Every finding on record at Lhcg Cxxxxiii LLC

The Emergency Preparedness regulations were reviewed as part of the Medicare re-certification survey completed on 04/20/2023. 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 Agencies.

A partial extended survey for Medicare recertification for the home health provider was completed on 04/20/2023. The agency had 146 current patients. The COVID-19 Health Care Staff Vaccination regulation was reviewed as part of the Medicare recertification survey. During the survey it was determined the home health provider was in compliance with the regulation.

Written notice of patient's rights CFR(s): 484.50(a)(1)(i) (i) Written notice of the patient's rights and responsibilities under this rule, and the HHA's transfer and discharge policies as set forth in paragraph (d) of this section. Written notice must be understandable to persons who have limited English proficiency and accessible to individuals with disabilities; This ELEMENT is not met as evidenced by: Based on review of the provider's current patient rights information and interview, the provider failed to update the written notice of patient rights to include: - Rights and responsibilities that are understandable to persons who have limited English proficiency; and - Rights and responsibilities accessible to individuals with disabilities. This deficient practice has the potential to affect the knowledge and comprehension of the rights and responsibilities of all the provider's patients. Findings included: The home health administrator provided an admission packet for review on 04/17/2023. The home health provider notice of patient rights and other information given to a patient during the initial visit failed to show written information regarding written notice must be understandable to persons who have limited English proficiency and accessible to individuals with disabilities. During an interview on 04/20/2023 at 9:50 AM, the home health administrator stated that he/she was unable to find in the patient rights information a written notice that included: - Rights and responsibilities that are understandable to persons who have limited English proficiency; and - Rights and responsibilities accessible to individuals with disabilities.

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 preprinted admission booklet, record review, home visit observation, and interview the provider failed to provide written notice of the updated state toll-free hotline hours of operation (7:00 AM to 8:00 PM, seven days a week), in three of three home visit record reviews and two of those 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. Review of the home health provider’s preprinted admission booklet, Home Health Hotline (page 10) showed: -The Missouri Department of Health and Senior Services has a toll free hotline for any complaints or questions concerning any Medicare Certified Home Health Agency; -Abuse or other ethical violations affecting the rights of patients witnessed and/or suspected by a patient, family member, or home care provider should be reported to the agency and the State of Missouri Hotline; and -The hours of operation for the State hotline number are 7:00 AM to 12 midnight, seven days a week. RECORD/PATIENT #1: Record review of the patient’s consent for care, showed the hours of operation for the State hotline number are 7:00 AM to 12 midnight, seven days a week. Observation on 04/18/2023, beginning at 2:29 PM, 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. RECORD/PATIENT #2: Record review of the patient’s consent for care, showed the hours of operation for the State hotline number are 7:00 AM to 12 midnight, seven days a week. Observation on 04/18/2023, beginning at 9:00 AM, showed the patient could not find his/her admission folder. During an interview on 04/20/2023 at 9:50 AM, the home health administrator stated that: -The admission booklets and consents needed updated; and -The home health provider would be updating the admission booklets and consents to include the current hotline hours, as well as getting the correct hotline hours out to the current patients. RECORD/PATIENT #3: Record review of the patient’s consent for care, showed the hours of operation for the State hotline number are 7:00 AM to 12 midnight, seven days a week. Observation on 04/18/2023, beginning at 9:50 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.

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, home visit observation, and interview, the home health provider failed to ensure a complete and accurate list of all the medications that the patient was currently using in three of three home visit observations (Records/Patients #1, #2, and #3). This deficient practice has the potential to affect the home health provider’s ability to ensure safe and effective use of medications for all patients served by the provider. Findings included: Review of the home health provider’s policy, titled “Medication Management,” dated revised 05/01/2019 showed in part the following: -To provide a process to ensure continuous monitoring of medications in the patient’s home; -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 no-compliance to the Patient Care Manager; -The physician is contacted immediately if any discrepancies between agency information and patient medications are found; and -The discipline responsible for the drug regimen review will compare medication list obtained from the facility from which the patient was transferred and/or physician orders to actual medications patient is taking. Review all medications including over the counter medications, vitamins, herbs and herbal products, breams and topical ointments, and medical marijuana, to identify issues. RECORD/PATIENT #1: Review of the clinical record showed the patient was admitted to the home health provider on 02/27/2023 after a hospital stay for a stroke affecting his/her dominant side. The patient lived at home. The patient received nursing, physical therapy, and occupational therapy. Observation on 04/18/2023 at 2:29 PM, during the patient’s home visit, showed the medications were reconciled using a current medication profile supplied by the home health provider and interview with the patient. This reconciliation showed the following discrepancies: -Elderberry gummies (gummy supplement that contains the juice or extract of berries from the elder plant) one daily failed to be on the provider’s list; and -Zinc (supplement) 50 milligram (mg) one daily failed to be on the provider’s list. RECORD/PATIENT #2: Review of the clinical record showed the patient was admitted to the home health provider on 02/08/2023 after a hospital stay for aftercare of a surgical wound of his/her digestive system. The patient lived at home. The patient received nursing. Observation on 04/18/2023 at 9:00 AM, during the patient’s home visit, showed the medications were reconciled using a current medication profile supplied by the home health provider and interview with the patient. This reconciliation showed the following discrepancies: -Hydromorphone (narcotic analgesic) 4 mg one every six hours as needed for pain was on the provider’s list, but the patient stated that he/she hadn’t taken that in “quite a while”; and -Percocet (narcotic analgesic) 10 mg/325mg one tablet every six hours as needed for pain failed to be on the provider’s list. The prescription date on the Percocet bottle was 03/28/2023. The patient stated that he/she was on Percocet prior to hospitalization and was only on hydromorphone for a short period before going back on the Percocet. RECORD/PATIENT #3: Review of the clinical record showed the patient was admitted to the home health provider on 03/31/2023 after a hospital and skilled nursing facility stay due to heart failure. The patient lived at home with his/her spouse/caregiver. The patient received nursing, physical therapy, and occupational therapy. Observation on 04/18/2023 at 9:50 AM, during the patient’s home visit, showed the medications were reconciled using a current medication profile supplied by the caregiver and interview with the caregiver. This reconciliation showed the following discrepancies: - Ultimate 16 Strain Probiotic with FOS (fructooligosaccharides) (promote digestive health) 3.2 billion CFU (colony forming units) one daily. The medication failed to be on the provider’s list; - Vitamin D3 (supplement) 50 mcg (2000 IU (international units)) one daily. The medication failed to be on the provider’s list; - Omega 3-6-9 (supplement to help lower levels of a certain blood fat (triglyceride) and to raise levels of "good" cholesterol (HDL) 1030 milligrams (mg) one daily. The medication failed to be on the provider’s list; - CoQ10 (supplement that provides antioxidant support to help fight free radicals and helps support heart health) 200 mg one daily. The medication failed to be on the provider’s list; - Antacid Tablets Ultra Strength two (1000 mg) every day. The medication failed to be on the provider’s list; - Vitamin K2 MK-7 (supplement for cardiovascular support) 100 mcg one daily. The medication failed to be on the provider’s list; - One A Day Vitamin Men’s 50 Plus one daily. The medication failed to be on the provider’s list; - Pure Ashwagandha with black pepper (supplement to calm the brain, reduce swelling, lower blood pressure, and alter the immune system) 1300 mg one daily. The medication failed to be on the provider’s list; - Astaxanthin (supplement to boost immune system) 4 mg and Zeaxanthin (supplement to protect against chronic eye and cardiovascular diseases, such as age-related macular degeneration (AMD), cataract, coronary heart disease, and stroke) 4 mg one daily. The medication failed to be on the provider’s list; - Allopurinol (treat gout) 150 mg one daily. The provider had 150 mg twice a day; and - Glucosamine (supplement that might increase the cartilage and fluid around joints and/or help prevent their breakdown) HCI 1500 mg with Chondroitin / MSM Complex (supplement used to ease the pain of arthritis) 1103 mg one twice a day. The provider had Glucosamine 500 mg one twice a day and Glucosamine Chondroitin Maximum Strength 500 mg-400 mg capsule two capsules daily. During an interview on 04/18/2023 at 3:28 PM, the administrator and clinical manager stated the following: - Therapy are to ask patient about medication changes and ask what has changed then call the physician for an order; - Therapy are to go over all medications including over the counter and supplements; - Staff are to pull the medications bottles and compare to the medication discharge list; - Staff are to call the physician and get a correction with any discrepancies; - All disciplines are to ask about medication changes; and - Staff are to reconcile medications every visit.

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 one of five full records reviewed (Record/Patient #1). 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 home health provider’s policy titled, “Plan of Care (POC),” dated revised 12/02/2021, showed in part the following: -Purpose: To ensure that physician/authorized practitioner’s orders are followed; -Policy: 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; and -Medications, treatments, and interventions are provided by qualified agency staff as ordered by the physician or authorized practitioner. RECORD/PATIENT #1: Review of the clinical record, showed the patient was admitted to service on 02/27/2023 following a hospitalization for a stroke affecting his/her dominant side. The patient lived at home with a spouse. Review of the POC, showed an order for OT (occupational therapy) one time for week one. Review of the OT notes failed to show a visit for week one (02/27/2023 through 03/04/2023). During an interview on 04/20/2023 at 10:05 AM, the administrator and clinical manager-A stated that OT did miss the visit during week one.

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 that each patient’s written individualized plan of care included all required elements 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 home health provider. Findings included: Review of the home health provider’s policy titled, “Plan of Care (POC),” dated revised 12/01/2021, showed in part the following: -Purpose: To assure appropriate POC is developed and revised in a timely manner for each patient; -Policy: 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: • Nutritional requirements; • Medications and treatments; • Safety measures to protect against injury; • Pertinent diagnosis(es); • Patient specific interventions and education; measurable outcomes and goals identified by the agency and patient; • Required equipment and supplies; and -The qualified clinician develops and revises the POC under the direction of the physician or authorized practitioner. RECORD/PATIENT #1: Review of the hospital discharge summary/orders, dated 02/24/2023, showed in part the following: -Consult to home health evaluate and treat regarding stroke; -Consult for home health to have PT (physical therapy) and OT (occupational therapy) to evaluate and treat. Registered Nurse (RN) to monitor meds and skin, and provide education. Aide for bathing. Start of care 02/28/2023; and -DME (durable medical equipment): Wheelchair, wheeled walker, bedside commode, gait belt, and ankle foot flex brace. Review of the POC, dated 02/27/2023, showed in part the following: -Primary diagnosis: Hemiplegia (paralysis of one side of the body) following a cerebral infarction (stroke) affecting right dominant side; -Skilled nurse (SN) one time a week for six weeks; -Physical therapy (PT) two times a week for four weeks, then once a week for five weeks; -Occupational therapy (OT) once a week for one week; -Clinical summary: The patient was referred to home care for PT, OT, RN, ST (speech therapy), and aide; and -DME and supplies: Walker- multi-wheeled (3-4 wheels). Review of the admission assessment, dated 02/27/2023, showed in part the following: -Able to participate in bathing self in shower or tub, but requires presence of another person throughout the bath for assistance and supervision; -Patient/Family Goals/Expectations: Be able to walk with a walker, not have to use a wheelchair, patient wants to be able to drive again; -Slow gait, decreased strength of right lower extremity, right foot flexor brace and wheeled walker, cues for upright posture, patient slow and cautious on turns; and -Walk on his/her own and do things he/she did before. Review of OT evaluation, dated 03/08/2023, showed in part the following: -DME available: Elevated toilet seat, rolling walker (2 wheeled only) and wheelchair; -DME recommended: None; and -Bathing/showering ability: Moderate assist. During an interview on 04/18/2023 at 2:29 PM, the patient stated that he/she was raising his/her grandkids and had taught one of them how to drive and wanted to be able to teach the younger one how to drive and that he/she really wanted to be able to drive again, so he/she could do that. The home health provider failed to ensure the patient’s POC was individualized and included the use of all DME equipment, the use of aide for bathing (there was no documentation showing the patient refused an aide for bathing). Also failed to provide interventions regarding the patient's driving. RECORD/PATIENT #2: Review of the clinical record showed the patient was admitted to home health services on 02/08/2023 following a hospitalization for surgery to his/her digestive system (colon). His/her primary diagnosis was aftercare following surgery on the digestive system. Other diagnosis included: Encounter for attention to colostomy (a surgical operation in which a piece of the colon is diverted to an artificial opening in the abdominal wall so as to bypass a damaged part of the colon), protein-calorie malnutrition (state of inadequate intake of food), anemia (blood doesn’t have enough healthy red blood cells), nicotine dependence (smokes), and long-term use of aspirin (blood thinner). The patient lived at home with a spouse. The POC failed to be individualized and include interventions and goals for the protein-calorie malnutrition, anemia, and the nicotine dependence. Review of the skilled nurse (SN) visit, dated 03/13/2023, showed that the patient had a fall and was complaining of back pain. The nurse advised the patient to apply ice to back for the first 24 hours to decrease inflammation. Further review of the POC, failed to show an order for the treatment with the ice. During an interview on 04/19/2023 at 3:30 PM, the clinical manager-A, stated that he/she expected the POC to be individualized and include the above findings.

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 home visit observation and interview, the provider failed to provide the patient/caregiver with an updated/current copy of written instructions outlining the patient’s medication schedule, including medication name, dosage, and frequency in one of three home visit observations performed (Record/Patient #3). This deficient practice has a potential to affect our patient serve by the agency. Findings included: Review of the provider's policy, titled “Medication Management” revised 05/01/2019 showed: - To provide a process to ensure continuous monitoring of medications in the patient’s home; and - 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. Record/Patient #3: A home visit observation on 4/18/2023 at 9:50 AM showed: - No updated/current medication profile list left in the patient’s home admission folder; and - The patient provided a copy of his or her own medication list (that was incomplete and not updated). During an interview on 04/18/2023 at 3:28 PM, the administrator stated that an updated/current medication profile lists should be left in the patient’s home and reconciled every visit.

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 home visit observation, and interview, the home health provider failed to provide in writing the name and contact information of the clinical manager in, but not limited to, two of three home visit observations (Record/Patient #1 and #3). This deficient practice has the potential to affect all patients served by the home health provider. Findings included: The agency did not provide a policy related to clinical manager's contact information to be left in the patient's home folder. RECORD/PATIENT #3: During a home observation visit on 04/18/2023 starting at 9:50 AM with COTA (certified occupational therapist assistant) A, the surveyor observed the patient's home folder. The agency failed to provide in writing the name of the current clinical manager. On 04/18/2023 at 9:50 AM, during an interview with the caregiver/spouse regarding who the clinical manager was, the caregiver/spouse stated that he/she didn’t know who the clinical manager was. RECORD/PATIENT #1: During a home visit observation on 04/18/2023 at 2:29 PM with PTA (physical therapy assistant)-B, 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 04/18/2023 at 2:29 PM with the patient, he/she stated that he/she did not know who the current clinical manager was.

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 provider failed to ensure staff communicated with all physicians or other health care practitioners related to the patient’s current plan of care for one of six full records reviewed (Record/Patient #2). This deficient practice has the potential to affect all the patients served by the home health provider. Findings included: Review of the home health provider’s policy titled, “Coordination of Care, From Admit Through Discharge,” dated as revised 04/01/2023, showed in part the following: -Purpose: To establish processes 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; and -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. RECORD/PATIENT #2: Review of the clinical record showed the patient was admitted to home health services on 02/08/2023 following a hospitalization for surgery to his/her digestive system (colon). His/her primary diagnosis was aftercare following surgery on the digestive system. Other diagnosis included: Encounter for attention to colostomy (a surgical operation in which a piece of the colon is diverted to an artificial opening in the abdominal wall so as to bypass a damaged part of the colon), protein-calorie malnutrition (state of inadequate intake of food), anemia (blood doesn’t have enough healthy red blood cells), nicotine dependence (smokes), and long-term use of aspirin (blood thinner). The patient lived at home with a spouse. Review of the plan of care (POC) showed for licensed professionals to report pain greater than six. Review of skilled nurse (SN) visit, dated 02/27/2023, showed a blood pressure of 86/46 (low blood pressure = under 90/60), this blood pressure was lower than all the patient’s previous blood pressures. The nurse failed to notify the physician of the low blood pressure. Review of the SN visit, dated 03/03/2023, showed the patient had pain and rated it a seven (greater than six) and had developed a productive cough with a small amount of clear sputum (mucus that settles in the lower airways of your lungs when you have an infection or a chronic illness). The nurse failed to notify the physician of the pain greater than six and the onset of a productive cough. During an interview on 04/20/2023 at 10:05 AM, the clinical manager-A stated that the nurse should have notified the physician of the above findings and failed to find any documentation that the physician was notified at the time of those visits of the findings.