Every finding on record at Lhcg Xciii LLC

An Emergency Preparedness recertification and re-licensure survey was conducted on 1/27/2025 to 1/29/2025. The facility meets all of the requirements for Emergency Preparedness. There were no deficiencies identified.

A recertification survey was conducted on 1/27/2025 to 1/29/2025. An entrance conference was held on 1/27/2025 at 9:15 AM, with the Executive Director. An exit conference was held on 1/29/2025 at 4:15 PM, with the agency's administration.

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, medical record review, observation and interview, the facility failed to ensure an updated and accurate medication profile for 7 of 7 (Patient #1, #2, #3, #4, #5, #6 and #7) sampled patients with home visits. The findings included: Based on policy review, medical record review, observation and interview, the facility failed to ensure an updated and accurate medication profile for 7 of 7 (Patient #1, #2, #3, #4, #5, #6 and #7) sampled patients with home visits. The findings included: 1. Review of the agency’s policy titled, “MONITORING MEDICATIONS,” dated 7/1/2024, revealed “…A drug regimen review will be performed on all patients in conjunction with all comprehensive assessment…the skilled nurse is responsible for medication review and reconciliation throughout the episode…the physician is contacted immediately if any discrepancies between agency information and patient medications are found…All clinicians participating in the patient’s care and responsible to assist with the maintenance of accurate patient medication information throughout the episode of care…Compare mediations patient is currently taking with medications ordered for the patient in order to identify and resolve discrepancies…The completed medication list will be provided and communicated to any authorized service provider, within or outside the organization 2. Record review for Patient #1 revealed a Start of Care (SOC) dated 10/17/2024 with diagnosis of Chronic Kidney Disease, Heart Failure, Diabetes, and Hypertension. Review of the Medicine List dated 1/28/2025 revealed Amiodarone (treat a fast or irregular heartbeat) 200 MG tablet 2 times daily and Centrium Silver (keep heart, brain and eye healthy) Woman 8 MG Iron (boost energy)-400 MCG (micrograms)-50 MCG tablet one daily. Observation during a home visit on 1/28/2024, revealed Amiodarone 200 Mg tablet one times daily, Refresh Liquigel (eye lubricant) eye drops 2 time daily as needed, Donepezil (treat dementia) 10 MG one daily, Hydralazine (help with allergic reactions) 100 MG tablet 2 times daily, Garlique (lowers blood pressure) one daily, Aspirin (prevent heart attack and strokes) 81 mg one daily, and Prevagen (supplement for memory enhancement) regular strength one daily. During an interview on 1/28/2025, Family Member #2 confirmed that Patient #1 started the Hydralazine on 1/13/2024, Donepezil on 12/5/2024, takes Amiodarone one daily, Refresh Liquigel takes twice a day as needed, Aspirin one daily, Prevagen one daily, and Garlique one daily. Record review for Patient #2 revealed a Start of Care (SOC) dated 12/4/2024 with diagnosis of Cystostomy, Urinary Tract Infection, Hypertension, Dementia, History of Falls, Atrial Fibrillation, and Chronic Kidney Disease. Review of the Medicine List dated 1/28/2025 revealed Potassium Chloride (treat low levels of potassium) 20 MEQ (milliequivalent) 0.5 daily, and Vitamin E (improve vision) (268 MG) (milligrams) one daily. Observation during a home visit on 1/28/2024, revealed Potassium Chloride 20 MEQ one tablet twice a day, Vitamin E 400 unit (180 Mg) daily, Trazodone 50 MG take 0.5 MG at bedtime and Clearlax (polyethylene Glycol) (constipation relief) 3350. Medical record review for Patient #3 revealed a Start of Care (SOC) date of 1/16/2025 with diagnoses of left hip infection, Chronic Obstructive Pulmonary Disease, Atrial Fibrillation, and Hypertension. Review of the Medicine List dated 1/28/2025 revealed Antacid (heartburn) 200 MG (As calcium carbonate 500 MG) chewable tablet (tab); 1 tab by mouth every 6 hours as needed, Aspirin 81 MG one daily, Eliquis 5 MG one 2 times a day, Lactobacillus and Acidophilus (bacterial regrowth) 0.5 MG 1 capsule (cap) daily, Observation during a home visit on 1/29/2024, revealed Oxycodone (mild to moderate pain) 5/325 MG one every 4 hours as needed, Probiotic (gut health) 30 billion one daily, Caltrate 600 MG Plus D3 one daily, Incruse Ellipta (relaxes muscle and improve breathing) 62.5 MCG one puff daily, and Multivitamin one daily. During an interview on 1/29/2025 at 11:45 AM, Patient #3 confirmed that she was no longer taking Antacid, Eliquis, Aspirin, and Lactobacillus. Patient #3 confirmed that the probiotic was ordered instead of the lactobacillus acidophilus. Patient #3 confirmed that she was started on Oxycodone 5/325 MG as needed, Multivitamin daily and the Incruse daily. Record review for Patient #4 revealed a Start of Care (SOC) dated 12/4/2024 with diagnosis of Covid -19 Osteoarthritis, Atrial Fibrillation, Hypertension and Polyneuropathy. Review of the Medicine List dated 1/29/2025, revealed Drisdol 1.250 MCG daily, Gabapentin 100 MG 3 time daily, and Reno Caps 1 MG daily. Observation during a home visit on 1/28/2025 at 11:45 AM, Registered Nurse (RN) #2 applied Mupirocin Ointment 2 % to each wound bed. Observation during a home visit on 1/29/2025, revealed Gabapentin 100 MG 4 time daily, Lutein 20 MG daily, Loratadine 10 MG daily, Biotin 5000 MCG daily, Tylenol 500 MG as needed, Refresh eye drops 3 times a day, Vitamin D3 5000 once a week, Mupirocin ointment weekly, and Iron 65 MG. During an interview on 1/28/2024 at 11:45 AM, the Clinical Director was asked when the Mupirocin ointment was started. The Clinical Director confirmed the Mupirocin was started on 1/24/2025 and the nurse must call the doctor to get any order for the medication. During an interview on 1/29/2025 at 2:00 PM, Family Member #4 provided a typed medication list and confirmed Patients #4’s additional medications. Family member #4 confirmed that Patient #3 no longer takes the Reno Capsules 1 MG daily and the Drisdol 1,250 MCG one daily. Record review for Patient #5 revealed a Start of Care (SOC) dated 1/21/2025 with diagnosis of Covid -19 Long term use of Aspirin, and Long-Term Use of Hypoglycemic Drugs. Review of the Medicine List dated 1/28/2025 revealed Fish Oil -Vit (vitamin) D3 29 MG (milligrams) -6 MG-133 MG-100 Unit daily, Multivitamin 50 Plus 50 mcg (micrograms) daily and Tylenol 650 Mg every 8 hours as needed. Observation during a home visit on 1/28/2025, revealed Vitamin D3 2000 Units (50 mcg) one daily, and the MiraLAX (used to relief constipation) one spoon as needed. During an interview on 1/28/2025 at 2:30 PM Family Member #3 was asked if Patient #5 was taking Fish Oil with Vitamin D3, Multivitamin, and Tylenol 650 Mg for pain as need. Family Member #3 stated, “…she takes the Vitamin D3 in a separate pill…she is not taking the Multivitamin…she stopped taking the Tylenol 650 mg ten days ago…” Family Member #3 was asked if Patient #5 took any other medication not listed. Family Member #3 stated, “…she takes MiraLAX one spoon full as need for constipation…” Medical record review for Patient #6 revealed a Start of Care (SOC) date of 12/11/2024 with Quadriplegia, Pressure Ulcers, Hypertension, Suprapubic Catheter, Colostomy, and Tracheostomy. Review of the Medicine List dated 1/28/2025 revealed Albuterol Sulfate (wheezing) 2.5 MG/3 ml (milliliter) 3 ml every 6 hours as needed, and Ondansetron (to treat nausea) 4 MG 1 tab every 6 hours as needed. During an interview on 1/29/2025 at 9:30 AM, Family Member #5 confirmed that Patient #6 had not been on the Albuterol for a while and was taken off the Ondansetron on 12/12/2024. Medical record review for Patient #7 revealed a Start of Care (SOC) date of 12/29/2024 with diagnoses of Chronic Obstructive Pulmonary Disease, Acute Respiratory Failure, Heart failure, and Diabetes. Review of the Medicine List dated 1/28/2025 revealed Tylenol (moderate pain) 325 MG 2 tablets every 8 hours as needed. Observation during a home visit on 1/29/2025, revealed Sodium Bicarbonate (neutralize the stomach acid) 650 MG one tablet 2 times a day, Mucinex (thins bronchial secretions) 1200 MG one tablet every 12 hours as needed Tylenol (pain) 500 MG 2 tabs as needed, Promethazine 6.25 MG- 15 MG/ 5 ml twice daily as needed, Doxycycline (treat bacterial infections) 100 MG one capsule twice daily, MiraLAX (treat constipation)17 grams daily as needed, and Nystatin topical powder (treat yeast infection) 100,000 IU (International Units)/ gram twice daily. During an interview on 1/29/2025 at 1:30 PM, Patient #7 confirmed that she had a change in the Tylenol to 500 MG as needed, and taking Sodium Bicarbonate, Mucinex Promethazine, Doxycycline, MiraLAX, and the Nystatin. Based on policy review, medical record review, observation and interview, the facility failed to ensure an updated and accurate medication profile for 7 of 7 (Patient #1, #2, #3, #4, #5, #6 and #7) sampled patients with home visits. The findings included: 1. Review of the agency’s policy titled, “MONITORING MEDICATIONS,” dated 7/1/2024, revealed “…A drug regimen review will be performed on all patients in conjunction with all comprehensive assessment…the skilled nurse is responsible for medication review and reconciliation throughout the episode…the physician is contacted immediately if any discrepancies between agency information and patient medications are found…All clinicians participating in the patient’s care and responsible to assist with the maintenance of accurate patient medication information throughout the episode of care…Compare mediations patient is currently taking with medications ordered for the patient in order to identify and resolve discrepancies…The completed medication list will be provided and communicated to any authorized service provider, within or outside the organization..." 2. Record review for Patient #1 revealed a Start of Care (SOC) dated 10/17/2024 with diagnosis of Chronic Kidney Disease, Heart Failure, Diabetes, and Hypertension. Review of the Medicine List dated 1/28/2025 revealed Amiodarone (treat a fast or irregular heartbeat) 200 MG [milligram] tablet 2 times daily and Centrium Silver (supplement) Woman 8 MG Iron (boost energy)-400 MCG (micrograms)-50 MCG tablet one daily. Observation during a home visit on 1/28/2024, revealed Amiodarone 200 Mg tablet one times daily, Refresh Liquigel (eye lubricant) eye drops 2 time daily as needed, Donepezil (treat dementia) 10 MG one daily, Hydralazine (antihypertensive) 100 MG tablet 2 times daily, Garlique (lowers blood pressure) one daily, Aspirin (prevent heart attack and strokes) 81 mg one daily, and Prevagen (supplement for memory enhancement) regular strength one daily. During an interview on 1/28/2025, Family Member #2 confirmed that Patient #1 started the Hydralazine on 1/13/2024, Donepezil on 12/5/2024, takes Amiodarone one daily, Refresh Liquigel takes twice a day as needed, Aspirin one daily, Prevagen one daily, and Garlique one daily. Record review for Patient #2 revealed a Start of Care dated 12/4/2024 with diagnosis of Cystostomy, Urinary Tract Infection, Hypertension, Dementia, History of Falls, Atrial Fibrillation, and Chronic Kidney Disease. Review of the Medicine List dated 1/28/2025 revealed Potassium Chloride (supplement) 20 MEQ (milliequivalent) 0.5 daily, and Vitamin E (supplement) (268 MG) (milligrams) one daily. Observation during a home visit on 1/28/2024, revealed Potassium Chloride 20 MEQ one tablet twice a day, Vitamin E 400 unit (180 Mg) daily, Trazodone [antidepressant] 50 MG take 0.5 MG at bedtime and Clearlax (polyethylene Glycol) (constipation relief) 3350. Medical record review for Patient #3 revealed a Start of Care (SOC) date of 1/16/2025 with diagnoses of left hip infection, Chronic Obstructive Pulmonary Disease, Atrial Fibrillation, and Hypertension. Review of the Medicine List dated 1/28/2025 revealed Antacid (heartburn) 200 MG (As calcium carbonate 500 MG) chewable tablet (tab); 1 tab by mouth every 6 hours as needed, Aspirin 81 MG one daily, Eliquis [anticoagulant] 5 MG one 2 times a day, Lactobacillus and Acidophilus (bacterial regrowth) 0.5 MG 1 capsule (cap) daily, Observation during a home visit on 1/29/2024, revealed Oxycodone (mild to moderate pain) 5/325 MG one every 4 hours as needed, Probiotic (gut health) 30 billion one daily, Caltrate 600 MG Plus D3 [supplement] one daily, Incruse Ellipta (relaxes muscle and improve breathing) 62.5 MCG one puff daily, and Multivitamin one daily. During an interview on 1/29/2025 at 11:45 AM, Patient #3 confirmed that she was no longer taking Antacid, Eliquis, Aspirin, and Lactobacillus. Patient #3 confirmed that the probiotic was ordered instead of the lactobacillus acidophilus. Patient #3 confirmed that she was started on Oxycodone [narcotic] 5/325 MG as needed, Multivitamin daily and the Incruse daily. Record review for Patient #4 revealed a Start of Care (SOC) dated 12/4/2024 with diagnosis of Covid -19 Osteoarthritis, Atrial Fibrillation, Hypertension and Polyneuropathy. Review of the Medicine List dated 1/29/2025, revealed Drisdol [supplement] 1.250 MCG daily, Gabapentin [treats seizures and pain] 100 MG 3 time daily, and Reno Caps [supplement] 1 MG daily. Observation during a home visit on 1/28/2025 at 11:45 AM, Registered Nurse (RN) #2 applied Mupirocin Ointment [antibiotic ointment] 2 % to each wound bed. Observation during a home visit on 1/29/2025, revealed Gabapentin 100 MG 4 time daily, Lutein 20 MG daily, Loratadine [treats allergy] 10 MG daily, Biotin [supplement] 5000 MCG daily, Tylenol [analgesic] 500 MG as needed, Refresh eye drops 3 times a day, Vitamin D3 5000 once a week, Mupirocin ointment weekly, and Iron 65 MG. During an interview on 1/28/2024 at 11:45 AM, the Clinical Director was asked when the Mupirocin ointment was started. The Clinical Director confirmed the Mupirocin was started on 1/24/2025 and the nurse must call the doctor to get any order for the medication. During an interview on 1/29/2025 at 2:00 PM, Family Member #4 provided a typed medication list and confirmed Patients #4’s additional medications. Family member #4 confirmed that Patient #3 no longer takes the Reno Capsules 1 MG daily and the Drisdol 1,250 MCG one daily. Record review for Patient #5 revealed a Start of Care (SOC) dated 1/21/2025 with diagnosis of Covid -19 Long term use of Aspirin, and Long-Term Use of Hypoglycemic Drugs. Review of the Medicine List dated 1/28/2025 revealed Fish Oil -Vit (vitamin) D3 29 MG (milligrams) -6 MG-133 MG-100 Unit daily, Multivitamin 50 Plus 50 mcg (micrograms) daily and Tylenol 650 Mg every 8 hours as needed. Observation during a home visit on 1/28/2025, revealed Vitamin D3 2000 Units (50 mcg) one daily, and the MiraLAX (used to relief constipation) one spoon as needed. During an interview on 1/28/2025 at 2:30 PM Family Member #3 was asked if Patient #5 was taking Fish Oil with Vitamin D3, Multivitamin, and Tylenol 650 Mg for pain as need. Family Member #3 stated, “…she takes the Vitamin D3 in a separate pill…she is not taking the Multivitamin…she stopped taking the Tylenol 650 mg ten days ago…” Family Member #3 was asked if Patient #5 took any other medication not listed. Family Member #3 stated, “…she takes MiraLAX one spoon full as need for constipation…” Medical record review for Patient #6 revealed a Start of Care (SOC) date of 12/11/2024 with Quadriplegia, Pressure Ulcers, Hypertension, Suprapubic Catheter, Colostomy, and Tracheostomy. Review of the Medicine List dated 1/28/2025 revealed Albuterol Sulfate (wheezing) 2.5 MG/3 ml (milliliter) 3 ml every 6 hours as needed, and Ondansetron (to treat nausea) 4 MG 1 tab every 6 hours as needed. During an interview on 1/29/2025 at 9:30 AM, Family Member #5 confirmed that Patient #6 had not been on the Albuterol for a while and was taken off the Ondansetron on 12/12/2024. Medical record review for Patient #7 revealed a Start of Care (SOC) date of 12/29/2024 with diagnoses of Chronic Obstructive Pulmonary Disease, Acute Respiratory Failure, Heart failure, and Diabetes. Review of the Medicine List dated 1/28/2025 revealed Tylenol (moderate pain) 325 MG 2 tablets every 8 hours as needed. Observation during a home visit on 1/29/2025, revealed Sodium Bicarbonate (neutralize the stomach acid) 650 MG one tablet 2 times a day, Mucinex (thins bronchial secretions) 1200 MG one tablet every 12 hours as needed Tylenol (pain) 500 MG 2 tabs as needed, Promethazine 6.25 MG- 15 MG/ 5 ml twice daily as needed, Doxycycline (treat bacterial infections) 100 MG one capsule twice daily, MiraLAX (treat constipation)17 grams daily as needed, and Nystatin topical powder (treat yeast infection) 100,000 IU (International Units)/ gram twice daily. During an interview on 1/29/2025 at 1:30 PM, Patient #7 confirmed that she had a change in the Tylenol to 500 MG as needed, and taking Sodium Bicarbonate, Mucinex Promethazine, Doxycycline, MiraLAX, and the Nystatin.

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, medical record review, and interview, the agency failed to follow the plan of care and notify the responsible physician for missed visits for 6 of 17 (Patient #3, #6, #7, #9, #11 and #12) sampled records reviewed. The findings included: Review of the agency's "Physician Orders," policy dated 10/1/2023, revealed, "...No medications, treatments, diagnostic studies or therapeutics will be administered without the order of a qualified physician or authorized practitioner..." Review of the agency's "Coordination of Care, From Admit Through Discharge," policy dated 9/1/2024, revealed, "...To establish processes and criteria so that the coordination of patient care will be optimal from admit through discharge... Coordination of care among disciplines and between in-person and virtual clinicians. Patient care is coordinated among various disciplines and services through care planning processes to ensure continuity of care from admission to discharge... All clinicians will report within 1 business day to the Patient Care Manager or Clinical Director by fax, telephone, in person at the agency, or through coordination notes by syncing point of care devices. Report will include... Missed visits and changes to scheduled visits... Reason for missed visit... Changes to patient schedule...| 2. Record review for Patient #3 revealed a Start of Care (SOC) of 1/16/2025 with diagnoses of a Left Hip Infection, Chronic Obstructive Pulmonary Disease, Atrial Fibrillation, and Hypertension. Review of the Home Health Certification and Plan of Care dated 1/16/2025 to 3/16/2025 revealed, "...OT [Occupational Therapy] effective 1/19/2025 1wk1 [1 time a week for 1 week]..." Review of the medical record for the week of 1/19/2025 revealed there was no documentation of an OT evaluation. During an interview on 1/28/2025 at 11:25 AM, the Executive Director (ED) confirmed there was a missed OT visit. 3. Record review for Patient #6 revealed a SOC of 12/29/2024 with diagnoses of Chronic Obstructive Pulmonary Disease, Diabetes Mellitus, Hypertensive Heart Disease with Heart Failure, and History of Nicotine Dependence. Review of the Coordination Note dated 12/29/2024 revealed, "... OT visit missed... no answer to door...| Review of the medical record for Patient #6 did not document an OT evaluation. During an interview on 1/29/2025 at 9:55 AM, the ED stated, "... the OT visit should have gotten rescheduled..." 4. Record review for Patient #7 revealed a SOC of 12/11/2024 with diagnoses of Stage 4 Pressure Ulcers on Left Buttock and Sacrum, Severe Protein Malnutrition, Morbid Obesity, Chronic Respiratory Failure, Hypertension and Depression. Review of the Home Health Certification and Plan of Care dated 12/11/2024 to 2/8/2025 revealed, "... SN [Skilled Nurse] 2wk1 [2 times a week for 1 week], 3 wk 8... Skilled nurse to perform and instruct patient/caregiver procedure of wound care to sacrum...| Review of the Wound Care Assessments dated 12/18/2024, 12/20/2024, 12/23/2024, 12/24/2024, 12/27/2024, 1/2/2025, 1/4/2025, 1/9/2025, 1/15/2025, 1/17/2025, and 1/22/2025 revealed no wound measurements for Patient #7's sacral wound. During an interview on 1/29/2025 at 9:50 AM, the ED stated, "she [Nurse] did the entire assessment of the sacral wound but didn't document any measurements. She [Nurse] knows better than that..." 5. Record review for Patient #9 revealed a SOC of 12/12/2024 with diagnoses of Hypertensive Heart and Kidney Disease with Heart Failure, Diabetes mellitus, and Spinal Stenosis. Review of the Home Health Certification and Plan of Care dated 12/12/2024 to 2/9/2024 revealed, "...OT effective 12/15/2024 1wk1...| Review of the medical record for Patient #9 revealed no documentation an OT evaluation was completed. During an interview on 1/29/2025 at 10:00 AM the ED stated, "... I do not see where OT saw the patient. The Physician should be notified. Physical Therapy calls the MD [Medical Doctor] with their evaluation and are supposed to put on the order PT can handle OT needs..." 6. Record review for Patient #11 revealed a SOC of 12/3/2024 with diagnoses of Diabetes Mellitus, Hypertensive Heart Disease with Heart Failure, Morbid Obesity, and Chronic Respiratory Failure with Hypoxia. Review of the Home Health Certification and Plan of Care dated 12/3/2024 to 1/31/2025 revealed, "... Skilled Nurse to perform/instruct patient/caregiver procedure of wound care..." Review of the Wound Care Assessment dated 1/7/2025 documented, "... Caregiver completed care..." During an interview on 1/29/2025 at 10:05 AM, the ED stated, "... I expect a head-to-toe assessment every visit..." 7. Record review for Patient #12 revealed a SOC 10/28/2024 with diagnoses of Stage 2 Sacral Pressure Injury, Respiratory Failure, Atrial Fibrillation, Heart Failure, Chronic Obstructive Pulmonary Disease, and Depression. Review of the Home Health Certification and Plan of Care dated 10/26/2024 to 12/26/2024 revealed "... Skilled nurse to obtain weight every visit and notify RN/Physician of weight gain or loss of 3 lb [pounds] within 1 day or 5 lbs within one week..." Review of the Coordination Notes dated 10/31/2024 and 11/14/2024 revealed no documentation of Patient #12's weight during the home health visit. During an interview on 1/29/2025 at 10:10 AM, the ED stated, "... unless the patient can't stand, weights should be obtained as ordered..." The ED also stated, "... the OT order came in on the intake referral and should have been included on the Home Health Certification and Plan of Care... It appears that OT is not getting rescheduled when they miss a visit... After PT [physical therapy] evaluated the patient, they can write an order that PT can handle the patient's OT needs, but I don't even see that in the order...|

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 review of records, policy review, observations, and interviews, the agency failed to ensure that sterile technique was used during catheter change and central line dressing change for 2 of 7 (Patient #2 and #3) sampled patients receiving onsite home visits during the survey. The findings included: The findings included: Medical record review for Patient # 3 revealed a Start of Care (SOC) date of 1/16/2025 with diagnoses of left hip infection, Chronic Obstructive Pulmonary Disease, Atrial Fibrillation, and Hypertension. Review of the “HOME HEALTH CERTIFICATION AND PLAN OF CARE” dated 1/16/2025 through 3/16/2025, revealed “…SKILLED NURSE TO PERFORM SITE CARE FOR INFUSION ACCESS DEVICE PICC [A Peripherally Inserted Central Catheter used obtain blood samples and administer medications] LINE TO RIGHT ARM WITH TEGADERM [A transparent adhesive dressing] DRESSING CHANGES ONCE A WEEK…USING STERILE TECHNIQUE CLEANSE SITE WITH CHLORHEXIDINE. SERURE WITH STATLOCK, APPLY ANTIMICROIAL DISK, COVER WITH TEGADERM…” Review of the agency’s policy, “DRESSING CHANGE PROCEDURE FOR VENTRAL VENOUS, MIDLINE, AND PERIPHERALLY INSERTED CENTRAL CATHETERS” revealed, “…Sterility will be maintained throughout this procedure…PROCEDURE:…Perform hand hygiene and don PPE (e.g., clean gloves and mask)…To remove old dressing, lift edge of dressing beginning at catheter hub and gently pull dressing perpendicular to skin…Remove catheter securement device [Statlock] and chlorhexidine-impregnated sponge [Biopatch]…Discard dressing in appropriate receptacle. Remove gloves, perform hand hygiene, and don sterile gloves…Cleanse site with chlorhexidine (preferred) in a back and forth motion…moving from the catheter insertion site outward…Consider application of chlorhexidine-impregnated sponge [Biopatch] to the site…Secure the catheter in place…Apply sterile dressing to site…” Observations during a home visit on 1/29/2025, revealed during a PICC line dressing change, Registered Nurse (RN) #3 peeled away the old PICC line dressing from Patient #3’s right upper arm. RN #3 did not discard the Statlock, Biopatch, and Tegaderm dressing. RN #3 placed the old dressing back onto the PICC line site. RN #3 removed her gloves and did not perform hand hygiene. RN #3 partially opened the PICC line dressing tray, removed the sterile glove package and a mask from inside the sterile dressing tray. RN #3 placed the sterile glove package directly on the table and then placed the mask over Patient #3’s nose and mouth. After hand sanitization, RN #3 opened the sterile glove package and then completely removed the lid from the PICC line dressing tray. RN #3 donned the sterile gloves and placed the tray on a drape. Using sterile gloves, RN #3 removed the old dressing from the PICC line site. RN #3 removed the chlorhexidine from the sterile tray. Moving counterclockwise, RN #3 wiped above and around the PICC line in a back-and-forth motion. RN #3 did not begin at the insertion site when cleansing with chlorhexidine, and she did not lift the PICC line dressing to cleanse beneath the insertion site. After placing the Statlock, RN #3 placed the Tegaderm over the PICC line site but did not place the Biopatch around the PICC line catheter at the insertion site. The Nurse Manager opened a Biopatch package and RN #3 pulled the Biopatch from the package and place the Biopatch at the PICC line insertion site. During an interview on 1/29/2025 at 12:45 PM, The Clinical Director confirmed that the PICC line site should be cleansed from the insertion site outward. During an interview on 1/29/2025 at 4:00 PM, the Executive Director confirmed that RN #3 should recleaned the PICC line site before placing a new dressing. Review of the facility’s policy titled “Agency “HAND HYGIENE,” dated 5/1/2019, revealed “…To help prevent the spread of microorganisms and infection by cross-contamination and to provide practice guidelines…Staff performs hand hygiene by …using and alcohol based hand sanitizer…before and after removal of personal protective equipment (PPE) Review of the facility’s policy titled “Agency “EXPOSURE CONTROL PLAN,” dated 5/1/2024, revealed “…Sharps…An object which can penetrate the skin…Sharps with Engineered Sharps Injury Protections…A non-need sharp or a needle device used for withdrawing body fluids, accessing a vein or artery…with build-in safety features or mechanism that effectively reduces the risk of an exposed incident…” Record review for Patient #2 revealed a Start of Care (SOC) dated 12/4/2024 with diagnosis of Cystostomy, Urinary Tract Infection, Hypertension, Dementia, History of Falls, Atrial Fibrillation, and Chronic Kidney Disease. Observation during a home visit on 1/28/2025 at 9:49 AM, revealed Patient # sitting in recliner with lower extremities elevated and covered with blanket. RN #1 donned pair of gloves and performed physical assessment on Patient #2. RN #1 removed her gloves and donned a new pair of gloves and failed to perform hand hygiene. RN #1 gathered supplies for venipuncture and placed the bag of supplies on Patient #2 blanket. RN #1 removed the supplies from the plastic bag and place the supplies on top of Patient #2 blanket. RN #1 made two attempts to obtain the blood samples and laid the Vacutainer with the butterfly needle (a device used to access a vein for drawing blood) with the needle exposed on Patient #2 blanket and failed to pull up the safety retractable features. RN #1 gathered the dirty supplies and place the Vacutainer in the sharps box. RN #1 assisted Patient #2 to the bed to change the suprapubic catheter change. RN #1 donned a pair of gloves and place the used catheter bag on top of the bed. RN #1 placed the catheter tray, the catheter bag and tubing and placed on Patient #2 bed without a barrier. RN #1 failed to change her gloves and perform hand hygiene before opening the new catheter tray. RN #1 opened the sterile catheter tray, donned her sterile gloves, opened the catheter tubing, and laid the end of the connecting tubing on the outside of the package without connecting the tubing to the drainage bag. RN #1 removed her sterile gloves place the used sterile gloves on top of a pile of clean gloves the family provided. RN #1 donned a new pair of clean gloves, deflated the bulb using a 10 CC syringe. RN #1 removed the suprapubic catheter and placed the bedside drainage bag with the catheter attached next to Patient #2. RN #1 removed her gloves, obtain a pair of gloves from an opened catheter kit provided by the family. RN #1 donned the gloves from the opened kit and failed to perform hand hygiene. RN #1 inserted the suprapubic catheter, obtained the 10 cc of syringe filled with normal saline and reinflate the old catheter balloon with approximately 3 cc of fluid, detached the syringe and placed the syringe on the new catheter and inflated the new ballon. RN #1 failed to obtain a new syringe to inflate the new catheter balloon.

Discharge and transfer summaries CFR(s): 484.110(a)(6)(i-iii) (i) A completed discharge summary that is sent to the primary care practitioner or other health care professional who will be responsible for providing care and services to the patient after discharge from the HHA (if any) within 5 business days of the patient's discharge; or (ii) A completed transfer summary that is sent within 2 business days of a planned transfer, if the patient's care will be immediately continued in a health care facility; or (iii) A completed transfer summary that is sent within 2 business days of becoming aware of an unplanned transfer, if the patient is still receiving care in a health care facility at the time when the HHA becomes aware of the transfer. This ELEMENT is not met as evidenced by: Based on policy review, medical record review and interview, the agency failed to ensure a discharge summary was sent to the physician or other healthcare professional responsible for care after discharge from the agency within 5 days of discharge and 2 days for transfers for 3 of 5 (Patient #13. #14. and #16) sampled discharged patients. The findings included: 1. Review of the Agency’s policy titled “ “PATIENT DISCHARGE/TRANSFER PROCESS,” dated 10/1/2023, revealed “…To ensure continuity of care when a patient is discharged, transferred, or referred…A Transfer Summary is sent to the primary care physician and the facility (if the patient is still receiving care in the facility at the time of agency becomes aware of the transfer) to which the patient is transferred within 2 business days of planned transfer or becoming aware of the unplanned transfer…A discharge summary including admission and discharge dated, reason for admission to home health, reason for discharge, services provided to the patient, patient’s condition at time of discharge, a brief summary of care provided, progress towards goals, patient’s discharge goals of care, patient’s treatment preferences, a list of community resources or referrals or other healthcare professional responsible for care after discharge from the agency within 5 business days of patient’s discharge…” 2. Record review for Patient #13 revealed a Start of Care (SOC) dated 12/13/2023 with diagnosis of Pressure Ulcer of Right Buttock Stage 1, Atrial Fibrillation, Diabetes, Hypertension, Dependence on Supplemental Oxygen, and Chronic Obstructive Pulmonary Disease. The facility discharge date was 10/30/2024. The discharge summary was sent to the physician or other healthcare professional responsible for care on 11/7/2024. Record review for Patient #14 revealed a Start of Care (SOC) dated 7/2/2024 with diagnosis of Heart Transplant Status, Heart Failure, Depression, and Chronic Kidney Disease. The facility discharge date was 10/29/2024. The discharge summary was sent to the physician or other healthcare professional responsible for care on 12/30/2024. Record review for Patient #16 revealed a Start of Care (SOC) dated 11/6/2024 with diagnosis of Diabetes, Hypertension, Anxiety Disorder, and Quadriplegia. The facility discharge date was 11/7/2024. There was no documentation the discharge summary was sent to the physician or other healthcare professional responsible for care. 3. During an interview on 1/28/2025 at 9:06 AM, the Executive Director confirmed that the patient’s discharge summaries should have been completed with in 5 days and the transfer summaries should have been completed in 2 days

An Emergency Preparedness recertification and re-licensure survey was conducted on 5/13/2023-5/16/2023. The facility meets all of the requirements for Emergency Preparedness. There were no deficiencies identified.

A recertification survey was conducted 6/13/2023 - 6/16/2023. An entrance conference was held on 6/13/2023 at 8:15 AM with the Executive Director. An exit conference was held on 6/16/2023 at 3:30 PM with the Executive Director, Clinical Manager and the agency's administration.

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, medical record review, and interview, the agency failed to update the medication profile for 6 of 7 (Patient #4, #6, #7, #10, #12, and #14) patients reviewed. The findings included: 1. Review of the agencies "Monitoring Medications," last revised 5/1/2019, revealed "...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. For patients receiving skilled nursing and therapy services, the skilled nurse is responsible for medication review and reconciliation throughout the episode. The therapist will participate by monitoring and reporting any identified medication issues or non-compliance to the Patient Care Manager. For patients receiving only therapy services, the therapist is responsible to facilitate drug regimen review and medication reconciliation throughout the episode...The physician is contacted immediately if any discrepancies between agency information and patient medications are found..." 2. Review of the medical record revealed Patient #4 was admitted to the agency on 10/28/2022 with diagnoses of Left Heel Stage 3 Pressure Ulcer, Diabetes Mellitus, Heart Failure, Chronic Kidney Disease, and Panic Disorder. Review of the Home Health Certification and Plan of Care for Patient #4 revealed "...10/4/2022...Gabapentin [anticonvulsant] 100 mg [milligram]...oral daily; 10/11/2022...Jantoven [anticoagulant] 3 mg... oral...daily; and 8/16/2022...Trazadone 50 [antidepressant] mg... oral...bedtime..." Review of Patient #4's home medications revealed "...2/13/2023...Levothyroxine [hormone] 88 mcg [micrograms]...oral every day; over the counter [OTC] B12 [supplement] 2,500 mcg; 4/22/2023...Hydroxyzine [antihistamine] 25 mg (1-2 tablets) every day as needed for sleep; 6/5/2023...Gabapentin 600 mg orally twice daily; 5/1/2023...Januvia [antiglycemic] 50 mg orally every day; 4/22/2023...Warfarin [anticoagulant] 3 mg orally on Tuesday & Thursday, 1 1/2 tablet all other days..." During an interview with his wife on 6/14/2023 at 3:50 PM, she stated "...not taking [in reference to Januvia]... not taking any more [in reference to Trazadone] ..." During an interview with the Clinical Director on 6/14/2023 at 4:05 PM, she confirmed the medications had not been reconciled. 3. Review of the medical record revealed Patient #6 was admitted to the agency on 10/31/2022 with diagnoses of Urinary Tract Infection, Obstructive and Reflux Atrophy, Chronic Kidney Disease, Anxiety, depression, and Gout. Review of the Home Health Certification and Plan of Care for Patient #6 revealed "...3/18/2023...Tamsulosin [urinary retention] 0.4 mg... orally... bedtime, and 5/20/2022...Warfarin 2.5 mg... orally... daily..." Review of Patient # 6's home medications revealed "...1/10/2023...Sucralfate [treats ulcers] 1 mg... orally four times a day; OTC Vit D3 1000 IU (25 mcg); 9/29/2022... Clotrimazole [antifungal] 10 mg... lozenge; OTC Psyllium Husk [fiber]; 10/27/2022...Metoclopramide [antiemetic] 10 mg... orally... three times daily; 1/13/2020... Acetaminophen-Codeine analgesic] 300 mg-30 mg... orally every 4 hours as needed; 5/5/2020... Oxycodone/Acetaminophen 5-325 mg narcotic] orally... twice a day; 12/19/2022... Warfarin 1 mg orally every day; 5/12/2023... Gabapentin 300 mg... orally... three times a day; 1/7/2023...Oxybutynin [bladder relaxant] 10 mg... orally... twice daily; 5/19/2023... Warfarin 5 mg... orally... every day; 3/28/2023... Vit D2 [supplement] 50,000 IU... orally... once a week; and 4/18/2023... Nitrofurantoin Macro [antibiotic] 50 mg... orally... every day ..." During an interview with the Clinical Director on 6/14/2023 at 11:05 PM, she confirmed the medications had not been reconciled. 4. Review of the medical record revealed Patient #7 had been admitted to the agency on 4/26/2023 with diagnoses of Dislocation of Right Hip Prosthesis, End Stage Renal Disease, and Dependence on Renal Dialysis. Review of Patient #7's home medications revealed "...OTC Benadryl [antihistamine] 25 mg; OTC Turmeric [supplement]; OTC Naproxin [antiinflammatory] 220 mg; OTC Neuriva [supplement]; OTC Iron 45 mg; OTC Leg Cramps; OTC Icey Hot Spray and Roll On; 9/2/2022...Omeprazole [treats heart burn] 40 mg... oral... every day; OTC Aspirin 81 mg; OTC Equate stool softener; OTC Potassium 99 mg; and OTC B12 500 mcg..." During an interview with the Clinical Director on 6/14/2023 at 2:40 PM, she confirmed the medications had not been reconciled. 5. Review of the medical record revealed Patient #10 was admitted to the agency on 5/2/2023 with diagnoses of Heart Failure, Diabetes Mellitus, Chronic Kidney Disease, Stage 3, Atrial Fibrillation Dementia, and Anxiety. Review of the Home Health Certification and Plan of Care revealed "...4/12/2023...Atorvastatin 10 mg... oral...daily; and 4/12/2023...Potassium Chloride 20 meq [milli-equivalents]... oral...daily..." During an interview with Patient #10 on 6/14/2023 at 12:15, he confirmed he did no longer takes Atorvastatin and Potassium Chloride. Review of Patient #10's home medications revealed "...3/29/2023...Metformin [anti-glycemic] 500 mg...oral...at night; 4/1/2023...Losartan [antihypertensive] 100 mg...oral...every day; 3/8/2023...Isosorbide [antihypertensive] 60 mg...oral every morning; 4/11/2023...Simvastatin [treats high cholesterol] 20 mg...oral...at night; OTC B12 100 mcg; OTC D3 50 mcg (2,000IU); OTC Vit C 500 mg; and OTC Fish Oil 1000 mg..." During an interview with the Clinical Director on 6/14/2023 at 12:15 PM, she confirmed the medications had not been reconciled. 6. Review of the medical record revealed Patient #12 was admitted to the agency on 9/7/2022 with diagnoses of Bladder Disorder, Atrial Fibrillation, Heart Failure, Hypertension, Anxiety, Depression, and Chronic Obstructive Pulmonary Disease. Review of the Home Health Certification and Plan of Care revealed "...3/21/2022...Flovent HFA 110 mcg/Actuation Aerosol Inhaler...2 times a day; 2/2/2022...Sertraline [antidepressant] 50 mg... orally... daily; and 4/20/2021...Trazadone 50 mg... orally... bedtime..." During an interview with Patient #12 on 6/14/2023 at 8:40 PM, he stated he no longer takes Sertraline 50 mg or use Flovent Inhaler. Review of Patient #12's home medications revealed "...OTC Tylenol 650 mg; OTC Afrin; OTC Equate Eye Drops; 11/13/2022...Trazadone 50 mg by mouth; 4/11/2023...Sertraline 100 mg orally every day; and OTC Imodium 2 mg..." During an interview with the Clinical Director on 6/14/2023 at 8:40 AM, she confirmed the medications had not been reconciled. 7. Review of the medical record revealed Patient #14 was admitted to the agency on 3/28/2023 with diagnoses of Multiple Sclerosis, Stage 2 Buttock Pressure Ulcer, Quadriplegia, Chronic Obstructive Pulmonary Disease, Hypertension, and Depression. Review of Patient #14's home medications revealed "...OTC Align Probiotic; OTC Acetaminophen 500 mg; OTC Vit D3 1000 IU (25mg); 1/27/2023...OTC Deep Sea moisturizing nasal spray; and 2/17/2023...Aspirin 81 mg everyday..." During an interview with the Clinical Director on 6/15/2023 at 10:00 AM, she confirmed the medications had not been reconciled.

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 medical record review and interview, the agency failed to follow the plan of care and notify the responsible physician of missed visits for 3 of 13 [Patient #3, #4, and #5] patients reviewed. The findings include: 1. Review of the medical record revealed Patient #3 was admitted to the agency on 4/7/2023 with diagnosis of Urinary Tract Infection, Displacement of Cystostomy Catheter, Stage 4 Pressure Ulcer of the Sacrum, Neuromuscular Dysfunction of Bladder, and Hypertension. Review of the Home Health Certification and Plan of Care revealed "...SN [Skilled Nurse] 1 wk [week] 9...SN 2 prn [as needed] for Urinary Complications...SN 2 prn for Wound Complications...Patient was referred to Home Care...wound care...SN to provide/Reinforce/Obtain return demonstration to CG [caregiver] of wound care..." Review of the Wound Notes revealed there were no measurements of Patient #3's wounds documented for the month of June 2023. During an interview with the Clinical Manager dated 6/16/2023 at 2:15 PM, she stated "...no actual measurements for June...Nurse is supposed to look at it..." 2. Review of the medical record revealed Patient #4 was admitted to the agency on 10/28/2022, with diagnoses of Left Heel Pressure Ulcer, Diabetes Mellitus, Heart Failure, Chronic Kidney Disease, and Panic Disorder. Review of the Home Health Certification and Plan of Care revealed "...SN 1 wk 9 and 2 PRN...Skilled Nurse to perform/Instruct/Reinforce Patient/Caregiver procedure of wound..." Review of the agency's calendar revealed Patient #4 did not receive Skilled Nursing visit for of the weeks of 5/28/2023 and 6/4/2023. Interview with the Clinical Manager on 6/16/2023 at 2:15 PM, she confirmed the visit for week 5/28/2023 and 6/4/2023 had been missed. She stated "...nothing shows who unscheduled these visits..." 3. Review of the medical record revealed Patient #5 was admitted to the agency on 2/17/2023 with diagnoses of Malignant Neoplasm of Rectum, Hypertension, and Coloscopy. Review of the Home Health Certification and Plan of Care revealed "...SN 1 wk 2, 1 every2wk6, 1 wk1..." There was no documentation of skilled Nursing missing a visit on the week of 4/30/2023. During an interview with the Clinical Manager on 6/16/2023 at 2:30 PM, she stated "...I don't see it either..." If the HHA misses a visit or a treatment or service as required by the plan of care, which results in any potential for clinical impact upon the patient, then the HHA must notify the responsible physician of such missed treatment or service.