Every finding on record at Lhcg Cxxxviii, LLC

A recertification survey was conducted by Healthcare Management Solutions, LLC on behalf of the State of Nevada Department of Health and Human Services. An unannounced on-site recertification survey at the above-named Home Health Agency (HHA) from 06/13/22 to 06/16/22 resulted in a finding of no deficiencies respective to the Emergency Preparedness Program Condition of Participation under 42 CFR 484.22. The HHA census was 111.

A recertification survey was conducted by Healthcare Management Solutions, LLC on behalf of the State of Nevada Department of Health and Human Services. An unannounced on-site recertification survey conducted at the above-named Home Health Agency (HHA) from 06/13/22 to 06/16/22 resulted in a finding of substantial compliance respective to the applicable condition of Participation (CoP) under 42 CFR 484, Subparts A through C with the following standard-level deficiencies listed below. The HHA census was 111.

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 policy review, record review, and interview, the home health agency (HHA) failed to ensure the registered nurse (RN) performed the initial assessment visit within 48 hours of the referral for two (Patient (P) 8, P11) of 13 sampled patient records reviewed for admission within 48 hours of the referral. This deficient practice had the potential to affect the current 111 patients and any future patient admitted to the agency for services. Findings include: Review of the policy titled "Admission Process," revised 01/01/21, indicated ". . . admission/initial visits are made within 48 hours from referral unless there is a specific physician ordered start of care. . ." 1. Review of P8's "Orders for Home Health Certification / Attestation and Face-to-Face Encounter," located under the "orders" tab in the electronic medical record (EMR), indicated the physician signed the order on 03/07/22 for home care services for skilled nursing, physical therapy, occupational therapy, and home health aide. Review of P8's "Home Health Certification and Plan of Care" for the certification period of 03/10/22 to 05/08/22, located under the "Orders" tab in the EMR, indicated P8's start of care/initial admission visit was performed on 03/10/22, 72 hours after the referral. There was no documentation of a physician order to change the start of care to 03/10/22. In an interview on 06/15/22 at 2:50 PM, Executive Director (who is an RN) stated the agency doesn't admit a patient until the agency has confirmed with the patient's primary care physician that the primary care physician will sign the home health orders. Executive Director stated the nurse taking the referral should have notified the referring physician of the delay and obtained an order to delay the start of care to 03/10/22. 2. Review of P11's "Rapid Referral Form," located under the "Orders" tab in the EMR, indicated the physician signed the referral for skilled nurse, physical therapy, and occupational therapy on 02/22/22. Review of P11's "Home Health Certification and Plan of Care" for the certification period of 03/09/22 to 05/07/22, located under the "Orders" tab in the EMR, indicated P11's start of care/initial admission visit was performed on 03/09/22. There was no documentation of a physician's order to delay the start of care to 03/09/22. In an interview on 06/16/22 at 9:25 AM, Executive Director stated he/she could find no physician order for the delay in the start of care.

Only as ordered by a physician CFR(s): 484.60(b)(1) Drugs, services, and treatments are administered only as ordered by a physician or allowed practitioner. This ELEMENT is not met as evidenced by: Based on policy review, record review, and interview, the home health agency (HHA) failed to ensure physician orders were obtained for wound care that was performed for two (Patient (P) 5, P7) of five patient records reviewed for wound care from a sample of 13 patients. This deficient practice had the potential to affect any of the 111 current patients with wounds and any future patient admitted for wound care by the HHA. Findings include: Review of the policy titled "Physician Orders," revised 11/01/21, indicated ". . . No medications, treatments, diagnostic studies or therapeutics will be administered without the order of a qualified physician or authorized practitioner. . ." 1. Review of P5's "Home Health Certification and Plan of Care" for the certification period of 04/09/22 to 06/07/22, located under the "Orders" tab in the electronic medical record (EMR), indicated there was no diagnosis of a wound to the coccyx. Review of P5's "Visit Note Report," located under the "Visits" tab in the EMR, dated 05/25/22, and documented by Registered Nurse (RN) 2, indicated ". . . During assessment I did find areas of maceration on a previously healed pressure area, but no open partial thickness wounds. I cleansed the area thoroughly and applied Calazime ointment [used to protect skin from wetness, urine, or stools] and an alginate dressing [can absorb wound fluid in the dry form and form gels that can provide a dry wound with a physiologically moist environment and minimize bacterial infections, thereby promoting rapid re-epithelialization and granulation tissue formation], per the discussion we had at care conference with both certified wound care RNs, RN1 and RN3. . ." Review of P5's "Visit Note Report," dated 06/07/22 and documented by RN4, indicated ". . . Coccyx, PU [pressure ulcer] Stage 1 . . . Wound care to superior gluteal [sic] cleft. Cleanse with normal saline pat dry apply thin layer of Calazime ointment and apply alginate dressing. . ." Review of P5's physician orders, located under the "Orders" tab in the EMR, indicated there was no order for wound care to stage one pressure ulcer to the coccyx. There was no documentation that RN2 and RN4 notified P5's physician of the newly identified pressure ulcer. In an interview on 06/13/22 at 4:35 PM, Executive Director (who is an RN) confirmed P5's EMR had no documentation that P5's physician was notified of the new coccyx pressure ulcer. Executive Director stated RN2 and RN4 should have obtained physician orders for wound care. 2. Review of P7's "Visit Note Report," located under the "Visits" tab in the EMR, dated 05/30/22 and 06/01/22, and documented by RN1, indicated ". . . Wound care not provided: covered by non-removable dressing or device. . ." Review of P7's physician orders, located under the "Orders" tab in the EMR, indicated there was no order to not perform wound care and to leave the non-removable dressing in place. In an interview on 06/15/22 at 1:10 PM, Executive Director stated RN1 should have obtained a physician's order when P7 presented with a non-removable dressing to assure no wound care was needed.

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 record reviews, policy review, observation, and interviews, the home health agency (HHA) failed to ensure the patient's current list of medications (medication profile) reflected what the patient was taking for five (Patient (P) 1, P2, P3, P4, P5) of five home visits made on 06/14/22. This deficient practice had the potential to affect the current 111 patients and any future patient admitted for services. Findings include: Review of the policy titled "Monitoring Medications," revised 05/01/19, indicated ". . . 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. For patients receiving skilled nursing and therapy services, the skilled nurse is responsible for medication review and reconciliation throughout the episode. The therapist will participate by monitoring and reporting any identified medication issues or non-compliance to the Patient Care Manager. For patients receiving only therapy services, the therapist is responsible to facilitate drug regimen review and medication reconciliation throughout the episode. . . The discipline responsible for the drug regimen review will: a. Compare medication list obtained from the facility from which the patient was transferred and/or physician orders to actual medications patient is taking b. Review all medications including over the counter (OTC) medications, vitamins, herbs and herbal products, creams and topical ointments, and medical marijuana (in states where legalized), to identify issues. . . All clinicians participating in the patient's care are responsible to assist with the maintenance of accurate patient medication information throughout the episode of care. . ." 1. Review of P1's list of current medications for the certification period of 05/31/22 to 07/29/22, located under the "Orders" tab in the electronic medical record (EMR), indicated Keppra 500 mg (milligram) tablet, one tablet, was to be taken orally two times a day. Observation during a home visit on 06/14/22 at 3:15 PM revealed a bottle of Keppra (used to treat seizures) dated 05/27/22 had instructions to take one-and-a-half tablets twice daily. In an interview on 06/14/22 at 3:32 PM, Licensed Practical Nurse (LPN) 1 stated he/she saw P1 on 06/06/22 and should have seen the change in dosage for Keppra and updated the medication profile. LPN1 confirmed he/she did not update P1's medication profile to reflect the actual dose being taken by P1. 2. Review of P2's physician order for medication reconciliation, dated 05/18/22 at 4:17 PM and located under the "Orders" tab in the EMR, indicated Tresiba Flex Touch U-100 insulin (used to treat diabetes) 100 unit/ml (unit per milliliter), 130 units subcutaneously, was to be administered daily. In an interview during a home visit on 06/14/22 at 9:35 AM, Executive Director, who was present during the home visit, confirmed P2's medication profile did not reflect the change that had been made to the insulin dose. In an interview during a home visit on 06/14/22 at 9:55 AM, P2 stated the insulin dose was changed to 60 units on 06/03/22 (review of the visit notes, located under the "Visits" tab in the EMR, indicated a skilled nurse had been conducted on 06/08/22). 3. Review of P3's medication profile for the certification period of 06/03/22 to 08/01/22, located under the "Orders" tab in the EMR, indicated "Bupropion Hcl Xl 150 mg 24 hr [hour] tablet [used to treat depression], extended release – oral" was to be taken daily and "Cyclobenzaprine 10 mg tablet – oral" (used short-term to treat muscle spasms) was to be taken one tablet every eight hours. Observation on 06/14/22 at 10:45 AM during a home visit revealed Bupropion HCl XL and Cyclobenzaprine were not in the home. Further observation revealed the following medications were present but not listed on P3's medication profile: Ondansetron (used to prevent nausea and vomiting) four mg tablet, take one orally every eight hours as needed for nausea, bottle dated 04/25/22 Oxycodone (used to relieve pain) 10 mg Immediate Release, take one every four hours as needed, bottle dated 06/08/22 Sucralfate (used in the treatment of gastric and duodenal ulcers) 1 gram tablet, take one four times a day, bottle dated 05/06/22. In an interview on 06/14/22 at 11:15 AM, Physical Therapist (PT) 1 confirmed Bupropion HCl XL and Cyclobenzaprine were not in the home, and Ondansetron, Oxycodone, and Sucralfate were not listed on P3's medication profile. 4. Observation during a home visit on 06/14/22 at 1:25 PM revealed a bottle dated 04/29/22 of Sodium Bicarbonate (used to relieve heartburn, sour stomach, or acid indigestion by neutralizing excess stomach acid) 650 mg tablet oral with instructions to take one tablet three times a day was in the home. Review of P4's medication profile for the certification period 05/15/22 to 07/13/22, located under the "Orders" tab in the EMR, indicated Sodium Bicarbonate was not listed on the medication profile. In an interview on 06/14/22 at 1:25 PM, Registered Nurse (RN) 1 confirmed P4's medication profile did not include Sodium Bicarbonate but should have since the bottle was dated prior to the start of the current certification period. 5. Review of P5's medication profile for the certification period 06/08/22 to 08/06/22, located under the "Orders" tab in the EMR, indicated Atorvastatin (used together with a proper diet to lower cholesterol and triglyceride (fats) levels in the blood) 20 mg tablet was to be taken orally at bedtime. Observation during a home visit on 06/14/22 at 12:50 PM revealed a bottle of Atorvastatin 40 mg tablets dated 04/21/22 was in the home, rather than 20 mg tablets. In an interview on 06/14/22 at 1:00 PM, P5 stated he/she takes Atorvastatin that is contained in the bottle dated 04/21/22 (40 mg).

Infection Prevention CFR(s): 484.70(a) Standard: Infection Prevention. The HHA must follow accepted standards of practice, including the use of standard precautions, to prevent the transmission of infections and communicable diseases. This STANDARD is not met as evidenced by: Based on policy review, observation, and interview, the home health agency (HHA) failed to ensure the occupational therapist (OT) implemented hand hygiene and glove use practices in accordance with agency policy during one (Patient (P) 2) of five home visits conducted on 06/14/22. This deficient practice had the potential to affect the current 111 patients and any future patient admitted for services. Findings include: Review of the policy titled "Hand Hygiene," revised 05/01/19, indicated ". . . Staff are required to perform hand hygiene prior to, at specified time points during, and following patient contact. . . Staff performs hand hygiene by handwashing with soap and water or using an alcohol-based hand sanitizer: a. before direct contact with patients. B. before performing an aseptic task ( e.g., [such as] insertion of invasive devices, wound care). C. after contact with blood, body fluids or excretions, mucous membranes, non-intact skin, wound dressings, or contaminated surfaces d. if moving from a contaminated body site to a clean body site during patient care. E. after contact with inanimate objects (including medical equipment . . .) in the immediate vicinity of the patient. F. before and after removal of personal protective equipment (PPE). G. at the conclusion of the visit after contact with a patient's intact skin. . . 8. Other aspects of Hand Hygiene" . . . c. Change gloves during patient care if moving from a contaminated body site to a clean body site." Observation during a home visit with P2 on 06/14/22 at 9:40 AM revealed OT1 used hand sanitizer and donned gloves. OT1 then assessed P2's blood pressure and oxygen saturation while wearing gloves. OT1 then, while wearing the same gloves used to assess P1, used a disinfectant wipe to disinfect the blood pressure cuff and oximetry probe (used to assess oxygen saturation). OT1 then wiped his/her gloved hands with a disinfectant wipe. OT1 then documented on his/her tablet while wearing the same contaminated gloves used to assess P2 and to disinfect the patient care equipment. OT1 then removed his/her gloves and sanitized his/her hands. OT1 did not change gloves and sanitize his/her hand between patient assessment, cleaning of patient care equipment, and documenting on his/her tablet. In an interview on 06/14/22 at 10:10 AM, after the above observations were reviewed with OT1, OT1 confirmed OT1 had breaches in infection control related to hand hygiene and glove use. OT1 confirmed he/she did not follow the agency's policy for hand hygiene and glove use.

Provide services in the plan of care CFR(s): 484.75(b)(3) Providing services that are ordered by the physician or allowed practitioner as indicated in the plan of care; This ELEMENT is not met as evidenced by: Based on policy review, record review, and interview, the home health agency (HHA) failed to ensure staff provided services as ordered by the physician for five (Patient (P) 3, P9, P10, P11, P12) of 13 sampled patients. This deficient practice had the potential to affect any of the 111 current patients and any future patient admitted for services by the HHA. Findings include: Review of the policy titled "Physician Orders," revised 11/01/21, indicated ". . . No medications, treatments, diagnostic studies, or therapeutics will be administered without the order of a physician or authorized practitioner. . . The agency accepts patient referrals from a physician/authorized practitioner or physician designee to collect information regarding the patient and services required. The referral intake serves as a verbal order to begin services. 4. The Plan of Care (POC), telephone and or verbal orders must be signed and dated by the physician or authorized practitioner within a timely manner per state regulation: . . . Nevada 20 days . . . " Review of the policy titled "Plan of Care," revised 12/01/21, indicated ". . . A POC is developed for all patients . . . 2. The POC includes: . . . b. Types, frequency, and duration of services required . . . Alterations to the POC are made only with the physician/authorized practitioner's approval. . ." Review of the policy titled "Coordination of care, From Admit Through Discharge," revised 08/01/19, indicated ". . . 1. Prior to Admission: a. The agency accepts the patient referral from a physician or physician designee and collects information regarding the patient and services required. . . 4. Coordination of care with physician: At admission, throughout care, and at discharge, coordination of services is promoted through routine communication with the patient's physician: a. When changes occur in the patient's condition or response to treatment b. When changes occur in caregiver support or the environment that affect patient treatment c. When a missed visit occurs altering the Plan of Care. . ." 1. Review of P3's physician order, located under the "Orders" tab in the electronic medical record (EMR), dated 04/21/22 at 10:21 AM from Physician (MD) 1 indicated "Add on nursing visit for a well check on 4/23/22. Patient is not feeling well. . ." Review of P3's "Visit Note Report," located under the "Visits" tab in the EMR and documented by Licensed Practical Nurse (LPN) 1, indicated P3's visit was performed by LPN1 on 04/22/22, rather than 04/23/22 as ordered. In an interview on 06/13/22 at 2:50 PM, Executive Director (who is an RN) stated LPN1 didn't follow P3's physician order when P3's visit was made on 04/22/22 rather than 04/23/22. 2. Review of P9's Resumption of Care Order, located under the "Orders" tab in the EMR, dated 05/18/22 at 12:47 PM, and received from Physician Assistant (PA) 1, indicated the frequency of skilled nurse visits ordered was "SN [skilled nurse] effective 05/15/22 2w2, 1w3" [two times a week for two weeks then one time a week for three weeks]. Review of P9's nurse visit notes, located under the "Visits" tab in the EMR, indicated one nurse visit was made the week of 05/15/22 (the resumption of care visit on 05/18/22). There was no documentation of a second visit the week of 05/15/22 as ordered. In an interview on 06/15/22 at 4:05 PM, Executive Director confirmed a nurse visit was missed the week of 05/15/22, there was no documentation of a missed visit note, and P9's physician/physician assistant was not notified of the missed visit. Executive Director confirmed this documentation should be included in P9's EMR. 3. Review of P10's "Orders for Home Health Certification / Attestation and Face-to-Face Encounter," located under the "orders" tab in the EMR and signed by the physician on 01/30/22 at 2:33 PM, indicated nursing, physical therapy, and aide services were ordered. Review of P10's "Home Health Certification and Plan of Care" for the certification period of 02/02/22 to 04/02/22, located under the "Orders" tab in the EMR, indicated the services ordered were skilled nursing, physical therapy, and social work. There was no documentation that aide services were included in the services provided to P10 as ordered in the referral. Review of the coordination notes, located under the "Coordination Notes" tab in the EMR, indicated there was no documentation of a reason aide services were not provided and that P10's physician was notified of aide services not being provided as ordered. Review of the P10's physician orders indicated there was no documentation of an order to cancel the request for aide services. In an interview on 06/16/22 at 9:40 AM, Executive Director stated he/she could find no documentation explaining why aide services were not provided to P10 and no physician order cancelling the order for aide services. Executive Director confirmed there should be documentation of this information in P10's EMR. 4. a. Review of P11's "Rapid Referral Form," located under the "Orders" tab in the EMR and signed by the physician on 02/22/22, indicated services ordered included nursing and physical therapy and occupational therapy to evaluate and treat. Review of P11's "Home Health Certification and Plan of Care" for the certification period of 03/09/22 to 05/07/22, located under the "Orders" tab in the EMR, indicated the services ordered included nursing, physical therapy, and social work. There was no documentation that occupational therapy services would be provided as ordered by the referring physician. Review of the coordination notes, located under the "Coordination Notes" tab in the EMR, indicated there was no documentation of a reason occupational therapy services were not provided and that P11's physician was notified of occupational therapy services not being provided as ordered. Review of the P11's physician orders indicated there was no documentation of an order to cancel the request for occupational therapy services. In an interview on 06/16/22 at 9:25 AM, Executive Director stated he/she could find no documentation explaining why occupational therapy services were not provided to P11 and no physician order cancelling the order for occupational therapy services. Executive Director confirmed there should be documentation of this in P11's EMR. b. Review of a physician order dated 05/10/22 at 1:24 PM, located under the "Orders" tab in the EMR, indicated "Post discharge chart audit correction: frequency correction: patient only seen once by SN [skilled nurse] week of 3/6-3/12/22. Correct frequency was 1w1, 2w2, 1w6 [one time a week for one week, two times a week for two weeks, one time a week for six weeks] for SN." Review of P11's "Home Health Certification and Plan of Care" for the certification period of 03/09/22 to 05/07/22, located under the "Orders" tab in the EMR, indicated the nursing frequency ordered was two times a week for three weeks then one time a week for six weeks. Review of P11's nursing visit notes, located under the "Visits" tab in the EMR, indicated one nursing visit was made the first week of services (03/09/22 to 03/12/22). In an interview on 06/16/22 at 9:25 AM, Executive Director stated a nursing visit on week one should have been documented as a missed visit during chart review and the physician notified of a missed visit, rather than a frequency change after the fact. 5. Review of P12's EMR indicated a physician referral for home health services was signed by the physician on 04/26/22 at 7:26 AM. The referral included "Skilled Nursing care for assessment, intervention & [and] education, Physical Therapy evaluation and treatment and Occupational therapy evaluation and treatment. . ." Review of P12's visit notes, located under the "Visits" tab in the EMR, indicated there was no documentation that an occupational therapy evaluation had been performed as ordered. In an interview on 06/16/22 at 10:05 AM, Executive Director stated he/she could find no documentation explaining why an occupational therapy evaluation was not done, that P12's physician was notified that the evaluation was not done, and a physician's order cancelling the evaluation. Executive Director confirmed this information should be documented in P12's EMR.

Communication with physicians CFR(s): 484.75(b)(7) Communication with all physicians involved in the plan of care and other health care practitioners (as appropriate) related to the current plan of care; This ELEMENT is not met as evidenced by: Based on policy review, record review, and interview, the home health agency (HHA) failed to ensure staff communicated with physicians and other disciplines related to the patient's plan of care (POC) for four (Patient (P) 3, P5, P8, P9) of 13 sampled patients. This deficient practice had the potential to affect any of the 111 current patients and any future patient admitted for services by the HHA. Findings include: Review of the policy titled "Coordination of Care, From Admit Through Discharge," revised 08/01/19, indicated ". . . 4. Coordination of care with physician: At admission, throughout care, and at discharge, coordination of services is promoted through routine communication with the patient's physician: a. When changes occur in the patient's condition or response to treatment b. When changes occur in caregiver support or the environment that affect patient treatment c. When a missed visit occurs altering the Plan of Care. . . In the event that a physician cannot be reached to communicate the status of a patient the following will occur: Medical Director and/or Supervisor will be contacted for assistance with contacting physician . . . All clinicians will report within 1 [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. Report will include: Evaluation findings. . . Significant changes in the patient's condition (i.e. [that is] new or worsening symptoms, new or changed orders, or vital signs not within physician ordered parameters) Missed visits and changes to scheduled visits a. Reason for missed visit b. Changes to patient schedule . . ." 1. Review of P3's "Visit Note Report" documented by Medical Social Worker (MSW) 1 on 04/27/22, located under the "Visits" tab in the electronic medical record (EMR), indicated ". . . Patient called 911 on Monday and was sent to [name of hospital] for evaluation. Patient stated that [he/she] has not been able to keep any food or liquid down and has lost 17 lbs. [pounds] in the past 2 [two] weeks. [He/she] describes a "terrible" experience at the hospital and reports the doctor asking [him/her] if [he/she] wanted to be admitted or discharged after telling [him/her] that [his/her] white blood count was elevated. [He/she] states[he/she] had called [name of health company] last week and they had prescribed 3 [three] antibiotics, which [his/her] system did not agree with and no [he/she] is not taking any of [his/her] medications. [He/she] reports the ER [emergency room] doctor also did not prescribe any medications and couldn't tell me what was wrong. Patient struggled with focus and concentration, derailing frequently. . . Due to [him/her] not feeling well and not being very clear cognitively today, MSW will postpone assisting with [his/her] power of attorney paperwork until the next visit. As [he/she] has not felt well for the past 2 [two] weeks, [he/she] has not located [his/her] social security award letter . . ." Review of the entire "Visit Note Report" indicated the section titled "Care Coordination Indicate if you communicated with other disciplines/individuals involved in this case." Had documentation of "No." In an interview on 06/13/22 at 2:50 PM, Executive Director (who is a registered nurse (RN) stated MSW1 should have reported P3's complaints to the RN and/or supervisor on 04/27/22. 2. Review of P5's "Visit Note Report," located under the "Visits" tab in the EMR, dated 05/25/22, and documented by Registered Nurse (RN) 2, indicated ". . . During assessment I did find areas of maceration on a previously healed pressure area, but no open partial thickness wounds. I cleansed the area thoroughly and applied Calazime ointment [used to protect skin from wetness, urine, or stools] and an alginate dressing [can absorb wound fluid in the dry form and form gels that can provide a dry wound with a physiologically moist environment and minimize bacterial infections, thereby promoting rapid re-epithelialization and granulation tissue formation], per the discussion we had at care conference with both certified wound care RNs, RN1 and RN3. . ." Review of P5's "Visit Note Report," dated 06/07/22 and documented by RN4, indicated ". . . Coccyx, PU [pressure ulcer] Stage 1 . . . Wound care to superior gluteal [sic] cleft. Cleanse with normal saline pat dry apply thin layer of Calazime ointment and apply alginate dressing. . ." Review of P5's coordination notes, located under the "Coordination Notes" tab in the EMR, indicated there was no documentation that RN2 and RN4 notified P5's physician of the newly identified pressure ulcer. In an interview on 06/13/22 at 4:35 PM, Executive Director confirmed P5's EMR had no documentation that P5's physician was notified of the new coccyx pressure ulcer. Executive Director stated RN2 and RN4 should have notified P5's physician of the new pressure ulcer and obtained physician orders for wound care. 3. Review of P8's "Visit Note report," located under the "Visits" tab in the EMR and documented by Licensed Practical Nurse (LPN) 2, indicated the following: a. 03/14/22 ". . . Respiratory . . . Abnormal breath sounds . . . diminished/distant breath sounds wheezes . . . left lower lobe right middle lobe right lower lobe . . . Care coordination . . . Patient/Family/Caregiver . . . education with patient and caregiver on pneumonia and proper use of inhaler . . . Narrative Patient seen for education and disease process management. Niece present for interpretation. Oxygen was not on at stary [sic] of visit and O2 [oxygen] saturation was 84% [percent]. I educated on use of O2. When concentrator was checked the knob didnnjot [sic] move ball. Cannupa [sic] applied and saturation did go above 90%. Call placed to oxygen company. Patient was instructed on inhaler use. [He/she] wqs [sic] not able to use appropriately with instruction from me with niece translating. This nurse to call PCP [primary care physician] tomorrow morning to report visit findings. . ." There was no documentation that LPN2 reported the findings to P8's physician or the Patient Care Manager or Clinical Director in accordance with the agency policy. b. 03/17/22 ". . . Respiratory . . . Bilateral breath sounds clear to auscultation . . . shortness of breath . . . Care coordination . . . Patient/Family/Caregiver . . . patient and caregiver educated on pneumonia and inhaled medications again . . . Education with inhaler shows poor use still. Communication to PCP regarding nebulizer treatments. . ." There was no documentation that LPN2 reported the findings to P8's physician or the Patient Care Manager or Clinical Director in accordance with the agency policy. c. 03/22/22 ". . . Respiratory . . . abnormal breath sounds cough oxygen . . . crackles diminished/distant breath sounds . . . crackles . . . left lower lobe right lower lobe . . . diminished breath sounds . . . left lower lobe right middle lobe right lower lobe . . . Care coordination . . . Physician Patient/Family/Caregiver . . . Subject discussed with physician [fax] communication regarding improper inhaler use and possible need for nebulizer treatments . . . Narrative . . . [He/she] is instructed again on inhaler. [He/she] is just not able to follow instructions. Communicated with PCP regarding this. . ." There was no documentation that LPN2 reported the findings to the Patient Care Manager or Clinical Director in accordance with the agency policy. d. 03/24/22 ". . . Respiratory . . . abnormal breath sounds cough oxygen shortness of breath . . . crackles diminished/distant breath sounds . . .crackles right lower lobe . . . diminished breath sounds left upper lobe left lower lobe right upper lobe right middle lobe right lower lobe . . . Care Coordination . . . Patient/Family/Caregiver . . .Narrative . . . Niece is present for visit to interpret for patient. Niece states no word from doctors regarding chest imaging result or this nurse's request for different delivery of respiratory medication. Patient continues with dry, tight sounding cough, crackles to right lower lobe. . ." There was no documentation that LPN2 reported the findings to P8's physician or the Patient Care Manager or Clinical Director in accordance with the agency policy. e. 03/29/22 ". . . Respiratory . . . abnormal breath sounds cough oxygen . . . crackles diminished/distant breath sounds . . . crackles right lower lobe . . . diminished breath sounds left upper lobe left lower lobe right upper lobe right middle lobe right lower lobe . . .Care coordination . . . Patient/Family/Caregiver . . ." There was no documentation that LPN2 reported the findings to P8's physician or the Patient Care Manager or Clinical Director in accordance with the agency policy. f. 04/11/22 ". . . Respiratory . . . abnormal breath sounds cough oxygen shortness of breath . . . diminished/distant breath sounds wheezes . . . diminished breath sounds right lower lobe . . . wheezes right middle lobe right lower lobe . . .Care coordination . . . Supervisor Patient/Family/Caregiver . . . subject discussed with supervisor lack of response from primary care provider. . ." Review of the above documentation indicated LPN2 assessed abnormal respiratory status and inability to get an appropriate response/action from P8's primary care physician for 29 days before communicating this information to the Patient Care Manager/Clinical Director/Medical Director in accordance with agency policy. Review of P8's "Client Coordination Note Report dated 04/06/22," located under the "Coordination Notes" tab in the EMR and documented by LPN2, indicated "Patient seen for education and disease process management. Niece is present for translating. . . Niece states that oxygen company did not receive order for nebulizer. Communicated with PCP who stated during [his/her] appt [appointment] on a call with this nurse that [he/she] would be ordering one as patient wasn't utilizing multi dose inhaler properly. Communication sent to PCP via [fax]." Review of P8's "Client Coordination Note Report dated 04/14/22 indicated Executive Director documented an "Emergent Care Notification" that read ". . . Niece notified homecare that paramedics were taking [him/her] to [name of emergency room] continued cough, lethargic . . . Patient was in ER [emergency room] for 4 [four] hours, treated and discharged home. . ." In an interview on 06/15/22 at 2:50 PM, Executive Director stated LPN2 should have notified the Medical Director as soon as there was a delay in reaching the PCP. Executive Director stated LPN2 should have reported the abnormal respiratory findings to the Patient Care Manager or Clinical Director as directed by the agency policy. 4. Review of P9's Resumption of Care Order, located under the "Orders" tab in the EMR, dated 05/18/22 at 12:47 PM, and received from Physician Assistant (PA) 1, indicated the frequency of skilled nurse visits ordered was "SN [skilled nurse] effective 05/15/22 2w2, 1w3" [two times a week for two weeks then one time a week for three weeks]. Review of P9's nurse visit notes, located under the "Visits" tab in the EMR, indicated one nurse visit was made the week of 05/15/22 (the resumption of care visit on 05/18/22). There was no documentation of a second visit the week of 05/15/22 as ordered. In an interview on 06/15/22 at 4:05 PM, Executive Director confirmed a nurse visit was missed the week of 05/15/22, there was no documentation of a missed visit note, and P9's physician/physician assistant was not notified of the missed visit. Executive Director confirmed this documentation should be included in P9's EMR.

Interventions and patient response CFR(s): 484.110(a)(2) All interventions, including medication administration, treatments, and services, and responses to those interventions; This ELEMENT is not met as evidenced by: Based on policy review, medical record review, and interview, the home health agency (HHA) failed to ensure the patient's clinical record contained documentation of wound care that was provided for two (Patient (P) 4, P7) of five patient records reviewed for wound care from a sample of 13 patients. This deficient practice had the potential to affect any of the 111 current patients with wounds and any future patient admitted for wound care by the HHA. Findings include: Review of the policy titled "Wound Assessment, Documentation, and Photography," revised 12/01/21, indicated ". . . Upon initial visit and subsequently as indicated below, all wounds will be assessed with appropriate documentation within the medical record. . . During routine visits, wound will be documented in the Wound Assessment Tool. . . Procedure: . . . 3. Document the following in the medical record: . . . i. Exact wound care performed, following physician orders. . ." 1. Review of P4's physician order, located under the "Orders" tab in the electronic medical record (EMR), dated 05/24/22 at 9:03 AM indicated ". . . Home care nurse to change dressing on Tuesdays, wound clinic to change on Fridays. Wound care to left forearm- Skilled nurse to cleanse wound with normal saline and gauze, pat dry with gauze. Prepare periwound area with skin prep, Puracol (wound dressing to promote natural healing) to exposed tendons, fill entire cavity with black foam. Cover with transparent drape and apply tubing. Apply negative pressure device at 100mm/hg [millimeters mercury] continuous. . ." Review of P4's "Visit Note Report," located under the "Visits" tab in the EMR, dated 05/31/22, and documented by Registered Nurse (RN) 1, indicated there was no documentation of the exact wound care performed in accordance with agency policy. In an interview on 06/13/22 at 3:30 PM, Executive Director (who is an RN) stated the wound care is documented on the Wound Assessment Tool that includes a picture of the human body that has areas for documenting wound measurements and has a section labeled "wound care provided." Executive Director stated he/she could not explain why the wound care provided by RN1 for P4 was not documented. 2. Review of P7's "Home Health Certification and Plan of Care" for the certification period 04/04/22 to 06/02/22, located under the "Orders" tab in the EMR, indicated ". . . Skilled nurse to perform, instruct and reinforce patient procedure of wound care to right BKA [below the knee amputation] ulcer site three times a week. Cleanse with wound cleanser. Apply Iodoflex [sterile antimicrobial dressing formulations made of Cadexomer Iodine]. Cover with 4x4 [four-by-four] gauze dressing and secure with tape using clean technique. Instruct patient/caregiver signs/symptoms of wound infection and proper disposal of dressings. . ." Review of P7's "Visit Note Report," located under the "Visits" tab in the EMR, dated 04/05/22, 04/11/22, 04/15/22, 04/22/22, 05/11/22, and 05/23/22 indicated there was no documentation of the exact wound care performed in accordance with agency policy. In an interview on 06/15/22 at 1:10 PM, Executive Director confirmed the above-listed nurse visit reports for P7 did not include documentation of the wound care that was performed.