Every finding on record at Lhcg Cxlvi LLC

The Emergency Preparedness regulations were reviewed as part of the Medicare recertification survey completed on 04/14/2026. During the survey it was determined the home health provider is in compliance with the requirements of 42 CFR 484.102 Condition of Participation: Emergency Preparedness for Home Health Providers.

A partial extended survey for Medicare recertification for the home health was completed on 04/14/2026. The provider had 183 current patients.

Health, psychosocial, functional, cognition CFR(s): 484.55(c)(1) 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: (1) The patient's current health, psychosocial, functional, and cognitive status; This ELEMENT is not met as evidenced by: Based on policy review, record review, and interview, the home health provider failed to ensure the comprehensive assessment accurately reflected the patient’s status and included the current health, psychosocial, functional, and cognitive status in one of six records reviewed (Records/Patients #1). This deficient practice has the potential to affect all the patients served by the provider. Findings included: Review of the provider’s policy titled, “Patient Assessment, Initial and Reassessment,” dated 12/01/2025, showed that all patients admitted to the provider will receive an initial assessment. Upon admission and reassessments, the clinician performs an assessment of the patient’s current health status, psychosocial, functional, and cognitive status. RECORD/PATIENT #1: Review of the clinical record showed the patient was admitted to home health services on 04/01/2026 for assessment and treatment following a fusion (permanent connection of two or more vertebrae) of the lumbar spinal (lower back) on 03/30/2026. The patient had a history of back pain and high blood pressure. The patient resided in his/her own home with the assistance of his/her spouse. Review of the physician discharge summary, dated 03/30/2026, showed that the patient was to: - Wear TED hose (Thrombo-Embolism-Deterrent, specialized compression stockings designed to prevent blood clots in the legs by applying gentle pressure to improve blood flow) until the first physician follow-up appointment following hospital discharge; - Perform incision care two to three days after surgery, on 04/01/2026 or 04/02/2026, by: * Removing the old dressing after the shower; * Patting the incision dry; * Applying a clean dry gauze dressing secured with tape; * Keeping a dressing over all incisions until drainage ceased; * Leaving non-draining incisions open to air; * Using no ointments or lotions to the incisions; and * Avoiding hot tubs or bathtubs and showering only. Review of the initial, comprehensive nursing assessment documentation, for the visit dated 04/01/2026, showed that: - The patient had an abdominal incision that: * Was covered with a non-removable dressing; and * The skilled nurse (SN) was unable to assess the incision or provide wound care; - A left sacral (tailbone) incision that: * Was covered with a non-removable dressing; and * The skilled nurse (SN) was unable to assess the incision or provide wound care; - A right sacral incision that: * Was covered with a non-removable dressing; * The skilled nurse (SN) was unable to assess the incision or provide wound care; - The patient utilized a back brace; and - The comprehensive assessment visit note failed to contain documentation of: * The condition of the patient’s incisional dressings (i.e., the dressing patency, visible drainage, odor, etc.) and care to be provided by the patient/spouse between SN visits; * Identification of the type of back brace used by the patient, application and removal of the brace, and how long to wear the brace (i.e., continuously, while out of bed, etc.); and * The use of TED hose. During an interview, on 04/07/2026 at 12:55pm, the patient care manager (PCM3) stated that they would expect the clinician to document an assessment of a non-removable dressing including any visible drainage, odor, dressing integrity and the skin surrounding the dressings, the use of a back brace, and TED hose.

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 policy review, record review, observation, and interview, the home health provider failed to ensure that all medications the patient was taking were current in one of three home visit observation records reviewed (Records/Patients #3). This deficient practice has the potential to affect all the patients served by the provider. Findings included: Review of the provider’s policy titled, “Monitoring Medications,” dated 04/01/2026, showed that a drug regimen review will be performed on all patients in conjunction with all comprehensive assessments. Additionally, all clinicians will participate in medication review and reconciliation throughout the episode. The physician will be contacted immediately if any discrepancies between agency information and patient medications are found. The clinician responsible for the drug regimen review will: - Compare the medication list obtained from the facility from which the patient was transferred and/or physician order to actual medications the patient is taking; - Review all medications, including over the counter medications, vitamins, herbs and herbal products, creams and topical ointments, medical marijuana (in states where legalized), and those administered in outpatient settings to identify issues; and - The physician is contacted immediately if any discrepancies between agency (provider) information and patient mediations are found. Review of the clinical record showed the patient was admitted to home health services on 03/04/2026 with a primary diagnosis of bronchiectasis (a lung condition that causes cough, sputum production, and recurrent respiratory infections) adult failure to thrive, repeated falls, and age-related osteoporosis without fracture. The patient resided at home with his/her spouse. Observation and interview on 04/07/2026 at 11:00 AM, showed the following discrepancies between the provider's current medication profile (printed on 04/07/2026) and the patient's home medication bottles: - The provider’s current medication profile showed the patient was to use cholestyramine (used primarily to lower high cholesterol and treat chronic diarrhea related to bile acid malabsorption or itching from biliary obstruction) 4 gram (gm) oral powder daily with 8 ounces of liquid; and - The patient stated that he/she did not take this medication and never took it. During an interview on 04/14/2026 beginning at 2:10 PM, the administrator stated that he/she would expect medications to be reconciled weekly with the medication bottles and medication list in the patient’s home and staff should ask at every visit about any medication changes or physician visits.

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 policy review, record review, observation, and interview, the home health provider failed to ensure the plan of care (POC) contained all medications and treatments and patient-specific interventions and education in two of five full records reviewed (Records/Patients #1 and #2). This deficient practice has the potential to affect all the patients served by the provider. Findings included: Review of the provider’s policy titled, “Plan of Care,” dated 03/01/2026, showed that a plan of care is developed for all patients and updated no less than every 60 days. The POC includes the patient’s medications and treatments, patient specific interventions and education, and measurable outcomes and goals identified by the agency (provider) and patient. RECORD/PATIENT #1: Review of the clinical record showed the patient was admitted to home health services on 04/01/2026 for assessment and treatment following a fusion (permanent connection of two or more vertebrae) of the lumbar spinal (lower back) on 03/30/2026. The patient had a history of back pain and high blood pressure. The patient resided in his/her own home with the assistance of his/her spouse. Review of the physician discharge summary document, dated 03/31/2026, showed that the patient was to: - Wear TED hose (Thrombo-Embolism-Deterrent, specialized compression stockings designed to prevent blood clots in the legs by applying gentle pressure to improve blood flow) until the first physician follow-up appointment following hospital discharge; - Perform incision care two to three days after surgery by: * Removing the old dressing after the shower; * Patting the incision dry; * Applying a clean dry gauze dressing secured with tape; * Keeping a dressing over all incisions until drainage ceased; * Leaving non-draining incisions open to air; * Using no ointments or lotions to the incisions; and * Avoiding hot tubs or bathtubs and showering only. Review of the home health certification and POC, dated 04/01/2026, showed that the POC failed to contain orders for: - Wound care orders for the right and left lumbar incisions; - The application and removal of the abdominal binder; - The use of TED hose; and - The plan for staple removal. During an interview on 04/14/2026 at 12:30 PM, the administrator stated that they would expect the plan of care to contain all interventions related to the patient's care; and the POC failed to contain: - Wound care orders for the incisions on the patient’s right and left lumbar (lower back, the POC did contain orders for a back incision, and the order failed to identify there was more than one incision, and the location of the incisions; - The application and removal of the abdominal binder; - The use of TED hose; and - The plan for staple removal. RECORD/PATIENT #2: Review of the clinical record showed the patient was admitted to home health services on 03/05/2026 with a primary diagnosis of rheumatoid arthritis of multiple sites. The patient had secondary diagnosis of arthritis of the right knee, high blood pressure, diabetes, and dementia. The patient resided in the private residence of his/her sibling. Review of the comprehensive physical therapy start of care assessment, dated 03/05/2026, showed that the patient had diabetes, was not taking insulin, and performing blood sugar testing was not applicable to the patient. Review of the home health certification and plan of care, dated 03/05/2026, showed that: - Physical therapy was to instruct patients on management of diabetes, review appropriate diet, and diabetic foot care. Therapist was to assess lower extremities for presence of lesions on every visit, and instruct on signs and symptoms of hyperglycemia (high blood sugar) and hypoglycemia (low blood sugar); - When vital signs were obtained, licensed professional was to report vital signs falling outside the following established parameters: FBS 250; and - The POC failed to contain orders for the clinician to monitor the patient’s blood sugar readings. During an interview on 04/14/2026 at 12:45 PM, the administrator stated that: - They would expect an order to monitor blood sugar readings if the POC contained established parameters for the blood sugars; and - The POC failed to contain orders to monitor the patient’s blood sugars.

Integrate all orders CFR(s): 484.60(d)(2) Integrate orders from all physicians or allowed practitioners involved in the plan of care to assure the coordination of all services and interventions provided to the patient. This ELEMENT is not met as evidenced by: Based on policy review, record review, observation, and interviews, the home health provider failed to ensure orders from all physicians or allowed practitioners involved were integrated in the plan of care to assure the coordination of all services and interventions provided to the patient in one of six records reviewed (Record/Patient #1). This deficient practice has the potential to affect all the patients served by the provider. Findings included: Review of the provider’s policy titled, “Coordination of Care, From Admit Through Discharge,” dated 12/01/2025, showed that coordination of care with the physician/authorized practitioner will occur at admission, throughout care, and at discharge, coordination of services is promoted through routine communication with the patient’s physician. RECORD/PATIENT #1: Review of the clinical record showed the patient was admitted to home health services on 04/01/2026 for assessment and treatment following a fusion (permanent connection of two or more vertebrae) of the lumbar spinal (lower back) on 03/30/2026. The patient resided in his/her own home with the assistance of his/her spouse. Review of the physician discharge summary document, dated 03/30/2026 and available to the clinician at time of admission via the electronic medical record (EMR), showed that the patient was to perform incision care two to three days after surgery by: - Removing the old dressing after the shower; - Patting the incision dry; - Applying a clean dry gauze dressing secured with tape; - Keeping a dressing over all incisions until drainage ceased; - Leaving non-draining incisions open to air; - Using no ointments or lotions to the incisions; and - Avoiding hot tubs or bathtubs and showering only. During an interview, on 04/07/2026 at 11:35AM, the patient and his/her spouse stated that: - They received written discharge instructions on 03/31/2026 when leaving the hospital; - They showed the documentation they received on 03/31/2026 to the nurse at the time of the admission visit on 04/01/2026; - The admitting nurse looked at the instructions and gave them back to the spouse. Review of the undated hospital discharge instruction document titled, “Anterior and Posterior Lumbar Fusion Post-op Instructions,” given to the patient at discharge from the hospital on 03/31/2026, showed that home care following surgery included: - Front/abdominal dressing: * 48 hours after surgery, remove the abdominal surgical dressing. Wash the incision gently with a clean bath cloth, gently pat dry, and apply Neosporin (Brand, an antibiotic ointment) over the incision and cover with Band-Aids (brand) or gauze and paper tape; * Replace the front/abdominal dressing daily with fresh Neosporin and Band-Aids/gauze and paper tape until your follow-up appointment; * The staples used to close your abdominal incision will be removed in four weeks; - Back/posterior dressings: * 72 hours after surgery, take your first shower and remove your back dressing. Wash the incision gently with a clean bath cloth, gently pat dry, and apply only paper tape and gauze for your back/posterior incision; * Do not use ointments to the back/posterior incisions; * If you notice your dressing is saturated, remove the dressing and apply a clean one; * The staples used to close the incisions on your back will be removed at the follow-up appointment in three weeks; - Showering: * You may shower 72 hours after surgery; * Do not rub the incision. Pat the incision gently when drying off; * Do not soak or immerse yourself in a bathtub, pool, or hot tub until the incisions are completely healed. This takes a minimum of six weeks; - Abdominal binder: * The abdominal binder should be always worn until your follow-up appointment; * It may only be removed to shower and change your dressings; * Wear a t-shirt under the binder to avoid skin irritation. Hand wash and air dry if needed; and - The compression stockings/TED hose (Thrombo-Embolism-Deterrent, specialized compression stockings designed to prevent blood clots in the legs by applying gentle pressure to improve blood flow) should be worn until your follow-up appointment to help prevent blood clots and reduce leg swelling. Review of the home health certification and plan of care (POC), dated 04/01/2026, showed that: - The skilled nurse (SN) to provide/instruct the client/caregiver on wound care to the abdomen and low back incision daily; - May begin showering two to three days after surgery leaving current dressing in place and removing after shower; - Pat the incision dry with a clean towel, never scrub the incision; - Cover with dry gauze, secure with tape; - The incision may be left open to air when no longer draining; - No ointments to the incisions; - No tub baths, shower only; and - Spouse or adult child to perform wound care in the absence of the SN. Observation and interview on 04/07/2026 at 12:20 PM, showed that: - The patient and spouse reported that they: * Had left the abdominal dressing in place during the patient’s shower on 04/01/2026, patted the dressing dry after the shower, and left the dressing in place. They had not removed the abdominal dressing since the patient came home from the hospital on 03/31/2026; * Were changing the dressing on the patient’s lower back daily by removing the old dressing, applying Neosporin ointment, covering with gauze, and securing with tape; and - Registered nurse (RN)-A called the patient’s physician to clarify the patient’s wound care orders. Review of the physician’s order, dated 04/07/2026, showed that: - Wash the front/abdomen incision gently with clean bath cloth, gently pat dry, and apply Neosporin over the incision using a cotton tipped applicator, cover with a band-aid or gauze, and secure with paper tape; - Allow water to wash over incision while in the shower daily, pat dry and leave open to air if there is no drainage. If it is draining, place dry gauze and secure with paper tape only. Do not apply ointments to back incision. During an interview on 04/08/2026 at 10:25 AM, the admitting skilled nurse (RN-B) stated that: - He/she had access to the physician discharge summary with the referral paperwork; - The patient and his/her spouse had showed him/her the document titled, “Anterior and Posterior Lumbar Fusion Post-op Instructions,” noted the wound care instructions were different than those on the physician discharge summary; and - He/she did not call the physician to clarify the orders as the physician discharge summary was signed by a physician on 03/30/2026. During an interview on 04/07/2026 at 12:55 PM, the patient care manager (PCM-3) stated that they would expect the admitting SN to: - Ask the patient for his/her discharge instructions from the hospital; and - Contact the physician to clarify inconsistencies between the referral paperwork and the paperwork given to the patient at the time of discharge.

Treatments and therapy services CFR(s): 484.60(e)(3) Any treatments to be administered by HHA personnel and personnel acting on behalf of the HHA, including therapy services. This ELEMENT is not met as evidenced by: Based on policy review, record review, observation, and interview, the home health provider failed to ensure patients received written instructions outlining treatments in one of three home visit observation records reviewed (Records/Patients #1). This deficient practice has the potential to affect all the patients served by the provider. Findings included: Review of the provider’s policy titled, “Coordination of Care, From Admit Through Discharge, “ dated 12/01/2025, showed that written information obtained from the plan of care (POC) will be provided to the patient and caregiver outlining the visit schedule, medication schedule and instructions, and treatments to administered by staff or contract workers, including therapy services. Pertinent instructions related to the patient’s care and treatments that the agency will provider, specific to the patient’s needs. RECORD/PATIENT #1: Review of the clinical record showed the patient was admitted to home health services on 04/01/2026 for assessment and treatment following a fusion (permanent connection of two or more vertebrae) of the lumbar spinal (lower back) on 03/30/2026. The patient had a history of back pain and high blood pressure. The patient resided in his/her own home with the assistance of his/her spouse. Review of the physician discharge summary document, dated 03/30/2026 and available to the clinician at time of admission, showed that the patient was to: - Wear TED hose (Thrombo-Embolism-Deterrent, specialized compression stockings designed to prevent blood clots in the legs by applying gentle pressure to improve blood flow) until the first physician follow-up appointment following hospital discharge; - Perform incision care two to three days after surgery by: * Removing the old dressing after the shower; * Patting the incision dry; * Applying a clean dry gauze dressing secured with tape; * Keeping a dressing over all incisions until drainage ceased; * Leaving non-draining incisions open to air; * Using no ointments or lotions to the incisions; and * Avoiding hot tubs or bathtubs and showering only. Observation on 04/07/2026 at 11:15 AM, showed that: - A review of the patient’s admission booklet showed the booklet failed to contain written instructions for the care of the patient’s incisions; and - This state agent (SA) observed the skilled nurse (SN) perform wound care: * He/she removed the old dressing from the abdominal wound, and the incision was clean, dry, had no redness, and had well approximated (touching without gaps) edges; * He/she removed the old dressing from the patient’s back exposing the incisions on the lower left and right back; and the incisions were clean, dry, had no redness, and had well approximated edges. During an interview on 04/07/2026 at 11:40 AM, the patient and his/her spouse stated that: - The admission nurse did not provide them with written instructions on the provision of wound care at the time of the admission visit; and - They had been using the written instructions titled, “Anterior and Posterior Lumbar Fusion Post-op Instructions,” provided to them at discharge from the hospital on 03/31/2026; - The patient had showered on 04/02/2026 with the abdominal bandage in place. He/she did not remove the bandage after the shower. The patient continued to have the same bandage on his/her abdomen that was present at discharge from the hospital 03/31/2026; - The spouse removed the dressing covering the incisions on the patient’s back, applied Neosporin to both back incisions, covered the incisions with dry gauze, and secured in place with paper tape. Review of the undated document titled, “Anterior and Posterior Lumbar Fusion Post-op Instructions,” given to the patient at discharge from the hospital, showed that home care following surgery included: - Front/abdominal dressing: * 48 hours after surgery, remove the abdominal surgical dressing. Wash the incision gently with a clean bath cloth, gently pat dry, and apply Neosporin (Brand, an antibiotic ointment) over the incision and cover with Band-Aids (Brand) or gauze and paper tape; * Replace the front/abdominal dressing daily with fresh Neosporin and Band-Aids/gauze and paper tape until your follow-up appointment; * The staples used to close your abdominal incision will be removed in four weeks; - Back/posterior dressings: * 72 hours after surgery, take your first shower and remove your back dressing. Wash the incision gently with a clean bath cloth, gently pat dry, and apply only paper tape and gauze for your back/posterior incision; * Do not use ointments to the back/posterior incisions; * If you notice your dressing is saturated, remove the dressing and apply a clean one; * The staples used to close the incisions on your back will be removed at the follow-up appointment in three weeks; - Showering: * You may shower 72 hours after surgery; * Do not rub the incision. Pat the incision gently when drying off; * Do not soak or immerse yourself in a bathtub, pool, or hot tub until the incisions are completely healed. This takes a minimum of six weeks. Review of the home health certification and POC, dated 04/01/2026, showed that: - The SN was to provide/instruct the client/caregiver on wound care to the abdomen and low back incision daily; - May begin showering two to three days after surgery leaving current dressing in place and removing after shower; - Pat the incision dry with a clean towel, never scrub the incision; - Cover with dry gauze, secure with tape; - The incision may be left open to air when no longer draining; - No ointments to the incisions; - No tub baths, shower only; and - Spouse or adult child to perform wound care in the absence of the SN. During an interview on 04/08/2026 at 10:25 AM, the admitting nurse stated that he/she did not leave written wound care instructions for the patient at the admission visit. The admitting nurse failed to provide written wound care instructions to the patient/caregiver at the time of admission. Without written instructions from the provider, the patient/caregiver had to use the discharge instructions from the hospital to provide wound care in the absence of the SN. The written instructions from the hospital were different from the wound care orders on the patient’s POC. During an interview on 04/07/2026 at 12:55 PM, a patient care manager (PCM-3) stated that they would expect written instructions for the wound care, as it appears on the provider’s plan of care, to be in the patient’s home at the end of the admission visit.

Services by skilled professionals CFR(s): 484.75(a) Standard: Provision of services by skilled professionals. Skilled professional services are authorized, delivered, and supervised only by health care professionals who meet the appropriate qualifications specified under §484.115 and who practice according to the HHA's policies and procedures. This STANDARD is not met as evidenced by: Based on policy review, record review, and interview, the home health provider failed to ensure that wound measurements and assessments were completed in one of six records reviewed (Record/Patient #3). This deficient practice has the potential to affect all the patients served by the provider. Findings included: Review of the provider’s policy titled, “Wound Assessment, Documentation, And Photography,” revised 09/01/2024, showed in part the following: - All wounds will be assessed with appropriate documentation within the medical record; - Wound location and description documentation is completed on all patients with wounds at the time of admit or upon development of a wound; * During routine visits, the wound will be documented in the wound assessment tool; - The qualified clinician will assess wounds weekly for patients receiving daily wound care performed by the agency; - Reassessments will be documented on the wound assessment tool; * The assessment includes measurement of the length, width, and depth, undermining and tunneling, wound bed description, wound edges, exposed tissue types, drainage, and the condition of the peri wound; * At each dressing change, the clinician should record the wound bed description, wound edges, exposed tissue types, drainage and the condition of the peri wound; - Document the following in the medical record; * Wound type (pressure injury, stasis ulcer, abscess, surgical wound, burn, trauma wound); * Location and laterality; * Stage or thickness; * Stage pressure injuries according to the National Pressure Ulcer Advisory Panel (NPUAP) Pressure Injury Stages; * For all other ulcers, document underlying etiology of the ulcer and skin involvement to include limited to breakdown of skin; fat layer exposed; necrosis of muscle; or necrosis of bone; * All other wounds will be described as either partial or full thickness. RECORD/PATIENT #3: Review of the clinical record showed the patient was admitted to home health services on 03/04/2026 with a primary diagnosis of bronchiectasis (a lung condition that causes cough, sputum production, and recurrent respiratory infections) adult failure to thrive, repeated falls, and age-related osteoporosis without fracture. The patient resided at home with his/her spouse. Review of the physical therapist (PT) initial start of care assessment dated 03/04/2026, showed in part: - The patient experienced pain in the intragluteal cleft superior with a triangular 4-centimeters (cm) by 9-cm triangular shape pressure sore, stage 1 (one) (a persistent area of skin redness without a break in the skin that does not disappear when pressure is relieved); - The patient had a stage 1 pressure ulcer of the gluteal superior cleft where pressure from coccyx caused problems. A triangular shape superior is 4-cm across with 9-cm angle; - Plans for next visit include assessment of pressure ulcer on his/her bottom. Review of the plan of care dated 03/04/2026 to 05/02/2026, showed an order for PT to monitor and provide instruction regarding pain control methodologies including non-pharmacologic methods – distraction, positional changes to relieve pressure of bottom; - Skilled nurse (SN) effective 03/08/2026, twice a week for two weeks and then one time a week for six weeks; - SN to provide skilled teaching to prevent pressure ulcers; - SN to instruct patient/caregiver procedure of wound care to coccyx daily and as needed (PRN) after toileting. Cleanse with soap and water and pat dry. Apply skin barrier cream. Review of the physical therapy assistant (PTA) visit dated 03/09/2026, showed the following: - Indicate location patient experiences pain: bottom; - Document other integumentary findings: No open wound. Redness on coccyx and buttocks; - Document communication with other disciplines/individuals involved in case, include appointments along with any changes made to the plan of care (POC) since last visit: Spoke with staff at provider's office regarding patients’ condition and confusion with medications. Going to get an order for nurse to come out. Review of the skilled nurse visit dated 03/10/2026, showed the following: - Patient reported “my butt hurts”; - Patient rated pain seven out of 10 on a numerical pain scale tool used to quantify pain severity, where 0 is no pain and 10 is the worst imaginable pain; - Wound assessment: * Coccyx, PU stage II (a partial thickness loss of the skin) (inactivated 10/05/2022), (reactivated 03/10/2026), onset date 09/08/2022; * Wound assessed - yes; * Measurements taken – no; * Reason measurements not taken – unable; * Depth description – Partial thickness (a skin injury that extends through the epidermis (outer layer) and into, but not through, the dermis (second layer). Common examples include abrasions, skin tears, and blisters; * Granulation tissue (soft, pink, new, healthy tissue in a healing wound) – intact; * Edges – indistinct; * Exudate (drainage) type- none; * Exudate amount – none; * Odor – none; * Epithelialization – 75 * Skin color surrounding wound – bright red; * Wound care provided – wound care to coccyx daily, cleansed with soap and water and patted dry. Apply skin barrier cream. Caregiver to perform wound care in absence of the skilled nurse; - Patient goal – to walk better, sore healed on bottom. Review of the skilled nurse visit dated 03/14/2026, showed the following: - Patient rated pain none; - Wound assessment: * Coccyx, PU stage II (inactivated 10/05/2022), (reactivated 03/10/2026), onset date 09/08/2022; * Wound assessed - yes; * Measurements taken – no; * Reason measurements not taken – unable; * Depth description – non-blanchable; * Granulation tissue – intact; * Edges – indistinct; * Exudate type- none; * Exudate amount – none; * Odor – none; * Epithelialization – 75 * Skin color surrounding wound – normal; * Wound care provided – cleansed with soap and water and patted dry. Applied skin barrier cream. Caregiver to perform wound care in absence of the skilled nurse; - Patient goal – to walk better, sore healed on bottom. Review of the skilled nurse visit dated 03/17/2026, showed the following: - Patient rated pain a five, located on buttock; - Care coordination – orders for Opti foam dressing (bordered foam dressing designed to manage moderate to high-drainage wounds, including pressure injuries, and ulcers) to buttocks; - Wound assessment: * Coccyx, PU stage II (inactivated 10/05/2022), (reactivated 03/10/2026), onset date 09/08/2022; * Wound assessed - yes; * Measurements taken – no; * Reason measurements not taken – unable; * Depth description – part thick; * Granulation tissue – intact; * Edges – indistinct; * Exudate type- none; * Exudate amount – none; * Odor – none; * Epithelialization – 100%; * Skin color surrounding wound – bright red; * Wound care provided – cleansed with soap and water and patted dry. Applied skin barrier cream. Caregiver to perform wound care in absence of the skilled nurse; - Patient goal – to walk better, sore healed on bottom. Review of the skilled nurse visit dated 03/19/2026, showed the following: - Patient rated pain a three, located on buttock; - Care coordination – another message left for primary care provider (PCP) orders for Opti foam dressing to buttocks as patient states it is really helping ; - Wound assessment: * Coccyx, PU stage II (inactivated 10/05/2022), (reactivated 03/10/2026), onset date 09/08/2022; * Wound assessed - yes; * Measurements taken – no; * Reason measurements not taken – unable; * Depth description – non-blanchable; * Granulation tissue – intact; * Edges – indistinct; * Exudate type- none; * Exudate amount – none; * Odor – none; * Epithelialization – 100%; * Skin color surrounding wound – normal; * Wound care provided – cleansed with soap and water and patted dry. Applied skin barrier cream. Caregiver to perform wound care in absence of the skilled nurse; - Patient goal – to walk better, sore healed on bottom. Review of the skilled nurse visit dated 03/25/2026, showed the following: - Patient rated pain a zero; - Care coordination – call to PCP requesting orders for Opti foam dressings to buttocks; - Wound assessment: * Coccyx, PU stage II (inactivated 10/05/2022), (reactivated 03/10/2026), onset date 09/08/2022; * Wound assessed - yes; * Measurements taken - no; * Reason measurements not taken – unable; * Depth description – non-blanchable; * Granulation tissue – intact; * Edges – indistinct; * Exudate type- none; * Exudate amount - none; * Odor - none; * Epithelialization - 100%; * Skin color surrounding wound – normal; * Wound care provided – cleansed with soap and water and patted dry. Applied skin barrier cream. Caregiver to perform wound care in absence of the skilled nurse; - Patient goal – to walk better, sore healed on bottom. Review of the skilled nurse visit dated 04/01/2026, showed the following: - Patient rated pain a zero, located on buttock; - Care coordination – POC discussed with patient; - Wound assessment: * Coccyx, PU stage II (inactivated 10/05/2022), (reactivated 03/10/2026), onset date 09/08/2022; * Wound assessed - yes; * Measurements taken – yes; * Length x Width x Depth cm – 1.2x0.5x0; * Depth description – partial thickness; * Granulation tissue – intact; * Edges – indistinct; * Exudate type- none; * Exudate amount – none; * Odor – none; * Epithelialization – 75 * Skin color surrounding wound – normal; * Wound care provided – cleansed affected area to coccyx with saline soaked gauze. Patted dry with gauze. Applied barrier cream to affected area on coccyx covered with sacral dressing daily and PRN. Caregiver to perform wound care in absence of the skilled nurse; - Patient goal – to walk better, sore healed on bottom. (The provider failed to complete measurements of the wound when documenting partial thickness). During an interview on 04/14/2026 beginning at 3:47 PM, the administrator stated that he/she would expect wound measurements to be documented and a description of what the area around the wound looks like if it is just a stage 1.

In accordance with current clinical practice CFR(s): 484.105(f)(2) All HHA services must be provided in accordance with current clinical practice guidelines and accepted professional standards of practice. This ELEMENT is not met as evidenced by: Based on review of Missouri statute, policy review, employee file review, and interview, the home health provider failed to ensure that a check of the Employee Disqualification List (EDL) was performed and failed to ensure the Family Care Safety Registry (FCSR) was checked prior to date of first patient contact, in one of six employee files reviewed, (Employee #4). This deficient practice has the potential to affect all the patients served by the provider. Findings included: Review of Section 192.2490.12 RSMo: "No person, corporation, organization, or association who received the employee disqualification list under subdivisions (1) to (7) of subsection 11 of this section shall knowingly employ any person who is on the employee disqualification list." Section 192.2495 RSMo, requires employees of licensed home health agencies under contract with the Missouri Department of Health and Senior Services, to register with the Family Care Safety Registry regardless of hire date. This section also requires home health agencies to conduct criminal background screenings by checking the Family Care Safety Registry. Review of Section 192.2495.6, RSMo: “A provider is guilty of a class A misdemeanor if the provider knowingly hires or retains a person to have contact with patients or residents and the person has been found guilty in this state or any other state or has been found guilty of a crime, which if committed in Missouri would be a class A or B felony violation of chapter 565, 566 or 569, or any violation of subsection 3 of section 198.070 or section 568.020.” Review of Section 192.2495.7, RSMo (effective August 28, 2018): “Any in-home services provider agency or home health agency shall be guilty of a class A misdemeanor if such agency knowingly employs a person to provide in-home services or home health services to any in-home services client or home health patient and such person either refuses to register with the family care safety registry or if such person: (1) Has any of the disqualifying factors listed in subsection 6 of this section; (2) Has been found guilty of or pleaded guilty or nolo contendere to any felony offense under chapter 195 or 579; (3) Has been found guilty of or pleaded guilty or nolo contendere to any felony offense under section 568.045, 568.050, 568.060, 568.175, 570.023, 570.025, 570.030, 570.040 as it existed prior to January 1, 2017, 570.090, 570.145, 570.223, 575.230, or 576.080; (4) Has been found guilty of or pleaded guilty or nolo contendere to a violation of section 577.010 or 577.012 and who is alleged and found by the court to be an aggravated or chronic offender under section 577.023; (5) Has been found guilty of or pleaded guilty or nolo contendere to any offense requiring registration under section 589.400; (6) Is listed on the department of health and senior services employee disqualification list under section 192.2490; (7) Is listed on the department of mental health employee disqualification registry under section 630.170; or (8) Has a finding on the child abuse and neglect registry under sections 210.109 to 210.183.” Review of the provider’s policy titled, “Background Checks,” revised 10/01/2025, Policy Number: 2.3.01, showed the following: - All employment offers are contingent upon acceptable background check results. Candidates will not have patient interaction until the search results have been returned and are deemed acceptable; - In Missouri, the EDL must be run through the FCSR prior to hiring a potential employee and checked quarterly for current employees through the Missouri Department of Health and Human Services. Employment may not be continued for current employees whose names appear on the EDL. EMPLOYEE #4: Review of the employee file showed: - Date of hire: 11/24/2025; - The EDL check was received on 04/07/2026 (141 days after hire); and - The FCSR check was received on 04/08/2026 (142 days after hire). During an interview on 04/08/2026 at 12:45 PM, patient care manager 2 stated that the FCSR and EDL on Employee #4 were late.

Authentication CFR(s): 484.110(b) Standard: Authentication. All entries must be legible, clear, complete, and appropriately authenticated, dated, and timed. Authentication must include a signature and a title (occupation), or a secured computer entry by a unique identifier, of a primary author who has reviewed and approved the entry. This STANDARD is not met as evidenced by: Based on policy review, record review, and interview, the home health provider failed to ensure that documentation of the patient's pressure ulcer was accurate and appropriately authenticated during assessments in one of six records reviewed (Record/Patient #3). This deficient practice has the potential to affect all the patients served by the provider. Findings included: Review of the provider’s policy titled, “Wound Assessment, Documentation, And Photography,” revised 09/01/2024, showed in part the following: - All wounds will be assessed with appropriate documentation within the medical record; - Wound location and description documentation is completed on all patients with wounds at the time of admit or upon development of a wound; and - During routine visits, the wound will be documented in the wound assessment tool. Review of the provider’s undated, Job Title, “Physical Therapist Assistant (PTA) – Home Health,” showed in part the, PTA will complete a progress note for each visit and submit progress notes per provider policy. RECORD/PATIENT #3: Review of the clinical record showed the patient was admitted to home health services on 03/04/2026 with a primary diagnosis of bronchiectasis (a lung condition that causes cough, sputum production, and recurrent respiratory infections) adult failure to thrive, repeated falls, and age-related osteoporosis without fracture. The patient resided at home with his/her spouse. Review of the physical therapist (PT) initial start of care assessment dated 03/04/2026, showed in part: - The patient experienced pain in the intragluteal cleft superior with a triangular 4-centimeters (cm) by 9-cm triangular shape pressure sore, stage 1 (a persistent area of skin redness without a break in the skin that does not disappear when pressure is relieved); - The patient had a stage 1 pressure ulcer of the gluteal superior cleft where pressure from coccyx caused problems. A triangular shape superior is 4-cm across with 9-cm angle; - Plan for next visit included an assessment of pressure ulcer on his/her bottom. Review of the plan of care dated 03/04/2026 to 05/02/2026, showed: - An order for PT to monitor and provide instruction regarding pain control methodologies including non-pharmacologic methods – distraction, positional changes to relieve pressure off bottom; and - Orders were obtained for skilled nursing (SN) and they would instruct the patient/caregiver on daily and as needed wound care to the coccyx - Cleanse with soap and water, pat dry, apply barrier cream. Review of the SN visit dated 03/17/2026 (13 days after the initial assessment) showed: - The patient had a partial thickness (Stage II) pressure ulcer to the coccyx; - Wound care was provided; and - The patient's goal was for the sore on his/her bottom to heal. Review of the SN visit dated 03/19/2026, showed: - The patient had a partial thickness pressure ulcer to the coccyx; - Wound care was provided; and - The patient's goal was for the sore on his/her bottom to heal. Review of the PTA visit dated 03/19/2026, showed the PTA documented an integumentary assessment that showed no wounds/wound care was not provided this visit. Review of the PTA visit dated 03/23/2026, showed the PTA documented an integumentary assessment that showed no wounds/wound care was not provided this visit. Review of the SN visit dated 03/25/2026, showed: - The patient had a partial thickness pressure ulcer to the coccyx; - Wound care was provided; and - The patient's goal was for the sore on his/her bottom to heal. Review of the PTA visit dated 03/31/2026, showed the PTA documented an integumentary assessment that showed the patient had no wounds/wound care was not provided this visit. Review of the skilled nurse visit dated 04/01/2026, showed: - The patient had a partial thickness pressure ulcer to the coccyx; - Wound care was provided; and - The patient's goal was for the sore on his/her bottom to heal. The PTA failed to accurately document the presence of the pressure ulcer on the patient's coccyx. During an interview on 04/14/2026 beginning at 3:47 PM, the administrator stated that he/she would expect the PTA to document something about the pressure ulcer in the documentation.

A complaint investigation 2736445 was completed on 02/13/2026 at the home health provider. The provider had 171 current patients. The complaint is substantiated. One or more of the allegations reported are verified and standard deficiencies were cited that are related to the allegations being investigated. One condition-level deficiency was identified during this survey. A condition-level deficiency is identified at §484.60 Condition of Participation: Care Planning, Coordination of Services, and Quality of Care. A home health provider that is found out of compliance with any Condition of Participation evaluated as part of a standard survey may not train or competency evaluate their home health aides for a period of two (2) years following the date of this survey. A deficiency has been cited at §484.80(f)(3) – see Tag G0782.

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 policy review, record review, and interview, the home health provider failed to ensure patients were accepted for treatment only when there was a reasonable expectation that the provider could meet the patients’ medical, nursing, rehabilitative, and social needs in the home setting. The provider failed to verify critical factors such as medication availability, required supplies, patient stability, caregiver support, and home safety prior to accepting referrals. This deficient practice resulted in unsafe conditions identified at the initial home visit, requiring emergency department evaluation or hospital transfer in, three of three records reviewed (Records/Patients #1, #2, and #3). The cumulative effect of this deficient practice placed all the patients at risk for unmet care needs and adverse outcomes Findings included: Review of the provider's policy titled, "Coordination of Care, From Admit through Discharge,” last revised 11/01/2025, showed in part the following: - Admitting only those patients whose health care needs can be met by the agency (provider) and making appropriate referrals to other organizations capable of meeting patient needs when the agency is unable to do so; and - Identifying patient needs through assessment and communication with other health care providers. Review of the provider's policy titled, " Acceptance of Patients/Admission Process,” last revised 11/01/2025, showed in part the following: - Patients admitted to home care services must meet admission criteria and have reasonable expectations that needs can be met safely in the home; - The policy required a safe home environment, availability of a capable caregiver if indicated, and confirmation that the agency could meet the patient’s needs; and - If the patient was not accepted, the policy required notification of the physician and referral source. RECORD/PATIENT #1: Record review showed the patient was discharged home from a nursing facility on 02/02/2026 with severe protein-calorie malnutrition, dysphagia (difficulty swallowing), psychiatric illness, and the need for 24-hour supervision. Record review showed the home health nurse conducted a visit on 02/03/2026. There failed to be a completed admission assessment, as the visit was designated a non-admit. However, the coordination note dated 02/03/2026 showed the nurse spent over one hour evaluating the patient in the home, found the patient lethargic and unable to answer questions, and identified that ordered tube-feeding supplies and medications were not available. The note further documented the spouse did not have the appropriate equipment to provide the ordered feedings and that the patient required transport to the hospital. These findings demonstrated the patient’s needs could not be met in the home and reflected that the provider acted on the referral without a reasonable expectation that those patient’s needs could be met. Emergency department documentation dated 02/03/2026 showed the home health nurse advised the patient that he/she required a 24-hour care facility and the spouse could not provide care during working hours. During an interview on 02/09/2026 at 10:18 AM, the registered nurse (RN) whom conducted the initial visit, stated that the patient was lethargic and minimally responsive, no medications were present in the home, the correct feeding supplies were not available, and the spouse did not know how to feed the patient and reported the patient had not received tube feedings since discharge from the nursing facility. There was no referral information attached in the patient record at the time of the visit. The nurse reported he/she had only a diagnosis, medication list, and tube-feeding instructions that were provided by the spouse. The nurse stated that he/she did not receive referral paperwork or coordinated information from the provider prior to the visit. The spouse reported he/she would return to work and expected the home health staff to remain with the patient; however, the nurse explained the provider did not provide 24-hour care. The nurse determined the patient was unsafe and sent the patient to the hospital by ambulance. RECORD/PATIENT #2: Record review showed the patient was discharged home with congestive heart failure (CHF; a decrease in the ability of the heart to pump blood), atrial fibrillation (abnormal heart rhythm characterized by rapid and irregular heartbeat), chronic kidney disease, generalized weakness, and needed assistance with personal care. Referral documentation dated 01/17/2026 showed physician orders for skilled nursing, physical therapy, and occupational therapy services. On 01/19/2026, during the initial assessment, the home health nurse documented the patient was unstable with atrial fibrillation and a heart rate of 135. The patient was instructed to go to the emergency room and the physician was notified. The referral was marked “no admit.” The record lacked evidence of caregiver availability verification, environmental safety review, medication verification, or supply and equipment confirmation prior to acceptance. RECORD/PATIENT #3: Record review showed referral orders dated 10/10/2025 for skilled nursing, physical therapy, and occupational therapy services. On 10/13/2025, the home health nurse documented the patient had been left at the home by facility staff. Upon arrival, the nurse found the home environment unsafe and unclean, with no access to a bathroom and no place for the patient to sleep. EMS was called and the patient was transported to the hospital for social work admission. There was no documentation that the provider verified the home environment or caregiver support prior to acting on the referral. During an interview on 02/09/2026 at 11:13 AM, the administrator stated that the provider required only physician orders for skilled services and a primary care physician to accept the referral. There was no documentation showing referrals were reviewed to verify the patient was appropriate for admission. During an interview on 02/10/2026 at 11:28 AM, the alternate administrator stated that the provider did not have a designated intake person, did not use a referral checklist, and did not verify medications, supplies, equipment, or caregiver availability prior to admission. The admitting nurse determined whether the patient was appropriate for home health services only after arriving at the home. There was no documentation showing referrals were reviewed to verify medications, supplies, caregiver availability, patient stability, or home safety prior to the initial visit.

Eligible training/competency evaluation orgs. CFR(s): 484.80(f) A home health aide training program and competency evaluation program may be offered by any organization except by an HHA that, within the previous 2 years: (1) Was out of compliance with the requirements of paragraphs (b), (c), (d), or (e) of this section; or (2) Permitted an individual who does not meet the definition of a "qualified home health aide" as specified in paragraph (a) of this section to furnish home health aide services (with the exception of licensed health professionals and volunteers); or (3) Was subjected to an extended (or partially extended) survey as a result of having been found to have furnished substandard care (or for other reasons as determined by CMS or the state); or (4) Was assessed a civil monetary penalty of $5,000 or more as an intermediate sanction; or (5) Was found to have compliance deficiencies that endangered the health and safety of the HHA's patients, and had temporary management appointed to oversee the management of the HHA; or (6) Had all or part of its Medicare payments suspended; or (7) Was found under any federal or state law to have: (i) Had its participation in the Medicare program terminated; or (ii) Been assessed a penalty of $5,000 or more for deficiencies in federal or state standards for HHAs; or (iii) Been subjected to a suspension of Medicare payments to which it otherwise would have been entitled; or (iv) Operated under temporary management that was appointed to oversee the operation of the HHA and to ensure the health and safety of the HHA's patients; or (v) Been closed, or had its patients transferred by the state; or (vi) Been excluded from participating in federal health care programs or debarred from participating in any government program. This STANDARD is not met as evidenced by: Based on the results of this extended level survey, resulting in noncompliance with one Condition of Participation: Care planning, coordination, quality of care, the home health provider may not train, or competency evaluate their home health aides for a period of two (2) years following the date of this survey. This restriction ends 02/13/2028.

The Emergency Preparedness regulations were reviewed as part of the Medicare certification survey completed on 05/03/2023. During the survey it was determined the home health provider is in compliance with the requirements of 42 CFR 484.102 Condition of Participation: Emergency Preparedness for Home Health Providers.

An extended survey for Medicare certification for Central Missouri Home Health was completed on 5/03/2023. The home health provider had 233 current patients. One (1) condition-level deficiency was identified during the survey. A condition level deficiency was identified at §484.60 Condition Participation: Care Planning, Coordination and Quality of Care. A home health provider found out of compliance with any Condition of Participation evaluated as part of a standard survey may not train or competency evaluate their home health aides for a period of two (2) years following the date of this survey. A deficiency has been cited at §484.80(f) (3) -see Tag G788. Complaint #97129 was investigated in conjunction with the survey and was substantiated with the deficiency included. (G572)

State toll free HH telephone hotline CFR(s): 484.50(c)(9) Be advised of the state toll free home health telephone hot line, its contact information, its hours of operation, and that its purpose is to receive complaints or questions about local HHAs. This ELEMENT is not met as evidenced by: Based on the home health provider’s pre-printed admission booklet, home visit observation, and interview, the provider failed to provide written notice of the updated state toll free home health telephone hotline hours of operation (7:00 AM to 8:00 PM, seven days a week), in three of three home visit observations (Records/Patients #1, #2 and #3). This deficient practice has the potential to affect the rights of all the provider’s patients. Findings included: Review of the home health provider’s pre-printed admission booklet, Patient Bill of Rights, showed: - The Missouri toll-free hotline, hours are 7:00 AM to 12:00 AM, 7days per week; and - The purpose of the hotline was for the receipt of complaints and questions regarding home health issues. RECORD/PATIENT #1:Record review of the patient’s consent for care dated 03/20/2023, showed the hours of operation for the State hotline number are 7:00 AM to 12 midnight, seven days a week. Observation on 05/01/2023, beginning at 1:09 PM, during the patient’s home visit, showed:-RN A obtained patient’s admission folder and updated with the correct hotline hours as he/she explained to the patient that the hotline hours had changed and he/she was updating them in his/her folder; and-The state toll-free hotline hours were listed as, 7:00 AM to Midnight, seven days a week, prior to being corrected. RECORD/PATIENT #2: -Observation on 04/02/2022, at 11:20 A.M., during the patient's home visit, showed: -Admission folder was reviewed; -The state toll-free hotline hours were listed as, 7:00 AM to 12:00 AM, 7days per week in the admission booklet; and -During an interview on 04/02/2022, at 11:20 A.M. the patient stated he/she was not aware of the current state hotline hours. RECORD/PATIENT #3: Observation on 05/02/2023, beginning at 10:00 AM, during the patient’s home visit, showed: -Admission folder was reviewed; and -The state toll-free hotline hours were listed as, 7:00 AM to Midnight, seven days a week. During an interview on 05/03/2023 beginning at 12:00 PM, the home health administrator stated that the clinicians had not yet updated the hours in the patient’s homes.

RN performs assessment CFR(s): 484.55(a)(1) A registered nurse must conduct an initial assessment visit to determine the immediate care and support needs of the patient; and, for Medicare patients, to determine eligibility for the Medicare home health benefit, including homebound status. The initial assessment visit must be held either within 48 hours of referral, or within 48 hours of the patient's return home, or on the physician or allowed practitioner - ordered start of care date. This ELEMENT is not met as evidenced by: Based on clinical record review and interview, the provider failed to conduct the initial assessment of the patient within 48 hours of the referral to home care, or 48 hours after the patient's return home, or on the physician ordered start of care date in, but not limited to, one of six full records reviewed (Record/Patient #1). This deficient practice has the potential to affect all patients served by the agency. Findings included: RECORD/PATIENT #1: Review of the referral information showed a physician signed the home health order dated 03/13/2023 and showed: - Reason: Wound Care/Physical Therapy; and - Diagnosis: Generalized weakness and ulcer of left lower extremity with bone involvement without evidence of necrosis. Review of the clinical record showed physical therapy admission assessment dated 03/20/2023 (seven days after the referral for home health) and registered nurse add on evaluation dated 03/21/2023 (eight days after referral for home health). During an interview on 05/03/2023 at 10:42 AM and 10:55 AM, the clinical manager stated: - Home health care was not started until 03/20/2023 due to there were no wound care orders; - The current treatment of wet to dry dressings were continued until the patient went to the wound clinic on 03/30/2023; - They received a physician SOC date for 03/20/2023 on 03/16/202 but it was still a late SOC; and - We (the provider) may have told the referring physician we didn’t have availability and the physician chose not to send referral elsewhere. The note does not explain why SOC was late.

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 policy review, record review and interview, the home health provider failed to ensure updates to the comprehensive assessment were completed within 48 hours of the patient’s return home from hospital admission, in two of six full records reviewed (Records/Patients #3 and #4). This deficient practice has the potential to affect all patients served by the home health provider. Findings included: Review of the home health provider’s policy titled, “Patient Assessment, Initial and Reassessment,” dated 03/01/2022, showed a qualified clinician performs a comprehensive assessment or reassessment visit within 48 hours from referral or physician orders start of care date. RECORD/PATIENT #3: Review of the clinical record showed the following: -Patient’s second certification period began on 03/31/2023; -Physical Therapy performed recertification visit on 04/04/2023; and -The provider failed to complete an updated comprehensive assessment within 48 hours of the patient’s recertification. During an interview on 05/03/2023 beginning at 12:00 PM, the clinical manager stated that he/she could not provide documentation for why the recertification visit was performed late. RECORD/PATIENT #4: Record review showed the patient’s consent for care was dated 04/10/2023. He/she was admitted to the hospital on 04/20/2023 and discharged on 04/22/2023 with cerebral vascular accident (CVA) and left leg pain with a referral to home health care. Review of the fax referral cover page sent to the home health provider was dated 04/22/2023. Review of the clinical record showed the following: - Resumption of care visit completed by the registered nurse was dated 04/25/2023 (three days after discharge from hospital and referral); - Occupational therapy add on evaluation was dated 04/26/2023 (four days after discharge from hospital and referral); - Physical therapy add on evaluation was dated 04/27/2023 (five days after discharge from hospital and referral); - Speech therapy add on evaluation was dated 04/28/2023 (six days after discharge from the hospital and referral); and - The provider failed to complete an updated comprehensive assessment within 48 hours of the patient’s return home from the hospital. During an interview on 05/03/2023 at 11:25 AM, the clinical manager stated that the patient was discharged from the hospital on 04/22/2023 and the intake note was probably put in the computer on 04/23/2023. He/she could not provide documentation for why the resumption of care visit was performed late.

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 policy review, record review, home visit observation, and interview, the agency failed to: - The home health provider failed to ensure staff followed an individualized plan of care that specified the care and services necessary to meet the patient-specific needs (G572); - All patient care orders, including verbal orders, must be recorded in the plan of care (G574); - Promptly alert the relevant physician(s) to any changes in the patient's condition (G590); - Coordinate care delivery to meet the patient’s needs (G608); - Provide a visit schedule, including frequency of visits to the patient (G614); - Patient medication schedule/instructions, including medication name, dosage and frequency and which medications will be administered by HHA personnel and personnel acting on behalf of the HHA (G616); and - Provide the name and contact information for the clinical manager to the patient (G622). The cumulative effect of these deficient practices has the potential to affect the provision of safe care for all patients served by the agency. .

Plan of care CFR(s): 484.60(a)(1) Each patient must receive the home health services that are written in an individualized plan of care that identifies patient-specific measurable outcomes and goals, and which is established, periodically reviewed, and signed by a doctor of medicine, osteopathy, or podiatry acting within the scope of his or her state license, certification, or registration. If a physician or allowed practitioner refers a patient under a plan of care that cannot be completed until after an evaluation visit, the physician or allowed practitioner is consulted to approve additions or modifications to the original plan. This STANDARD is not met as evidenced by: Based on policy review, record review, and interview, the home health provider failed to ensure staff followed an individualized plan of care that specified the care and services necessary to meet the patient-specific needs for two of six full records reviewed (Records/Patients #1 and #2). This deficient practice has the potential to affect the accurate and consistent care provided to all the provider’s patients. Findings included: Review of the provider’s policy titled, "Plan of Care", revised 12/01/2021 showed: - Each patient has an individualized POC developed in consultation with the patient, physician or authorized practitioner, and staff that integrates comprehensive assessment findings to address patient problems, needs, and goals, as well as to address specific services being provided; - The POC includes types, frequency, and duration of services required; - The qualified clinician develops and revises the POC under the direction of the physician or authorized practitioner; - Alterations to the POC are made only with the physician/authorized practitioner’s approval; and - An aide plan of care will be developed by the registered nurse or other appropriate skilled professional that is familiar with the patient if aide services have been ordered. Review of the provider’s policy titled, "Coordination of Care, From Admit Through Discharge", revised 04/01/2023 showed: - Patient care is coordinated among various disciplines and services through care planning processes to ensure continuity of care from admission to discharge; and - All clinicians will report within one business day to the Patient Care Manager or Clinical Director missed visits and changes to scheduled visits, reason for missed visit and changes to patient schedule. RECORD/PATIENT #1: Review of the POC, dated 04/10/2023 to 06/08/2023, showed home health aide (HHA) frequency once a week times one week, two times a week times two weeks and once a week times one week for assistance with personal care and activities of daily living (ADLs) secondary to functional limitations, which prevent self-care. Review of the Aide Care Plan Report, dated 04/10/2023 to 06/08/2023, showed HHA frequency once a week times one week, two times a week times two weeks and once a week times one week for bathing, applying lotion, dressing and stand-by assistance with ambulation and use of walker. Review of the clinical record showed: - Start of care 04/10/2023; - HHA visit 04/14/2023, week of 04/10/2023 through 04/15/2023; - HHA visit 04/17/2023, week of 04/16/2023 through 04/22/2023; and - No HHA visits week of 04/23/2023 through 04/29/2023. During an interview on 05/03/2023 at 11:32 AM, the clinical manager stated the HHA visits were missed and there should be a note regarding missed visit and notification to the patient care manager. The patient care manager should get an order to discontinue HHA visits if the patient does not want the visit. RECORD/PATIENT #2: Review of the clinical record, showed the patient was admitted to service on 04/21/2023, following a hospitalization which included Acute Kidney Injury, weakness, uterine cancer, and left foot pain. Review of the Plan of Care (POC), showed an order dated 04/23/2023, for OT (Occupational Therapy) two times for four weeks. Review of the OT notes failed to show one of two scheduled visits during week two of OT services. During an interview on 05/03/2023 at 11:20 A.M., the clinical manager stated OT staff had failed to provide one of two scheduled visits to be provided by home health provider during the second week of services as directed by the POC, the week of 04/23/2023 through 04/29/2023. RECORD/PATIENT #5 Review of the plan of care (POC) dated 02/17/2023 to 04/17/2023, showed the following: - The patient the patient was recently hospitalized due to shortness of breath and chest pain due to atherosclerosis (plaque buildup in the wall of the arteries that supply blood to the heart) status post a cardiac catheterization and stent (used to treat narrowed coronary arteries that provide the heart with oxygen-rich blood); - The patient also had the following co-morbidities that are new or have exacerbated within the last month: Cerebral vascular disease (stroke), diabetes mellitus (chronic condition that affects the way the body processes blood sugar), hypertension, neuropathy and chronic obstructive pulmonary disease, and anxiety; - The patient is considered unstable evidenced by pain, dyspnea (difficult or labored breathing), reported unstable blood sugars, and incontinence; and - Effective 02/26/2023, skilled nursing two times a week for two weeks. Review of the skilled nursing notes failed to show one of the two visits during week two of skilled nursing visits.

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 policy review, record review, and interview the home health provider failed to ensure staff developed a complete, individualized plan of care (POC) in one of six records reviewed (Record/Patient #5). This deficient practice has the potential to affect all patients served by the home health provider. Finding included: Review of the home health provider's updated policy revised 12/01/2021, showed in part, each patient has an individualized POC developed in consultation with the patient, physician or authorized practitioner, and staff that integrates comprehensive assessment findings to address patient problems, needs, and goals, as well as to address specific services being provided. The patient is monitored for response to treatment and progress toward goals. The plan of care includes: Patient's mental, psychosocial, and cognitive status, patient specific interventions and education, and measurable outcomes and goals, patient/caregiver education and training for a timely discharge, and all patient care orders. RECORD/PATIENT #5: Review of the cardiology admission note, dated 02/10/2023 at 8:13 AM, showed the following allergies: Betadine, Cleocin (antibiotic), iodine, Keflex (antibiotic), penicillins (antibiotic), sulfa drugs (antibiotics containing chemicals called sulfonamides), tetracycline (antibiotic), gabapentin (anticonvulsant and nerve pain medication), Lyrica (can treat nerve and muscle pain), Glucophage (anti-diabetic medication), Lipitor (can treat high cholesterol and triglyceride levels), Reglan (used to treat heartburn caused by gastric reflux), shellfish allergy, Ditropan XL (bladder relaxant), and Prevacid (used to treat heartburn). Review of the physician discharge summary dated 02/11/2023 at 2:32 PM showed the patient was to wear his/her home CPAP (continuous postitive airway pressure)/bipap (bilevel positive airwaway pressure) (PAP- common treatment for sleep apnea) during times of sleepiness, unless otherwise instructed. Review of the physical therapy admission OASIS (Outcome and Assessment Information Set) dated 02/17/2023, showed: - Admitted to home health services on 02/23/2023; - Diagnosis included arteriosclerotic heart disease of native coronary artery (plaque buildup in the wall of the arteries that supply blood to the heart), type two diabetes (chronic condition that affects the way the body processes blood sugar) with diabetic peripheral angiopathy (complications that arise from chronic diabetes), obstructive sleep apnea (intermittent airflow blockage during sleep), hypertensive heart disease with heart failure, depression, and chronic obstructive pulmonary disease (COPD); - Decline in mental, emotional, or behavioral status and difficulty complying with any medical instructions in the past three months; - The patient had fluctuations of inattention and disorganized thinking that changes in severity, anxious daily but not constantly; - Sometimes feels lonely or isolated from those around him/her; - Impaired decision-making: Failure to perform usual activities of daily living, inability to appropriately stop activities, jeopardizes safety through actions; - At least daily has disruptive behavior symptoms of any physical, verbal, or other disruptive/dangerous symptoms that are injurious to self or others or jeopardize personal safety; - Knowledge based deficits included pathophysiology of disease, signs and symptoms to report, who and when to call for help; - Skilled nurse to monitor pain; - Pain clinic for pain management; - Physician managing diabetes [Dr. Younker] and this was not the patient’s primary physician and the PT; - The patient had symptoms of being cold and shaky from low blood glucose (when the blood sugar levels drop below 70 mg (milligram)/dl(deciliter), and at this level action is needed to bring the blood sugar back up); - The patient could not find glucometer (a small device used to measure how much sugar is in a blood sample) during the visit, the patient reported he/she has a glucometer but has not been checking blood sugars recently; - Education on blood sugar management needed; - Anticoagulation and fall precautions (blood thinner); - Ask for a referral to a podiatrist due to patient having loss of protective sensation, -heavy callus, deformity or wound. Ask the physician for referral to durable medical equipment if patient does not have diabetic shoes; - The patient was recently hospitalized due to shortness of breath and chest pain due to atherosclerosis and underwent cardiac catheterization (the insertion of a catheter into the chamber or vessel of the heart) and stent (a small mesh tube typically used to hold open passages in the body, such as weak or narrowed arteries); and - Communication regarding the POC and home health orders received from the patient’s physician [Dr. Younker] (the physician manages the patient’s diabetes is not listed on the POC) and verbal orders were received. Review of the POC dated 02/17/2023 through 04/17/2023, failed to show the following: - Allergies: Betadine, Cleocin, iodine, Keflex, penicillins, sulfa drugs, tetracycline, gabapentin, Lyrica, Glucophage, Lipitor, Reglan, shellfish allergy, Ditropan XL, and Prevacid (the POC showed no known allergies); - CPAP/Bipap; - Individualized interventions of pain management, where the pain was located, tolerable level of pain for the patient, and the pain clinic was managing pain; - Problems, interventions and goals for the patient’s decline in mental, emotional, or behavioral status and difficulty complying with any medical instructions, fluctuations of inattention and disorganized thinking that changes in severity, anxiety, feeling of loneliness or isolated from those around him/her, impaired decision-making, and disruptive behavior symptoms that are injurious to self or others or jeopardize personal safety; - The physician managing diabetes; - Problems, interventions and goals on symptoms of low blood sugar and patient unable to find glucometer and not checking blood sugar (physician orders to check blood sugar twice a day with parameters); - An order for podiatrist and diabetic shoes; - Problems, individualized interventions, and goals for arteriosclerosis; - Problems, interventions and goals for recent cardiac catheterization and stent placement; - Individualized interventions for anticoagulation and fall risk; - Knowledge based deficits included pathophysiology of disease, signs and symptoms to report, who and when to call for help; and - The physician listed on the plan of care signed and dated the POC on 02/27/2023 (10 days after the start of care) and there was no verbal orders from this physician. During an interview on 05/03/2023 at 10:05 AM, the patient care manager (case manager) stated that the staff should have notified the physician the patient was not checking his/her blood sugars twice a day. There was no individual interventions for anticoagulation precautions and fall risk. Staff should monitor for bruising. During an interview on 05/03/2023 beginning at 10:05 AM, the clinical director (clinical manager) and administrator stated that when the POC is developed there is an “order set” that is already individualized according to the start of care assessment and interventions can be added.

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 policy review, clinical record review, and interview the home health provider failed to promptly alert the physician or allowed practitioner to changes in the patient’s condition that suggest the plan of care should be altered in two of six full records reviewed (Records/Patients #4 and #5). This deficient practice has the potential to affect all patients served by the home health provider. Findings included: Review of the home health provider’s policy titled, “Coordination of Care, from Admit though Discharge,” updated 04/01/2023 showed: - At admission, throughout care, and at discharge, coordination of services is promoted through routine communication with the patient’s physician: * When changes occur in the patient’s condition or response to treatment * When a missed visit occurs altering the plan of care (POC) * When there is a need to change the patient’s POC. RECORD/PATIENT #5: Review of the plan of care (POC) dated 02/17/2023 to 04/17/2023, showed the following: - The patient the patient was recently hospitalized due to shortness of breath and chest pain due to atherosclerosis (plaque buildup in the wall of the arteries that supply blood to the heart) status post a cardiac catheterization and stent (used to treat narrowed coronary arteries that provide the heart with oxygen-rich blood); - The patient also had the following co-morbidities that are new or have exacerbated within the last month: Cerebral vascular disease (stroke), diabetes mellitus (chronic condition that affects the way the body processes blood sugar), hypertension, neuropathy and chronic obstructive pulmonary disease, and anxiety; - The patient is considered unstable evidenced by pain, dyspnea (difficult or labored breathing), reported unstable blood sugars, and incontinence; and - Skilled nurse to instruct patient on blood glucose testing two times a day. Review of the physical therapy assistant visit note report, dated 02/24/2023 at 10:18 AM showed the patient complained of a little chest pain and took one nitroglycerin (can treat and prevent chest pain) and was fine. There was no documentation to show physician notification. Review of the emergency room report events report dated 02/24/2023 at 11:58 AM, showed the patient presented to the emergency department (ED) with chest pain, “onset 9:30 AM, took two nitroglycerin at home, cardiac history, gave aspirin 324 mg in route”. The patient presented with concerns for “chest pain temp”, dyspnea, and weakness. Approximately 2.5 hours ago prior to examination the patient began to develop some dyspnea and anterior chest pain radiating into his/her right shoulder, typical to the pain he/she experienced with previous cardiac events. He/she also felt somewhat dyspneic. He/she took a nitroglycerin with complete relief of the pain but his/her dyspnea seemed to be getting worst. He/she was given an aspirin by the emergency medical system. About two weeks ago, he/she had a cardiac catheterization with a stent placed. Since awakening this morning about five hours ago, he/she had generalized weakness. . There was no documentation to show physician notification. Review of the skilled nurse visit note report, dated 03/09/2023 at 4:44 PM, showed the licensed practical nurse documented respiratory findings: CPAP (continuous positive airway pressure) (a machine that uses mild air pressure to keep breathing airways open while sleeping). The patient was not checking his/her blood sugars per the physician’s order because he/she could not find the glucometer. The patient report as feeling suicidal and when asked if he/she has a plan he/she stated he/she always had a plan. During the course of the visit, the patient wavered between extreme emotional outbursts and telling jokes to being irate. The patient’s daughter was present during the visit. There was no documentation to show physician notification of the CPAP, not checking blood sugars, statement of feeling suicidal and behaviors. Review of the client coordination note report, dated 03/10/2023, showed a late entry for the 03/09/2023 skilled nurse visit. The LPN documented the patient is not checking blood sugars despite using insulin, the patient reported he/she couldn’t find the glucometer, and then stated he/she knows where it is but doesn’t know how to use all the pieces. The LPN offered to assist the patient with it and he/she stated it was lost in the house and he/she doesn’t need it/use it. Education was given about the safety with insulin, monitoring blood sugar in the home. The patient was unconcerned and stated he/she didn’t plan of finding or using it (glucometer). There was no documentation the physician notification the patient was not monitoring his/her blood sugar per the physician’s order. Review of the client coordination note report, dated 03/11/2023 at 11:37 AM, the on call nurse documented the reason for the call was chest pain. Interventions: The RN attempted to reach patient by phone and no answer, LPN reached out to the on-call RN saying he/she was on the phone when the RN was calling, after talking with the patient they (LPN) felt like the patient was having anxiety. The RN told the patient to call the on-call nurse if pain returned or with any further questions. The physician was not notified, no visit was required, no supplemental order written and the call was not triaged. Visit with physician assistant 03/14/2023 and skilled nurse to follow up 03/15/2023. Review of the skilled nurse visit note report, dated 03/15/2023 at 10:16 AM, showed the licensed practical nurse documented the patient rated his/her pain a five (using a pain scale with zero representing no pain and ten being the worst pain possible) of the anterior chest, the patient had shortness of breath on exertion. The patient had coronary artery disease, congestive heart failure and hypertension. The patient had diarrhea three times today. The patient reported mediastinal (part of the chest that lies between the sternum and the spinal column and between the lungs) that radiates to the left shoulder when coughing. The patient has not taken any nitroglycerin for the chest pain because “it is not as painful as other times”. Vital signs stable and no other concerns noted. Towards the end of the visit, the chest pain had improved slightly. The patient is unable to find glucometer and is unconcerned about checking blood sugar. The patient does want the nurse to contact the primary care physician for new glucometer. Educated on edema management (no assessment) and monitoring of fluid overload. There was no documentation to show physician notification of the chest pain, shortness of breath, diarrhea, not checking blood sugars, request for glucometer and edema. Review of the skilled nurse visit note report, dated 03/22/2023 at 1:49 PM, showed the licensed practical nurse documented the patient complained of chest pain (no assessment) and took two nitroglycerin with some relief. He/she states he/she has been having chest pain for the last couple of days. He/she stated he/she used nitroglycerin times two today and it did relieve the pain. The nurse suggested if the chest pain persists and is unrelieved by nitroglycerin he/she should proceed to the emergency room. The documentation showed care coordination was non-applicable. There was no documentation of physician notification the patient was having chest pain for the last couple of days. Review of the skilled nurse visit note report, dated 03/31/2023 at 3:41 PM, showed the registered nurse documented the patient did not have a glucometer and does not want to check (blood sugar) in home. The patient has edema to the lower extremities (no assessment). The patient does not feel well but unable to give specific symptoms. No chest pain in last few days. There was documentation of physician notification of the patient’s edema and not checking blood sugars per the physician orders. Review of the physical therapy assistant visit note report, dated 04/11/2023 at 12:05 PM, showed the patient had a fall, complete fall notification coordination note. The patient complained of pain to his/her head, back and left shoulder. The skin assessment showed wound(s) (no assessment). The care coordination note showed no changes. There was no documentation of physician notification of the pain. Review of a client coordination note report, dated 04/11/2023, showed the PTA documented the patient states he/she fell in his/her bathroom and again in the hallway the last two days. He/she has a skin tear on left thumb. There was no ER visit and the family assisted the patient up. Communication of the fall reported to PT. There was no documentation of physician notification of the patient two times within the last two days. There was no physician notification of the patient falling in the hallway. Review of the ED report, dated 04/13/2023 at 5:22 PM, showed the patient has fallen three times since Friday (04/07/2023), reports he/she has fallen backwards, denies hitting head, complains of headache, and reports that he/she takes Plavix. The patient presented to the ED with concerns for headache and neck pain that has been going on for the last several days. He/she has fallen three times since Friday and did lose consciousness at least once. He/she has a laceration on his/her left thumb had scant purulent drainage and the wound was dressed with triple antibiotic ointment and nonstick gauze. He/she was started on antibiotics for laceration. He/she has extensive allergies including clindamycin, sulfa, Keflex and other penicillin’s, and tetracyclines. The patient was started on ciprofloxacin HCL 500 mg (milligrams) two times daily. The patient diagnosis was fall, initial encounter, acute post-traumatic headache, not intractable, neck pain, and infected laceration. There was no physician notification. Review of the client coordination note report, dated 04/17/2023 (four days after the emergent care), showed an emergent care notification and the physical therapist documented the reason for the emergent care visit was weakness. The patient went to the ER on 04/13/2023; the patient was discharged the same day with no changes. There was no documentation to show physician notification of the patient went to the ER due to falls, post-traumatic headache, the lacerated left thumb treatment of triple antibiotic ointment and gauze, antibiotics and allergies. During an interview on 05/03/2023 at 9:10 AM and 10:05 AM, the administrator stated that the patient could not find the glucometer and there was no communication with the physician and clinical manager. If the patient did not get relief from the nitroglycerin, he/she would have expected them to notify the physician. It was unknown if the patient had edema and there was no further documentation. He/she expects staff to notify the physician when a patient has a change in condition. There was no communication with physician and case manager on 03/15/2023 and 03/22/2023. There was no additional information provided. RECORD/PATIENT #4: Review of the start of care assessment dated 04/10/2023 showed history of arthritis, cerebrovascular accident/transient ischemic attack (CVA/TIA) (stroke), osteoporosis, wounds, recent lumbar surgery with anterior and posterior fusion, discectomy, two or more falls in past 12 months, and occasional pain interfering with sleep, therapy activities and day to day activities. The patient reported the level of pain was an eight out of 10 (zero representing no pain and 10 representing the worst pain). The location of the pain was in his/her back consisting of aching, shooting and sore. Rest, prescription pain medication and over the counter medication relieves the pain. The patient and caregiver knowledge deficits include medications. No documentation provided the physician was notified of patient’s pain rated an eight. Review of the POC dated 04/10/2023 through 06/08/2023, showed, in part: - The patient was admitted to home health services on 04/10/2023; - Diagnoses included: orthopedic aftercare, acute post procedural pain, spondylolisthesis of lumbar region, spinal stenosis of lumbar region with neurogenic claudication, osteoporosis, arthrodesis status, low back pain and muscle weakness; - PT/OT (physical therapy/occupational therapy) to evaluate/assess and develop physical/occupational therapy plan of care; - SN (skilled nurse) to monitor pain and instruct/reinforce patient regarding pharmacologic and non-pharmacologic pain control measures such as relaxation techniques; - SN to instruct on low back pain to include definition, causes, signs and symptoms, and treatment; - Licensed professional to report vital signs falling outside the established parameters of pain greater than seven; - Amitriptyline (antidepressant to treat depressive disorders or pain syndromes) 100 milligram (mg) one daily; - Cyclobenzaprine (muscle relaxer) 10 mg one every eight hours as needed; and - Hydrocodone (opioid analgesic) 5 mg – Acetaminophen (analgesic) 325 mg one every six hours as needed. Review of the skilled nurse visit note dated 04/13/2023 showed the patients pain eight out of 10 to abdomen, back and left hip. Taking Norco hydrocodone/acetaminophen) every six hours with 1000 mg APAP (analgesic for minor aches and pains) in between and Flexeril (muscle relaxer) every eight hours with no relief less than six out of 10. Encouraged patient to decrease APAP to one extra strength between Norco dosages due to maximum daily dosage at current regimen over 5400 mg. Explained importance of safe medication regimens and message left for physician to make aware of ineffective pain management. Encouraged use of ice/heat to left hip, repositioning, and muscle rub. Review of the client coordination note report dated 04/14/2023 at 7:30 PM showed: - Reason for call - uncontrolled pain and low grade fever; - Registered nurse called and spoke with patient’s daughter. Patient has had pain since surgery but it continues to worsen to the point she is having difficulty walking. Called hospital to get in touch with physician or physician taking his call. Informed they do not have coverage, only option is to send patient to the emergency room (ER). Notified the patient’s caregiver and he/she is taking patient to ER tonight; and - Comments: The patient was seen in ER, received gabapentin (anticonvulsant to treat neuropathic pain), Percocet (treats moderate to severe pain) and Toradol (nonsteroidal anti-inflammatory to treat pain) shot. Pain relieved. Was sent home and told to follow-up with primary care physician (PCP). No documentation provided the physician was notified of patient’s ER visit regarding pain. Review of the skilled nurse visit note dated 04/18/2023 showed the following: - The patient was in the ER last weekend (4/14/2023) and diagnosed with sciatica (pain from irritation of the sciatic nerve); and - Patient was given a prescription for gabapentin and it is helping, today his/her pain is seven out of 10 which is tolerable per the patient report. Review of the client coordination note report dated 04/18/2023 showed: - Emergent care notification; - Reason - severe back and hip pain; - Diagnosed with sciatica; and - Given a prescription for gabapentin. No documentation provided the physician was notified of patient’s ER visit regarding pain. Review of the occupational therapy (OT) visit note dated 04/20/2023 showed the following: - The patient’s pain was eight out of 10 and is managing with Tylenol; - Pain is stabbing in the left hip was in the ER last weekend (4/14/2023); - Follow-up comment entered by SN on 04/20/2023; and - Fax sent to physician at 11:26 AM. Review of the skilled nurse visit note dated 04/20/2023 showed the following: - The patient was wasn’t acting right and reports being dizzy, double vision, awkward responses, and flat affect, muscle spasms in arms causing patient to throw/lose control of cups. Reports it started yesterday and has worsened today; - Patient was seen by OT previous to this visit with no concerns; - Patient reporting significant hip pain to the left side; - Answers to questions were delayed and sometimes off, he/she struggled to make eye contact and didn’t actively participate in majority of conversation. Pupils were constricted and non-reactive to light, but able to follow finger. Daughter is concerned and would like patient to go to ER but patient is refusing; and - Licensed practical nurse (LPN) discussed with registered nurse (RN) and patient was advised to go to ER. Daughter and patient agreed and will go by private car. No documentation provided the physician was notified of patient’s pain and sent to ER. Review of the client coordination note report dated 04/20/2023 showed: - The patient was seen for routine SN visit; - This nurse was met by patient’s daughter expressing concerns that patient wasn’t acting right. He/she reports being dizzy, double vision, awkward responses, and flat affect, muscle spasms in arms causing patient to throw/lose control of cups. Reports it started yesterday and has worsened today; - Patient was seen by OT previous to this visit with no concerns; - Patient reporting significant hip pain to the left side; - Answers to questions were delayed and sometimes off, he/she struggled to make eye contact and didn’t actively participate in majority of conversation. Pupils were constricted and non-reactive to light, but able to follow finger. Daughter is concerned and would like patient to go to ER but patient is refusing; and - Licensed practical nurse (LPN) discussed with registered nurse (RN) and patient was advised to go to ER. Daughter and patient agreed and will go by private car. During an interview on 05/03/2023 at 11:41 AM, the clinical manager stated the patient is followed in the pain clinic but there are no notes in the chart and there is no communication regarding the patient’s pain and follow-up with the pain ratings greater than seven.

Coordinate care delivery CFR(s): 484.60(d)(4) Coordinate care delivery to meet the patient's needs, and involve the patient, representative (if any), and caregiver(s), as appropriate, in the coordination of care activities. This ELEMENT is not met as evidenced by: Based on policy review, clinical record review and interview the agency failed to ensure coordination of care delivery to meet the patient's needs in two of six records reviewed (Records/Patients #4 and #5). This deficient practice has the potential to affect the coordination of care and services for all patients on service with the agency. Findings included: Review of the home health provider’s policy titled, “Coordination of Care, from Admit though Discharge,” updated 04/01/2023 showed: - The agency provides care and services within an integrated continuum of care system. This is accomplished by: * Identifying patient needs through assessment and communication with other health care providers * Coordinating patient care among various disciplines to ensure that services are continuous and coordinated from admission through discharge - Patient care is coordinated among various disciplines and services through care planning processes for continuity of care. This includes: * Appropriate, timely communication with the patient, caregivers, and staff involved in the patient’s care regarding patient needs, goals, and care as well as changes in these * All clinicians will report within one business day to the patient care manager or clinical director by fax, telephone, in person at the agency, or through coordination notes by synching point of care devices and the report will include significant changes in the patient’s condition. RECORD/PATIENT #5: Review of the plan of care (POC) dated 02/17/2023 to 04/17/2023, showed the following: - The patient the patient was recently hospitalized due to shortness of breath and chest pain due to atherosclerosis (plaque buildup in the wall of the arteries that supply blood to the heart) status post a cardiac catheterization and stent (used to treat narrowed coronary arteries that provide the heart with oxygen-rich blood); - The patient also had the following co-morbidities that are new or have exacerbated within the last month: Cerebral vascular disease (stroke), diabetes mellitus (chronic condition that affects the way the body processes blood sugar), hypertension, neuropathy and chronic obstructive pulmonary disease, and anxiety; - The patient is considered unstable evidenced by pain, dyspnea (difficult or labored breathing), reported unstable blood sugars, and incontinence; and - Skilled nurse to instruct patient on blood glucose testing two times a day. Review of the physical therapy assistant visit note report, dated 02/24/2023 at 10:18 AM showed the patient complained of a little chest pain and took one nitroglycerin (can treat and prevent chest pain) and was fine. No coordination of care with physical therapist, patient care manager, clinical manager, administrator and/or physician. Review of the emergency room report events report dated 02/24/2023 at 11:58 AM, showed the patient presented to the emergency department (ED) with chest pain, “onset 9:30 AM, took two nitroglycerin at home, cardiac history, gave aspirin 324 mg in route”. The patient presented with concerns for “chest pain temp”, dyspnea, and weakness. Approximately 2.5 hours ago prior to examination the patient began to develop some dyspnea and anterior chest pain radiating into his/her right shoulder, typical to the pain he/she experienced with previous cardiac events. He/she also felt somewhat dyspneic. He/she took a nitroglycerin with complete relief of the pain but his/her dyspnea seemed to be getting worst. He/she was given an aspirin by the emergency medical system. About two weeks ago, he/she had a cardiac catheterization with a stent placed. Since awakening this morning about five hours ago, he/she had generalized weakness. There was no documentation to show coordination of care with physical therapist, patient care manager, clinical manager, administrator and/or physician. Review of the skilled nurse visit note report, dated 03/09/2023 at 4:44 PM, showed the licensed practical nurse documented respiratory findings: CPAP (continuous positive airway pressure) (a machine that uses mild air pressure to keep breathing airways open while sleeping). The patient was not checking his/her blood sugars per the physician’s order because he/she could not find the glucometer. The patient report as feeling suicidal and when asked if he/she has a plan he/she stated he/she always had a plan. During the course of the visit, the patient wavered between extreme emotional outbursts and telling jokes to being irate. The patient’s daughter was present during the visit. There was no documentation to show coordination of care with physical therapist, patient care manager, clinical manager, administrator and/or physician. Review of the client coordination note report, dated 03/10/2023, showed a late entry for the 03/09/2023 skilled nurse visit. The LPN documented the patient is not checking blood sugars despite using insulin, the patient reported he/she couldn’t find the glucometer, and then stated he/she knows where it is but doesn’t know how to use all the pieces. The LPN offered to assist the patient with it and he/she stated it was lost in the house and he/she doesn’t need it/use it. Education was given about the safety with insulin, monitoring blood sugar in the home. The patient was unconcerned and stated he/she did not plan of finding or using it (glucometer). There was no documentation to show coordination of care with physical therapist, patient care manager, clinical manager, administrator and/or physician. Review of the client coordination note report, dated 03/11/2023 at 11:37 AM, the on call nurse documented the reason for the call was chest pain. Interventions: The RN attempted to reach patient by phone and no answer, LPN reached out to the on-call RN saying he/she was on the phone when the RN was calling, after talking with the patient they (LPN) felt like the patient was having anxiety. The RN told the patient to call the on-call nurse if pain returned or with any further questions. The physician was not notified, no visit was required, no supplemental order written and the call was not triaged. Visit with physician assistant 03/14/2023 (three days after the patient’s call) and skilled nurse to follow up 03/15/2023 (four days after the patient’s call). Review of the skilled nurse visit note report, dated 03/15/2023 at 10:16 AM, showed the licensed practical nurse documented the patient rated his/her pain a five (using a pain scale with zero representing no pain and ten being the worst pain possible) of the anterior chest, the patient had shortness of breath on exertion. The patient had coronary artery disease, congestive heart failure and hypertension. The patient had diarrhea three times today. The patient reported mediastinal (part of the chest that lies between the sternum and the spinal column and between the lungs) that radiates to the left shoulder when coughing. The patient has not taken any nitroglycerin for the chest pain because “it is not as painful as other times”. Vital signs stable and no other concerns noted. Towards the end of the visit, the chest pain had improved slightly. The patient is unable to find glucometer and is unconcerned about checking blood sugar. The patient does want the nurse to contact the primary care physician for new glucometer. Educated on edema management (no assessment) and monitoring of fluid overload. There was no documentation to show coordination of care with physical therapist, patient care manager, clinical manager, administrator and/or physician. Review of the skilled nurse’s visit note report, dated 03/22/2023 at 1:49 PM, showed the licensed practical nurse documented the patient complained of chest pain and took two nitroglycerin with some relief. He/she states he/she has been having chest pain for the last couple of days. He/she stated he/she used nitroglycerin times two today and it did relieve the pain. The nurse suggested if the chest pain persists and is unrelieved by nitroglycerin he/she should proceed to the emergency room. The documentation showed care coordination was non-applicable. Review of the skilled nurse visit note report, dated 03/31/2023 at 3:41 PM, showed the registered nurse documented the patient did not have a glucometer and does not want to check (blood sugar) in home. The patient has edema to the lower extremities (no assessment). The patient does not feel well but unable to give specific symptoms. No chest pain in last few days. There was no documentation to show coordination of care with physical therapist, patient care manager, clinical manager, administrator and/or physician. Review of the ED report, dated 04/13/2023 at 5:22 PM, showed the patient has fallen three times since Friday (04/07/2023), reports he/she has fallen backwards, denies hitting head, complains of headache, and reports that he/she takes Plavix. The patient presented to the ED with concerns for headache and neck pain that has been going on for the last several days. He/she has fallen three times since Friday and did lose consciousness at least once. He/she has a laceration on his/her left thumb had scant purulent drainage and the wound was dressed with triple antibiotic ointment and nonstick gauze. He/she was started on antibiotics for laceration. He/she has extensive allergies including clindamycin, sulfa, Keflex and other penicillin’s, and tetracyclines. The patient was started on ciprofloxacin HCL 500 mg (milligrams) two times daily. The patient diagnosis was fall, initial encounter, acute post-traumatic headache, not intractable, neck pain, and infected laceration. There was no documentations to show coordination of care with physical therapist, patient care manager, clinical manager, administrator and/or physician. 8Review of the client coordination note report, dated 04/17/2023 (four days after the emergent care), showed an emergent care notification, the physical therapist documented the reason for the emergent care visit was weakness. The patient went to the ER on 04/13/2023; the patient was discharged the same day with no changes. There was no documentation to show coordination of care patient care manager, clinical manager, administrator and/or physician. During an interview on 05/03/2023 at 9:10 AM and 10:05 AM, the administrator stated that the patient could not find the glucometer and there was no communication with the physician and clinical manager. If the patient did not get relief from the nitroglycerin, he/she would have expected them to notify the physician. It was unknown if the patient had edema and there was no further documentation. He/she expects staff to notify the physician when a patient has a change in condition. The skilled nurse that assesses the patient's change in the condition should notify the physician because they have assessed the patient and can answer questions. The case manager coordinates the care. There was no communication with physician and case manager on 03/15/2023 and 03/22/2023. There was no additional information provided. RECORD/PATIENT #2: Review of the start of care assessment dated 04/10/2023 showed history of arthritis, cerebrovascular accident/transient ischemic attack (CVA/TIA) (stroke), osteoporosis, wounds, recent lumbar surgery with anterior and posterior fusion, discectomy, two or more falls in past 12 months, and occasional pain interfering with sleep, therapy activities and day to day activities. The patient reported the level of pain was an eight out of 10 (zero representing no pain and 10 representing the worst pain). The location of the pain was in his/her back consisting of aching, shooting and sore. Rest, prescription pain medication and over the counter medication relieves the pain. The patient and caregiver knowledge deficits include medications. There was no documentation to show coordination of care with, clinical manager, administrator and/or physician. Review of the POC dated 04/10/2023 through 06/08/2023, showed, in part: - The patient was admitted to home health services on 04/10/2023; - Diagnoses included: orthopedic aftercare, acute post procedural pain, spondylolisthesis of lumbar region, spinal stenosis of lumbar region with neurogenic claudication, osteoporosis, arthrodesis status, low back pain and muscle weakness; - PT/OT (physical therapy/occupational therapy) to evaluate/assess and develop physical/occupational therapy plan of care; - SN (skilled nurse) to monitor pain and instruct/reinforce patient regarding pharmacologic and non-pharmacologic pain control measures such as relaxation techniques; - SN to instruct on low back pain to include definition, causes, signs and symptoms, and treatment; - Licensed professional to report vital signs falling outside the established parameters of pain greater than seven; - Amitriptyline (antidepressant to treat depressive disorders or pain syndromes) 100 milligram (mg) one daily; - Cyclobenzaprine (muscle relaxer) 10 mg one every eight hours as needed; and - Hydrocodone (opioid analgesic) 5 mg – Acetaminophen (analgesic) 325 mg one every six hours as needed. Review of the skilled nurse visit note dated 04/13/2023 showed the patients pain eight out of 10 to abdomen, back and left hip. Taking Norco (hydrocodone/acetaminophen) every six hours with 1000 mg APAP (analgesic for minor aches and pains) in between and Flexeril (muscle relaxer) every eight hours with no relief less than six out of 10. Encouraged patient to decrease APAP to one extra strength between Norco dosages due to maximum daily dosage at current regimen over 5400 mg. Explained importance of safe medication regimens and message left for physician to make aware of ineffective pain management. Encouraged use of ice/heat to left hip, repositioning, and muscle rub. There was no documentation to show coordination of care with, patient care manager, clinical manager, administrator and/or physician. Review of the client coordination note report dated 04/14/2023 at 7:30 PM showed: - Reason for call - uncontrolled pain and low grade fever; - Registered nurse called and spoke with patient’s daughter. Patient has had pain since surgery but it continues to worsen to the point she is having difficulty walking. Called hospital to get in touch with physician or physician taking his call. Informed they do not have coverage, only option is to send patient to the emergency room (ER). Notified the patient’s caregiver and he/she is taking patient to ER tonight; and - Comments: The patient was seen in ER, received gabapentin (anticonvulsant to treat neuropathic pain), Percocet (treats moderate to severe pain) and Toradol (nonsteroidal anti-inflammatory to treat pain) shot. Pain relieved. Was sent home and told to follow-up with primary care physician (PCP). Review of the skilled nurse visit note dated 04/18/2023 showed the following: - The patient was in the ER last weekend (4/14/2023) and diagnosed with sciatica (pain from irritation of the sciatic nerve); and - Patient was given a prescription for gabapentin and it is helping, today his/her pain is seven out of 10 which is tolerable per the patient report. There was no documentation to show coordination of care with, clinical manager, administrator and/or physician regarding patient’s ER visit. Review of the client coordination note report dated 04/18/2023 showed: - Emergent care notification; - Reason - severe back and hip pain; - Diagnosed with sciatica; and - Given a prescription for gabapentin. Review of the occupational therapy (OT) visit note dated 04/20/2023 showed the following: - The patient’s pain was eight out of 10 and is managing with Tylenol; - Pain is stabbing in the left hip was in the ER last weekend (4/14/2023); - Follow-up comment entered by SN on 04/20/2023; and - Fax sent to physician at 11:26 AM. There was no documentation to show coordination of care with, clinical manager, administrator and/or no follow-up with fax sent to physician. Review of the skilled nurse visit note dated 04/20/2023 showed the following: - The patient was wasn’t acting right and reports being dizzy, double vision, awkward responses, and flat affect, muscle spasms in arms causing patient to throw/lose control of cups. Reports it started yesterday and has worsened today; - Patient was seen by OT previous to this visit with no concerns; - Patient reporting significant hip pain to the left side; - Answers to questions were delayed and sometimes off, he/she struggled to make eye contact and didn’t actively participate in majority of conversation. Pupils were constricted and non-reactive to light, but able to follow finger. Daughter is concerned and would like patient to go to ER but patient is refusing; and - Licensed practical nurse (LPN) discussed with registered nurse (RN) and patient was advised to go to ER. Daughter and patient agreed and will go by private car. There was no documentation to show coordination of care with, clinical manager, administrator and/or physician that patient was sent to the ER. Review of the client coordination note report dated 04/20/2023 showed: - The patient was seen for routine SN visit; - This nurse was met by patient’s daughter expressing concerns that patient wasn’t acting right. He/she reports being dizzy, double vision, awkward responses, and flat affect, muscle spasms in arms causing patient to throw/lose control of cups. Reports it started yesterday and has worsened today; - Patient was seen by OT previous to this visit with no concerns; - Patient reporting significant hip pain to the left side; - Answers to questions were delayed and sometimes off, he/she struggled to make eye contact and didn’t actively participate in majority of conversation. Pupils were constricted and non-reactive to light, but able to follow finger. Daughter is concerned and would like patient to go to ER but patient is refusing; and - Licensed practical nurse (LPN) discussed with registered nurse (RN) and patient was advised to go to ER. Daughter and patient agreed and will go by private car. During an interview on 05/03/2023 at 11:41 AM, the clinical manager stated the patient is followed in the pain clinic but there are no notes in the chart and there is no communication regarding the patient’s pain and follow-up with the pain ratings greater than seven.

Visit schedule CFR(s): 484.60(e)(1) Visit schedule, including frequency of visits by HHA personnel and personnel acting on behalf of the HHA. This ELEMENT is not met as evidenced by: Based on home visit observation and interview, the home health provider failed to provide in writing the visit schedule in one of three home visit observations (Record/Patient #3). This deficient practice has the potential to affect all patients served by the home health provider. Findings included: The provider did not provide a policy related to the visit frequency to be left in the patient’s home folder. RECORD/PATIENT #3: Review of the plan of care showed that physical therapy was scheduled to see the patient at the following frequency: -Two times weekly for eight weeks; -One time a week for two weeks; and -Two times a week for seven weeks. Observation on 05/02/2023, beginning at 10:00 AM, during the patient’s home visit, showed: -Admission folder was reviewed; and -The visit frequency was not provide in writing. During an interview on 05/03/2023 beginning at 12:00 PM, the home health administrator stated that he/she would expect the visit frequency to be included in the home folder.

Patient medication schedule/instructions CFR(s): 484.60(e)(2) Patient medication schedule/instructions, including: medication name, dosage and frequency and which medications will be administered by HHA personnel and personnel acting on behalf of the HHA. This ELEMENT is not met as evidenced by: Based on the home visit observation and interview, the home health provider failed to provide in writing a list of the patient’s medications in one of three home visit observations (Record/Patient #3). This deficient practice has the potential to affect all patients served by the home health provider. Findings included: The provider did not provide a policy related to the medication list to be left in the patient’s home folder. RECORD/PATIENT #3: Review of the document titled, “Medication List,” showed the patient was on the following medications: -Acetaminophen (used to treat minor aches and pains, and reduces fever) 500 milligrams (mg) every six hours as needed for discomfort; -Flomax (used to treat an enlarged prostate) 0.4 mg capsule daily; -Furosemide (used to treat fluid retention (edema) and swelling caused by congestive heart failure, liver disease, kidney disease, and other medical conditions) 20 mg tablet daily; -Metoprolol (used to treat high blood pressure, chest pain (angina), and heart failure) 50 mg tablet two times daily; -Pantoprazole (used to treat gastroesophageal reflux disease (GERD) and a damaged esophagus) 40 mg tablet two times daily; and -Tramadol (used to treat moderate to severe pain) 50 mg every four hours as needed for pain. Observation on 05/02/2023, beginning at 10:00 AM, during the patient’s home visit, showed: -Admission folder was reviewed; and -The medication list was not provided in writing. During an interview on 05/03/2023 beginning at 12:00 PM, the home health administrator stated that he/she would expect the medication list to be included in the home folder.

Treatments and therapy services CFR(s): 484.60(e)(3) Any treatments to be administered by HHA personnel and personnel acting on behalf of the HHA, including therapy services. This ELEMENT is not met as evidenced by: Based on the home visit observation and interview, the home health provider failed to provide in writing a list of treatments to be administered by the home health provider personnel in one of three home visit observations (Record/Patient #3). This deficient practice has the potential to affect all patients served by the home health provider. Findings included: The provider did not provide a policy related to the list of treatments to be left in the patient’s home folder. RECORD/PATIENT #3: Review of the document titled, “Home health certification and plan of care,” showed the patient was receiving the following treatments: -Physical therapy (PT) to provide bed mobility training; -PT to instruct on safe transfers; -PT to provide gait training; -PT to monitor pain control; -PT to provide balance training exercise; -PT to provide therapeutic exercise; and -PT to provide education in fall risk reduction strategies. Observation on 05/02/2023, beginning at 10:00 AM, during the patient’s home visit, showed: -Admission folder was reviewed; and -A list of treatments to be provided was not provided in writing. During an interview on 05/03/2023 beginning at 12:00 PM, the home health administrator stated that he/she would expect the list of treatments to be included in the home folder.

Name/contact information of clinical manager CFR(s): 484.60(e)(5) Name and contact information of the HHA clinical manager. This ELEMENT is not met as evidenced by: Based on the home visit observation and interview, the home health provider failed to provide in writing the name and contact information of the clinical manager in one of three home visit observations (Record/Patient #3). This deficient practice has the potential to affect all patients served by the home health provider. Findings included: RECORD/PATIENT #1: During a home visit observation on 05/01/2023 at 1:09 PM with RN (registered nurse)-A, the surveyor observed the patient’s home folder. The home health provider failed to provide in writing the name and contact information for the current clinical manager. During an interview on 05/01/2023 at 1:35 PM with the patient, he/she stated that he/she did not know who the current clinical manager was.

Interdisciplinary assessment of the patient CFR(s): 484.75(b)(1) Ongoing interdisciplinary assessment of the patient; This ELEMENT is not met as evidenced by: Based on policy review, record review, and interview the agency failed to complete ongoing interdisciplinary assessment of the patient in one of six records reviewed (Record/Patient #5). This deficient practice has the potential to affect all patients served by the agency. Findings included: Review of the home health provider’s policy titled, “Coordination of Care, from Admit though Discharge,” updated 04/01/2023 showed: - The agency provides care and services within an integrated continuum of care system. This is accomplished by: * Identifying patient needs through assessment and communication with other health care providers * Coordinating patient care among various disciplines to ensure that services are continuous and coordinated from admission through discharge - Patient care is coordinated among various disciplines and services through care planning processes for continuity of care. This includes: * Appropriate, timely communication with the patient, caregivers, and staff involved in the patient’s care regarding patient needs, goals, and care as well as changes in these * All clinicians will report within one business day to the patient care manager or clinical director by fax, telephone, in person at the agency, or through coordination notes by synching point of care devices and the report will include significant changes in the patient’s condition. Review of the home health provider’s policy titled, “Patient Assessment, Initial, and Reassessment,” updated 03/01/2022 showed that a qualified clinician performs a comprehensive assessment or reassessment visit when the instability or acuity of the patient’s medical condition warrants assessment. RECORD/PATIENT #5: Review of the plan of care (POC) dated 02/17/2023 to 04/17/2023, showed the following: - The patient the patient was recently hospitalized due to shortness of breath and chest pain due to atherosclerosis (plaque buildup in the wall of the arteries that supply blood to the heart) status post a cardiac catheterization and stent (used to treat narrowed coronary arteries that provide the heart with oxygen-rich blood); - The patient also had the following co-morbidities that are new or have exacerbated within the last month: Cerebral vascular disease (stroke), diabetes mellitus (chronic condition that affects the way the body processes blood sugar), hypertension, neuropathy and chronic obstructive pulmonary disease, and anxiety; and - The patient is considered unstable evidenced by pain, dyspnea (difficult or labored breathing), reported unstable blood sugars, and incontinence. Review of the physical therapy assistant visit note report, dated 02/24/2023 at 10:18 AM showed the patient complained of a little chest pain and took one nitroglycerin (can treat and prevent chest pain) and was fine. There was no assessment of the chest pain (site, onset, character, radiates, associated symptoms, time/duration, exacerbating/relieving factors, and severity). There was no documentation to show coordination of care with physical therapist, patient care manager, clinical manager, administrator and/or physician. Review of the emergency room report events report, dated 02/24/2023 at 11:58 AM, showed the patient presented to the emergency department (ED) with chest pain, “onset 9:30 AM, took two nitroglycerin at home, cardiac history, gave aspirin 324 mg in route”. The patient presented with concerns for “chest pain temp”, dyspnea (difficult or labored breathing), and weakness. Approximately 2.5 hours ago prior to examination the patient began to develop some dyspnea and anterior chest pain radiating into his/her right shoulder, typical to the pain he/she experienced with previous cardiac events. He/she also felt somewhat dyspneic. He/she took a nitroglycerin with complete relief of the pain but his/her dyspnea seemed to be getting worst. He/she was given an aspirin by the emergency medical system. About two weeks ago, he/she had a cardiac catheterization with a stent placed. Since awakening this morning about five hours ago, he/she had generalized weakness. There was no documentation to show coordination of care with physical therapist, patient care manager, clinical manager, administrator and/or physician. Review of the skilled nurse visit note report, dated 03/09/2023 at 4:44 PM, showed the licensed practical nurse documented the patient report as feeling suicidal and when asked if he/she has a plan, he/she stated he/she always had a plan. During the course of the visit, the patient wavered between extreme emotional outbursts and telling jokes to being irate. The patient’s daughter was present during the visit. There was no assessment if additional services were needed, what the plan was, and if he/she had the ability to follow through with feeling suicidal. There was no documentation to show coordination of care with physical therapist, patient care manager, clinical manager, administrator and/or physician. Review of the client coordination note report, dated 03/11/2023 at 11:37 AM, the on call nurse documented the reason for the call was chest pain. Interventions: The RN attempted to reach patient by phone and no answer, LPN reached out to the on-call RN saying he/she was on the phone when the RN was calling, after talking with the patient they (LPN) felt like the patient was having anxiety. The RN told the patient to call the on-call nurse if pain returned or with any further questions. The physician was not notified and no visit was required. There was no assessment of the chest pain. Review of the skilled nurse visit note report, dated 03/15/2023 at 10:16 AM, showed the licensed practical nurse documented the patient rated his/her pain a five (using a pain scale with zero representing no pain and ten being the worst pain possible) of the anterior chest, the patient had shortness of breath on exertion. The patient had coronary artery disease, congestive heart failure and hypertension. The patient had diarrhea three times today. The patient reported mediastinal (part of the chest that lies between the sternum and the spinal column and between the lungs) that radiates to the left shoulder when coughing. The patient has not taken any nitroglycerin for the chest pain because “it is not as painful as other times”. Vital signs stable and no other concerns noted. Towards the end of the visit, the chest pain had improved slightly. Educated on edema management and monitoring of fluid overload. There was no assessment of the chest pain (onset, character, time/duration, exacerbating/relieving factors, and severity) and edema (location, type and description). There was no documentation to show coordination of care with physical therapist, patient care manager, clinical manager, administrator and/or physician. Review of the skilled nurse’s visit note report, dated 03/22/2023 at 1:49 PM, showed the licensed practical nurse documented the patient complained of chest pain and took two nitroglycerin with some relief. He/she states he/she has been having chest pain for the last couple of days. He/she stated he/she used nitroglycerin times two today and it did relieve the pain. The nurse suggested if the chest pain persists and is unrelieved by nitroglycerin he/she should proceed to the emergency room. There was no assessment of the chest pain. There was no documentation to show coordination of care with physical therapist, patient care manager, clinical manager, administrator and/or physician. Review of the skilled nurse visit note, dated 03/31/2023 at 3:41 PM, showed the registered nurse documented the patient has edema to the lower extremities. There was no assessment of the edema. There was no documentation to show coordination of care with physical therapist, patient care manager, clinical manager, administrator and/or physician. During an interview on 05/03/2023 at 9:10 AM and 10:05 AM, the administrator stated that if the patient did not get relief from the nitroglycerin, he/she would have expected them to notify the physician. It was unknown if the patient had edema and there was no further documentation. He/she expects staff to notify the physician when a patient has a change in condition. The skilled nurse that assesses the patient's change in the condition should notify the physician because they have assessed the patient and can answer questions. The case manager coordinates the care. There was no additional information provided.

Org. had partial/extended survey CFR(s): 484.80(f)(3) Was subjected to an extended (or partially extended) survey as a result of having been found to have furnished substandard care (or for other reasons as determined by CMS or the state); or This ELEMENT is not met as evidenced by: Based on the results of this extended level survey, resulting in noncompliance with one Condition of Participation: Care planning, coordination of services and quality of care. The agency may not train or competency evaluate their home health aides for a period of two (2) years following the date of this survey. The restriction ends 05/03/2025. .

In accordance with current clinical practice CFR(s): 484.105(f)(2) All HHA services must be provided in accordance with current clinical practice guidelines and accepted professional standards of practice. This ELEMENT is not met as evidenced by: Based on state law, the employee file review, and interview, the Home Health Provider failed to ensure one staff member (Employee-B) had completed Alzheimer’s Training upon job orientation after his/her hire date with the provider. This deficient practice has the potential to affect all patients served by the agency. Findings included: Review of “Missouri State Specific Requirements” used by the provider as guidance for educational requirements for home health providers showed direct care staff and provider contractors are required to maintain Alzheimer’s disease and related dementia training upon hire and annually. Review of Employee B’s personnel file showed: -He/she was a Licensed Practical Nurse (LPN); -Date of hire: October 19, 2022; -Date of first patient contact: None documented; -Showed Family Care Safety Register (FCSR) with no restrictions, completed October 18, 2022; and -Documentation failed to show of Alzheimer’s disease and related dementia training upon hire date. During interview conducted on 05/03/2023 at 11:40 A.M., the administrator stated the following: -The provider did not have a specific policy regarding Alzheimer’s training, and used the document “Missouri State Specific Requirements” as guidance; -Employee B, an LPN, had not completed Alzheimer’s disease and related dementia training on, or followed the hire date of October 19, 2022; and -Employee B did not have daily physical contact with patients, and worked within the provider’s office.

Authentication CFR(s): 484.110(b) Standard: Authentication. All entries must be legible, clear, complete, and appropriately authenticated, dated, and timed. Authentication must include a signature and a title (occupation), or a secured computer entry by a unique identifier, of a primary author who has reviewed and approved the entry. This STANDARD is not met as evidenced by: Based on policy review, record review, and interview, the home health provider failed to ensure all entries were clear, complete, and appropriately authenticated in one of five full records reviewed (Record/Patient #3). This deficient practice has the potential to affect all patients served by the home health provider. Findings included: Review of the home health provider’s policy titled, “Documentation Guidelines,” dated 07/19/2019, showed all entries shall be legible and include clear, concise, and pertinent patient information. RECORD/PATIENT #3: Review of the clinical record showed the following: -Patient’s initial admission assessment contained documentation that the patient had wounds; -Patient’s discharge paperwork from hospital showed the patient’s skin was intact and no wounds were present -Patient’s visits after the initial visit showed patient’s skin is intact; and -The provider failed to ensure documentation on the initial assessment was accurate. During an interview on 05/03/2023 beginning at 12:00 PM, the administrator stated that this was an incorrect documentation and he/she would expect the clinician to add an entry containing the correct assessment information.