Every finding on record at Lhcg Li, LLC

A recertification survey was conducted on 8/5/25 to 8/6/25 and EAMC-Lanier Home Health was found to be in substantial compliance with the Conditions of Participation for Home Health Emergency Preparedness.

A recertification survey was conducted on 8/5/25 to 8/6/25 and EAMC-Lanier Home Health. Standard level deficiencies were cited that will require an acceptable plan of correction.

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 review of medical records (MR), agency policy and procedures, observations and staff interviews, it was determined the agency failed to keep the medication profile current. This did affect two of five home visits (HV) including HV # 1, and HV # 5 and had the potential to negatively affect all persons served by the agency. Findings include: Agency Policy: Monitoring Medications Policy Number: 10.008 Revised Date: 7/1/24 Purpose: To provide a process to ensure continuous monitoring of medications in the patient's home. Policy: 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... Procedure: 1. The discipline responsible for the drug regimen review will: a. Compare the medication list... to actual medications the patient is taking. b. Review all medications including over the counter (OTC) medications, vitamins, herbs and herbal products, cream and topical ointments. 2. HV # 5 was admitted to the agency on 7/15/25 with diagnoses including Venous Insufficiency (chronic) (peripheral), and Non-Pressure Chronic Ulcer of Left Calf with Other Severity. A review of the POC dated 7/15/25 revealed an order for SN (skilled nurse) visits two times a week for nine weeks. A HV was conducted on 8/6/25 at 9:00 AM to observe care provided by EI # 6, Licensed Practical Nurse. During the HV, the ML printed on 8/6/25 and provided to the surveyor was compared to the medications observed in the home. The following discrepancy was observed: Amoxicillin 875 mg-Potassium Clavulanate 125 mg tablet, take one tablet by mouth twice daily for ten days for wound infection was found in the home but not on the ML. A physician's order dated 7/29/25 confirmed the above medication. An interview was conducted on 8/6/25 at 1:49 PM with EI # 1, who confirmed staff failed to keep the medication profile current. 1. HV # 1 was admitted to the agency on 7/29/25 with a primary Diagnosis of Hemiplegia Following Cerebral Infarction Affecting Left Nondominant Side. A review of the Home Health Certification Plan of Care (POC) dated 7/29/25 revealed an order for Physical Therapy two times a week for two weeks and one time a week for one week. Occupational Therapy one time a week for one week effective week of 8/3/25, and Speech Therapy one time a week for three weeks. A HV was conducted on 8/5/25 at 10:27 AM to observe care provided by Employee Identifier (EI) # 4, Physical Therapy Assistant. During the HV, the Medication List (ML) printed on 8/5/25 and provided to the surveyor was compared to the medications observed in the home. The following discrepancies were observed: Biaxin 500 milligram (mg) take one tablet by mouth twice a day for seven days, with a fill date of 7/28/25, was not listed on the ML. Metronidazole 500 mg take one tablet by mouth twice a day for seven days, with a fill date of 7/29/25, was not listed on the ML. Hydrocodone 7.5/325 mg take one tablet by mouth every four hours as needed for pain, with a fill date of 7/18/25, was not listed on the ML. The following medications were listed on the ML and confirmed by the patient not to be accurate: Nicotine 4 mg Buccal Lozenge 1 lozenge every four to eight hours discontinued 7/28/25. Pataday Once Daily Relief 0.7 % Eye Drops. One drop daily discontinued 7/28/25. Systane Nighttime 94 % - 3 % Eye Ointment one application in left eye at night discontinued 7/28/25. Claritin 10 mg one tablet daily discontinued 7/22/25. An interview was conducted on 8/6/25 at 1:59 PM with EI # 1, Area Administrator, who confirmed staff failed to keep the medication profile current.

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 medical record (MR) review, agency policies and procedures, and staff interview, it was determined the agency failed to ensure staff followed the physician's order for wound care. This affected MR # 8 in one of six MRs reviewed with wound care ordered and had the potential to negatively affect all patients with wounds serviced by the agency. Findings include: Agency Policy: Plan of Care Policy Number: 2.1.007 Revision Date: 4/1/25 Policy: Every patient has an individualized Plan of Care (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. Procedure: ...2. The POC includes: ...b. Types, frequency, and duration of services required... f. Medications and treatments... i. Patient specific interventions... n. All patient care orders... 6. Physician/authorized practitioner's orders are obtained to update the POC. 7. Medications, treatments, and interventions are provided by authorized agency staff as ordered by the physician or authorized prescriber. Agency Policy: Wound Assessment, Documentation, and Photography Policy Number: 2.2.001 Revision Date: 9/1/24 Procedure: ...2. Perform wound care according to LHC adopted clinical skills guidelines and physician orders. MR # 8 was admitted to the agency on 5/29/25 with diagnoses that included Erythema Intertrigo and Pressure Ulcer of unspecified part of the back. Review of the Home Health Certification and Plan of Care (HHCPOC) from 5/29/25 to 7/27/25 revealed physician orders for Skilled Nurse (SN) to perform/instruct patient/caregiver procedure of wound care to wound # 1 midline vertebrae stage III pressure ulcer every three days and as needed (prn) for soilage or dislodgement. Cleanse with soap and water and wash cloth and pat dry. Cover with RTD (brand) dressing and border gauze dressing. Wound # 2 right upper quadrant intertrigo cleanse with soap and water and wash cloth daily and pat dry. Apply silvadene cream two times daily and prn using clean technique. Instruct patient/caregiver signs/symptoms of wound infection and proper disposal of dressings. Further review of the MR revealed a physician order on 6/5/25 for SN to perform/instruct patient/caregiver procedure of wound care to wound # 1 midline vertebrae stage III pressure ulcer-cleanse with wound cleanser, cover with RTD dressing and border gauze dressing every three days and prn for soiled or dislodged dressing. SN to perform on visit days, caregiver to perform all other days after a successful return demonstration. Wound # 2 right upper quadrant intertrigo-cleanse with soap and water and wash cloth daily and pat dry. Apply silvadene cream two times daily and prn. SN to perform on visit days, caregiver to perform all other days after successful return demonstration. Review of the SN Visit Note Reports (VNR) dated 6/11/25 and 6/25/25,revealed the SN failed to clean the wound with wound cleanser, per the physician's order. Review of the SN VNR dated 7/2/25, revealed the SN failed to perform the wound care during his/her visit, per the physician's order. An interview was conducted on 8/6/25 at 1:36 PM with Employee Identifier # 1, Area Administrator, who confirmed staff failed to perform wound care per the physician's order.

Promptly alert relevant physician of changes CFR(s): 484.60(c)(1) The HHA must promptly alert the relevant physician(s) or allowed practitioner(s) to any changes in the patient's condition or needs that suggest that outcomes are not being achieved and/or that the plan of care should be altered. This ELEMENT is not met as evidenced by: Based on review of medical records (MR), agency policy and procedure, and staff interview, it was determined the agency failed to notify the physician of changes in the patient condition. This affected MR # 1, MR # 8, and MR # 6 in three of thirteen MRs reviewed and had the potential to negatively affect all patients serviced by the agency. Findings include: Agency Policy: Coordination of Care, From Admit Through Discharge Policy Number: 2.1.017 Revision Date: 9/1/24 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 care among various disciplines and between in-person and virtual clinicians to ensure that services are continuous and coordinated from admission through discharge. Procedure: ...4. Coordination of care with physician/authorized practitioner: 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. 3. MR # 6 was admitted to the agency on 2/1/25 and resumed for continued care on 2/27/25 with a primary diagnosis of Diabetes Mellitus with Ketoacidosis without coma. A review of the Resumption of Care order dated 2/27/25 revealed an order for the physician to be notified of a glucose level of greater than 250. A review of the SN VNR dated 3/20/25 revealed the patients glucose was reported to the nurse as between 147-325 for the last seven days, no documentation the patient notified the physician or the nurse notified the physician per the order. The nurse documented the patient needed reinforcement for education on new glucose meter due to knowledge deficits. An interview on 8/6/25 at 1:58 PM with EI # 1, confirmed there was no documentation to confirm the physician was notified regarding glucose levels greater than 250 per the physician orders. 1. MR # 1 was admitted to the agency on 5/7/25 with a diagnosis of ST Elevation Myocardial Infarction of Unspecified site. Review of the Home Health Certification and Plan of Care (HHCPOC) dated 7/1/25 to 8/29/25 revealed orders for Skilled Nurse (SN) to instruct patient/caregiver on Myocardial Infarction to include definition, signs/symptoms, signs/symptoms to report, management and causes. Further review of the HHCPOC dated 7/1/25 to 8/29/25 revealed orders for SN to perform up to two as needed visits for cardiac complications such as chest pain, dyspnea, ... increase in weight of five pounds in one week... Review of the SN Visit Report Note (VRN) dated 7/1/25 revealed a documented weight of 245 pounds (lbs) Review of the SN VRN dated 7/7/25 revealed a documented weight of 255 lbs. Further review of the SN VRN dated 7/7/25 revealed the SN documented in his/her assessment the patient had not experienced unwanted weight gain/loss of more than two pounds since the last visit or three pounds in the last week. There was no documentation the SN notified the physician of the ten pound weight gain from 7/1/25 to 7/7/25 per the facility policy. An interview was conducted on 8/6/25 at 2:00 PM with Employee Identifier (EI) # 1, Area Administrator, who confirmed the staff failed to report changes in the patient's condition to the physician. 2. MR # 8 was admitted to the agency on 5/29/25 with diagnoses that included Erythema Intertrigo and Pressure Ulcer of unspecified part of the back. Review of the HHCPOC dated 5/29/25-7/27/25 revealed orders for SN to instruct patient/caregiver on Peripheral Vascular Disease to include definition, signs and symptoms, signs and symptoms to report... Review of the SN VRN dated 7/2/25 revealed an ankle circumference of 22 centimeters (cm) documented for the left ankle. There was no documentation of the right ankle circumference. Review of the SN VRN dated 7/8/25 revealed an ankle circumference of 32.5 cm documented for the left ankle and 32 cm documented for the right ankle. Further review of the SN VNR dated 7/8/25 revealed the skilled nurse documented in his/her assessment there had not been an increase in ankle circumference of two cm. Review of the SN VNR dated 7/18/25 revealed an ankle circumference of 33.5 cm for the left ankle and 35 cm for the right ankle. Further review of the SN VNR dated 7/18/25 revealed the SN documented in his/her assessment there had not been an increase in ankle circumference of two cm. There was no documentation the SN notified the physician of changes in the patient's ankle circumference. An interview was conducted on 8/6/25 at 1:36 PM with EI # 1, who confirmed staff failed to report changes in the patient's condition to the physician.

Patient and caregiver education CFR(s): 484.75(b)(5) Patient and caregiver education; This ELEMENT is not met as evidenced by: Based on Medical Record (MR) review, agency policy and procedure, and staff interview, it was determined the agency failed to ensure staff educated the patient and/or caregiver on sliding scale insulin administration. This affected one of four patients reviewed with Diabetes to include MR # 6, and had the potential to affect all patients served by the agency. Findings include: Agency policy: Patient Education Policy Number: 3.001 Revised date: 11/17 Purpose: To describe patient and/or caregiver interactions designed to promote and maximize patient health and safety. Policy: The agency plans, supports and coordinates patient and caregiver education designed to promote optimal patient health and safety. Patients receive oral and/or written information for this purpose on an ongoing basis while being care for by the agency. Procedure: 1. Educational resources are made available through appropriate educational methods to the patient and caregiver based on assess and/or potential learning needs of the patient and caregiver... 6. Per assessed knowledge deficit, patient and caregivers receive oral and/or written information on medication education to include: a. Dosage, route, duration b. Description, purpose, expected actions. c. Potential side affects, contraindications, avoidance of interactions, reactions to report... f. Self-administration and monitoring techniques... k. High alert medications, as appropriate. i. Range order with appropriate dosing interval. 7. Using the progress/visit note, the clinician documents the level of patient/caregiver comprehension, patient/caregiver return demonstration of skill(s) taught, compliance, and any follow up with team members. Concerns are reports to the patient's physician. 1. MR # 6 was admitted to the agency on 2/1/25 with a primary diagnosis of Diabetes Mellitus with Ketoacidosis without coma. A review of the Home Health Certification and Plan of Care dated 2/1/25 revealed nursing services were ordered to visit one time a week for five weeks, and one time every other week for four weeks, with two as needed visits for signs and symptoms of Hypo/hyperglycemia. Orders included to educate the patient to instruct on prescribed medications to treat diabetes, new or changed medications, high risk medications, and any applicable drug interactions. Orders for Novolog U-100 Insulin Aspart 100 unit/milliliter (mL) solution sliding scale, to be given Subcutaneous with a start date of 1/11/25 without any documentation of the parameters for use. A review of the RN Outcome Assessment Information Set (OASIS) Admission note dated 2/1/25 revealed the patient had no documentation of education on the use of sliding scale insulin and no documentation of the parameters for the sliding scale. A review of the nursing Visit Note Report dated 2/6/25 revealed glucose levels ranging from 109-300 in the last seven days. No documentation of sliding scale use or education documented in the visit note. A review of the nursing Visit Note Report dated 2/10/25 revealed glucose levels documented of 300 or less in the last seven days. No documentation of sliding scale use or education documented in the visit note. A review of the nursing Visit Note Report dated 2/17/25 revealed a glucose level documented of 42 during the visit. The patient was transferred to the hospital and was admitted from 2/17/25 to 2/26/25 related to Hypoglycemia. An interview was conducted on 8/6/25 at 1:58 PM with Employee Identifier # 1, Area Administrator who confirmed there was no documentation of patient education regarding sliding scale use or sliding scale parameters in the medical record prior to the 2/17/25 transfer to the hospital for hypoglycemia.

During a recertification survey conducted 8/9/22 to 8/11/22, EAMC (East Alabama Medical Center)-Lanier Home Health was found to be in substantial compliance with Emergency Preparedness 484.102, Condition of Participation for Home Health Agencies and related standards.

A recertification survey was conducted from 8/09/22 to 8/11/22 at EAMC-Lanier Home Health and standard level deficiencies were cited.

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 review of agency policy and procedure, medical records (MR), observations and interviews with staff, it was determined the agency failed to update the medication list (ML) per policy. This deficient practice affected four of thirteen MR's reviewed including HV (Home Visit) # 1, HV # 4, MR # 4, HV # 5 and had the potential to affect all patients served by the agency. Findings include: Agency Policy Number: 10.008 Title: Monitoring Medications Revised Date: 5/01/19 Purpose: To provide a process to ensure continuous monitoring of medications in the patient's home. Policy: A drug regimen review will be performed on all patients...throughout the episode... Procedure: 1...a. Compare medication list...to actual medications patient is taking. b. Review all medications...to identify issues such as: i. Potential adverse effects and drug reactions iv. Drug allergies v. Contraindications medications... vii. Duplicate drug therapy e. Notify the physician of any of the above issues/discrepancies...ensure supportive documentation is evident in the medical record. 2. All clinicians...are responsible to assist with the maintenance of accurate patient medication information throughout the episode of care... 4. HV # 5 was admitted to the agency on 6/9/22 with diagnosis including Encounter for Fitting and Adjustment of Urinary Device and Type 2 Diabetes Mellitus with Diabetic Neuropathy, Unspecified. Review of the HHC and POC dated 6/9/22 to 8/7/22 revealed orders for the SN to visit one time per week for nine weeks. Review of the HHC and POC dated 8/8/22 to 10/6/22 revealed orders for the SN to visit once per week for one week... A home visit was conducted on 8/10/22 at 8:30 AM to observe EI # 7 LPN (Licensed Practical Nurse) provide care. During the visit, the medications in the home were compared to the medication list provided to the surveyor and the following discrepancies were observed: Stool Softener 100 mg, one daily found in the home and not on the ML. The caregiver and patient (cg/pt), stated he/she had been taking for three to four weeks. Melatonin 5 mg tablets, one tablet every night found in the home and not on the ML. The cg/pt, stated he/she has been taking for about one month. Metamucil 0.4 gram capsule daily was on the ML. The cg/pt, stated he/she discontinued the medication three to four weeks ago. Bicalutamide 50 mg tablet one daily was on the ML. The cg/pt, stated he/she discontinued the medication about 3 weeks ago. An interview conducted on 8/11/22 at 9:30 AM with EI # 1 confirmed the ML was not updated per agency policy. 1. HV # 1 was admitted to the agency on 7/21/22 with diagnoses including Hypertensive Heart Disease with Heart Failure and Type Two Diabetes Mellitus without Complications. Review of the 7/21/22 to 9/18/22 Home Health Certification (HHC) and Plan (POC) revealed SN (skill nurse) visits were ordered one time a week for nine weeks. A HV was conducted on 8/9/22 at 10:57 AM to observe care provided by EI (Employee IdentifIer) # 4, Home Health Aide (HHA). Also present during visit was EI # 1, Executive Director. Medication reconciliation was performed with the caregiver (CG) using the agency ML and medications found in the home. The following medications were found in the home, verified by the CG, and not documented on the agency ML: (a) Mupirocin two % cream, apply a small amount to right leg three times a day, filled 5/10/22. (b) Clonazepam 1 (one) mg (milligram), one and one half tabs (tablet) po (orally) daily as needed at bedtime, refilled 8/3/22. (c) Lovastatin 40 mg one tab po daily, filled 7/16/22. The following medications were documented on the agency ML and had different dosage/administration directions from the medication prescription bottles found in the home. The CG confirmed current use of the medications below: (a) Cabergoline 0.5 mg po 0.5 tab every week, filled 6/2/22. Cabergoline 0.5 mg tab po daily was documented on agency ML. (b) Gabapentin 300 mg capsule (cap) two caps po at bedtime, filled 6/2/22. Gabapentin 300 mg po one cap three times a day was documented on the agency ML. (c) Isosorbide Mononitrate Extended Release 60 mg po two tabs daily, filled 5/10/22. Isosorbide Mononitrate Extended Release 60 mg po one tab daily was documented on the agency ML. In an interview conducted on 8/9/22 at 11:55 AM, EI # 1 confirmed staff failed to ensure HV # 1’s ML was accurately reconciled throughout the episode of care. 2. HV # 4 was admitted to the agency 5/19/22 and recertified for continued care 7/18/22 to 9/15/22 with diagnoses including Type 2 Diabetes Mellitus with Foot Ulcer. Review of the 7/18/22 HHC and POC revealed SN visits were ordered one time a week for nine weeks. A HV was conducted on 8/9/22 at 1:55 PM with EI # 3, Registered Nurse to assess new wounds and establish wound care. EI # 5, PCM (Patient Care Manager) was also in attendance. Medications were reviewed by EI # 3 and the surveyor utilizing the ML provided by the agency and the medications bottles in the home. Documented on the agency ML and found in the home was Dilantin Extended 100 mg cap 1 cap three time daily. Also documented on the agency ML was Phenytoin Sodium Extended 100 mg cap 1 cap three times daily, the generic medication for Dilantin. Documented on the agency ML and found in the home was Cholestyramine Light 4 gm oral powder 1 gm daily. Also documented on the agency ML was Prevalite 4 gm powder per instruction daily, which is the brand name for Cholestyramine. In an interview conducted on 8/9/22 at 2:10 PM, EI # 5 confirmed two duplicate medications were documented on HV # 4’s agency ML. 3. MR # 4 was admitted to the on agency 6/1/22 with diagnoses including Burn Third Degree of Single Right Finger Except Thumb. Review of the referral documentation which included the hospital admission history and physical dated 5/19/22 revealed drug allergies included Levaquin [effects], (unknown). Review of the HHC and POC dated 6/1/22 to 7/30/22 revealed MR # 4’s four documented allergies included Levaquin. Further review of the 6/1/22 HHC and POC medications revealed Levofloxacin 750 mg 1 tab daily was ordered, start 6/1/22 end 6/21/22. MR review revealed no documentation the allergy to Levaquin and the current Levaquin prescription was reviewed with the patient and physician for a potential adverse complication. An interview conducted 8/11/22 at 8:26 AM with EI # 6, PCM confirmed there was no documentation the Levaquin allergy was reported to the physician.

Conformance with physician orders CFR(s): 484.60(b) Standard: Conformance with physician or allowed practitioner orders. This STANDARD is not met as evidenced by: Based on review of agency policy and procedure, medical records (MR) and staff interviews, it was determined the agency failed to follow the physician orders for the following: 1. Teaching a diabetic patient how to use a new blood glucose monitor. 2. Teaching a patient/caregiver (pt/cg) how to assess the blood glucose as ordered. 3. Teaching a pt/cg what blood glucose range is considered therapeutic. 4. Reporting of blood glucose readings outside established parameters. This deficient practice affected 2 of 13 MRs reviewed and did affect MR # 1, MR # 6, and Home Visit (HV) # 1 and had the potential to affect all patients served by the agency. Findings include: Agency Policy Number: 2.1.007 Title: Plan of Care (POC) Purpose: ...To ensure that physician...orders are followed. Policy: Each patient has an individualized POC...to address patient problems, needs, and goals... Procedure: 1. A POC is developed for all patients... 2. The POC includes: i. Patient specific interventions...measurable outcomes and goals as identified by the agency and patient. ...n. All patient care orders ...7. Medications, treatments, and interventions are provided by qualified staff as ordered by the physician... 8. Alterations to the POC are made only with the physicians'...approval. 9. The patient is monitored for response to treatment and progress towards goals... 3. HV # 1 was admitted to the agency on 7/21/22 with diagnoses including Hypertensive Heart Disease with Heart Failure, Morbid Obesity, History of Falling and Type Two Diabetes Mellitus. Review of the 7/21/22 to 9/18/22 HHC and POC revealed SN visit orders for one time a week for nine weeks. The SN orders included instruct on Diabetes disease process, blood glucose testing daily, report FBS (fasting blood surgar) and RBS (random blood sugar) less than 70 and greater than 250 to licensed professional. Review of the SN Admission VNR (Visit Note Report) dated 7/21/22 documented by the SN revealed HV # 1 was not performing blood glucose testing daily, and stated “it is always high, no point in checking it”. There was no documentation FBS/RBS testing was performed 7/21/22 and within the ordered range and no documentation patient noncompliance with FBS/RBS testing was reported to the physician. In an interview conducted on 8/11/22 at 8:32 AM, EI # 6 Patient Care Manager (PCM) confirmed there was no documentation on the 7/21/22 Admission VNR that HV # 1’s blood glucose level was within acceptable range. 1. MR # 1 was admitted to the agency on 3/24/22 with diagnosis including Urinary Tract Infection, site not specified, Other Bacterial Agents as the Cause of Diseases Classified Elsewhere and Type Two Diabetes Mellitus with Hypoglycemia without Coma. Review of the Home Health Certification and Plan Of Care (HHC and POC) dated 3/24/22 to 5/22/22 revealed orders for the skilled nurse (SN) to, "Evaluate patient and develop a plan of care... to provide services as necessary and appropriate according to the patient's condition... to instruct patient on blood glucose testing, frequency for blood glucose testing two times daily. Patient's therapeutic blood glucose range is 70mg/dL (milligrams per deciliter) to 300 mg/dl." Review of the Admission Visit Note Report (VNR) by the Registered Nurse (RN) dated 3/24/22 revealed documentation the patient had a brand new blood glucose machine which was misplaced and the patient/caregiver was unable to assess the blood sugar two times daily as ordered. Further review of the admission VNR by the RN dated 3/24/22 revealed documentation of, "they have a new monitor, but husband/wife will find it so home health can watch him/her, help him/her make sure they understand how to use." Review of the Client Coordination Note Report (CCNR) dated 4/1/22 which was 8 days after the initial visit, revealed contact via telephone with the caregiver that patient cannot sit up and won't talk and an ambulance was called. Review of the CCNR dated 4/5/22 revealed patient transferred to the hospital for hypoglycemia on 4/1/22. Further review of the medical record revealed no documentation the pt/cg was provided instructions on how to use the new blood glucose machine, how to assess the blood glucose twice daily as ordered and what blood glucose range was therapeutic for the patient. An interview conducted on 8/11/22 at 9:30 AM with Employee Identifier (EI) # 1, Executive Director confirmed the pt/cg was not provided instructions on how to use the new blood glucose machine, how to assess the blood glucose twice daily as ordered and what blood glucose range was therapeutic for the patient. 2. MR # 6 was admitted to the agency on 6/23/22 with diagnoses including Type Two Diabetes with Diabetic Peripheral Angiopathy without Gangrene and Chronic Obstructive Pulmonary Disease, Unspecified. Review of the HHC and POC dated 6/23/22 revealed the patient's therapeutic blood glucose range is 70mg/dL to 250mg/dL and licensed professional to report vital signs falling outside the following established parameters: FBS (Fasting Blood Sugar) 250 (Less than 70, Greater than 250) and RBS (Random Blood Sugar 250. Review of the VNR by the SN dated 7/7/22 revealed blood glucose ranges from 170 to 350. There was no documentation the physician was notified of the blood glucose readings greater than 250 mg/dL as ordered. An interview conducted on 8/11/22 at 9:30 AM with EI # 6, PCM (Patient Care Manager) confirmed there was no documentation the physician was notified of the blood glucose readings falling outside the established parameters as ordered.

Infection Prevention CFR(s): 484.70(a) Standard: Infection Prevention. The HHA must follow accepted standards of practice, including the use of standard precautions, to prevent the transmission of infections and communicable diseases. This STANDARD is not met as evidenced by: Based on observations, agency policy and procedure, and interview with staff, it was determined the agency failed to ensure staff followed infection control practices for hand hygiene and glove use in one of five HV (Home Visits) for wound care and assessment. This affected HV # 4 and had the potential to negatively affect all patients admitted to the agency. Findings include: Agency Policy and Procedure Hand Hygiene Policy Number: 8.004 Revised Date: 05/01/19 Purpose: To help prevent the spread of...infection by cross-contamination and to provide practice guidelines Policy: Staff are required to perform hand hygiene prior to, at specified time points during, and followng patient contact...uising soap and water or...hand sanitizer. Procedure: 1. Staff performs hand hygiene... a. before direct contact with patients. b. before performing...wound care... e. after contact with...nonintact skin, wound dressings, or contaminated surfaces f. before and after removal of personal protective equipment... 1. HV # 4 was admitted to the agency on 5/19/22 and recertified for continued care 7/18/22 to 9/15/22 with diagnoses including Type 2 Diabetes Mellitus with Foot Ulcer, Non-Pressure Chronic Ulcer Other Part Left Foot with Unspecified Severity. A HV was conducted on 8/9/22 at 1:55 PM to observe Employee Identifier (EI) # 3, Registered Nurse assess wounds and provide wound care. EI # 5, Patient Care Manager was also present. HV # 4 had one wound to the left foot, one wound to the sacrum and one wound to the lower abdomen. EI # 3 performed wound care to the left foot wound, removed gloves, and sanitized hands. EI # 3 donned gloves, exited the patient room wearing the gloves, entered the kitchen, retrieved a paper measuring device, returned to the patient room wearing the same gloves, then measured the left foot wound. EI # 3 failed to remove gloves, perform hand hygiene and don clean gloves after exiting the patient room, retrieving the supply and before patient contact once returning to the patient's room. Next, EI # 3 evaluated the sacral wound, removed gloves and exited the patient room and home to his/her car and retrieved wound supplies. EI # 3 failed to perform hand hygiene following patient care and after glove removal. In an interview on 8/9/22 at 2:46 PM following the home visit, EI # 5 confirmed staff failed to perform hand hygiene after glove removal and before and after patient care.

Interdisciplinary assessment of the patient CFR(s): 484.75(b)(1) Ongoing interdisciplinary assessment of the patient; This ELEMENT is not met as evidenced by: Based on review of agency policy and procedure, medical records (MR) and staff interview, it was determined the agency failed to assess a diabetic patient's daily blood glucose test results for therapeutic range as ordered. This deficient practice affected 1 of 5 home visit (HV) medical records reviewed and did affect HV # 5 and had the potential to affect all patients served by the agency. Findings include: Agency policy: Plan of Care (POC) Policy Number: 2.1.007 Policy Revised Date: 12/1/21 Policy: Each patient has an individualized POC developed...to address patient problems, needs, and goals... Procedure: 2. The POC includes: i. Patient specific interventions and education; measurable outcomes and goals... n. All patient care orders 1. HV # 5 was admitted to the agency on 6/9/22 with diagnoses including Sepsis, Unspecified Organism and Urinary Tract Infection, Site Not Specified. Review of the Home Health Certification (HHC) and POC dated 6/9/22 to 8/7/22 revealed orders for patient/caregiver to perform blood glucose testing daily. Patient's therapeutic CBG (Capillary Blood Glucose) range is 70 mg/dL (Milligrams per Deciliter) to 250 mg/dL. Licensed Professional to report vital signs falling outside the following established parameters: FBS (Fasting Blood Sugar) 250 (Less than 70, Greater than 250), RBS (Random Blood Sugar) 250. Review of nine Visit Note Reports (VNR) by the Skilled Nurse (SN) dated from 6/9/22 to 8/3/22 revealed no documentation of the patient's blood glucose results from daily testing and no assessment of the patients daily blood glucose levels to assess for therapeutic blood glucose range as ordered. An interview conducted on 8/11/22 at 9:30 AM with EI (Employee Identifier) # 5, PCM (Patient Care Manager) confirmed there was no documentation the SN assessed the patients daily blood sugar testing results for FBS/RBS falling outside the established parameters.

Services provided by HH aide CFR(s): 484.80(g)(2) A home health aide provides services that are: (i) Ordered by the physician or allowed practitioner; (ii) Included in the plan of care; (iii) Permitted to be performed under state law; and (iv) Consistent with the home health aide training. This ELEMENT is not met as evidenced by: Based on review of agency policy and procedure, Agency Aide Checklist Documentation, observation, medical records (MR) and staff interviews, it was determined the Home Health Aide (HHA) failed to follow the Aide Care Plan Report (ACPR) and: a) Complete all tasks assigned by the Registered Nurse (RN). b) Notify the RN when services were not provided as ordered, and for possible change in the Plan of Care (POC). c) Document the care provided to the patient during the Home Visit (HV). This deficient practice affected one of five HVs including HV # 1 and had the potential to affect all patients served by the agency. Agency Policy: Plan of Care Policy Number: 2.1.007 Effective Date: 12/01/21 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, goals, as well as to address specific services being provided. Procedure : 1. A POC is developed for all patients... ...14. An aide POC will be developed by the Registered Nurse (RN)... HHA Aide Checklist Documentation Date Revised: 12.9.2020 ...Indicate each...task...precautions and other special instructions as complete/incomplete. Provide supportive note for why task is not completed. Enter coordination notes as needed. Report any abnormalities or pertinent information observed during the visit to the Patient Care Manager (PCM)... 1. HV # 1 was admitted to the agency on 7/21/22 with diagnoses including Hypertensive Heart Disease with Heart Failure, Morbid Obesity, History of Falling and Type Two Diabetes Mellitus without Complications. Review of the 7/21/22 to 9/18/22 Home Health Certification (HHC) and POC revealed HHA visits were ordered one time a week for five weeks effective 7/24/22. Review of the ACPR printed 8/9/22 for the care episode dated 7/21/22 revealed services to be performed every visit included temperature, respirations, pulse, shampoo, shaving, dressing, apply lotion, apply deodorant, bathing (chair in tub), comb/brush hair, assist and supervise oral care, ambulate with walker, empty trash, date of last bowel movement, oxygen, fall and bleeding precautions. Review of the Aide VNR dated 7/26/22 revealed services completed on the initial visit were shaving, and bathing (chair in tub). There was no documentation temperature, respirations, pulse, shampoo, shaving, dressing, apply lotion, apply deodorant, comb/brush hair, assist/gather oral supplies, supervise oral care, ambulate with walker, empty trash, date of last bowel movement, oxygen, fall, and bleeding precautions were completed every on 7/26/22. There was no documentation the Aide notified the RN all ordered services were not completed on 7/26/22. A HV was conducted on 8/9/22 at 10:57 AM to observe care provided by EI # 4, HHA. Also present during visit was EI #1, Executive Director. During the HV, EI # 4 assisted the patient transfer from a power wheelchair into a shower then onto a shower chair and completed a shower bath. The surveyor asked the patient if he/she ever got a tub bath? The patient’s response was no, we do not have a tub, only a shower. On the 8/9/22 visit, the patient denied the need for a shave and oral care. Review of the ACPR during the HV revealed services ordered every visit and not provided on 8/9/22 were comb/brush hair, ambulate use of walker, and empty trash. Review of the 8/9/22 Aide VNR documentation provided to the surveyor on 8/10/22 revealed shaving, bathing (chair in tub), comb/brush hair, assist/gather oral supplies, ambulate use of walker were completed. These tasks were not observed during the HV but were documented as completed. The HHA failed to document the actual services completed on the 8/9/22 HV. There was no documentation the HHA notified the RN regarding the potential need to change/amend the ACPR bath type and ambulation status. In an interview conducted on 8/11/22 at 8:32 AM, EI # 5, Patient Care Manager confirmed the HHA failed to complete all tasks ordered, notify the RN when ordered tasks were not completed, and when a change in the Aide Care Plan was needed. EI # 5 confirmed the HHA failed to document the actual care provided on the 8/9/22.