Every finding on record at Lhcg Lxiv, LLC

A recertification survey was conducted at Troy Regional Medical Center Home Health from 4/7/26 to 4/9/26. Troy Regional Medical Center Home Health was found to be in substantial compliance with the Conditions of Participation for Emergency Preparedness.

A recertification survey was conducted at Troy Regional Medical Center Home Health from 4/7/26 to 4/9/26. Standard level deficiencies were cited and will require an acceptable plan of correction.

5 calendar days after start of care CFR(s): 484.55(b)(1) The comprehensive assessment must be completed in a timely manner, consistent with the patient's immediate needs, but no later than 5 calendar days after the start of care. This ELEMENT is not met as evidenced by: Based on medical record (MR) review, agency policy and procedure, and interviews it was determined the agency failed to ensure the comprehensive assessments were completed within five days of the Start of Care (SOC). This deficient practice affected two of three MR's reviewed including, home visit (HV) # 3, and MR # 4 and had the potential to negatively affect all patients admitted to this agency. Findings include: Agency Policy: Patient Assessment, Initial and Reassessment Policy Number: 2.1.002 Revised: 9/1/24 ...Policy: All patients admitted to the agency will receive an initial assessment...by a staff Registered Nurse, Speech Therapist, Physical Therapist, or Occupational Therapist...OASIS (Outcome and Assessment Information Set) comprehensive assessments are completed at patient admission... Procedure: ...d. Physical Therapist, Speech Therapist, Occupational Therapist, ...may make initial evaluations of the patient status to determine the need for specific therapies. This initial discipline specific evaluation(s) will occur within 5 days from the SOC date... 1. HV # 3 was admitted on 1/15/26 and recertified for continued care from 3/16/26 to 5/14/26 with diagnoses including Hypertensive Heart Disease with Heart Failure and Acute Systolic (Congestive) Heart Failure. A review of the Home Health Certification (HHC) and Plan of Care (POC) dated 3/11/26 revealed physician's orders for Occupational Therapy (OT) one visit a week for one week, and Physical Therapy (PT) to evaluate/assess and develop Physical Therapy plan of care that will be approved by the physician prior to implementation. A review of the MR revealed no documentation the OT or PT assessments were performed within the five days of SOC. An interview was conducted on 4/9/26 at 2:39 PM with Employee Identifier (EI) # 5, Executive Director, who confirmed the agency failed to ensure all comprehensive assessments were completed within five days of the SOC. 2. MR # 4 was admitted on 1/24/26 with diagnoses including Aftercare Following Joint Replacement Surgery and Prescence of Artificial Knee Joint, Bilateral. A review of the HHC and POC dated 1/24/26 revealed physician's orders for OT one visit a week for one week. A review of the OT Add-On-Evaluation Visit Note Report dated 2/23/26 revealed the OT initial assessment was completed thirty days after the SOC. An interview was conducted on 4/9/26 at 2:40 PM with EI # 5, who confirmed the agency failed to ensure all comprehensive assessments were completed within five days of the SOC.

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 procedure, observations, and staff interviews, it was determined the agency failed to ensure patient medication profiles were accurate. This deficient practice affected five of five home visits (HV) including HV # 1, HV # 4, HV # 2, HV # 5, and HV # 3, and had the potential to affect all persons served by the agency. Findings include: Agency Policy: Monitoring Medications Policy Number:10.008 Revised Date: 4/01/26 Purpose: To provide a process to ensure continuous monitoring of all medications the patient is currently taking. Policy: A drug regimen 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 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, ... 2. 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... 5. HV # 3 was admitted on 1/15/26 and recertified for continued care from 3/16/26 to 5/14/26 with diagnoses including Hypertensive Heart Disease with Heart Failure and Acute Systolic (Congestive) Heart Failure. A review of the POC dated 3/11/26 revealed physician's orders for SN one visit a week for nine weeks, OT one visit a week for one week, and Physical Therapy (PT) to evaluate/assess and develop Physical Therapy plan of care that will be approved by the physician prior to implementation A HV was conducted on 4/7/26 at 2:03 PM to observe care provided by EI # 4, Physical Therapy Assistant. During the HV, a review of the CMR revealed the following discrepancies: a. Benzonate 200 MG capsule, take three times a day was noted on the CMR. Benzonate 100 MG capsule, take 3 three times daily as needed was in the home dated 10/29/25. b. Hydrocodone-Acetaminophen 5-325 MG one tablet every six hours as needed for pain was found in home with a fill date of 3/27/26. There was no documentation of the Hydrocodone-Acetaminophen on the agency CMR. c. Megestrol 400 MG/10 ML oral suspension, take 3 ML two times daily as needed was on the CMR. Megestrol 5 ML take two times daily was in the home dated 3/31/26. d. Quetiapine 150 MG tablet, one tablet daily was listed on the CMR. Quetiapine 25 MG tablet, take one tablet daily was in the home dated 2/20/26. e. Terbinafine Hydrochloric Acid 250 MG tablet, take one tablet every twelve hours was listed on the CMR. Terbinafine HCL 250 MG tablet, take one tablet daily was in the home dated 3/8/26. f. Albuterol 0.083% Nebulizer, use one vial in nebulizer three times a day was in the home with a fill date of 3/8/26. There was no documentation of the Albuterol on the agency CMR. An interview was conducted on 4/9/26 at 2:39 PM with EI # 5, who confirmed staff failed to keep the medication profile current. 3. HV # 2 was admitted to the agency on 1/29/26 with diagnoses including Aftercare Following Joint Replacement Surgery and Complete Rotator Cuff Tear/Rupture of Right Shoulder, not Trauma. A review of the POC for the certification period dated 3/30/26 to 5/28/26 revealed Occupational Therapy (OT) visits were ordered two times a week for four weeks. A HV was conducted on 4/7/26 at 1:26 PM to observe care provided by EI # 7, OT. During the HV, a review of the CMR revealed the following discrepancies: a. Duloxetine 30 MG delayed release capsule, take one daily by mouth as needed. HV # 2 stated she/he "does not recognize this medication" and it is not present in the home. b. People's Choice Women's Daily Vitamin with Iron, take one tablet as needed daily. HV # 2 stated she/he has taken this vitamin for a while. An interview was conducted on 4/9/26 at 2:27 PM with EI # 5, who confirmed staff failed to keep the medication profile current. 4. HV # 5 was admitted to the agency on 3/19/26 with diagnoses including Pressure Ulcer Left Buttock, Unstageable and Encounter for Surgical Aftercare following Surgery on the Skin and Subcutaneous Tissue. A review of the POC for the certification period 3/19/26 to 5/17/26 revealed SN visits were ordered once a week for nine weeks. A HV was conducted on 4/8/26 at 9:40 AM to observe wound care provided by EI # 2, RN and accompanied by EI # 6. During the HV, a review of the CMR revealed the following discrepancies: a. Vitamin C, take one a day, was not listed on the CMR and was in the home with a fill date of 3/19/26. b. Vitamin D, take one a day, was not listed on the CMR and was in the home with a fill date of 3/19/26. An interview was conducted on 4/9/26 at 2:37 PM with EI # 5 who confirmed staff failed to keep the medication profile current. 1. HV # 1 was admitted to the agency on 10/26/26 with diagnoses including Pressure Ulcer of Sacral Region, Stage 4 and Pressure Ulcer of Left Buttock, Stage 3. A review of the Plan of Care (POC) for the certification period of 2/1/26 to 4/18/26 revealed skilled nurse (SN) visits were ordered one visit weekly for eight weeks, two visits every week for one week, and lastly one visit every week for one week. A HV was conducted on 4/7/26 at 1:08 PM with Employee Identifier (EI) # 6, Dothan Executive Director (ED) to observe care provided by EI # 1, Registered Nurse (RN). During the HV, A review of the Client Medication Report (CMR) revealed the following discrepancies: a. Amitriptyline 10 milligrams (MG) take one tablet by mouth three times daily, was not listed on the CMR and was found in the home with a fill date of 1/15/26. b. Verapamil 80 MG take one tablet by mouth three times daily, was listed on the CMR as 40 MG. Verapamil 80 MG was found in the home with a fill date of 1/15/26. c. Clindamycin 400 MG one scoop in 30 milliliters (ML) of solution. Shake and spray wound1-2 times daily during dressing change, was not listed on the CMR and was found in home with a filled date of 2/25/26. d. Levofloxacin 750 MG one scoop in 30 ML of solution. Shake and spray wound 1-2 times daily during dressing change, was not listed on the CMR and was found in home with a filled date of 2/25/26. An interview was conducted on 4/9/26 at 3:04 PM with EI # 5, Troy ED who confirmed staff failed to keep the medication profile current. 2. HV # 4 was admitted to the agency on 4/4/26 with a diagnosis of Hypertensive Chronic Kidney Disease with Stage 1-4, Unspecified Chronic Kidney. A review of the POC for the certification period of 4/4/26 to 6/2/26 revealed SN visits were ordered two visits a week for one week, three visits a weeks for one week, and finally one visit a week for eight weeks. A HV was conducted on 4/8/26 at 10:33 AM to observe care provided by EI # 3, RN. During the HV, a review of the CMR revealed the following discrepancies: Dilt-XR 120 MG capsule take one capsule by mouth daily, was listed on the CMR and was not found in the home. HV # 4 stated he/she did not know anything about that medication and did not know when he/she had last taken the medication. An interview was conducted on 4/9/26 at 2:22 PM with EI # 5 who confirmed staff failed to keep the medication profile current.

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 policies and procedures, and staff interviews, it was determined the agency failed to ensure staff: 1. Maintained sterility throughout the Peripherally Inserted Central Catheter (PICC) Line dressing change. 2. Followed agency policy for cleaning the PICC Line site. 3. Performed hand hygiene per agency policy. This did affect two out of five home visits (HV), including HV # 1, HV # 5, and had the potential to affect all persons served by this agency. Findings Include: Policy: Dressing Change Procedure For central Venous, Midline, And Peripherally Inserted central Catheters Policy Number: 10.027 Revised Date: 03/01/26 Purpose: To keep insertion sites clean, stabilize catheters and minimize the risk of infection. Policy: ...Sterility will be maintained throughout this procedure... Procedure: ...6. Remove old dressing... b. Remove catheter securement device and chlorhexidine-impregnated sponge... 9. Cleanse the site with chlorhexidine (preferred) in a back and forth motion for at least 30 seconds. If povidone-iodine is used, use swabs to apply in a circular motion, moving from the catheter insertion site outward in concentric circles... 12. Secure the catheter in place. The use of a sutureless stabilization device is preferred to tape and sutures. Agency Policy: Hand Hygiene Policy Number: 8.004 Revised Date: 5/01/19 Purpose To help prevent the spread of microorganisms and 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 following patient contact. Hand hygiene will be performed using soap and water or an alcohol-based hand sanitizer. Procedure: 1. Staff performs hand hygiene... b. Before performing an aseptic task ( ergo [e.g.], 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... 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, ( e.g., when taking vital signs, and lifting a patient)... Other aspects of Hand Hygiene: a. Wear gloves when contact with blood or other potentially infectious materials, mucous membranes, and non-intact skin could occur... c. Change gloves during patient care if moving from a contaminated body site to a clean body site. 2. HV # 5 was admitted to the agency on 3/19/26 with diagnoses including Pressure Ulcer Left Buttock, Unstageable and Encounter for Surgical Aftercare Following Surgery on the Skin Subcutaneous tissue. A review of the POC revealed SN visits once a week for nine weeks. A HV was conducted on 4/8/26 at 9:40 AM to observe EI # 2, Registered Nurse (RN), provide wound care. During the HV, the following was observed: a. EI # 2, failed to perform hand hygiene three times when performing wound care. b. EI # 2 cleaned the wound with wound cleanser and gauze then removed gloves. EI # 2 failed to perform hand hygiene after removing gloves. EI # 2 then donned clean gloves, measured the wound, obtained clean wound care supplies, performed wound care, then returned the unused wound care supplies to area where the clean wound care supplies were stored. EI # 2 removed gloves and without performing hand hygiene initialed and dated the wound dressing, measured the patients ankles, obtained cleaned equipment used during the visit and placed the clean equipment in the agency bag which contaminated the clean equipment. An interview was conducted on 4/9/26 at 2:37 PM with EI # 5, who confirmed staff did not perform hand hygiene per agency policy. 1. HV # 1 was admitted to the agency on 10/26/26 with diagnoses including Pressure Ulcer of Sacral Region Stage 4 and Pressure Ulcer of Left Buttock, Stage 3. A review of the Plan of Care (POC) for the certification period of 2/1/26 to 4/18/26 revealed skilled nurse (SN) visits were ordered one visit weekly for eight weeks, two visits every week for one week, and lastly one visit every week for one week. A HV was conducted on 4/7/26 at 1:08 PM with Employee Identifier (EI) # 6, Dothan Executive Director (ED) to observe the care provided by EI # 1, Registered Nurse. During the HV the following was observed: a. EI # 1 was observed to contaminate the sterile field during PICC line dressing change set up by opening a nonsterile normal saline flush labeled "do not place on a sterile field," on to the sterile field. b. EI # 1 failed to clean under the sutureless stabilizing device during the PICC line dressing change. A interview was conducted with EI # 5, Troy ED on 4/9/26 at 3:04 PM who confirmed that sterility was not maintained throughout the PICC line dressing changed, and proper cleaning techniques were not used while cleaning PICC line site.

A recertification survey was conducted on 5/2/23 to 5/4/23 and Troy Regional Medical Center Home Health was found to be in substantial compliance with the Conditions of Participation for Emergency Preparedness.

A recertification survey was conducted on 5/2/23 to 5/4/23 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 observations, agency policy and procedure, Medical Record (MR) review, and interviews it was determined the agency failed to ensure the medications were reconciled in two of five home visits including Home Visit (HV) # 2, HV # 3, and one of five MR's reviewed with Diabetes, including MR # 4. This deficient practice had the potential to affect all patients served by this agency. Findings include: Agency policy: Patient Assessment, Initial and Reassessment Policy number: 2.1.002 Revised: 3/1/22 ...Procedure: Upon admission and reassessments, the qualified clinician performs the following assessment activities... e. Review of all medications patient is currently using in order to identify any potential adverse effects and drug reactions... 2. HV # 3 was admitted to the agency on 4/7/23 with diagnoses including Encounter for Change or Removal of Surgical Wound Dressing, Encounter for Surgical Aftercare Following Surgery on the Genitourinary System and Type 2 Diabetes Mellitus without Complications. Review of the HHC and POC dated 4/7/23 to 6/5/23 revealed a Skilled Nurse (SN) frequency of twice a week for one week then three times a week for one week then twice a week for seven weeks. A HV was conducted on 5/3/23 at 8:45 AM with EI # 5, Licensed Practical Nurse, to observe wound care provided. During the observation, a review of the medications in the home was conducted. Review of the agency CMR revealed Testosterone Cypionate 200 mg/ml (milliliter) 2 ml Intramuscular (IM) monthly. The patient verbalized he/she had not taken the Testosterone since March 23. An interview was conducted on 5/4/23 at 11:21 AM with EI # 2, who confirmed the agency staff failed to ensure the medications in the home were reconciled per the agency policy. 3. MR # 4 was admitted to the agency on 1/4/23 with diagnoses including Influenza Due to Other Identified Influenza Virus with Other Specified Pneumonia and Type 1 Diabetes with Diabetic Peripheral Angiopathy without Gangrene. Review of the HHC and POC dated 1/4/23 to 3/4/23 revealed a SN frequency of once a week for nine weeks. Review of the SN Visit Note Report (VNR) dated 1/19/23 revealed the patient had an insulin pump which contained Humalog insulin. Review of the agency CMR revealed no documentation of the Humalog insulin. An interview was conducted on 5/4/23 at 11:33 PM with EI # 2, who confirmed there was no documentation of the Humalog insulin on the agency CMR. 1. HV # 2 was admitted to the agency on 3/8/23 with diagnoses including Unspecified Chronic Bronchitis, Hypertensive Heart and Chronic Kidney Disease, and Heart Failure. Review of the Home Health Certification and Plan of Care (HHC and POC) dated 3/8/23 revealed a Physical Therapy (PT) frequency of one visit per week for four weeks and a Occupational Therapy (OT) frequency of one visit per week for eight weeks. A HV was conducted on 5/2/23 to observe care provided by Employee Identifier (EI) # 4, Occupational Therapist. EI # 1, Executive Director, was also present during the HV. A review of the medications in the home revealed prescription bottles for Tavalisse 100 milligrams (mg) take one every morning and Tavalisse 150 mg take one every afternoon. Review of the CMR (Client Medication Report) revealed Tavalisse 100 mg twice a day was discontinued on 3/6/23. There was no order for Tavalisse 150 mg. An interview was conducted on 5/2/23 at 4:05 PM with HV # 2, who stated he/she had been taking the Tavalisse 100 mg every morning and Tavalisse 150 mg every night for two years. An interview was conducted on 5/4/23 at 10:41 AM with EI # 2, Executive Director, sister agency, who confirmed the medications had not been reconciled per agency policy.

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 medical records (MR) agency policies and procedures and staff interviews it was determined the agency staff failed to document the following per the physician orders: 1. Weight 2. Blood sugar 3. Oxygen saturation This deficient practice did affect three of thirteen records reviewed, including Home Visit (HV) # 3, MR # 8, MR # 5 and had the potential to affect all patient's served by the agency. Findings include: Agency Policy: Plan of Care (POC) Policy Number: 2.1.007 Revised Date: 12/1/21 Purpose: ...To ensure that physician/authorized practitioner's orders are followed. Policy: Each patient has an individualized POC developed in consultation with the...physician...to address specific services being provided. Procedure: ...2. The POC includes: ...i. Patient specific interventions... Agency Policy: Physician Orders Policy Number: 2.1.008 Revised Date: 4/1/23 ...Procedure: ...10. Services are provided according to the most recent orders... 1. HV # 3 was admitted to the agency on 4/7/23 with diagnoses including Encounter for Change or Removal of Surgical Wound Dressing, Encounter for Surgical Aftercare Following Surgery on the Genitourinary System and Type 2 Diabetes Mellitus without Complications. Review of the Home Health Certification (HHC) and POC dated 4/7/23 to 6/5/23 revealed a physician order for Skilled Nurse (SN) visits twice a week for one week then three times a week for one week then twice weekly for seven weeks. Further review revealed an order for the patient or caregiver to perform blood glucose testing daily and the licensed professional was to report a fasting blood sugar below 70 or above 250 or a random blood sugar below 70 or above 300 to the physician. Review of nine SN Visit Note Reports (VNR) dated 4/7/23 to 4/26/23 revealed no documentation of a blood sugar reading to ensure the patient's blood sugar was within the physician ordered parameters. An interview was conducted on 5/4/23 at 11:21 AM with Employee Identifier (EI) # 2, Executive Director, sister agency, who confirmed there was no documentation of the blood sugar reading to ensure the patient's blood sugar was within the physician ordered parameters. 2. MR # 8 was admitted to the agency on 4/11/23 with diagnoses including Pneumonia, Unspecified Organism, Heart Failure, Unspecified and Type 2 Diabetes mellitus with Diabetic Chronic Kidney Disease. Review of the HHC and POC dated 4/11/23 to 6/9/23 revealed a physician order for the SN twice a week for one week then weekly for eight weeks. Further review revealed an order for the patient or caregiver to obtain the patient's weight every morning and notify the physician of a weight gain of two pounds in a day, five pounds within seven days, below 283 or above 293. Review of the SN VNR dated 4/14/23 revealed no documentation of a weight to ensure the patient's weight was within the physician ordered parameters. An interview was conducted on 5/4/23 at 11:38 AM with EI # 2, who confirmed there was no documentation of a weight to ensure the patient's weight was within the physician ordered parameters. 3. MR # 5 was admitted to the agency on 2/15/23, and recertified for continued care from 4/16/23 to 6/14/223, with diagnoses including Type 2 Diabetes Mellitus with Hyperglycemia and Unspecified Systolic (Congestive) Heart Failure. Review of the HHC and POC dated 4/16/23 to 6/14/23 revealed a physician order for a weekly SN visit and for the SN to perform pulse oximetry to monitor the patient's respiratory status. Review of the SN VNR's dated 4/20/23 and 4/28/23 revealed no documentation of a pulse oximetry reading. An interview was conducted on 5/4/23 at 11:32 AM with EI # 2, who confirmed there was no documentation of a pulse oximetry reading.

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 interviews it was determined the agency failed to ensure the physician was promptly notified of: 1. A new wound. 2. Blood sugar reading outside of therapeutic range. 3. Need to increase Skilled Nursing visit frequency. 4. No blood sugar monitor in the home. This deficient practice affected three of thirteen records reviewed, including Home Visit (HV) # 2, MR # 8 and HV # 3 and had the potential to affect all patients admitted to this agency. Findings include: Agency policy: Coordination of Care, From Admit Through Discharge Policy number: 2.1.017 Revised: 4/1/23 ...Policy: The agency provides care and services within an integrated continuum of care system. This is accomplished by: ...Coordinating patient care among various disciplines to ensure that services are continuous and coordinated from admission through discharge. Procedure... Coordination of care with physician: At admission, throughout care... coordination of services is promoted through routine communication with the patient's physician: a. When changes occur in the patient condition... ...e. When there is a need to change the patient's plan of care. 5. Coordination of care among disciplines:... i. All clinicians will report within 1 (one) business day to the Patient Care Manager or Clinical Director...Significant changes in the patient's condition... 2. MR # 8 was admitted to the agency on 4/11/23 with diagnoses including Pneumonia, Unspecified Organism, Heart Failure, Unspecified and Type 2 Diabetes mellitus with Diabetic Chronic Kidney Disease. Review of the HHC and POC dated 4/11/23 to 6/9/23 revealed a physician order for the patient or caregiver to perform blood glucose testing daily with a therapeutic range of 60 Milligrams per decilitre (mg/dL) to 120 mg/dl fasting. Review of the Skilled Nurse (SN) Visit Note Report (VNR) dated 4/24/23 revealed a fasting blood sugar of 124 mg/dl. There was no documentation the physician was notified of the fasting blood sugar outside of therapeutic range. Review of the SN VNR dated 5/1/23 revealed a fasting blood sugar of 140 mg/dl. There was no documentation the physician was notified of the fasting blood sugar outside of therapeutic range. An interview was conducted on 5/4/23 at 11:38 AM with EI # 2, who confirmed there was no documentation the physician was notified of the fasting blood sugars outside of the therapeutic range. 3. HV # 3 was admitted to the agency on 4/7/23 with diagnoses including Encounter for Change or Removal of Surgical Wound Dressing, Encounter for Surgical Aftercare Following Surgery on the Genitourinary System and Type 2 Diabetes Mellitus without Complications. Review of the HHC and POC dated 4/7/23 to 6/5/23 revealed physician orders for a SN frequency of twice a week for one week then three times a week for one week then twice a week for 7 weeks. Further review of the HHC and POC dated 4/7/23 to 6/5/23 revealed physician orders for the patient or caregiver to perform blood glucose testing daily and the licensed professional to report a fasting blood sugar below 70 or above 250 or a random blood sugar below 70 or above 300 to the physician. Further review of the HHC and POC dated 4/7/23 to 6/5/23 revealed the SN was to perform/instruct/reinforce the following wound care to be performed to wound # 1, surgical incision to the scrotum daily: Cleanse with Vashe (wound cleanser) and gauze, pat dry with gauze, cover with Vashe moistened gauze and dry gauze. Cover with abdominal pad and secure with undergarments. Review of the SN VNR dated 4/7/23 revealed SN documentation the patient did not have a caregiver to perform the wound care daily to wound # 1 and the SN was to perform the wound care per the physician orders of daily. There was no documentation the physician was notified to increased the SN visit to daily. Review of the SN VNRs dated 4/8/23 and 4/9/23 revealed the patient did not monitor the blood sugar at home. There was no documentation the physician was notified of the patient not monitoring the blood sugar at home. Review of the SN VNR dated 4/13/23 revealed the patient reported blood sugars were not being monitored because he/she had lost the blood sugar monitor. There was no documentation the physician was notified of the patient not monitoring the blood sugar at home. Review of the SN VNR dated 4/15/23 and 4/21/23 revealed the patient was not obtaining blood sugars due to there was no functioning blood sugar monitor in the patient home. There was no documentation the physician was notified of the patient's inability to obtain blood sugars. A HV was conducted on 5/3/23 at 8:45 AM with EI # 5, Licensed Practical Nurse, to observe wound care. During the observation, the patient was unable to obtain a blood sugar. There was no functioning blood sugar monitor in the home. An interview was conducted on 5/4/23 at 11:21 AM with EI # 2, who confirmed there was no documentation the care was coordinated with the physician to obtain the blood sugar monitor in the home and increase the SN visit frequency. 1. HV # 2 was admitted on 3/8/23 with diagnoses including Unspecified Chronic Bronchitis, Hypertensive Heart and Chronic Kidney Disease, and Heart Failure. Review of the Home Health Certification and Plan of Care (HHC and POC) dated 3/8/23 revealed orders for Physical Therapy (PT) one visit per week for four weeks and Occupational Therapy (OT) one visit per week for eight weeks. Review of the Oasis PT Admission note dated 3/8/23 revealed the Physical Therapist documented the presence or a skin tear to the anterior distal right mid pretibial area measuring 2 cm (centimeters) length, 2 cm width, and 0 cm depth, date of onset 3/8/23. There was no documentation the physician or nurse was promptly notified of the wound. An interview was conducted on 5/4/23 at 10:41 AM with Employee Identifier (EI) # 2, Executive Director, sister agency, who confirmed the staff failed to promptly notify the physician of the new wound.

Coordinate care delivery CFR(s): 484.60(d)(4) Coordinate care delivery to meet the patient's needs, and involve the patient, representative (if any), and caregiver(s), as appropriate, in the coordination of care activities. This ELEMENT is not met as evidenced by: Based on review of medical records (MR), agency policy and procedure, and interview it was determined staff failed to communicate with the physician, changes in the patient's (Pt) condition that required a change in the plan of care (POC). This deficient practice affected two of eight MR reviewed, including MR # 3 and Home Visit (HV) # 3, and had the potential to negatively affect all patients admitted to the agency. Findings include: Agency Policy: Coordination of Care, From Admit Through Discharge Policy Number 2.1.01 Revised Date: 04/01/23 ...Policy: The agency provides care and services within an integrated continuum of care system. This is accomplished by: Identifying Pt needs through assessment and communication with other health care providers. ...Coordinating patient care among various disciplines to ensure that services are continuous and coordinated from admission through discharge. Procedure... Coordination of care with physician: At admission, throughout care... coordination of services is promoted through routine communication with the patient's physician: a. When changes occur in the patient condition... ...e. When there is a need to change the patient's plan of care. ...In the event that a physician cannot be reached to communicate the status of a patient the following will occur: ...Pts with critical needs as determined by the clinician will be advised to seek emergency medical treatment 5. Coordination of care among disciplines:... i. All clinicians will report within one business day to the Patient Care Manager (PCM) or Clinical Director (CD) ...significant changes in the Pts condition ( i.e. new or worsening symptoms, new or changed orders...). 1. MR # 3 was admitted to the agency on 9/3/22 with diagnoses including Urinary Tract Infection, Site Not Specified and Hypertensive Chronic Kidney Disease with Stage one - four Unspecified Chronic Kidney Disease. Review of the Home Health Certification (HHC) and Plan of Care (POC) dated 9/3/22 to 11/1/22 revealed a skilled nurse (SN) frequency of once a week for nine weeks and a Physical Therapy (PT) frequency of one visit per week for one week then beginning 9/12/22 two visits per week for two week, then one visit per week for three weeks. Home Health Aide (HHA) two times per week for two weeks then one time per week for three weeks. Review of PT visit note dated 10/11/22 revealed the Pts caregiver stated "Pt has been making a gurgling sound when breathing today." "Pt unable to voice if in pain or not with Pt asleep and lethargic during treatment. Pt lethargic throughout treatment today. Unable to stay awake or follow simple commands. Pt. unsafe to attempt transfers today. Pt cg educated on proper bed mobility and positioning to decrease skin breakdown on bony prominences with 100% understanding." Further review of the PT visit note dated 10/11/22 revealed there was no documentation of communication regarding the change in the Pts condition with the other disciplines or the physician. An interview was conducted on 5/4/23 at 1108 with Employee Identifier (EI) # 1 Executive Director (ED) and EI # 2 ED, sister agency who confirmed there was no documentation the PT Assistant notified other disciplines of the change in the Pts condition.

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 the review of medical records (MR) and staff interviews it was determined the nurse failed to update the Aide (HHA) Plan of Care (POC). This deficient practice affected one of one MR's reviewed for an indwelling catheter, including MR # 7, and had the potential to affect all patients who received HHA services. 1. MR # 7 was admitted to the agency on 2/9/23, recertified for continued care from 4/10/23 to 6/8/23, with diagnoses including Pressure Ulcer of Right Heel, Stage 2 and Benign Prostatic Hyperplasia without lower urinary tract symptoms. Review of the Physician order dated 2/14/23 revealed an order to discontinue indwelling urinary catheter. Review of the HHA Care Plan Report dated 4/10/23 revealed the HHA was to perform routine catheter care at every visit. Review of the HHA Visit Note Report dated 4/13/23 revealed documentation the patient did not have a catheter, which was reported to the nurse. Review of the MR revealed no documentation the nurse had updated the HHA POC to discontinue the catheter care. An interview was conducted on 5/4/23 at 11:35 AM with Employee Identifier (EI) # 2, Executive Director, sister agency, who confirmed the patient's catheter was discontinued on 2/14/23 and the nurse failed to update the HHA POC.