Every finding on record at Lane Home Health an Affiliate of Lane Regional Medical Center

The entity is in compliance with the federal emergency preparedness requirements.

Recertification Survey. Abbreviations: gm - gram INR – International Normalized Ratio mg – milligram OASIS – Outcome and Assessment Information Set PT – Prothrombin Time PT – Physical Therapist RN – Registered Nurse SLP – Speech Language Pathologist

Encoding and transmitting OASIS CFR(s): 484.45(a) Standard: An HHA must encode and electronically transmit each completed OASIS assessment to the CMS system, regarding each beneficiary with respect to which information is required to be transmitted (as determined by the Secretary), within 30 days of completing the assessment of the beneficiary. This STANDARD is not met as evidenced by: Based on interviews and record reviews, the agency failed to ensure each OASIS (Outcome and Assessment Information Set) Assessment was successfully transmitted to the Center for Medicare and Medicaid Services (CMS) system within 30 days of completion. Findings: Review of the agency’s Reporting of OASIS Information Policy, dated 02/2024, and revealed the following, in part: Procedure: The agency will report electronically all OASIS data collected according to current federal and/ or state requirements. Review of the agency’s OASIS Agency Final Validation Reports, submitted 01/14/2025 through 12/01/2025, revealed, in part, the following Assessments were not submitted within 30 days of completion: Submission Date: 01/14/2025 – 4 of 25 Assessments were submitted late; Submission Date: 03/20/2025 – 2 of 17 Assessments were submitted late; Submission Date: 03/24/2025 – 2 of 34 Assessments were submitted late; Submission Date: 04/16/2025 – 2 of 138 Assessments were submitted late; Submission Date: 06/16/2025 – 5 of 42 Assessments were submitted late; Submission Date: 06/24/2025 – 14 of 108 Assessments were submitted late; Submission Date: 08/21/2025 – 1 of 42 Assessments were submitted late; Submission Date: 10/23/2025 – 2 of 71 Assessments were submitted late; and Submission Date: 12/01/2025 – 17 of 121 Assessments were submitted late. On 12/10/2025 at 10:39 a.m., an interview was conducted with S3BS. She confirmed she was responsible for submitting the agency’s OASIS Assessments. She confirmed OASIS Assessments should be submitted within 30 days of completion and the aforementioned assessments were not. On 12/10/2025 at 12:30 p.m., an interview was conducted with S1ADM. She confirmed she expected OASIS Assessments to be submitted within 30 days of completion.

Accuracy of encoded OASIS data CFR(s): 484.45(b) Standard: The encoded OASIS data must accurately reflect the patient's status at the time of assessment. This STANDARD is not met as evidenced by: Based on interview and record review, the agency failed to ensure each OASIS accurately reflected the patient’s status for 1 (#17) of 3 discharge records reviewed with Pressure Ulcers. Findings: Review of the agency’s policy revised February 2024 and titled, “Reporting of OASIS Information,” revealed the following, in part: Policy: The agency will report required data collected for the OASIS items. Procedure: The agency will report electronically all OASIS data collected according to current federal and/or state regulations.8. The encoded OASIS data must accurately reflect the patient’s status at the time of the assessment. Review of Patient #17’s Clinical Record revealed a start of care date of 07/04/2024, a discharge date of 04/16/2025, and diagnosis of Stage 4 Sacral Pressure Ulcer. Further review revealed Patient #17 had a Stage 4 Sacral Pressure Ulcer at the time of discharge, and Patient #17 did not have a Stage 2 Pressure Ulcer. Review of Patient #17’s Discharge OASIS dated 04/16/2025 revealed the following, in part: M1306 – Does this patient have at least one unhealed Pressure Ulcer/Injury at Stage 2 or higher or designated as Unstageable? – Yes; M1311 – Current number of unhealed pressure ulcers/injuries at each stage, Stage 2 – number of stage 2 pressure ulcers – 1; and M1324 – Stage of most problematic unhealed pressure ulcer/injury that is stageable: Stage 2. An interview was conducted with S2RN on 12/10/2025 at 10:51 a.m. She reviewed Patient #17’s Clinical Record. She confirmed Patient #17’s Pressure Ulcer was a Stage 4. S2RN confirmed the above question on Patient #17’s discharge OASIS dated 04/16/2024 revealed Patient #17 had a Stage 2 Pressure Ulcer at the time of discharge, which was inaccurate.

A review of all current medications CFR(s): 484.55(c)(5) A review of all medications the patient is currently using in order to identify any potential adverse effects and drug reactions, including ineffective drug therapy, significant side effects, significant drug interactions, duplicate drug therapy, and noncompliance with drug therapy. This ELEMENT is not met as evidenced by: Based on observations, interviews, and record reviews, the agency failed to ensure each patients’ comprehensive assessment included a review of all medications the patients were currently using. The agency failed to ensure skilled nursing and therapy staff reconciled patients’ medications for 3 (#3, #4, and #6) of 7 patients reviewed with home visits. Findings: Review of the agency’s policy revised February 2024 and titled, “Medication Reconciliation,” revealed the following, in part: Policy: The agency will reconcile patients’ medications at time of admission and on an ongoing basis in order to identify any potential adverse effects and drug reactions. Procedure: At time of admission, the admitting RN, PT, or SLP will create and document a complete list of medications that patient is taking at home, including dose, strength, route, and frequency. Patient #3 Review of Patent #3’s Clinical Record revealed a start of care date of 11/28/2025 and a current certification period of 11/28/2025 to 01/26/2026. Patient #3 had diagnoses, which included Aftercare Following Joint Replacement Surgery, Presence of Left Artificial Knee Joint, Congestive Heart Failure, Longstanding Persistent Atrial Fibrillation, Presence of Cardiac Pacemaker, and Unspecified Glaucoma. Further review revealed Patient #3 was ordered to receive a skilled nurse admission visit, physical therapy visits once weekly for one week then three times weekly for two weeks, and occupational therapy visits once weekly for one week then twice weekly for two weeks. A home visit was conducted with Patient #3 on 12/08/2025 at 2:30 p.m. with S2RN and S4PT present. Patient #3’s medications were reconciled during the home visit. The following medication discrepancies were identified based on the current Medication Profile provided by the Home Health Agency and medications Patient #3 was receiving: Eliquis 5 mg by mouth daily was on the medication profile, Patient #3 was taking Eliquis 5 mg by mouth twice daily, and the medication bottle had a fill date of 10/08/2025; Metoprolol Tartrate 25 mg by mouth daily was on the medication profile and Patient #3 was taking Metoprolol Tartrate 25 mg by mouth twice daily; Prednisolone Acetate Ophthalmic 1% 1 drop in each eye daily was on the medication profile and Patient #3 was administering in the right eye only per the instructions on the bottle; and Xiidra one drop in both eyes daily was not on the medication profile and was present in the home. An interview was conducted with Patient #3’s family member during the home visit. Patient #3 and his family member verbalized the family member managed Patient #3’s medications. The family member verified Patient #3 was taking Eliquis and Metoprolol twice daily. The family member verified Patient #3 was administering the Prednisolone eye drops in the right eye only and Xiidra in both eyes daily. Patient #4 Review of Patent #4’s Clinical Record revealed a start of care date of 12/05/2025 and a current certification period of 12/05/2025 to 02/02/2026. Patient #4 had diagnoses, which included Other Spondylosis with Radiculopathy Lumbar Region, Other Chronic Pain, Hereditary and Idiopathic Neuropathy, and Dizziness. Further review revealed Patient #4 was ordered to receive physical therapy visits once weekly for one week then twice weekly for three weeks and occupational therapy visits twice weekly for two weeks then once weekly for two weeks. A home visit was conducted with Patient #4 on 12/09/2025 at 9:00 a.m. with S2RN present. Patient #4’s medications were reconciled during the home visit. The following medication discrepancies were identified based on the current Medication Profile provided by the Home Health Agency and medications Patient #4 was receiving: Phenazopyridine HCl 200 mg three times daily was on the medication profile and not present in the home; Mirtazapine 15 mg one tablet at bedtime was on the medication profile and not present in the home; Gabapentin 300 mg two capsules at bedtime was on the medication profile and not present in the home; Estradiol Micronized Transdermal 0.4% 2 gm apply vaginally once in the morning was on the medication profile and not present in the home; Calcium Citrate 250 mg daily was on the medication profile and not present in the home; and Alprazolam 0.25 mg once at night as needed for anxiety was on the medication profile and not present in the home. A telephone interview was conducted with Patient #4’s family member during the home visit. She stated Patient #4 had not taken Phenazopyridine, Mirtazipine, Gabapentin, Estradiol, Calcium Citrate, or Alprazolam in a “long time” and not since admission to the home health agency. Patient #6 Review of Patent #6’s Clinical Record revealed a start of care date of 09/10/2025 and a current certification period of 11/09/2025 to 01/07/2026. Patient #6 had diagnoses, which included Gastro-esophageal Reflux Disease. Further review revealed Patient #6 was ordered to receive skilled nursing visits once weekly for nine weeks. A home visit was conducted with Patient #6 on 12/09/2025 at 11:00 a.m. with S5RN present. Patient #6’s medications were reconciled during the home visit. The following medication discrepancies were identified based on the current Medication Profile provided by the Home Health Agency and medications Patient #4 was receiving: Zofran 4 mg by mouth every 8 hours as needed for nausea/vomiting was on the medication profile and not present in the home; and Pantoprazole Sodium 40 mg tablet one by mouth twice daily was on the medication profile and not present in the home. An interview was conducted with Patient #6 during the home visit. She stated she managed her own medications. She stated she had not taken Zofran since her surgery in September 2025 and had not taken Pantoprazole in years. An interview was conducted with S2RN on 12/09/2025 at 1:20 p.m. S2RN confirmed medications should have been reconciled each nursing visit and therapists should ask about medication changes each visit. S2RN confirmed the patient’s medication profile should have reflected the medications the patient was taking.

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 observations during home visits, interviews, and record reviews, the agency failed to ensure nursing staff followed accepted standards of practice to prevent the transmission of infections and communicable diseases for 2 (#1 and #5) of 7 patients reviewed with home visits. The agency failed to ensure: S6RN performed proper glove changes and hygiene during Patient #1’s wound care; andS5RN performed proper glove changes and hand hygiene during Patient #5’s PT/INR, a measure to check how long it takes for a person’s blood to clot, check. Findings: Review of the agency’s policy revised February 2025 and titled, “Standard Precautions,” revealed the following, in part: Policy: Blood and body fluid precautions will be followed for all patients. Purpose: To prevent transmission of communicable diseases. Procedure: The concept of body substance isolation encompasses all the principles of Standard Precautions/blood and body fluid precaution, and extends to all moist body parts/tissues/surfaces, including fluids, solids, tissue, and moist areas. 1. Patient #1 Review of Patient #1’s Clinical Record revealed a start of care date of 09/17/2025, a current certification period of 11/16/2025 to 01/14/2026, and diagnoses, which included Type II Diabetes Mellitus with Foot Ulcer, Non-Pressure Chronic Ulcer of Right Foot, Non-Pressure Chronic Ulcer of Left Heel and Mid-foot, and Other Acute Osteomyelitis of Left Ankle and Foot. Further review of the Clinical Record revealed Patient #1 was ordered to receive skilled nursing visits twice weekly for eight weeks then once weekly for one week for treatments, including wound care. A home visit was conducted with Patient #1 on 12/08/2025 at 9:00 a.m. with S6RN present. An observation was made of S6RN performing wound care to Patient #1’s right and left foot wounds during the home visit. S6RN donned a pair of clean gloves and removed Patient #1’s sock on her right foot. S6RN removed Patient #1’s soiled dressing on her right foot. Without removing her soiled gloves or performing hand hygiene, S6RN cleansed Patient #1’s right foot wound, applied aquacel silver, foam, an adhesive dressing, and Patient #1’s sock. Without removing her soiled gloves or performing hand hygiene, S6RN removed Patient #1’s sock and soiled dressing on her left foot, sprayed the left foot with wound cleanser, and cleansed the wound. Without removing her soiled gloves or performing hand hygiene, S6RN applied hydrogel, an adhesive dressing, and Patient #1’s sock to the left foot. S6RN removed her soiled gloves, applied clean gloves, and palpated Patient #1’s left knee. S6RN removed her gloves and performed hand hygiene. An interview was conducted with S6RN on 12/08/2025 at 9:42 a.m. following the above home visit. S6RN confirmed she did not change her gloves and perform hand hygiene when moving from soiled to clean and from one wound to another wound and should have. S6RN confirmed hand hygiene should have been performed between glove changes. An interview was conducted with S2RN on 12/09/2025 at 1:20 p.m. S2RN confirmed hand hygiene and glove changes should have been performed between moving from a soiled area to a clean area and when moving from one wound to another. S2RN confirmed hand hygiene should have been performed between glove changes. 2. Patient #5 Review of Patient #5’s Clinical Record revealed a start of care date of 08/30/2025, a current certification period of 10/29/2025 to 12/27/2025, and diagnoses, which included Encounter for Surgical Aftercare Following Surgery on the Circulatory System, Presence of Aortocoronary Bypass Graft, Unspecified Atrial Fibrillation, and Encounter for Therapeutic Drug Level Monitoring. Further review of the Clinical Record revealed Patient #5 was ordered to receive skilled nursing visits once weekly for nine weeks for treatment, including PT/INR level checks. Review of Patient #5’s current Medication Profile revealed he was taking Coumadin (Warfarin), a blood thinning medication, 5 mg by mouth daily. A home visit was conducted with Patient #5 on 12/09/2025 at 10:00 a.m. with S5RN present. An observation was made of S5RN obtaining Patient #5’s PT/INR during the home visit. S5RN donned a pair of clean gloves, and obtained a lancet from a bag and a test strip from the test strip bottle utilized for multiple patients. S5RN used the lancet to prick Patient #5’s right middle finger. S5RN milked Patient #5’s finger to attempt to get enough blood for the PT/INR test. S5RN put the blood on the test strip, and it was not enough for the machine to read the PT/INR. With her soiled gloves, S5RN obtained a new lancet from the bag and a new test strip from the test bottle, both utilized for multiple patients. An interview was conducted with S2RN on 12/09/2025 at 1:20 p.m. She confirmed S5RN should have removed her gloves and performed hand hygiene after retrieving blood from Patient #5 and prior to removing a new lancet and new test strip for Patient #5. S2RN confirmed the PT/INR machine, lancets, and test strips were the property of the home health agency and utilized for more than one patient.

The entity is in compliance with the federal emergency preparedness requirements.

Recertification Survey Abbreviations: CM – Clinical Manager RN – Registered Nurse LPN – Licensed Practical Nurse PT – Physical Therapist SLP – Speech Language Pathologist ER – Extended Release MEQ – Milliequivalents mg – milligrams mL - Milliliters NP – Nurse Practitioner MD – Medical Doctor

A review of all current medications CFR(s): 484.55(c)(5) A review of all medications the patient is currently using in order to identify any potential adverse effects and drug reactions, including ineffective drug therapy, significant side effects, significant drug interactions, duplicate drug therapy, and noncompliance with drug therapy. This ELEMENT is not met as evidenced by: Based on observations during home visits, interviews, and record review, the agency failed to ensure the patients’ comprehensive assessments included a review of all medications the patients were currently using. The agency failed to ensure skilled nursing staff reconciled a patient’s medications for 2 (#6 and #7) of 7 (#1, #2, #3, #4, #5, #6, and #7) patients reviewed with home visits. Findings: Review of the Agency’s policy titled, “Medication Reconciliation” revealed the following, in part: Procedure: 1. At time of admission, the admitting RN, PT, or SLP will create and document a complete list of medications that patient is taking at home… • Discrepancies include duplications, omissions, changes… 2. Medications ordered while the patient is receiving care will be compared to the medication list/profile. The medication list/profile will be updated with each new or changed medication. Patient #6 Review of the Clinical Record for Patient #6 revealed a start of care date of 08/04/2022 and a current certification period of 12/02/2022 to 01/30/2023. Patient #6 had diagnoses, which included, Atherosclerotic Heart Disease of Native Coronary Artery, Type 2 Diabetes Mellitus, Chronic Kidney Disease – Stage 3, Occlusion and Stenosis of Bilateral Carotid Arteries, and Old Myocardial Infarction. Further review revealed Patient #6 was receiving Skilled Nursing Visits once weekly beginning the week of 12/05/2022. A home visit was conducted with Patient #6 at an Assisted Living Facility on 12/28/2022 at 10:00 a.m. Patient #6’s medications were reviewed with S3LPN during the visit. The following medication discrepancies were identified based on the current Medication Profile provided by the Home Health Agency and medications Patient #6 was receiving: Potassium Chloride ER Oral 10 MEQ by mouth once daily – on Medication Profile but not present in the home Norvasc 5mg by mouth daily – on Medication Profile but not present in the home Fenofibrate Oral 54mg daily – on Medication Profile but not present in the home Novolin R per sliding scale twice daily – receiving medication but not on Medication Profile An interview was conducted with S3LPN at the Assisted Living Facility on 12/28/2022 at 10:10 a.m. She confirmed she administered Patient #6’s medications. She confirmed Patient #6 had not received Norvasc or Fenofibrate in approximately 2 months and Potassium Chloride in two weeks. She confirmed Patient #6 had received Novolin R per sliding scale for a couple months. Patient #7 Review of the Clinical Record for Patient #7 revealed a start of care date of 12/19/2022 and a current certification period of 12/19/2022 to 02/16/2023. Patient #7 had diagnoses, which included, Fractured Vertebra. Further review revealed Patient #7 was receiving Skilled Nursing Visits twice weekly for 1 week, then once weekly for 8 weeks. A home visit was conducted with Patient #7 on 12/28/2022 at 11:00 a.m. Patient #7 stated she managed her medications. Patient #7’s medications were reviewed during the visit and confirmed with Patient #7. The following medication discrepancies were identified based on the current Medication Profile provided by the Home Health Agency and medications Patient #7 was receiving: Norco Oral 10-325 mg 1 tablet by mouth every 4 hours as needed for pain- on Medication Profile but not present in the home. Patient #7 said her last dose was 5 days ago. Fluticasone Propionate nasal 50 mcg spray, 1 spray to each nares daily – on Medication Profile but not present in the home. Patient #7 said her last dose of Fluticasone Propionate nasal spray was 2 months ago. Claritin Oral 10mg 1 tablet by mouth daily – on Medication Profile but not present in the home. Patient #7 said her last dose was 2 months ago Tylenol oral 325mg tab 2 tablets by mouth every 6 hours as needed for mild pain – on Medication Profile but not present in the home. Repatha Subcutaneous 140mg/mL 1 injection subcutaneously every 2 weeks – on Medication Profile but not present in the home. Patient #7 said her last dose was 1 month ago. Gabapentin oral 100mg 1 capsule by mouth three times a day as needed for pain – on Medication Profile but not present in the home. Patient #7 said her last dose 2 months ago. An interview was conducted with S1CM on 12/28/2022 at 10:50 a.m. She stated each patient’s medications should have been reconciled every visit by the Home Health Agency nurse. She confirmed Patient #6 and Patient #7’s medications should have been accurate on their medication profile.

Communication with physicians CFR(s): 484.75(b)(7) Communication with all physicians involved in the plan of care and other health care practitioners (as appropriate) related to the current plan of care; This ELEMENT is not met as evidenced by: Based on interview and record review, the agency failed to communicate with the NP/MD for 1 (#17) of 5 (#13, #14, #15, #16 and #17) discharged records reviewed. The agency failed to ensure the NP/MD was notified when Patient #17 had a change in condition. Review of the clinical record for Patient #17 revealed the patient began receiving services with the agency on 05/19/2021. The patient had diagnoses which included Type 2 Diabetes Mellitus, Chronic Osteomyelitis, Hypertensive Heart Disease with Heart Failure and Pressure Ulcer of Right Heel, Stage 3. Review of the current Plan of Care for Patient #17 revealed he was certified to receive services from 11/15/2021 – 01/13/2022. He received skilled nurse services 2 times a week for 8 weeks then one time a week for 1 week. Review of the current Physician Orders for Patient #17 revealed the following, in part: Skilled Nurse to report any new symptoms or concerns to the Medical Doctor. Review of S2RN’s Skilled Nursing visit note dated 12/20/2021 for Patient #17 revealed the following, in part: Wife and son informed me patient was acting differently since getting the medications. Stated he had been sleepy and talking more garbled. Patient did seem more tired today. Review of the Physician’s visit note dated 12/22/2021 for Patient #17 revealed the following, in part: The patient was very confused and talked incoherently and was unable to follow commands or answer questions. The Emergency Department doctor was contacted and will send him there for evaluation of Altered Mental Status. According to the clinical record, the patient is currently on Daptomycin and Ertapenem. Review of the Physician’s Discharge Summary from the local hospital dated 12/30/2021 revealed Patient #17 was admitted to the hospital for evaluation and treatment of Altered Mental Status. An interview was conducted on 12/29/2022 at 12:00 p.m. with S1CM. She reviewed the clinical record for Patient #17 and verified S2RN documented on 12/20/2021 she had been informed by Patient #17’s wife and son that he had been acting differently since receiving the prescribed antibiotics listed above. S1CM verified S2RN also documented Patient #17 did seem more tired that day. S1CM confirmed S2RN did not notify Patient #17’s doctor when she was made aware of his change in condition and should have.