained a physician’s order for care. The SN documented the wound was washed with Vashe, Aquacel was applied and it was covered with gauze and Kerlix by the caregiver. There was no physician’s order for the care that was provided to the wound. On 03/18/22 the DPS documented in the coordination note the agency had a telephone call at 02:55 pm to the wound care clinic in an attempt to obtain wound care orders for #9, the right lower leg partial-thickness wound that has not had orders since its discovery, 02/14/22. Documented on 03/18/22 at 02:55 pm as a late entry is another telephone call to the primary care provider regarding “clarification” of order for the right lower leg wound, and the nurse relayed a message would be left. The WCC informed the SN are not providing orders at this time as they haven’t seen the patient since February. The patient has canceled appointments but does have an appointment on 03/23/22. On 03/21/22 the surveyor conducted an observational home visit. During the visit, the SN removed the dressing and assessed wound #9 on the right lower posterior calf. The SN was unsuccessful in attempting orders for care when the Wound Care Clinic (WCC) would not give orders for care until the patient was seen. The SN informed the caregiver “you’ll have to put it on after I leave, I’m not allowed to do it without orders”. The SN failed to obtain orders for wound #9 from 02/14/22 until 03/23/22. On 03/09/22, the patient was discharged from the hospital with new wound care orders after the heels had been surgically debrided. The patient was unable to get to the wound care clinic the following Wednesday. The SN called the WCC and attempted to obtain orders for the wounds. The WCC would not give orders until the patient was seen in the clinic. On 03/21/22 the surveyor conducted an interview with the RN clinical coordinator (RNCC) at the WCC. The RNCC stated that a nurse from the home care agency had called for wound care orders, however, the physician would not give orders after the patient’s recent hospitalization due to the patient not being seen at the follow-up appointment. The instructions given were to first, utilize the orders from the hospital discharge team, as they were the clinicians having most recently cared for the wounds. A backup would be to use the patient’s primary care physician. The RNCC stated the patient had not been to the clinic since 03/02/22 when she was immediately sent to the hospital, and prior to that, the last visit was 02/02/22, prior to the start of care with the agency. On 03/21/22, the Administrator and Director of patient Services were interviewed. When asked if they knew the patient had not been making appointments at the wound care clinic, they replied “no” and when asked when they found they both replied “today, when you told us” although the DPS wrote a note on 03/18/22. On 03/17/22 and 03/21/22, the SN documented the use of foam heel dressings on both heels. Foam heel dressings were not included in the post-debridement hospital discharge orders/plan of care for wound care to both heels. On 04/01/22 the surveyor conducted an interview with the Clinical Field Staff Supervisor (CFSS) regarding the 03/17/22 assessment and wound care visit to the patient. The surveyor asked about the documentation that indicated "wound care completed with (caregiver)", right pre-tibial wound washed with Vashe, Aquacell applied, covered with gauze, and kerlix by the caregiver. The CFSS said the wound care clinic again would not give orders for this wound as the patient had canceled the appointment, and referred the CFSS to the primary care provider (PCP) for orders. The CFSS went on to say a message was left at the PCP to relay the care that was provided and awaited a return call for further orders. When asked how the materials were chosen to apply to the wound, the CFSS indicated it was better to have something on the wound than to leave it open, and the son selected dressing materials. Medications The POC included the following incomplete medication orders: - The 02/02/22 Initial Agency referral medications included Vancomycin 125 mg capsule 4 times daily, disp. #48 with no refills, for 12 days. (discontinue on or around 02/14/22) The patient's record medication list on 03/15/22 indicated the medication was active without a stop date. - The 03/09/22 Hospital discharge instructions included Vancomycin 125mg capsule, 1 capsule 2 times daily for 5 doses. The resumption of care medication order failed to include the instructions for the medication that included it was for 5 doses only and should have terminated several days after the patient's discharge from the hospital. - As of 03/15/22, the medication remained current on the profile. - On 04/01/22, the medication profile was again reviewed. The 02/02/22 Vancomycin 125mg 4 times daily order was noted as discontinued by the resumption of care nurse on 03/11/22 which had not been present when the profile had been printed 03/15/22. Patient # 8 was admitted to the agency on 02/17/22 with a diagnosis of surgical amputation left great toe, type 2 diabetes, chronic ulcer bilateral feet, and hypertension. The 02/17/22 Certification and Plan of Care was incomplete as follows: INTERVENOUS (IV) MEDICATIONS The agency plan of care (POC) included skilled nurse /patient/caregiver may infuse ertapenem 1 gram mixed with normal saline via gravity pump slash gravity to physician specified lumen. May use alternate lumen for infusion if designated lumen is without blood return or unable to flush. Flush IV access with saline and heparin. POC medications included: - ertapenem 1 gram daily - normal saline flush injection syringe flush both lumens daily and as needed for labs - heparin lock flush syringe flush both lumens daily The plan of care failed to include: - which lumen was “physician specified” to administer medication - dosage/number of ml of saline and heparin - instructions for administration of saline and heparin (to administer saline before and after medication infusion, and heparin after saline) WOUND CARE / SKINCARE Referral information/hospital discharge instructions dated 02/16/22 included wound care to bilateral feet, change daily and as needed. Agency coordination notes on 02/16/22 included wound frequency daily and as needed. The 02/17/22 plan of care included: wound care to right** lower extremity amputated site healed and bilateral plantar diabetic ulcers: cleanse the wound with wound cleanser, apply Aquacel Ag to wound base, dry gauze, wrap bilateral feet and ankles with Kerlix and secure with tape. Apply triamcinolone cream to bilateral feet and ankles. Change 3 times weekly and as needed for strikethrough drainage or dressing dislodgment. Skilled nursing to see patient 2 times weekly, patient and caregiver proficient at wound care as demonstrated, patient/caregiver may be taught to perform wound care. -The agency plan of care included an incorrect site of amputation; frequency of wound care 3 times weekly rather than daily, and nursing visits 2 times weekly, without explanation. On 03/01/22 a fax from the wound clinic to the agency included: left and right plantar wound, right 5th MTP (metatarsophalangeal joint located at the base of the little toe), cleanse with soap and water, do not scrub, apply Aquacel Ag, ABD pad, Kerlix, secure with tape, every 2 days. On 03/08/22 another fax was received with the same wound care orders for “all wounds on both feet” every 2 days. On 03/10/22 an agency order dated 03/10/22 stated “order found in attachments dated 3/9. Using clean technique skilled nurse to cleanse wound wounds to bilateral feet with soap and water, pat dry and apply Aquacel followed by ABD pad and wrapped with Kerlix. To be changed every 2 days. Patient able to do wound care if needed.” -The agency failed to update the plan of care with the 03/01 revised orders and frequency until 03/10/22. Hospital discharge instructions included triamcinolone ointment to bilateral feet and ankles twice weekly for two weeks then weekly for two weeks. The POC medications included triamcinolone topical cream 2 times daily for 2 weeks, then 1 time daily for 2 weeks. There is no explanation in the record for using 1-2 x daily rather than 1-2 times weekly. LABS Referral information included an order for lab work repeated every Monday and as needed. There was no end date ordered for labs. The agency POC included: Skilled nurse to perform IV line draw from red lumen for CRP, CMP, ESR, and CBC with differential. Results to the physician. Use alternate lumen for lab draws if designated lumen without blood return or unable to flush. Labs were drawn on 02/21/22 and 02/28/22. During the interview on 03/22/22, the SN stated labs were automatically discontinued when the PICC line was discontinued (on 03/07/22). The plan of care failed to specify dates, frequency or end date of blood draws for lab work. BLOOD GLUCOSE The plan of care included blood glucose checks 3 three times daily and failed to include any parameters for physician notification of high or low blood glucose. EDEMA Referral information included to “Elevate your foot 12 inches above your heart 3 - 4 times daily for 1 – 1.5 hours at a time to decrease the swelling in the foot.” During the initial assessment on 02/17/22, the SN documented swelling in the bilateral lower extremities. The plan of care failed to include any interventions for assessing, monitoring, reporting, or treating edema. WEIGHT-BEARING Referral information / discharge instructions included: -strict non-weight bearing to left lower extremity, right lower extremity partial weight-bearing to heel - diabetic shoes with three insoles and a forefoot offloading wedge shoe for the left foot The agency plan of care failed to include weight-bearing precautions and diabetic/offloading shoes. On 03/22/22 at 2:30 PM the record was reviewed with the Administrator, DPS, Quality Assurance, and Compliance Directors. They acknowledged the findings and provided no additional information.

Conformance with physician orders CFR(s): 484.60(b) Standard: Conformance with physician or allowed practitioner orders. This STANDARD is not met as evidenced by: Based on clinical record reviews and interviews with the Administrator, Director of Patient Services (DPS), and agency staff was determined 3 of 8 records (patients # 1, 7 and 8), agency staff failed to provide care as ordered by the physician. On 03/14/22 at 12:00 pm it was determined the failure to provide wound care and assessment visits as ordered by the physician placed the patient in immediate jeopardy. (Patient # 1) Evidence as follows: Patient # 1 was admitted to the agency on 02/04/22 with diagnoses of an open wound to the top of the right foot, type 1 diabetes mellitus with diabetic chronic kidney disease, metabolic encephalopathy. The SN visited the patient on 02/04/22 and documented wound measurements of 3.2 x 5.3 x 0.2 (length x width x depth). The physician orders were for wound care until the wound was healed and to cleanse the wound (right dorsum, top of foot) with soap and water and apply xeroform as primary dressing and apply foam pad. If foam not available, cover with dry gauze and wrap with kerlix and secure with tape and change dressing 3 times a week. - The wound care was ordered 3 times a week from 02/04/22 to 03/08/22. The SN only completed 6 visits from 02/04/22 to 03/08/22. The patient's caregiver wasn’t taught the wound care and wasn’t willing to provide wound care. The physician was not notified that wound care wasn’t provided. On 03/11/22 at 1:30 pm the SN was interviewed by the surveyor and asked if the physician was notified regarding the wound care not provided. The SN confirmed that the physician was not notified that the wound care was not provided as ordered. On 03/11/22, the SN visited the patient and identified two new wounds, and contacted the physician to notify and obtain new wound care orders. Failure to provide SN assessment and wound care 3 times a week as ordered has the potential to cause serious harm including wound deterioration and infection as well as delay in wound healing. Patient # 7 was admitted to the agency by the physical therapist on 02/09/22 following extensive surgery of the neck for cervical and upper thoracic spine. The plan of care included: Physical therapy (PT) 1 week 1; 2 week 4; 1 week 2 (1 visit the first week; 2 visits a week for 4 weeks; 1 visit a week for 2 weeks) Home Health Aide Services 2 week 4 - effective 02/13/22. (2 visits a week for 4 weeks beginning 02/13/22) Occupational Therapy 1 week 1 – effective 02/13/22. (1 visit the week of 02/13/22) usually to evaluate the patient. The agency failed to provide HHA services as ordered by the physician to assist with personal care and apply therapeutic anti-embolic stockings. The PT admission narrative note identified the patient's need for a home health aide as follows: pain of 7/10 on a scale of 0 to 10 in neck, upper back, and bilateral shoulders with the use of medications; moderate difficulty with dressing, toileting, and self-care; was unable to move and reach back with either upper extremity, as well as pull up her pants due to pain or apply TEDS (ordered apply in the morning remove in the evening). The PT determined the patient would benefit from an OT evaluation and orders obtained for home health aide services. The patient was admitted to the home of her ex-husband to avoid the stairs at her second-floor apartment where she lives alone. The PT documented she has limited to no assistance. The patient never received home health aide services from 02/10/22 to 03/11/22. On 03/11/22, an interview was conducted with the Director of Patient Services and the Administrator regarding the lack of aide services provided. They stated that they have very few aides and just couldn't provide the services. The findings were reviewed with the Administrator and DPS on 03/15/22, they acknowledged the findings and provided no additional information. Patient #3 was admitted to the agency on 02/10/22 with a primary diagnosis of pressure ulcers and secondary diagnoses of type II diabetes, kidney disease, depression, unspecified myoneural disorder, post-laminectomy syndrome, and bed-confinement status. The SN failed to provide wound care in accordance with the physician's orders/plan of care. The 02/02/22 referral document included: wound care every 2 days or at least 3 times a week to the sacrum and bilateral heels. The "Home Health Care Certification and Plan of Care" included 3 times daily and PRN (as needed) to the left upper back and bilateral heels, and daily and PRN to the sacrum. The 02/02/22 initial referral also included “multivitamin daily”. The patient was not started on a multivitamin until after the resumption of care post-hospitalization. The 02/02/22 Wound care physician provided instructions in the referral: Very Important to go to the Emergency Department if any worse or new problems occur, including fever, chills, purulence, worse or new redness or new ulcerations. The SN failed to incorporate these instructions when developing the Plan of Care. The Plan of Care was developed on 02/10/22 for the agency to provide wound care 2 times per week and the 3rd dressing change/assessment would be completed at the wound care clinic. The agency failed to identify the patient was not going to the wound care clinic each week and had not been seen since prior to the start of care on 02/02/22, and again on 03/02/22 when the patient was sent emergently to the hospital with hypotension (low blood pressure) and sepsis. Patient # 8 was admitted to the agency on 02/17/22 with a diagnosis of surgical amputation left great toe, type 2 diabetes, chronic ulcer bilateral feet, and hypertension. Referral information/hospital discharge instructions dated 02/16/22 included wound care to bilateral feet daily and as needed. The 02/17/22 plan of care included: wound care three times weekly and as needed for strikethrough drainage or dressing dislodgment. Skilled nursing to see patient two times weekly, patient and caregiver proficient at wound care as demonstrated, patient /caregiver may be taught to perform wound care. On 03/01/22 the wound care clinic faxed updated orders to the agency that included wound care was to be completed every 2 days. On 03/10/22 the agency updated its orders / POC to reflect wound care every 2 days. The agency visited the patient and provided wound care on 02/17, 02/21, 02/24, 02/28, 03/04, 03/07, 03/10, and 03/18/22; and by the wound care clinic on 03/01, 03/08, and 03/15/22. A review of the patient’s record revealed no evidence the patient/caregiver was instructed regarding or assessed for, the ability to provide care until an SN visit on 03/18/22 when the SN documented the patient “was unable to demonstrate wound care with proficiency.” On 03/21/22 the surveyor completed an observational home visit with the SN. Upon completion of the visit, the surveyor interviewed the patient. The patient stated he is seen at the wound care clinic every Tuesday, and the agency typically comes on Mondays and either Thursday or Friday. When asked whether he was taught how to perform wound care/dressing change the patient stated that “last Friday the nurse taught me, she did the left and I did the right.” When asked whether he had changed the dressing himself before or since then he stated he had not, that there was no reason for him to do so because “you do it a lot better than me so if it’s 2 or 3 days I’ll wait for you to do it.” When asked if anyone else, his father or mother, ever changed the dressing he stated, “no one else changes it” there was “no need”. From 03/01/22 through 03/21/22 the agency failed to ensure wound care was being provided every 2 days as ordered. On 03/22/22 at 2:30 PM the record was reviewed with the Administrator, DPS, Quality Assurance, and Compliance Directors. They acknowledged the findings and provided no additional information.

Only as ordered by a physician CFR(s): 484.60(b)(1) Drugs, services, and treatments are administered only as ordered by a physician or allowed practitioner. This ELEMENT is not met as evidenced by: Based on clinical record reviews and interviews with the Administrator, Director of Patient Services (DPS), and agency staff it was determined in 2 of 8 records (patients # 3 and 6), agency staff failed to ensure drugs, services, and treatments are administered only as ordered by a physician or allowed practitioner. Evidence as follows: 1. Patient #3 was admitted to the agency on 02/10/22 with a primary diagnosis of pressure ulcers (4) and secondary diagnoses of type II diabetes, hypertension, kidney disease, depression, myoneural disorder (unspecified), post-laminectomy syndrome, and bed-confinement status. The skilled nurse provided wound care without physician's orders. On 02/14/22, the SN identified a new wound on the R lower extremity, and documented "wound covered with an ABD pad (thick cushioned surgical pad) and rolled gauze. MD office notified of the new wound". A message was left on the nurse's line with a callback number. The SN failed to follow up, never discussed the wound with the physician, or received orders for the wound care. For SN visits on 02/14, 02/17, 02/21, 02/25, 02/28/22 the SN documented wound care was provided to wound #9 (#10) and no physician orders for care were present. None of the documentation specified what care had been provided, only that care had been provided by the SN per the MD order. The Administrator and Director of Patient Services were interviewed and stated they became aware of this on 03/21/22 when the surveyor reviewed findings and informed them the patient had not been to the wound care clinic since 02/02/22. Orders for this wound were attempted to be obtained. The physician would not provide orders until the wound could be directly assessed in the wound care clinic, and the patient was scheduled to attend on 03/23/22. On 03/15/22, the record was reviewed with the Administrator, Director of Patient Services (DPS) Quality Director, and Compliance Director. They acknowledged the findings, and no further information was provided. 2. Patient #6 was admitted to the agency on 02/28/22 with a primary diagnosis of cellulitis of the left lower limb and secondary diagnoses of type II diabetes, subacute osteomyelitis of the left foot and ankle, COPD, asthma, hypertension, lumbago, and bipolar disorder. The skilled nurse failed to perform a comprehensive assessment as follows: On 03/01/22, the SN visited and documented with arm re-positioning, that both lumens (of the peripherally inserted central catheter - PICC) were able to be flushed. Heparin was placed into each lumen and allowed to remain in the line for 10 minutes. The SN notified the infectious disease clinic staff and documented they were aware of the issues and they asked for a call back if issues persist. On 03/12/22, the surveyor requested the Agency’s PICC policies and occluded line policy. The surveyor was provided a policy from the Visiting Nurses Association of America Copyright 2014 titled "Infusion Therapy - Central Line: Occlusion and TPA". The Director of Patient Services (DPS) informed the surveyor they did not have a policy for instilling Heparin to unclog PICC lines, and although this policy existed, they did not use TPA at their agency for “un-clogging” PICC lines. Placing heparin into each lumen for 10 minutes did not follow agency policy and procedure, and the SN failed to obtain a physician’s order to perform the procedure. On 03/16/22, the record was reviewed with the Administrator, Director of Patient Services (DPS) Quality Director, and Compliance Director. They acknowledged the findings, and no further information was provided. Failure to ensure drugs, services and treatments are administered only as ordered by a physician or allowed practitioner has the potential for patient harm.

Promptly alert relevant physician of changes CFR(s): 484.60(c)(1) The HHA must promptly alert the relevant physician(s) or allowed practitioner(s) to any changes in the patient's condition or needs that suggest that outcomes are not being achieved and/or that the plan of care should be altered. This ELEMENT is not met as evidenced by: Based on a review of clinical records, policies, and procedures and interviews with the Administrator and Director of Patient Services (DPS) it was determined for 3 of 8 records (Patients # 1, 3, and 6) the Skilled Nurse (SN) failed to communicate with the physician when changes in the patient's condition occurred. Evidence as follows: Patient # 1 was admitted to the agency on 02/04/22 with diagnoses of an open wound to the top of the right foot, type 1 diabetes mellitus with diabetic chronic kidney disease, metabolic encephalopathy. Between 02/04/22 to 03/08/22, the SN visited the patient 1 time per week although the wound care was ordered 3 times a week. The SN failed to notify the physician that the wound care was not provided as ordered. On 03/11/22 the SN visited the patient with the Supervising Nurse, during the visit, the SN discovered the patient had 2 more wounds. One additional wound on the right foot and a new wound on the left leg. The SN contacted the physician to obtain new wound orders, however, there is no evidence the physician was informed that the previous orders were not followed. On 03/01/22, the SN documented review of the patient’s blood glucose ranges since the last visit were 87 and 487 and documented a random blood sugar at the visit of 336. The SN failed to notify the physician of the significantly elevated blood sugar reading of 487 to determine if a change in the plan of care was necessary. Failure to notify the physician of changes in condition and care provided places this patient at risk for serious injury and harm. Patient #3 was admitted to the agency on 02/10/22 with a primary diagnosis of pressure ulcers and secondary diagnoses of type II diabetes, kidney disease, depression, unspecified myoneural disorder, post-laminectomy syndrome, and bed-confinement status with generalized edema. The skilled nurse (SN) failed to notify the physician of changes in the wound. On 02/10/22, the Skilled Nurse (SN) visited for the comprehensive assessment and performed wound care and assessment to both heel wounds and documented: L heel wound (#2) 3 x 2.5 x 0.1 purulent scant, no odor On 02/02/22, the wound care clinic physician performed wound care and documented: L heel wound - moderate amount of tan serosanguinous drainage, no odor The SN failed to identify the status of the dressing prior to removal or when or by whom the dressing was last changed. The referral indicates the patient had an appointment at the wound care clinic on 02/09/22 which the patient did not attend. There was no evidence the physician was notified wound #2 (L heel) had deteriorated having serosanguinous drainage to purulent drainage, or the patient was advised to go to the emergency department as per the referral instructions for purulence. On 02/28/22, the SN visited and performed wound care and assessment to both heel wounds and documented: R heel wound (#6) – no measurements taken, serosanguinous scant drainage with a faint odor The reason measurements were not taken to the right heel was “unable” and no further explanation was given. There is no evidence the physician was notified of the change in the R heel wound when the SN assessed changes in odor and measurability on 02/28/22. The patient went to the wound care clinic appointment on 03/02/22 where the physician documented increased purulent drainage from sacral decubitus ulcer with significant hypotension and was sent emergently to the emergency department. The patient was given 2 liters of intravenous fluids, and IV antibiotics and diagnosed with sepsis. MRI studies showed new osteomyelitis in both heels, right greater than left with cellulitis in the subcutaneous tissue of both. The coccyx/sacral ulcer had enlarged and showed signs of increased osteomyelitis. On 03/16/22 the record was reviewed with the Administrator and Director of Patient Services. They acknowledged the findings. Patient #6 was admitted to the agency on 02/28/22 with a primary diagnosis of cellulitis of the left lower limb and secondary diagnoses of type II diabetes, subacute osteomyelitis of the left foot and ankle, COPD, asthma, hypertension, lumbago, and bipolar disorder. The skilled nurse failed to notify the physician the antibiotic dose had been delayed and to assist in obtaining the medication rapidly from the infusion company. On 03/06/22, the patient called the SN to inform the antibiotic had accidentally been left at room temperature for 11 hours. The SN documented "informed the patient to call the infusion company". The SN failed to ensure the patient received another dose on 03/06/22 and was able to give the medication as scheduled 48 hours from the dose given at the ID office on 03/04/22. On 03/07/22, the SN visited and documented "new medications viewed in the home - Daptomycin...SN observed patient complete IV infusion correctly". On 03/16/22 the record was reviewed with the Administrator and Director of Patient Services. They acknowledged the findings. Failure to ensure the physician is notified regarding changes in the patient's condition has the potential for unmet patient needs.

Integrate all services CFR(s): 484.60(d)(3) Integrate services, whether services are provided directly or under arrangement, to assure the identification of patient needs and factors that could affect patient safety and treatment effectiveness and the coordination of care provided by all disciplines. This ELEMENT is not met as evidenced by: Based on a review of patient records, observational home visits, and interviews with the Administrator, Director of Patient Services (DPS), and Skilled Nurses, it was determined in 5 out of 8 patients (patients # 1, 2, 3, 6 and 7) the agency failed to provide coordinated care to meet the needs of the patients. Evidence as follows: Patient # 7 was admitted to the agency by the physical therapist on 02/09/22 following extensive surgery of the neck for cervical and upper thoracic spine. The agency failed to provide care coordination to ensure the basic needs of this patient were met: The home health certification and plan of care included: Physical therapy (PT) 1 week 1; 2 week 4; 1 week 2 Home Health Aide Services 2 week 4 - effective 02/13/22. Occupational Therapy 1 week 1 – effective 02/13/22. On 02/09/22, the physical therapist visited the patient and documented in the initial narrative note: the patient had a pain level of 7/10 on a scale of 0 - 10 in her neck, in upper back and bilateral shoulders, takes her pain medications with little effectiveness due to her neck brace. The patient has limited range of motion and requires moderate assistance for dressing, toileting and self care. Has difficulty with toileting hygiene and requires assistance since she is unable to move and reach back with upper extremities to pull up her pants. Has mild non pitting edema and required assistance donning her anti-embolic stockings (TEDS), she is unable to put them on independently. The PT further documented that the patient lives alone at her primary residence in a second floor apartment but is currently staying with her ex-husband but is planning to move back home by next week. The PT documented the patient would benefit from a home health aide. Between 02/09/22 and 03/14/22, the patient never received home health aide services. Although there was documentation that the physical therapist developed an aide care plan, and the aide scheduling department assigned an aide, there was no coordination with the physician, or the DPS to express the patient's significant need for aide services and look into alternate mechanisms to provide personal care. On 03/09/22, an interview with the DPS was completed regarding the lack of aide services and it was determined the licensed agency only employs 6 aides in this region, and the agency just doesn't have enough aides. Patient # 1 was admitted to the agency on 02/04/22 with diagnoses of an open wound to the top of the right foot, type 1 diabetes mellitus with diabetic chronic kidney disease, metabolic encephalopathy. The agency failed to ensure care coordination between to ensure the patient's needs are met as follows: On 02/04/22, the admission nurse documented in a narrative note "wife can provide care". The admission nurse failed to assess the competence and willingness of the caregiver to provide wound care ordered 3 times a week. There was no evidence that the SN case manger was aware of the outcome of the initial assessment visit, or that the plan of care included wound care completing 3 times a week by the SN. The admission SN documented in the narrative note the patient didn't have Lantus insulin and that it was called in to the pharmacy. There was no evidence that the SN was aware that the patient needed to pick up the Lantus insulin and that she should verify that the patient had the medication available for use at night. On 03/08/22, the SN case manager was interviewed regarding her knowledge of the insulin missing. The SN didn't recall anything about missing insulin from the admission nurse. On 03/15/22, the surveyor interviewed the caregiver (wife) and asked if she ever provided wound care, the caregiver said that she was too busy and that is why the nurses were supposed to come. She also stated that the nurse showed her how to do the dressing on 03/11/22, but usually her granddaughter does the dressing if it is needed. There is no evidence the patient's granddaughter was observed providing wound care. The hospital discharge referral dated 02/03/22 included a request for Nursing, Physical Therapy and Home Health Aide. There is no evidence that the agency coordinated care to ensure the patient received a home health aide for assistance with personal care and physical therapy home exercises. On 02/15/22, the SN documented in a narrative note discussion with the physical therapist due to the patient requesting a home health aide. The SN documented the PT will order an occupational therapy evaluation. On 02/15/22 at 10:46 am, the supervising nurse documented in an interdisciplinary communication note a return call to the patient's wife verbalizing frustration regarding lack of aide services as they were promised. "complaint filed on behalf of patient regarding lack of aide care as promised." On 03/08/22 the surveyor requested all complaints filed from February to current. There was no complaint filed on 02/15/22 for this patient, there was one on 03/03/22, around 2 weeks later. Aide services were not initiated until 03/04/22. On 03/15/22, the above findings were reviewed with the Administrator and DPS, they acknowledged the findings but provided no additional information. Patient #2 was admitted to the agency on 02/14/22 with diagnoses closed fracture of the left femur, hypertensive heart failure, acute systolic (congestive) heart failure, cardiomyopathy, lymphedema (extremity swelling). The agency failed to ensure the development and implementation of a coordinated comprehensive plan of care for skilled nursing and physical therapy. The 02/14/22 home health certification and plan of care included: SN 1 visit per week for 3 weeks PT 2 visits per week for 4 weeks OT 2 visits per week for 2 weeks then 1 visit per week for 1 week. During the weekly nursing completed on 02/14/22, 02/23/22 and and 03/02/22 the SN documented the patient's weight, but failed to document any assessment of lower extremity edema, and failed to assess if the patient is monitoring weights daily. During PT visits completed on 02/15/22, 02/18/22, 02/24/22 the PT documented the patient had 1 + mild pitting edema, and on 02/15/22, the PT documented that the edema to bilateral lower extremities limits mobility but failed to document a patient weight or if the patient was self monitoring weights daily. There was no evidence of communication or coordination between the SN and the PT regarding the differences in lower extremity assessments of edema. The SN documented an 8.5 pound weight gain between 02/14/22 and 02/23/22 (241 pounds and 249.5 pounds), noted a call to the physician to report the weight gain, but failed to document if any changes to the plan of care were needed and discharged the patient from skilled nursing a week later on 03/02/22. On 03/15/22, the above findings were reviewed with the Administrator and DPS, they acknowledged findings but provided no additional information. Failure to ensure coordination of care is provided has the potential for unmet patient needs and negative outcomes for the agency's patient population. 1. Patient #3 was admitted to the agency on 02/10/22 with a primary diagnosis of pressure ulcers (4) and secondary diagnoses of type II diabetes, kidney disease, depression, myoneural disorder (unspecified), post-laminectomy syndrome, and bed-confinement status. The skilled nurse (SN) failed to coordinate care to ensure the patient received wound care and personal care aide services as ordered by the physician The 02/10/22 Home Health Certification and Plan of Care included orders from the Wound Care Clinic (WCC) physician for (SN) 2 times per week in combination with 1 visit weekly to the Wound Care Clinic (WCC) to ensure the patient received wound care to multiple sites every other day, or at least 3 times per week. Referral information included a physician note: “transportation is challenging, caregiver reports they will do their best to get the patient here (to the WCC) weekly for the next couple of weeks.” During the comprehensive assessment, the SN documented the following barriers for the patient to attending appointments: - “lack of reliable transportation” - “low socioeconomic status/ financial concerns” - “exhaustion” - “confined to bed” - “requires (Hoyer or Grandson) lift for transfer” - “Requires special transportation services” The SN failed to identify if the patient and caregiver had been successful in managing the transfer and transportation needs necessary to attend the appointment at the WCC the day prior, which would be part of the plan of care to ensure the wounds were assessed and changed by clinicians "every other day or least 3 times per week." There is no evidence the SN instructed the patient to notify the agency if the patient could not or did not attend the appointment. The SN visited on 02/17/22 one day after a scheduled WCC appointment and on 02/25/22, 2 days after a scheduled WCC appointment. There is no evidence the SN determined the patient had missed the WCC appointments on 02/16/22, and 02/23/22. The case managing SN visited on 02/28/22 and performed wound care. There is no evidence the case managing SN assessed how the WCC appointments and transportation were going or determined why the patient had missed the WCC appointments since the start of care, and the day prior to the start of care. On 02/14/22, the SN documented calling the MD to obtain orders, failed to identify the MD notified, and failed to obtain the orders. At each nursing visit that occurred on 02/17. 02/21, 02/25, and 02/28/22 the SN failed to identify that orders were not obtained for wound #9 due to the patient not attending the WCC, and was not receiving the ordered wound care 3 times per week. All visiting skilled nurses failed to assess if the patient had been to the wound care clinic since 02/02/22, and failed to coordinate with the patient, caregivers, WCC, and supervisors to ensure the patient’s needs were met. On 02/10/22, the Home Health Certification and Plan of Care included an order for a Social Work (SW), Reason for Medical Social Work referral: Long Term Aide Services.” The physician's social work referral also requested the following: “Assess social and emotional factors related to the patient's illness, need for care, response to treatment, and adjustment to care; To be followed by a collaboration with the physician and nurse to develop a plan of care." The SW documented "Patient is approved for aide service however, no staffing has been found. Patient's primary concern is lack of aides." The SW evaluation was completed on 03/15/22, 1 month after the 02/10/22 start of care. The SW assessment report was left on a phone message line at the incorrect physician's office and failed to address the emotional factors related to the patient's illness, the need for care, the response to treatment, and adjustment to care. (The patient was unavailable from 03/02/22 – 03/09/22 while hospitalized during that period.) The SW documented attempting to reach the patient on 02/15/22, and again on 02/17/22 “unable to schedule a time to meet with the patient this the week; will attempt to schedule the following week”. The SW documented “MD office was notified on 02/17” and failed to identify with whom the message was left and at what MD office. After the evaluation, the SW reported the evaluation summary via telephone message to the patient’s primary care provider’s nurse message line, who was not the ordering physician’s nurse. There is no evidence the ordering physician received any communication from the SW regarding the delay or the findings. On 03/16/22, the Agency received a fax from the patient's primary care physician ordering personal care aide service to include: - housekeeping - grocery Shopping - cooking - cleaning - all ADLs, bathing, and toileting There is no documentation regarding the physician's order for the aide service, no evidence the agency attempted to locate aide service, and no evidence the agency notified the physician aide service could not be provided. On 03/16/22 and 03/22/22 the record was reviewed with the Administrator, Director of Patient Services (DPS), Director Of Quality Assurance, and Director of Compliance 2. Patient #6 was admitted to the agency on 02/28/22 with a primary diagnosis of cellulitis of the left lower limb and secondary diagnoses of type II diabetes, subacute osteomyelitis of the left foot and ankle, COPD, asthma, hypertension, lumbago, and bipolar disorder. The skilled nurse failed to coordinate care to ensure all of the patient's needs were met. The 02/28/22 Home Health Certification and Plan of Care contained orders for the skilled nurse (SN) to visit 2 times per week for 1 week and 1 time per week for 8 weeks. On 03/01/22 the SN visited the patient and documented the visit was for educational purposes. The patient demonstrated and provided a return demonstration on IV administration. The patient is using a Curlin Pump. The next day 03/02/22, the same SN documented "SN spoke to the patient regarding antibiotic administration, the patient was having extreme difficulty setting up the pump." the SN continued documenting the patient was successful after the SN walked the patient through the process. This documentation was presumably phone assistance given. The SN also documented the Infectious Diseases clinic would be notified in the morning to discuss alternatives to the Curlin Pump. On 03/03/22, the SN documented reporting the patient was having "extreme difficulty" with the Curlin pump to the Infectious disease (ID) and infusion company to discuss alternatives even though the patient's problem with the pump had been successfully resolved the evening prior and the SN had instructed the patient with successful return demonstration 2 days prior. The SN documented the patient was proficient when documenting a successful return demonstration with the Curlin pump on 03/01/22, and then was able to infuse the vancomycin successfully with phone prompting on 03/02/22, but reported "extreme difficulty" on 03/03/22 and failed to attempt to provide further education to avoid disruption in antibiotic therapy. Another note dated 03/03/22 states "spoke with ID, vancomycin will be discontinued and daptomycin will be started in the office tomorrow." A verbal order is noted in the record. The SN failed to ensure the patient was aware of the directions on infusing the vancomycin and the instructions regarding the change of antibiotics that was to occur on 03/04/22. On 03/06/22, the patient called the SN to inform the antibiotic had accidentally been left at room temperature for 11 hours. The SN informed the patient to call the infusion company. The SN failed to ensure the patient received another dose on 03/06/22 and was able to give the medication as scheduled 48 hours from the dose given at the ID office on 03/04/22. On 03/07/22, the SN visited and documented "new medications viewed in the home - Daptomycin...SN observed patient complete IV infusion correctly". On 03/08/22, the SN reported to the office of the nurse practitioner the WAT score had increased from 21 to 27 yesterday, indicating the wound had deteriorated. On 03/09/22, the infectious disease clinic ordered an antibiotic frequency change, confirmed the Infusion company was aware and the patient would be informed in the clinic that day. The SN failed to coordinate with the infusion company to ensure the replacement dose of daptomycin arrived on 03/06/22 so that the every 48-hour dose was not delayed, and to coordinate with the physician and the infusion company to ensure the dosage could be delivered timely. On 03/16/22 the surveyor reviewed the record with the Administrator and DPS. They acknowledged the findings and provided no additional information. Failure to coordinate patient care has the potential for unmet patient needs and negative patient outcomes.

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 2 observational home visits with skilled nurses (SN), a review of agency policy and procedure, and interviews with the Administrator and Director of Patient Services (DPS), it was determined during 2 of 2 visits (patients #3 and 8), the skilled nurse (SN) failed to follow accepted standards of infection control practices. 1. Patient #3 was admitted to the agency on 02/10/22 with a primary diagnosis of pressure ulcers (4) and secondary diagnoses of type II diabetes, hypertension, kidney disease, depression, myoneural disorder (unspecified), post-laminectomy syndrome, and bed-confinement status. On 03/21/22 the surveyor completed an observational home visit for wound care to the sacrum, right lower calf ulcer, and bilateral heels with the SN and observed the following: The skilled nurse removed the outer dressing from wound #9 (10), right mid-lateral/posterior calf, and realized the inner dressing had dried, adhering to the wound bed. The SN placed a barrier beneath the calf on the bedsheet and drizzled saline over the wound while pulling the adhered dressing free from the wound bed. The SN said to the patient and caregiver, "I need to phone the physician’s office to get orders. We don’t have orders for this one.” The SN made the call, then stated orders could not be obtained and told the caregiver you’ll have to do this after I leave, I cannot do this without orders. The SN then lifted the patient’s leg, wrapped the soiled dressing in the barrier, discarded the waste, and lowered the leg with the open wound onto the bedsheet without a dressing or barrier. At the conclusion of the visit, the SN left the home with an open wound on the bedsheet. On 08/26/21 the surveyor reviewed the record and findings with the DPS and clinical managers. They acknowledged the findings. 2. Patient # 8 was admitted to the agency on 02/17/22 with a diagnosis of surgical amputation left great toe, type 2 diabetes, chronic ulcer bilateral feet, and hypertension. On 03/21/22 the surveyor completed an observational home visit for wound care to bilateral lower extremities with the SN and observed the following: - As the SN was setting up supplies to complete the dressing changes, the patient’s father carried in a large (approximately 50–60-quart size) clear plastic storage bin. - He set it on the floor in front of the couch in the pathway from the room to the front door and stated the SN could use that for trash. - The SN placed a small clear bag inside the bin. - The SN removed the soiled dressing from the patient’s left foot and placed the dressing inside the plastic bag in the bin. - The SN removed the dressing from the patient’s right foot and placed it in the bin outside of the plastic bag. Each removed dressing had a small amount of bloody drainage and numerous large flakes of skin loosely attached. Each time the SN changed gloves, and when he disposed of the gauze used for cleansing the wounds, he tossed the soiled items in the bin outside of the plastic bag. At the conclusion of his visit, the SN left the open plastic bin with the soiled materials in place. On 03/22/22 at approximately 10 am the surveyor requested the policy related to wound care/disposal of waste. Policies provided included “Wound Care Standards of Practice” (undated) and “Infection Control Plan” (12/18). Neither policy addressed the disposal of waste. On 03/22/22 at 2:30 PM the findings were reviewed with the Administrator, DPS, Quality Assurance, and Compliance Directors. The surveyor again requested the policy for the disposal of medical waste. They acknowledged the findings and provided no additional information. On 04/01/22, the policy, from the Visiting Nurses Association of America Copyright 2014 titled "Infection Control - VISIT: GENERATED WASTE" states: for medical waste disposal, the clinician is to: - prepare a plastic bag to dispose of items contaminated with blood, excrement, body fluids (e.g., dressings) as they are removed - after the care is completed, close the bag securely - consider if the bag should be double-bagged to protect others - throw in household trash The 01/21/21 agency Plan of Correction included mandatory re-education for all clinical staff on infection control policy and practices to include proper disposal of contaminated medical waste. In lieu of any new policy being provided the previous policy was used for reference. The SN failed to follow agency policy and acceptable infection control practices. Failure to ensure the SN is oriented to agency policies and procedures regarding standard precautions for the prevention and transmission of infectious agents has the potential for unmet patient needs and possible negative patient outcomes.

This statement of deficiencies report is the result of an onsite complaint investigation survey initiated on 04/29/21 and was continued on until 05/10/21. A review of 11 records was completed and interviews conducted with the Administrator, Director of Patient Services and Supervising Nurses throughout the survey. The allegation was substantiated. A federal deficiency is being cite in G606 - Integrate All Services.

Integrate all services CFR(s): 484.60(d)(3) Integrate services, whether services are provided directly or under arrangement, to assure the identification of patient needs and factors that could affect patient safety and treatment effectiveness and the coordination of care provided by all disciplines. This ELEMENT is not met as evidenced by: Based on a review of clinical records, and interviews with the Administrator, Director of Patient Services (DPS) and Supervising Nurses, it was determined in 3 of 11 records (Patients # 1, 2, and 5) the agency failed to coordinate care to meet all patient needs: This was evidenced by: 1. Patient #1 was admitted to the agency on 03/11/21 with diagnoses of methicillin resistant staphylococcus aureus (MRSA) sepsis, endocarditis, atrial fibrillation, a stage 2 pressure ulcer to the coccyx,and diabetes. The patient was discharged from a skilled nursing facility with the need for vancomycin intravenous infusion therapy via a peripherally inserted central catheter (PICC) line. The agency failed to coordinate to ensure needed lab work was obtained. The 03/03/21 initial referral from the skilled nursing facility (SNF) informed the agency the discharge was planned for 03/04/21 or 03/05/21 and the SNF orders included lab work every Monday which included a vancomycin trough, necessary for proper dosing of the medication and prevention of toxicity. The 03/05/21 SNF fax informed the agency the patient had been discharged. The SNF information included the agency was unable to admit the patient until 03/11/21, however the agency documentation failed to include evidence the agency discussed the patient's needs, including the need for specialized care and lab work, to coordinate a plan for an earlier admission to meet them. The 03/11/21 to 05/09/21 plan of care included weekly labs from the red lumen of the PICC line including complete blood count, basic metabolic profile, erythrocyte sedimentation rate, and c reactive protein. The vancomycin trough was not included in the orders. The vancomycin trough was not added until the Tuesday 03/16/21 verbal order although the request had been included in the referral information. On 03/16/21 the SN visited the patient and documented a blood draw was done to be sent to the lab. On 03/17/21 the entered a verbal order for a repeat vancomycin trough by Thursday 3/18/21. On 03/19/21 the SN documented in a narrative note the patient had to go to a local lab for the vancomycin level. On 05/07/21 at 2 pm the surveyor reviewed the record with the Administrator, DPS, and Supervising Nurse. They acknowledged the findings and provided no additional information. 2. Patient #2 was admitted to the agency on 03/10/21 with diagnoses of digestive system surgery for incarcerated hernia with gangrene, type 2 diabetes, congestive heart failure, and history of respiratory failure. The agency failed to ensure ordered lab work was obtained and Occupational Therapy services were provided . The 03/03/21 fax from the provider ordered weekly labs to include a complete blood count, comprehensive metabolic profile, and lipase level. The 03/06/21 hospital after visit summary also included these labs to be faxed to the provider. The 03/10/21 plan of care failed to include an order for weekly labs. On 03/19/21 the SN visited the patient and documented performing a venipuncture and obtaining the labs. The SN entered a verbal order for weekly labs effective 03/21/21. The previous lab orders had not been implemented and the labs had not been done. The plan of care included an order for an occupational therapy evaluation. There was no evidence this was completed or the physician was informed it was not done and to discontinue the order. On 05/07/21 at 2 pm the surveyor reviewed the record with the Administrator, DPS, and Supervising Nurse. They acknowledged the findings and provided no additional information. 3. Patient # 5 was admitted to the agency on 04/01/21 with diagnoses of post-surgical infection to left knee with peripherally inserted central catheter (PICC) for antibiotic infusion, type 2 diabetes and Parkinson's disease. The agency clinicians failed to coordinate care to ensure all patient needs were met. Wound Care On 04/01/21 the SN documented in the initial comprehensive assessment the patient had a non-removable dressing to the left knee that was to remain intact until the follow-up visit with the physician in 2 weeks. On 04/13/21, the SN documented in the visit note the patient had a dressing to her left leg but refused to allow the SN to assess. The note included the patient stated it was fine and she would take care of it. There was no evidence the SN communicated with the physician to report the patient did not allow the SN to assess the left knee dressing/wound, determine the status of the non-removable dressing and/or need to obtain orders for wound care. The SN next visited the patient for re-assessment on 04/16/21, 04/20/21, 04/29/21 and 05/05/21. There was no evidence the SN assessed the patient's left knee surgical wound/dressing or coordinated care with the physician regarding the status of the dressing/wound or need for wound care/dressing orders. Therapy Service On 04/01/21 the SN documented in the initial comprehensive assessment occupational therapy (OT) services were necessary. The 04/01/21 plan of care included an order for OT to evaluate for OT services and develop a plan of care. There was no evidence the OT therapist evaluated the patient as specified in the plan of care. The agency failed to coordinate care to ensure all needed services were in place. On 05/07/21 at 2:00 PM the surveyor reviewed the findings with the Administrator, DPS and Supervising Nurse. They acknowledged the findings and no additional information was provided. Failure to ensure that care is effectively coordinated has the potential for unmet patient needs and possible negative outcomes.