Every finding on record at Lhcg Cxxxvii, LLC

A complaint investigation (for Intakes 114348, 113406, and 113179) was conducted on 07/31/2025. Licensed and Certified census was 498. Abbreviations/Acronyms: Admin-Administrator Alt.-Alternate DON-Director of Nursing (ADON-Assistant DON) Mgr.-Manager NOMNC-Notice of Medicare Non-Coverage POC- Plan of Care SOC- Start of Care SN- Skilled Nursing RN-Registered Nurse PT-Physical Therapist/Therapy OT-Occupational Therapist/Therapy ST-Speech Therapist/Therapy D/C-Discharged PCM-Patient Care Managers

Written notice for non-covered care CFR(s): 484.50(c)(8) Receive proper written notice, in advance of a specific service being furnished, if the HHA believes that the service may be non-covered care; or in advance of the HHA reducing or terminating on-going care. The HHA must also comply with the requirements of 42 CFR 405.1200 through 405.1204. This ELEMENT is not met as evidenced by: Based on record review, observation, and interview, the agency failed to ensure proper written notice was provided, in advance of terminating on-going care in one (Patient # 6) of two inactive patient records reviewed for discharge notices. The agency failed to provide Patient # 6 with the Centers for Medicare and Medicaid form titled “Notice of Medicare Non-Coverage (NOMNC)”. The failure placed the patient’s health and safety at risk and could result in harm due to lack of consistent and continuing care in the patient’s post discharge needs. The failure caused the patient to not have written advance notice to appeal the discharge decision. Findings include: Review of the agency’s patient discharge roster revealed a discharge date for Patient # 6 as 01/28/2025. Inactive Clinical Record # 6: Record review of the clinical record for Patient # 6 revealed a POC for the certification period of 01/03/2025 to 03/03/2025. Review of the POC revealed a start of care date of 01/03/2025 with a diagnosis of hypertensive heart and chronic kidney disease with heart failure (a condition where heart failure and kidney disease occur when high blood pressure damages the heart and the kidneys). The POC was dated 01/03/2025 and electronically signed by RN A. The POC contained an order for skilled nursing visits one time per week for nine weeks and two as needed visits, PT visits one time per week for one week effective 01/12/2025, and OT visits one time per week for one week effective 01/05/2025. Continued review of the record revealed a RN discharge visit note signed by RN A and dated 01/28/2025. Review of the discharge visit note read in part: “…Narrative…Collaborated with [Admin] concerning visit and unsafe feeling, advised to DC [discharge]…” Further review of Patient # 6’s records did not reveal that the patient or patient representative received a proper written notice of intent to discharge no later than two days in advance of terminating on-going care on, 01/28/2025. The record did not include a written NOMNC (Notice of Medicare Non-Coverage). During a home visit on 08/01/2025 at 10:15 a.m. with Patient # 6’s, family member 100, family member 200, and family member 300, the surveyor asked family member 200 to explain what happened during (RN A’s) visit on 01/28/2025. Family member 200 walked the surveyor to the client’s former bedroom and the surveyor observed two beds in the room, a chair, and family member 300 sitting in a wheelchair. Family member 200 stated that (family member 200) was standing against a wall on the opposite side of the room from (RN A). Family member 200 stated that when (RN A) began to speak loudly, agitatedly at family member 100 he told RN A twice that (RN A) needed to “take it down a notch.” Family member 200 stated that he did stand up straighter (not leaning against the wall) the second time that he asked (RN A) to take it down a notch. Family member 300 stated I was in the room (on 1/28/2025). The surveyor asked family member 300 if (family member 300) saw any physical contact between family member 200 and RN A. “I have never heard of (family member 200) doing anything like that much less to a nurse. Family member 300 stated that he did not see any physical contact between family member 200 and RN A and he stated (family member 200) wouldn't do that.” Family member 300 stated that “the nurse was not a very caring person. It was like (RN A) just wanted to come in and leave.” Family member 200 walk the surveyor to the living area of the home where family member 100 was sitting on a couch. The surveyor asked family member 100 what happened when RN A visited on 1/28/25. Family member 100 stated that RN A would always come in and sigh, “[Family member 100!] her legs are swollen and should be in this position!” Family member 100 stated that the RN A had been consistently rude and condescending to (family member 100) so she asked (Family member 200) to be at the visit that day. Family member 100 stated that when the RN A came for the visit (RN A) was upset that the family had not let RN A know about an antibiotic that Client # 6 had taken. Family member 100 stated that because (RN A) was speaking loudly agitatedly to (Family member 100), (family member 200) asked (RN A) to “take it down a notch,” twice. Family member 100 stated that RN A started to kind of wave her tablet (computer) around and kind of took a step towards her family member 200 while shaking the tablet. Family member 100 and 200 stated that they stopped talking to RN A at that point and let RN A finish examining Client # 6. Family member 200 stated that when RN A finished, they let her leave the home without escorting her to the door. Family member 200 stated that the family had no intention of complaining against the agency or wanted to change services from the agency the family was just going to ask for a new nurse. Family member 100 stated that when (family member 100) called the agency to change nurses (the Admin) told (family member 100) that Client # 6 was terminated effective immediately. The surveyor asked if the agency provided a written notice to Client # 6 at least two days prior to discharge. Family member 200 stated that the agency had not provided a written notice prior to discharge. Family member 200 stated that the agency mailed a letter on 01/31/2025 and the family received the notice on 02/03/2025. Review of agency complaint records revealed a complaint report dated 01/28/2025 and processed by the Admin. Review of the complaint report revealed that a family member # 100 called the agency after a skilled nursing visit from RN A that read as follows: “…Nurse was very rude and this is not the first time. [Family member 100] stated things got heated and I got upset…I just did not like how RN A was talking to me due to us not letting agency know when patient started [antibiotic], I have dealt with a lot of doctors and they don’t talk to me like I’m nothing. So, I don’t want her coming back out to [Patient # 6] …” Further review of the complaint report revealed that the Admin, “called [Family member 100] with no answer at this time. [The Admin] spoke to [RN A] who stated [Family member 200] stood up and ‘bumped up’ to [RN A] while [RN A] was in the home trying to obtain patient information. [Patient Care Manager A] let patient [Family member 100] know when the complaint was made that they will be discharged immediately. [The Admin] spoke to [Family member 100 and family member 100 reported that RN A] made her feel like she was not caring for patient adequately and [family member 200] got upset during the conversation. [Family member 100] reports [family member 200] did ‘stand up’ but was not aggressive. [The Admin] explained we have to discharge due to unsafety in the home…Complaint closed and patient is discharged…” The review of Patient # 6’s clinical record and the agency’s complaint records did not reveal any records that indicated the agency provided a written 2-day notice of intent to discharge Patient # 6; or according to agency policy for protection of staff made a reasonable effort to communicate to patient, patient’s family, physician, appropriate state/local authorities, concerns for staff prior to discharge of Patient # 6. During a telephone interview with RN A on 08/06/2025 at 1:57 p.m., the surveyor asked if RN A could tell the surveyor what happened during the visit with Client # 6 on 01/28/2025. Initially, RN A stated that she did not remember, then replied, “Oh!” The surveyor asked if RN A wanted to add anything to her written statement at the agency. RN A replied, “That’s been months ago. I don’t have anything else to add.” The surveyor asked if there had been any physical contact between RN A and (family member 200). RN A replied, “No. I felt threatened. I left the home. They did not walk me out as usual. I left and called my manager.” RN A stated that RN A was instructed by the Admin to discharge Patient # 6 after leaving the patient’s home. RN A did not provide a written notice of intent to discharge. During an interview on 08/06/2025 at 3:00 p.m. with the Alt Admin/ADON, the surveyor reviewed the findings and asked who at the agency was responsible for providing the discharge notice. The Alt Admin/ADON stated the Admin (the Admin was on vacation during the interview) was responsible because the Admin did the follow-up on the complaint. The surveyor asked why the agency had not provided written notice of the intent to discharge with the NOMNC form no later than two days in advance of terminating on-going care for Patients # 6. The Alt Admin/ADON stated that she did not know, and the Admin was on vacation. The surveyor asked if the agency tried to resolve the concern prior to discharge. The Alt Admin/ADON stated that she did not know. The surveyor asked why there was no documentation of any attempts to resolve the concern. The Alt Admin/ADON stated that she did not know. The surveyor asked how the failure could adversely affect the patient. The Alt Admin/ADON stated that if post discharge needs are not met it could cause a risk of rehospitalization or increased risk of infection. Review of agency policy titled, “Notice of Non-Coverage, Expedited Determination & Reconsideration for Discharge” last revised date 12/01/2021 read in part: " Purpose: To outline the rights of a Medicare beneficiary who disagrees with a provider termination or discharge and to outline the steps of an expedited determination...Procedure: 1. Before the termination of services, regardless of whether or not the Medicare beneficiary agrees with the discharge and/or goals are met, the agency will deliver a valid written termination notice to the Medicare beneficiary of the decision to terminate services. (See Notice of Medicare Provider Non-Coverage Form.) …3. The notice will be issued no later than two days before the proposed end of services for all states except those listed below with more stringent notification timeline...Texas [:] No later than 5 days prior to the end of services [:] Not required in cases where discharge was due to patient’s transfer OR; medical emergency requiring transfer OR; natural disaster and health and safety of patient at risk OR; protection of staff or patient after agency has made a reasonable effort to communicate to patient, patient’s family, physician, appropriate stat/local authorities concerns for staff or patient safety…14…A copy of the Notice of Medicare Non-Coverage will be maintained in the patient’s medical record.”

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 record review and interview the agency failed to ensure that a registered nurse conducted an initial assessment to determine immediate care and support needs for the patient within 48 hours of the referral for five (Patients # 2, 4, 5, 6, and 8) of nine records reviewed. The failure placed the patients at increased risk of missed visits, rehospitalization, or infections due to immediate care and support needs not being assessed timely. Findings include: Patient # 2: Record review of the clinical record for Patient # 2 revealed a POC for the certification period of 03/10/2025 to 05/08/2025. Review of the POC revealed a start of care date of 03/10/2025 with a diagnosis of hemiplegia following cerebral infarct affecting left side (paralysis on the left side after a stroke). The POC was dated 03/10/2025 and electronically signed by RN B. The POC contained an order for skilled nursing visits one time per week for two weeks, one time every three weeks, one time every four weeks, and two as needed visits; PT visits one time per week for one week effective 03/23/2025; ST and OT visits one time per week for one week effective 03/23/2025. Continued review of Patient 2’s record revealed a “Patient Information Report.” Review of the report revealed a referral date of 03/06/2025 from a hospital facility. Further review of the report revealed that Patient # 2 was admitted to the hospital on 03/06/2025 and discharged on 03/07/2025. Continued review of the record revealed Patient # 2’s initial assessment was conducted on 03/10/2025 and signed by RN B. Continued review of the record did not reveal any documentation to Client # 2’s physician that the initial assessment was delayed or an order from the physician with a start of care day. There was no documentation in the record that indicate why the initial assessment was not conducted within the required 48 hours of the patient’s return home from the medical facility on 03/07/2025. Patient # 4: Record review of the clinical record for Patient # 4 revealed a POC for the certification period of 05/27/2025 07/25/2025. Review of the POC revealed a start of care date of 05/27/2025 with a diagnosis of type 2 diabetes mellitus (a disease where insulin is not effectively used in the body which leads to elevated level of sugar in the blood). The POC was dated 05/29/2025 and electronically signed by PT A. The POC contained an order for PT visits one time per week for nine weeks and OT visits one time per week for one week effective 06/01/2025. Continued review of Patient 2’s record revealed a “Patient Information Report.” Review of the report revealed a referral date of 05/23/2025 from a hospital facility. Further review of the report revealed that Patient # 4 was admitted to the hospital on 05/22/2025 and discharged on 05/23/2025. Continued review of Patient # 4’s record revealed that the initial assessment was conducted on 05/27/2025 and signed by PT A. Continued review of the record did not reveal any documentation to Client # 4’s physician that the initial assessment was delayed or an order from the physician. There was no documentation in the record that indicate why the initial assessment was not conducted within the required 48 hours of the patient’s return home from the medical facility on 05/23/2025. Patient # 5: Record review of the clinical record for Patient # 5 revealed a POC for the certification period of 06/16/2025 to 08/14/2025. Review of the POC revealed a start of care date of 06/16/2025 with a diagnosis of Osteoporosis with pathological fractures (bones become weak, brittle, and more susceptible to fractures during daily activities or minor falls). The POC was dated 06/16/2025 and electronically signed by RN C. The POC contained an order for skilled nursing visits one time per week for nine weeks and PT and OT visits one time per week for one week effective 06/22/2025. Continued review of Patient 5’s record revealed a “Patient Information Report.” Review of the report revealed a referral date of 06/09/2025 from a medical facility. Further review of the report revealed that Patient # 5 was admitted to the medical facility on 05/13/2025 and discharged on 06/12/2025. Continued review of the record revealed that Patient # 5’s initial assessment was conducted on 06/16/2025 and signed by RN C. Continued review of the record did not reveal any documentation to Client # 5’s physician that the initial assessment was delayed or an order from the physician. There was no documentation in the record that indicate why the initial assessment was not conducted within the required 48 hours of the patient’s return home from the medical facility on 06/12/2025. Patient # 6: Record review of the clinical record for Patient # 6 revealed a POC for the certification period of 01/03/2025 to 03/03/2025. Review of the POC revealed a start of care date of 01/03/2025 with a diagnosis of hypertensive heart and chronic kidney disease with heart failure (a condition where heart failure and kidney disease occur when high blood pressure damages the heart and the kidneys). The POC was dated 01/03/2025 and electronically signed by RN A. The POC contained an order for skilled nursing visits one time per week for nine and two as needed visits, PT visits one time per week for one week effective 01/12/2025, and OT visits one time per week for one week effective 01/05/2025. Continued review of Patient 6’s record revealed a “Patient Information Report.” Review of the report revealed a referral date of 12/30/2024 from a physician’s office. Continued review Patient # 6’s record revealed the initial assessment was conducted on 01/03/2025 and signed by RN A. Continued review of the record did not reveal any documentation to Patient # 6’s physician that the initial assessment was delayed or an order from the physician. There was no documentation in the record that indicate why the initial assessment was not conducted within the required 48 hours of the patient’s return home from the referral on 12/30/2024. Patient # 8 Record review of the clinical record for Patient # 8 revealed a POC for the certification period of 03/28/2025 05/26/2025. Review of the POC revealed a start of care date of 01/27/2025 with a diagnosis of type 2 diabetes mellitus with foot ulcer (a disease where insulin is not effectively used in the body which leads to elevated level of sugar in the blood, with a foot wound). The POC was dated 03/24/2025 and electronically signed by RN A. The POC contained an order for skilled nursing visits one time per week for one week, three times per week for eight weeks, and two as needed visit. Continued review of Patient 8’s record revealed a “Patient Information Report.” Review of the report revealed a referral date of 01/23/2025 from a physician’s office. Continued record review revealed that Patient # 8’s initial assessment was conducted on 01/27/2025. Continued review of the record did not reveal any documentation to Client # 8’s physician that the initial assessment was delayed or an order from the physician. There was no documentation in the record that indicate why the initial assessment was not conducted within the required 48 hours of the patient’s referral date on 01/23/2025. During an interview on 08/06/2025 at 3:11 p.m. with the Alt Admin/ADON and Business Mgr., the surveyor asked where the initial assessment visit for the agency’s clients were documented. The Alt Admin and the Business Mgr. stated the assessments were documented on the OASIS (Outcome and Assessment Information Set). The surveyor reviewed the findings and asked who was responsible for documenting the referral dates and ensuring that the initial assessment is completed within the 48-hour timeframe. The Alt Admin/ADON stated that the scheduler documented the dates and the PCM (patient care managers) ensured that the assessments were completed. The surveyor asked why the initial assessments were not completed within 48 hours of the referral or return home of the patients. The Alt Admin/ADON reviewed Patient # 2’s record and stated that she was the PCM. The Alt Admin/ADON and the Business Mgr. stated that the delay for the late assessments was probably a delay in discharge from the hospital or the patient requested to not be seen. The surveyor asked why there was no documentation of physician notification of the delay and an order for the delay. The Alt Admin/ADON replied, “It was probably a weekend, so it (the physician notification was) more likely to fall through the cracks.” The surveyor asked how the failure could adversely affect the patients. The Alt Admin/ADON stated there would be a risk of missed visits, rehospitalizations, or infections. Review of agency policy titled; “Acceptance of Patients/Admission Process” last revised 01/01/2025 revealed the following: “…b. admission/initial visits are made within 48 hours from referral unless there is a specific physician ordered start of care (SOC) date which would supersede the state established timeframes…”

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 record review and interview the agency failed to coordinate care delivery to meet the patient's needs and involve the patient in the coordination of care activities, in that: the agency failed to coordinate skilled nursing initial assessment and therapy service evaluations for one of two patients (Patient # 2), whose record was reviewed for therapy service delivery. The failure caused a delay in nursing, physical, and occupational therapy service delivery and placed the client’s health and safety at risk related to increased risk of falls, rehospitalizations, or both. Findings include: Patient # 2: Record review of the clinical record for Patient # 2 revealed a POC for the certification period of 03/10/2025 to 05/08/2025. Review of the POC revealed a start of care date of 03/10/2025 with a diagnosis of hemiplegia following cerebral infarct affecting left side (paralysis on the left side after a stroke). The POC was dated 03/10/2025 and electronically signed by RN B. The POC contained an order for skilled nursing visits one time per week for two weeks, one time every three weeks, one time every four weeks, and two as needed visits; PT visits one time per week for one week effective 03/23/2025; ST and OT visits one time per week for one week effective 03/23/2025. Continued review of Patient 2’s record revealed a “Patient Information Report.” Review of the report revealed a referral date of 03/06/2025 from a hospital facility. Further review of the report revealed that Patient # 2 was admitted to the hospital on 03/06/2025 and discharged on 03/07/2025. Review of Patient # 2’s record revealed the skilled nursing initial assessment as conducted on 03/10/2025; PT and OT evaluation was conducted on 03/25/2025. Continued review of the record did not reveal any documentation to Client # 2’s physician that the initial assessment was delayed (beyond the required 48 hours after discharge from the hospital); PT and OT delayed evaluation (five days after the 03/23/3035 effective date on the POC) or an order from the physician with a specific start of care date. There was no documentation in the record that indicate why the initial assessment and therapy evaluations were delayed or that the patient or patient’s representative was notified by the agency of the delay. Further review of the record revealed a client coordination note report dated 03/18/2025 that read in part: “…Patient called requesting information for future visits. SN discussed with patient that PT, OT, and ST on calendar for next week…” Continued review of the record revealed a client coordination note report dated 03/26/2025 that read in part: “…Received call from patient wanting to know about physical therapy visits…PCM called and made patient aware PT eval will be 03/27/2025 per…Scheduler…” Further review of Patient # 2’s record revealed a PT evaluation dated 03/28/2025 signed by PT A and an OT evaluation dated 03/28/2025 signed by OT A. Telephone interview with Patient # 2 on 08/04/2025 at 3:20 p.m. the patient declined a home visit. Patient # 2 stated that he was no longer with the agency (Patient # 2 was discharged on 05/08/2025). Patient # 2 stated that he did receive PT visit from the agency but did not remember if there were any missed visits because he did not know the number of visits, he was schedule to receive. During the telephone interview Patient # 2’s family member (Identifier 400) stated that they had to call the agency to see when the therapy would begin, the agency did not inform them of why there was a delay. During an interview with the Alt Admin/ADON and Business Mgr., on 08/06/2025 the surveyor reviewed the findings and asked who was responsible for coordination of care delivery for the agency’s patients. The Alt Admin/ADON stated that the PCMs were responsible. The surveyor asked what the agency’s coordination of care processes were. The Alt Admin/ADON stated the clinical and coordination notes were sent to the PCMs for review and follow-up. The surveyor asked why there was no coordination between patient, physician, and agency staff; and no documentation of coordination of care delivery for patient # 2’ skilled nursing initial assessment and therapy services. The Alt Admin/ADON replied, “Honestly, I can’t give you a straight answer for that. Coordination of care should be done. Coordination notes if they are being utilized are fail-proof.” The surveyor asked how the failure could adversely affect the patient. The Alt Admin/ADON stated replied, “The same thing (risk for rehospitalizations, and infections); missed visit, which means we are not moving in accordance with M. D. orders.” Review of agency policy titled; “Coordination of Care…” last reviewed 08/01/24 read in part: “Purpose: To establish process and criteria so that the coordination of patient care will be optimal from admit through discharge. Policy: 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 are among various disciplines and in-person and virtual clinicians to ensure that services are continuous and coordinated from admission through discharge…5. Coordination of care…includes…c. Appropriate, timely communication with the patient, caregiver, and staff…Missed visits and changes to scheduled visits…reasons for missed visits…”

Purpose: Recertification Survey Entrance Date: 1/13/2022 at 10:13 a.m. with the Administrator/Director of Nursing. Census: Licensed and Certified - 438 patients. Exit Date: 1/24/2022 at 12:05 p.m. with the Administrator/Director of Nursing, the Alternate Administrator/Alternate Director of Nursing, and via computer team, the Quality Department #1, the Quality Department #2, the Regional Vice President, and the Area Vice President. The agency was given the opportunity to provide additional information during the survey. The preliminary findings were discussed. Written instructions were given for submitting a plan of correction within 10 days of the receipt of the Statement of Deficiencies and the time frame that the agency would receive the Statement of Deficiencies. The agency was in compliance with 42 CFR Part 484.22, Emergency Preparedness Requirements for Home Health Agencies.

Purpose: Recertification Survey Entrance Date: 1/13/2022 at 10:13 a.m. with the Administrator/Director of Nursing. Census: Licensed and Certified - 438 patients. Exit Date: 1/24/2022 at 12:05 p.m. with the Administrator/Director of Nursing, the Alternate Administrator/Alternate Director of Nursing, and via computer team, the Quality Department #1, the Quality Department #2, the Regional Vice President, and the Area Vice President. The agency was given the opportunity to provide additional information during the survey. The preliminary findings were discussed. Written instructions were given for submitting a plan of correction within 10 days of the receipt of the Statement of Deficiencies and the time frame that the agency would receive the Statement of Deficiencies. Deficiencies cited. The agency was in compliance with 42 CFR Part 484, Conditions of Participation for Home Health Agencies.

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 record review and interview, the agency failed to include a medication review as part of the Discharge comprehensive assessment to identify potential adverse effects, drug reactions, ineffective drug therapy, significant side effects, significant drug interactions, duplicate drug therapy and noncompliance with drug therapy in 4 (#14, #15, #16, #17) of 4 patients that were discharged with goals met. The failure placed the patients at risk of over-medication, under-medication, side effects, and adverse reactions to their medications. Findings include: Patient #14: Record Review of Patient #14’s clinical record revealed a Plan of Care dated 9/13/2021 to 11/11/2021. The Plan of Care indicated that Patient #14 started on the agency’s services on 9/13/2021. The Plan of Care included Diabetes Mellitus with Diabetic Neuropathy, Bipolar Disorder, Anxiety, and Gastro-Esophageal Reflux Disease as diagnoses. The Plan of Care listed the following medications: Carvedilol – used to treat high blood pressure and heart failure, Dicyclomine – used to treat irritable bowel syndrome Duloxetine – used to treat depression, anxiety, and diabetic peripheral neuropathy Magnesium – mineral supplement required for proper function of nerves, muscles, neutralize stomach acid Metoclopramide – used to treat gastro-esophageal reflux disease Pantoprazole – used to treat gastro-esophageal reflux disease Pregabalin – used to treat nerve and muscle pain Prochlorperazine Maleate – used to treat schizophrenia and nausea/vomiting Trimethobenzamide – used to treat nausea/vomiting The record contained the following: A Discharge comprehensive assessment was conducted on 9/24/2021 by Physical Therapy F. The Discharge comprehensive assessment did not indicate that a review of medications was conducted for potential adverse effects, drug reaction, ineffective drug therapy, significant side effects and drug interactions, duplication, and non-compliance with drug therapy. A Discharge Summary Report (unsigned) indicated that Patient #14 was discharged on 9/24/2021 with goals me. The Discharge Summary Report did not indicate that a review of medications had been conducted at the Discharge comprehensive assessment for potential adverse effects, drug reaction, ineffective drug therapy, significant side effects and drug interactions, duplication, and non-compliance with drug therapy. A “Client Medication Report” that listed Patient #14’s medication. The medication report was signed by Physical Therapist F on 9/13/2021 (start of care date) and indicated acknowledgement of a review of Patient #14’s medications for potential adverse effects, drug reaction, ineffective drug therapy, significant side effects and drug interactions, duplication, and non-compliance with drug therapy. The medication report did not indicate that the medications were reviewed as part of the Discharge comprehensive assessment conducted on 9/24/2021. Patient #15: Record Review of Patient #15”s clinical record revealed a Plan of Care dated 7/23/2021 to 9/20/2021. The Plan of Care indicated that Patient #15 started on the agency’s services on 5/24/2021. The Plan of Care listed Hyperlipidemia, Myasthenia Gravis, and Other Specified Diseases of the Pancreas as diagnoses. The Plan of Care listed the following medications: Atorvastatin – used to treat high cholesterol and triglyceride levels Creon – used to treat malabsorption syndrome due to pancreatic problems Lorazepam – used to treat anxiety. The record contained the following: A Discharge comprehensive assessment was conducted on 8/10/2021 by Speech Therapist F. The Discharge comprehensive assessment did not indicate that a review of medications had been conducted for potential adverse effects, drug reaction, ineffective drug therapy, significant side effects and drug interactions, duplication, and non-compliance with drug therapy. A Discharge Summary Report (unsigned) indicated that Patient #15 was discharged on 8/10/2021 with goals met. The Discharge Summary Report did not indicate that a review of medications had been conducted with the Discharge comprehensive assessment for potential adverse effects, drug reaction, ineffective drug therapy, significant side effects and drug interactions, duplication, and non-compliance with drug therapy. A “Client Medication Report” that listed Patient #15’s medication. The medication report was signed by Speech Therapist G on 7/21/2021 (recertification date) and indicated acknowledgement that a review of Patient #15’s medications for potential adverse effects, drug reaction, ineffective drug therapy, significant side effects and drug interactions, duplication, and non-compliance with drug therapy had been conducted on 7/21/2021. The medication report did not indicate that the medications were reviewed as part of the Discharge comprehensive assessment conducted on 8/10/2021. Patient #16: Record review of Patient #16’s clinical record revealed a Plan of Care dated 5/23/2021 to 7/21/2021. The Plan of Care indicated that Patient #16 started on the agency's services on 5/23/2021. The Plan of Care listed Fracture of Second Lumbar Vertebrae, Hypertension, Atrial Fibrillation, Diabetes Mellitus, and Other Chronic Pain as diagnoses. The Plan of Care listed the following medications: Amlodipine - used to treat high blood pressure and chest pain Aspirin - used to treat pain, fever, headache, inflammation, reduce risk of heart attack Bacitracin - prevention of infection of minor cuts, burns, scrapes Lisinopril - used to treat high blood pressure and heart failure Melatonin - dietary supplement used to treat short-term insomnia Methocarbamol - used to treat muscle spasms and pain Novolin 70/30 - used in the treatment of Diabetes Mellitus Oxycodone - used to treat moderate to severe pain Polyethylene Glycol - used to treat constipation Vitamin D3 - supplement to increase absorption of calcium, magnesium, phosphate and other biological effects. The record contained the following: A Discharge comprehensive assessment was conducted on 7/7/2021 by Physical Therapist H. The Discharge comprehensive assessment did not indicate that a review of medications had been conducted for potential adverse effects, drug reaction, ineffective drug therapy, significant side effects and drug interactions, duplication, and non-compliance with drug therapy. A Discharge Summary Report (unsigned) indicated that Patient #16 was discharged on 7/7/2021 with goals met. The Discharge Summary Report did not indicate that a review of medications had been conducted with the Discharge comprehensive assessment for potential adverse effects, drug reaction, ineffective drug therapy, significant side effects and drug interactions, duplication, and non-compliance with drug therapy. A “Client Medication Report” that listed Patient #16’s medication. The medication report was signed by Registered Nurse I on 5/23/2021 (start of care date) and indicated that Patient #16’s medications were reviewed for potential adverse effects, drug reaction, ineffective drug therapy, significant side effects and drug interactions, duplication, and non-compliance with drug therapy had been conducted on 5/23/2021. The medication report did not indicate that the medications were reviewed as part of the Discharge comprehensive assessment conducted on 7/7/2021. Patient #17: Record review of Patient #17's clinical record revealed a Plan of Care dated 7/30/2021 to 9/27/2021. The Plan of Care indicated that Patient #17 started on the agency's services on 7/30/2021. The Plan of Care listed Encounter for Orthopedic Aftercare, Spinal Stenosis Lumbar Regions. Hypertension, Supraventricular Tachycardia, Mitral Valve Prolapse, Depressive Disorder, Gastro-Esophageal Reflux Disease, and Hypothyroidism as diagnoses. The Plan of Care listed the following medications: Acetaminophen with Codeine - used to treat mild to moderately severe pain Ascorbic Acid - supplement essential to the repair of tissue, formation of collagen, and production of certain neurotransmitters Calcium and Vitamin D3 - supplement to promote bone health Carvedilol - used to treat high blood pressure and heart failure Citalopram - used to treat depression Diltiazem - used to treat high blood pressure and chest pain Diphenoxylate/Atropine - used to treat diarrhea Fluticasone Propionate - used to treat seasonal and year-round allergic/non-allergic nasal symptoms Livalo - used to treat high cholesterol and triglyceride levels Methocarbamol - used to treat muscle spasms and pain Montelukast - used to treat allergies and prevent asthma attacks Omeprazole - used to treat gastroesophageal reflux disease Pramipexole - used to treat Parkinson's disease and restless legs syndrome Preservision Areds - vitamin/mineral supplement used to reduce the progression of advanced age-related macular degeneration Sennosides/Docusate Sodium - used to treat constipation Synthroid - used to treat hypothyroidism Telmisartan/Hydrochlorothiazide - used to treat high blood pressure Trazodone - used to treat depression Vitamin D3 - supplement to increase absorption of calcium, magnesium, phosphate and other biological effects. The record contained the following: A Discharge comprehensive assessment was conducted on 8/13/2021 by Physical Therapist J. The Discharge comprehensive assessment did not indicate that a review of medications had been conducted for potential adverse effects, drug reaction, ineffective drug therapy, significant side effects and drug interactions, duplication, and non-compliance with drug therapy. A Discharge Summary Report (unsigned) indicated that Patient #16 was discharged on 8/13/2021 with goals met. The Discharge Summary Report did not indicate that a review of medications had been conducted with the Discharge comprehensive assessment for potential adverse effects, drug reaction, ineffective drug therapy, significant side effects and drug interactions, duplication, and non-compliance with drug therapy. A “Client Medication Report” that listed Patient #17’s medication. The medication report was signed by Physical Therapist J on 7/30/2021 (start of care date) and by Registered Nurse B on 8/4/2021 and indicated that Patient #17’s medications were reviewed for potential adverse effects, drug reaction, ineffective drug therapy, significant side effects and drug interactions, duplication, and non-compliance with drug therapy had been conducted on on 7/30/2021 and 8/4/2021. The medication report did not indicate that the medications were reviewed as part of the Discharge comprehensive assessment conducted on 8/13/2021. During an interview on 1/19/2022 at approximately 3:15 p.m. with the Administrator/Director of Nursing, and the Alternate Administrator/Alternate Director of Nursing, the surveyor discussed the discharge comprehensive assessment and review of medications and asked questions. the Administrator/Director of Nursing informed the surveyor that they would look into it and that staff knew that medication reviews were to be done at discharge. During an interview on 1/24/2021 at approximately 9:16 a.m. with the Administrator/Director of Nursing, and the Alternate Administrator/Alternate Director of Nursing, the surveyor requested the review of medications that was conducted with the discharge comprehensive assessments. The agency did not provide documentation to the surveyor that reviews of medications for potential adverse effects, drug reaction, ineffective drug therapy, significant side effects and drug interactions, duplication, and non-compliance with drug therapy had been conducted as part of the discharge comprehensive assessments.

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 record review and interview, the agency failed to include Heparin and Saline intravenous flushes in the Plan of Care in 1 (#1) of 2 patients that required intravenous flushes via a venous access device, a peripherally inserted central catheter. This failure could have resulted in agency nurses failing to perform the flushes causing reduced blood flow and occlusion of the venous access device. Findings include: The clinical record was an electronic medical record. Patient #1: Record review of Patient #1's clinical record revealed a Plan of Care dated 10/23/2021 to 12/21/2021. The Plan of Care listed Volume Depletion and Encounter for Adjustment and Management of VAD as diagnoses. The Plan of Care contained the following orders: Patient #1 was to receive Lactated Ringers (intravenous solution) 1000 milliliters at 75 milliliters per hour daily, the catheter site care of the peripherally inserted central catheter with dressing changes was to be done weekly, and the catheter injection cap was to be changed once a week. The record contained documentation of skilled nurse visits. The documents were titled, "Visit Note Report." A Start of Care comprehensive assessment was conducted on 10/23/2021 by Registered Nurse C. Registered Nurse C documented that Patient #1 had infusion access via a peripherally inserted central catheter in the left upper arm, that the catheter was flushed with "10 Normal Saline" and "5 Heparin," and that the interventions provided were ordered by the physician; however, the Saline and Heparin flushes were not included in the Plan of Care. Licensed Vocational Nurse D conducted skilled nurse visits on 10/28/2021 and 11/4/2021. Licensed Vocational Nurse D document that the catheter was flushed with "10" Normal Saline and "5" Heparin. Licensed Vocational Nurse E conducted a skilled nurse visit on 11/18/2021. Licensed Vocational Nurse E documented that the catheter was flushed with "10" Normal Saline and "0" Heparin. During an interview on 1/19/2022 at approximately 3:15 p.m. with the Administrator/Director of Nursing, and the Alternate Administrator/Alternate Director of Nursing, the surveyor discussed and asked questions about the Plan of Care not including the Heparin and Saline flushes. The Administrator/Director of Nursing stated that they had been informed by Quality that the Heparin and Saline flushes did not have to be included in the Plan of Care. During an interview on 1/24/2022 at approximately 9:16 a.m., with the Administrator/Director of Nursing and Alternate Administrator/Alternate Director of Nursing, the surveyor was informed by the Administrator/Director of Nursing that, "Yes, the Heparin and Saline were not included in the Plan of Care." During an interview on 1/24/2022 at approximately 12:30 p.m. with the Administrator/Director of Nursing and the Alternate Administrator/Alternate Director of Nursing, the surveyor discussed and asked questions regarding the intravenous medication orders. The Administrator informed the surveyor that the intravenous orders were kept in the patients' home folders. The Administrator stated, "the pharmacy won't send out the medications without a physician's order."

Visit schedule CFR(s): 484.60(e)(1) Visit schedule, including frequency of visits by HHA personnel and personnel acting on behalf of the HHA. This ELEMENT is not met as evidenced by: Based on record review and interview, the agency failed to provide a written schedule of visits made by the agency's staff, in 4 (#2, #3, #4, #6) of 5 home visits conducted to the agency's patients where the home folder was available for review. The failure resulted in that the patients did not know when the next visit would be made by the agency's staff. Findings include: Patient #2: Record review of Patient #2's clinical record revealed a Plan of Care dated 12/25/2021 to 2/22/2022. The Plan of Care indicated that Patient #2 started on the agency's services on 12/25/2022. The Plan of Care contained orders for Patient #2 to receive skilled nursing services, physical therapy services, occupational therapy services, and home health aide services. A home visit was conducted on 1/20/2022 at 9:57 a.m. with Patient #2 and Patient #2's family member. The home folder provided by the agency was reviewed. Patient #2 and Patient #2's family member informed the surveyor that none of the papers provided in the folder had been removed or become separated from the folder. Patient #2 and Patient #2's family member stated that the agency's staff would call the the day or night before a visit was going to be made. Patient #2 and Patient #2's family member stated that no written visit schedule had been provided by the agency. Patient #2's home folder had calendars in the home folder that were blank. Patient #2 and Patient #2's family member did not know when a staff member of the agency would make the next visit. Patient #3: Record review of Patient #3's clinical record revealed a Plan of Care dated 12/6/2021 to 2/3/2022. The Plan of Care indicated that Patient #3 started on the agency's services on 12/6/2021. The Plan of Care contained orders for skilled nursing services and physical therapy services. A home visit was conducted on 1/20/2022 at 1:58 p.m. with Patient #3 and Patient #3's family member. The home folder provided by the agency was reviewed. Patient #3 and Patient #3's family member informed the surveyor that none of the papers provided in the folder had been removed or become separated from the folder. Patient #3 and Patient #3's family member stated that the agency's staff would call the day before the visit was going to be made. Patient #3 and Patient #3's family stated that no written visit schedule had been provided by the agency. Patient #3 and Patient #3's family member did not know when a staff member of the agency would make the next visit. Patient #4: Review of Patient #4's clinical record revealed a Plan of Care dated 12/13/2021 to 2/10/2022. The Plan of Care indicated that Patient #4 started on the agency's services on 12/13/2021. The Plan of Care contained an order for physical therapy services. A home visit was conducted on 1/20/2022 at 8:59 a.m. with Patient #4 and Patient #4's family member. The home folder provided by the agency was reviewed. Patient #4 and Patient #4's family member informed the surveyor that none of the papers provided in the folder had been removed or become separated from the folder. Patient #4 and Patient #4's family member stated that the agency's staff would call the day before a visit was to be made and prior to arrival. Patient #4 stated, "Haven't planned next week yet, I just got out of a sling." Patient #4 and Patient #4's family stated that no written visit schedule had been provided by the agency. Patient #6: Record Review of Patient #6's clinical record contained a Plan of Care dated 12/13/2021 to 2/10/2022. The Plan of Care indicated that Patient #6 started on the agency's services on 10/14/2021. The Plan of Care contained an order for skilled nursing services and social work services. A home visit was conducted on 1/20/2022 at 12:57 p.m. with Patient #6. The home folder provided by the agency was reviewed. Patient #6 informed the surveyor that none of the papers provided in the folder had been removed or become separated from the folder. Patient #6 stated that the agency's staff would call or text the day before a visit was going to be made. Patient #6 stated that no written schedule had been provided by the agency. Patient #6 stated, "I told you, she calls or texts me the day before." During an interview on 1/24/2022 at approximately 9:16 a.m. with the Administrator/Director of Nursing and the Alternate Administrator/Alternate Director of Nursing, the surveyor discussed and asked questions regarding the home visits, blank calendars, no written schedules were given to the patients, and that the patients did not know when the next visit by an agency staff member was going to be made. The Administrator/Director of Nursing informed the surveyor that the agency provided the patients a document that instructed the patients on the frequency of visits but not the specific date of visits.