Every finding on record at Lhcg Xxix, LLC

A recertification survey was conducted 3/12/25 to 3/14/25 at Keller Home Care. The agency was found to be in substantial compliance with the Conditions of Participation for Emergency Preparedness.

A recertification survey was conducted 3/12/25 to 3/14/25 at Keller Home Care. Standard level deficiencies were cited and will require an approved 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), observations, agency policy and procedure, and interviews with staff, it was determined the agency failed to ensure medications were reconciled in four of seven home visits (HV) conducted. This affected HV # 1, HV # 2, HV # 4, and HV # 7, and had the potential to negatively affect all patients served by the agency. Findings include: Agency Policy: Monitoring Medications Policy Number: 10.008 Date Revised: 7/1/2024 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: 1a...Compare medication list to actual medications the patient is taking. 1b. Review all medications including over the counter (OTC) medications, vitamins, herbs and herbal products, creams and topical ointments... 3. HV # 4 was admitted to the agency on 1/22/25 with a primary diagnosis of Dislocation of Internal Left Hip Prosthesis, Subsequent Encounter. Review of the Home Health Certification (HHC) and Plan of Care (POC) for certification period 1/22/25 to 3/22/25 revealed orders for the Skilled Nurse (SN) to visit one time a week for five weeks, and Physical Therapy (PT) to visit one time a week for one week, two times a week for three weeks, and one time a week for five weeks. A HV was conducted on 3/12/25 at 3:30 PM to observe care provided by EI # 7, Licensed PT Assistant (LPTA). EI # 6, Patient Care Manager, was also present during the visit. During the HV, the CMR was compared to the medications the patient was currently taking. The following medications were listed on the CMR as current and not observed in the home: a. Memantine five mg tablet, take one tablet daily. b. Phenazopyridine 200 mg tablet, take one tablet three times daily as needed . c. Promethazine 6.25 mg/5 ml (milliliter) oral syrup, take five ml every six hours as needed. d. Qunol Mega COQ10 100 mg capsule, take one capsule daily. e. Tramadol 50 mg tablet, take two tablets every six hours as needed. Vitamin D3 50 microgram (mcg) capsule, take one capsule daily was also listed on the CMR. A 100 count bottle of Vitamin D3 25 mcg tablets with approximately 50 tablets remaining in the bottle was observed in the home. HV # 4 confirmed he/she was taking the 25 mcg strength tablet. EI # 6 confirmed during the HV the CMR was not reconciled with the current home medications. 4. HV # 7 was admitted to the agency on 1/8/25 with a primary diagnosis of Fracture of Unspecified Part of Neck of Left Femur, Subsequent For Closed Fracture With Routine Healing. A HV was conducted on 3/13/25 at 10:33 AM to observe care provided by EI # 10, Registered Nurse. EI # 6 was also present during the visit. During the HV, the CMR was compared to the medications the patient was currently taking. A 90 count bottle of Hydrochlorothiazide (HCTZ) 12.5 mg tablets with a fill date of 10/21/24 was observed in the home. HCTZ was not listed on the CMR. HV # 7 stated during the visit he/she was currently taking the HCTZ. EI # 6 confirmed during the HV the CMR was not reconciled with the current home medications. 2. HV # 2 was admitted to the agency on 2/27/25 with a primary diagnosis of Diverticulosis of the Large Intestine Without Perforation or Abscess with Bleeding. A HV was conducted on 3/12/25 at 1:35 PM to observe care provided by EI # 5, Occupational Therapist. During the HV, the CMR was compared to the medications the patient was currently taking. The following was observed: a. Clorazepate Dipotassium 3.75 mg tablets, take two times daily, was listed on the CMR but was not present in the home. b. Children's Aspirin 81 mg chewable tablet, take one tablet daily, was discontinued on 3/6/25 and was still listed on the CMR. c. Clopidogrel 75 mg tablet, take one tablet daily, was discontinued on 2/26/25 and was still listed on the CMR. An interview was conducted on 3/14/25 at 10:30 AM with EI # 3, who confirmed staff failed to follow the policy for monitoring medications. 1. HV # 1 was admitted to the agency on 1/28/25 with resumption of care on 3/8/25 with a primary diagnosis of Chronic Obstructive Pulmonary Disease Unspecified. A HV was conducted on 3/12/25 at 11:10 AM to observe care provided by Employee Identifier (EI) # 4, Licensed Practical Nurse. EI # 3, Patient Care Manager (PCM) was also present during the HV. During the HV, the Client Medication Report (CMR) was compared to the medications the patient was currently taking. The following was observed: a. Melatonin 10 milligrams (mg) tablet take two gummies at bedtime was listed on the CMR. HV # 1 reported he/she could not recall taking the medication. b. Bupropion HCL (Hydrochloride) XL (extended release) 150 mg 24 hour tablet was observed in the home with fill date 12/3/24. HV #1 reported taking the medication. Bupropion was not on the CMR. An interview was conducted on 3/14/25 at 10:35 AM with EI # 1, Regional Director, who confirmed staff failed to follow the policy for monitoring medications.

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 medial record (MR) review, observation, agency policy and procedure, and interview, it was determined the home health agency failed to ensure the skilled nurse (SN) performed hand hygiene (HH) and maintained sterile technique during peripherally inserted central catheter (PICC) line dressing change in accordance with the agency's policy. This deficient practice affected Home Visit (HV) # 3, and had the potential to negatively affect all patients with PICC lines served by this agency. Findings include: Agency Policy: Dressing Change Procedure for Central Venous, Midline and Peripherally Inserted Central Catheters Policy Number: 10.027 Revised Date: 10/01/16 Purpose: To keep insertion sites clean, stabilize catheters and minimize the risk of infection. Policy: The nurse shall demonstrate competency and knowledge of dressing change procedures... Procedure: ...3. Perform hand hygiene and don clean gloves... ...5. Remove the old dressing... 6. Discard dressing in appropriate receptacle. 7. Remove gloves, perform hand hygiene, and don sterile gloves. 1. HV # 3 was admitted to the agency on 6/21/24, and recertified for care 2/16/25 to 4/16/25, with a primary diagnosis of Encounter for Adjustment and Management of (VAD) Vascular Access Device. A HV was conducted on 3/12/25 at 3:03 PM to observe the PICC line dressing change provided by Employee Identifier (EI) # 8, Registered Nurse (RN). EI # 9, RN, was also present during the HV. During the dressing change, EI # 8 donned sterile gloves without performing HH and removed the old PICC line dressing from HV # 3's left arm. While wearing the same gloves, EI # 8 obtained a sterile chloraprep sponge applicator and cleaned the PICC line site, secured the sterile statlock, applied the sterile antimicrobial disk and covered the PICC line site with a sterile tegaderm dressing. EI # 8 failed to follow agency policy and remove the gloves, perform HH and don new sterile gloves after removing the old dressing. An interview was conducted on 3/14/25 at 10:37 AM with EI # 1, Regional Director, who confirmed the staff failed to follow the policy for PICC line dressing change.

A recertification survey was conducted on 3/22/22 to 3/24/22. Keller Home Care was found to be in substantial compliance with the Condition of Participation at 484.102 Emergency Preparedness.

A recertification survey was conducted at Keller HomeCare on 3/22/22 to 3/24/22. Standard level deficiencies were cited which will require a 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 observations, review of medical records (MR), agency policy and procedure, and interviews, it was determined the agency failed to ensure staff reconciled medications in 3 of 7 active MRs reviewed, including Home Visit (HV) # 2, HV # 3, and MR # 3, and had the potential to negatively affect all patients receiving services by this agency. Findings include: Agency Policy: Monitoring Medications Policy Number: 10.008 Revised Date: 5/1/19 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 in conjunction with all comprehensive assessments. Additionally, all clinicians will participate in medication review and reconciliation throughout the episode. ...For patients receiving only therapy services, the therapist is responsible to facilitate drug regimen review and medication reconciliation throughout the episode... The therapist will collaborate with the Patient Care Manager to complete the process... The physician is contacted immediately if any discrepancies between agency information and patient medications are found. Procedure: 1. The discipline responsible for the drug regimen 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... to identify such issues as: ...ix. Dosage errors... e. Notify the physician of any of the above identified issues /discrepancies. Collaborate with the Patient Care Manager and ensure that supportive documentation is evident in the medical record. 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. During the patient's episode of care the following will occur: a. Through a collaborative process the care team will: i. Compare medications patient is currently taking with medications ordered for the patient in order to identify and resolve discrepancies... b. The Physician will be notified of discrepancies and documentation of notification must be evident in the medical record. 2. HV # 3 was admitted to the agency on 3/16/22 with diagnoses including Type 2 Diabetes Mellitus with Other Specified Complications, and Acute Hematogenous Osteomyelitis, Left Ankle and Foot. A HV was conducted on 3/22/22 at 12:30 PM to observe care provided by EI # 3, RN. During the HV, the surveyor reviewed the medications listed on the Home Health Certification (HHC) and Plan of Care (POC) dated 3/16/22 to 5/14/22 , and compared the list to the medications in the home, with the following discrepancies observed: Ampicillin 500 mg capsule, 1 capsule, 3 times daily, was on the Medication list and not in the home. EI # 3 confirmed the medication was completed in the hospital, and should not be on the list. Santyl 250 Unit/Gram Topical Ointment, Apply to heel daily and cover with Telfa, was on the Medication list, and not in the home. EI # 3 confirmed this medicine was discontinued on 3/16/22. An interview was conducted on 3/24/22 at 10:30 AM with EI # 1, who confirmed staff failed to reconcile the patient's medications. 3. MR # 3 was admitted to the agency on 3/3/22 with diagnoses including Emphysema, Unspecified, and Essential (Primary) Hypertension. Review of the HHC and POC dated 3/3/22 to 5/1/22 revealed an order for Oxygen 1 liter, As Needed/ PRN (as needed). Review of the SN (Skilled Nurse) Oasis Admission Note dated 3/3/22 revealed the SN documented the following in the Respiratory Assessment, "Oxygen Flow Rate: 2 Liters/ Minute, Oxygen Flow Rate Corresponds with Physician Orders? Yes, Oxygen Frequency: Continuous." The SN failed to reconcile and clarify the oxygen order with the physician. Review of 5 SN Visit Notes, dated 3/5/22, 3/7/22, 3/11/22, 3/17/22, 3/21/22, revealed the SN documented the Oxygen at 2 Liters/ Minute, and answered "Yes" to the question "Oxygen Flow Rate Corresponds with Physician Orders. The SN failed to reconcile the oxygen order with the physician. An interview was conducted on 3/24/22 at 11:00 AM with EI # 1, who confirmed the SN failed to perform medication reconciliation per policy. 1. HV # 2 was admitted to the agency on 1/28/22 with diagnoses including Unspecified Fracture of Left Tibia, Subsequent For Closed Fracture With Routine Healing and Multiple Myeloma Not Having Achieved Remission. A HV was conducted on 3/22/22 at 10:55 AM to observe care provided by Employee Identifier (EI) # 2, Licensed Physical Therapy Assistant. Prior to the HV, the surveyor received a current Client Medication Report (CMR) printed 3/22/22 at 9:28 AM. The CMR was compared to the medications in the home, and the following discrepancy was observed: Oxycodone 5 mg (milligram) tablet, 1 tablet every 4 hours for pain was on the CMR. The bottle in the home, date filled 2/23/22, read 1 tablet every 6 hours as needed for pain and confirmed by the patient and EI # 2. An interview was conducted on 3/24/22 at 10:27 AM with EI # 1, Registered Nurse (RN) Clinical Director (CD), who verified the staff failed to reconcile the patient's medications.

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 medical record (MR) review, agency policy, and interview, it was determined the home health agency failed to ensure physician orders for weekly site care to a PICC (peripherally inserted central catheter) line were followed. This deficient practice affected 1 of 2 active records reviewed with a PICC, including Home Visit (HV) # 1, and had the potential to negatively affect all patients served by the agency. Findings include: Agency Policy: Dressing Change Procedure for Central Venous, Midline, and PICCs Policy Number: 10.027 Revision Date: 10/1/16 Purpose: To keep insertion sites clean, stabilize catheters and minimize the risk of infection Policy: ...Transparent semi-permeable membrane (TSM) dressings shall be changed at the time of access, site rotation, or every 3-7 days, whichever comes first. 1. HV # 1 was admitted to the agency on 2/2/22 with diagnoses including Aftercare Following Surgery for Neoplasm, and Squamous Cell Carcinoma of the Skin, Unspecified Upper Limb, Including Shoulder. Review of the Home Health Certification (HHC) and Plan of Care (POC) dated 2/2/22 to 4/2/22 revealed a Skilled Nurse (SN) visit frequency of 2WK (week) 9, which also included orders for the SN to perform site care weekly for HV # 1's PICC line. Review of the SN Visit Note Report (SNVNR) dated 2/21/22, 2/23/22, and 2/25/22 revealed no documentation PICC line site care was performed that week. Review of the SNVNR dated 3/14/22 and 3/16/22 revealed no documentation PICC line site care was performed that week. The SN failed to follow the physician orders and agency policy, and perform PICC line site care weekly. In an interview conducted 3/24/22 at 10:40 AM with Employee Identifier (EI) # 1, Registered Nurse Clinical Director, EI # 1 confirmed the SN failed to follow the physician orders and agency policy, and perform PICC line site care weekly.

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 review of medical records (MR), policy and procedure, and interviews, it was determined the agency failed to ensure all physician orders included the frequency of wound care, and route of oxygen administration. This affected 2 of 7 active records reviewed, and did affect HV (Home Visit) # 3, and MR # 3, and had the potential to affect all patients served by the agency. Findings include: Agency policy: Physician Orders Policy number: 2.1.008 Date revised: 11/01/21 ...Policy: No medications, treatments, diagnostic studies, or therapeutics will be administered without the order of a qualified physician... Procedure: ...11. Orders containing medication must be entered into the software system or written legibly in ink and at a minimum include: a. Name of medication, dose, dilution, frequency, route, rate of infusion. 1. HV # 3 was admitted to the agency on 3/16/22 with diagnoses including Type 2 Diabetes Mellitus with Other Specified Complications, and Acute Hematogenous Osteomyelitis, Left Ankle and Foot. Review of the physician order dated 3/17/22 revealed the following ordered wound care: "Nurse to perform/ instruct/ reinforce patient/ caregiver procedure of wound care to # 5 LT (left) great toe callous and # 17 heel, LT open blister as follows: cleanse with wound cleanser and gauze, pat dry with gauze. Apply Aquacell AG (Alginate) to wound bed, cover with non stick Telfa, secure with Kerlix and Coban, using clean technique. Instruct patient/ caregiver signs/ symptoms of wound infection and proper disposal of dressings." There was no frequency included in the order for wound care, per policy. An interview was conducted on 3/24/22 at 10:30 AM with Employee Identifier (EI) # 1, Registered Nurse, Clinical Director, who confirmed staff failed to include the frequency of wound care in the physician order, per policy. 2. MR # 3 was admitted to the agency on 3/3/22 with diagnoses including Emphysema, Unspecified, and Essential (Primary) Hypertension. Review of the Home Health Certification and Plan of Care dated 3/3/22 to 5/1/22 revealed the following order for Oxygen, 1 Liter, As Needed/ PRN (as needed). There was no route of administration in the order, per policy. An interview was conducted on 3/24/22 at 11:00 AM with EI # 1, who confirmed the order failed to include the route of administration.

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 interview, it was determined the agency failed to ensure staff followed the policy for hand hygiene and dress code. This affected 1 of 4 Home Visits (HV), including HV # 3, and had the potential to affect all patients served by the agency. Findings include: Agency Policy: Hand Hygiene Policy number: 8.004 Date revised: 5/1/19 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... Procedure: 1. Staff performs hand hygiene... c. After contact with blood, body fluids or excretions, mucous membranes, non-intact skin, wound dressings, or contaminated surfaces. ...e. After contact with inanimate objects... f. Before and after removal of personal protective equipment (PPE). Agency Policy: Dress Code Policy number: 6.013 Date revised: 11/01/19 Purpose: In order to establish guidelines for the employees... the following are established as minimum standards. The following factors have been taken into consideration in defining the appearance standards policy: ...Infection Control... Policy: ...Employees will dress in a manner that... maintains the health and safety of patient... Procedure: ...4. All staff will wear appropriate, professional attire suited for their job. The appearance standards for all staff are as follows: ...g. Hair shall be clean, well-groomed... 5. ...The dress code for direct, hands-on caregivers is as follows: ...h. Hair shall be clean, well groomed, and worn in such a manner that it will not interfere with patient care. 1. HV # 3 was admitted to the agency on 3/16/22 with diagnoses including Type 2 Diabetes Mellitus with Other Specified Complications, and Acute Hematogenous Osteomyelitis, Left Ankle and Foot. A HV was conducted on 3/22/22 at 12:30 PM to observe care provided by Employee Identifier (EI) # 3, Registered Nurse (RN). During observation of medication administration via PICC (Peripherally Inserted Central Catheter) line, the SN (skilled nurse) used a gloved hand to retrieve used gauze that had fallen to the carpeted floor. The SN then removed the one glove used to pick up the gauze, and donned a clean glove and proceeded to flush the PICC line. The SN failed to remove both gloves and perform hand hygiene before donning clean gloves and flushing the PICC line. During observation of wound care to the left toe and heel, the scissor package being used as a barrier fell off the chair to the floor. EI # 3 retrieved the pack off the floor with a gloved hand, and continued to remove the dressings from the wounds. The SN failed to remove the contaminated gloves, perform hand hygiene and don clean gloves before continuing with wound care. While dressing the wounds, EI # 3 was holding opened bandage scissors in one hand, and reached to get supplies from the barrier. While doing so, EI # 3's hair brushed across the open blades of the bandage scissors. EI # 3 then used the scissors to cut the gauze. EI # 3 failed to secure hair in a manner to not interfere with patient care. After dressing the wounds, EI # 3 removed gloves and reached in pocket to retrieve a pen, and then dated and initialed the dressing. EI # 3 failed to perform hand hygiene after removing gloves, per policy. An interview was conducted on 3/24/22 at 10:30 AM with EI # 1, RN, Clinical Director, who confirmed the SN failed to perform hand hygiene and failed to secure hair in a manner that did not interfere with patient care.

Preparing clinical notes CFR(s): 484.75(b)(6) Preparing clinical notes; This ELEMENT is not met as evidenced by: Based on a review of medical records (MR), agency on-call (OC) logs, agency policies and procedures, and staff interviews, it was determined the agency failed to ensure the staff: 1. Documented accurate assessments of the patients ability to manage injectable medications per agency policy. 2. Contacted patients and documented event's when on-call per agency policy. 3. Accurately documented OT (Occupational Therapy) Evaluations. 4. Accurately documented assessments of patients with PICC (Peripherally Inserted Central Catheter) Lines. This did affect 1 of 3 discharged records reviewed including MR # 4; 1 of 5 OC log event's reviewed including OC # 1, and 2 of 7 active records reviewed including HV (Home Visit) # 3, and HV # 1. This had the potential to negatively affect all patients receiving services by this agency. Agency Policy: Medical Records Documentation Policy Number: 2.008 Revised Date: 2/1/22 Purpose: To define the contents and documentation requirements of the medical record. Policy: The Practice will create and maintain a medical record for each patient that will include pertinent facts, findings, and observations... treatments, and outcomes... Procedure: General Principles of Medical Record Documentation: 1. The medical record should be complete... 2. The documentation of each patient encounter should include: a. Reason for the encounter... b. Assessment, clinical impression, or diagnosis... Agency Policy: OC Process (To Include During and After Hours Care) Policy Number: 5.008 Revised Date: 3/1/19 Policy: The agency ensures that patients... have access to a staff clinician 24 hours -a-day by means of providing an OC nurse during and after office hours... Procedure: 1. The agency will provide each client, upon admission to services, a designated OC telephone number and will instruct each client to call this number to access care from the agency after regular business hours. ...4. The total response time from patient/caregiver call to patient/caregiver contact by clinician will be no longer than 30 minutes. 5. Clinicians will document responses and outcomes of appropriate calls on the OC Event Coordination note. 4. HV # 1 was admitted to the agency on 2/2/22 with diagnoses including Aftercare Following Surgery for Neoplasm, and Squamous Cell Carcinoma of the Skin, Unspecified Upper Limb, Including Shoulder. Review of the HHC and POC dated 2/2/22 to 4/2/22 revealed orders for the RN to provide PICC line care. Review of the SNVNR dated 2/4/22, 2/21/22, 3/2/22, 3/7/22, 3/11/22, and 3/16/22 revealed the LPN documented "No" to the question, "Does the patient have an infusion access?" There was no other documentation regarding the PICC line in the note. An interview was conducted on 3/24/22 at 10:40 AM with EI # 1, who confirmed HV # 1 had a PICC Line and the staff made an error in documentation. 3. HV # 3 was admitted to the agency on 3/16/22 with diagnoses including Type 2 Diabetes Mellitus with Other Specified Complications, and Acute Hematogenous Osteomyelitis, Left Ankle and Foot. Review of the HHC and POC dated 3/16/22 to 5/14/22 revealed orders for the RN to provide PICC line care. Review of the SNVNR dated 3/21/22 revealed the LPN (Licensed Practical Nurse) documented "No" to the question "Does the patient have an infusion access?" There was no other documentation regarding the PICC line in the note. An interview was conducted on 3/24/22 at 10:30 AM with EI # 1, who confirmed HV # 3 had a PICC Line and the staff made an error in documentation. 1. MR # 4 was admitted to the agency on 10/22/21 with diagnoses including Type 1 Diabetes Mellitus with Hyperglycemia and Type 1 Diabetes with Diabetic Autonomic (Poly) Neuropathy. Review of the Home Health Certification (HHC) and Plan of Care (POC) dated 10/22/21 to 12/20/21 revealed a Skilled Nurse (SN) frequency of 1 wk 9 (1 time a week for 9 weeks). Further review of the HHC and POC dated 10/22/21 to 12/20/21 revealed, "Medications:... Humalog Kwikpen (U-100) Insulin 100 units/ ml (milliliter) subcutaneous: Humalog 4 units before meals, if CBG (capillary blood glucose) over 300 administer 4 units... Toujeo Solostar U-300 Insulin 300 unit /ml (1.5 ml) subcutaneous: 16 units daily". Review of the SN Visit Note Report (SNVNR) dated 10/22/21 revealed, "Medications... Management of injectable medications: Patient's current ability to prepare and take all prescribed injectable medications reliably and safely... NA (Not applicable) - No injectable medications prescribed". The SN failed to document an accurate medication assessment of the patients ability to manage injectable medications. An interview was conducted on 3/24/22 at 11:01 AM with Employee Identifier (EI) # 1, Registered Nurse (RN) Clinical Director (CD), who confirmed the staff failed to document an accurate medication assessment of the patients ability to manage injectable medications on 10/22/21. 2. A review of the agencies OC logs from January to March 2022 revealed the following: OC # 1, "Date Received 1/7/22 5:06 PM Message Re (Regarding): Req (Requested) nurse to come out check his leg and clean it up, it looks dry" and "Date Received: 1/7/22 7:22 PM Message Re: Pt (patient) needs wound checked to see if it's clean - 2nd (second) call". There was no documentation the SN contacted the patient within 30 minutes and documented the on-call events per the agency on-call policy. An interview was conducted on 3/23/22 at 4:10 PM with EI # 1 who confirmed there was no documentation the SN contacted the patient or documented the on-call events per agency policy on 1/7/22.

Interventions and patient response CFR(s): 484.110(a)(2) All interventions, including medication administration, treatments, and services, and responses to those interventions; This ELEMENT is not met as evidenced by: Based on medical record (MR) review, agency policy and procedure, Lippincott Nursing Procedures 8th Edition, Copyright 2019, documentation standard for urine specimen collection and venipuncture, and interview, it was determined the agency failed to ensure: 1. The Skilled Nurse (SN) documented in the MR obtaining an ordered urine specimen for UA/CS (urinalysis/culture and sensitivity), including the date and time of collection, method utilized to obtain the specimen, color and clarity of the urine obtained, the patient's response, and where the specimen was taken to process results. 2. The SN documented in the MR obtaining an ordered blood specimen for multiple labs, including the date and time of collection, from what site the specimen was obtained, the patient's response, and where the specimen was taken to process results. This deficient practice had the potential to affect all patients served by the agency requiring specimen collection, and did affect 1 of 7 active records reviewed, including Home Visit (HV) # 1. Findings include: Agency Policy: Medical Records Documentation Policy Number: 2.008 Revision Date: 2/1/22 Purpose: To define the contents and documentation requirements of the MR. Policy: The Practice will create and maintain a MR for each patient that will include pertinent facts, findings, and observations about the patient's health, including ...examinations, tests, treatments, and outcomes. Procedure: ...2. The documentation of each patient encounter should include: a. Reason for the encounter in the home... ...c. Plan for care... ...7. The codes and diagnosis reported on the health insurance claim form or billing statement should be supported by the documentation in the MR. a. Verifies services were performed, and b. Supports that the services rendered were, "reasonable and necessary" and required the level of care that was delivered (medically necessary). General Principles of MR Documentation: Lippincott Nursing Procedures Copyright 2017 Documentation Urine Specimen Collection: Record the time of specimen collection and when the specimen was transported to the laboratory. Specify the test as well as the appearance, odor, color, and any unusual characteristics of the specimen. Documentation Venipuncture: Record the date, time and site of venipuncture, name of the test, time you sent the sample to the laboratory, and amount of blood you collected. Note any adverse reactions and how the patient tolerated the procedure. 1. HV # 1 was admitted to the agency on 2/2/22 with diagnoses including Aftercare Following Surgery for Neoplasm, and Squamous Cell Carcinoma of the Skin, Unspecified Upper Limb, Including Shoulder. Review of the MR revealed a physician order dated 2/25/22 at 11:20 AM for the SN to collect UA/CS and CBC (complete blood count) and take to XXX Hospital lab for results. Review of the SN Visit Note Report (SNVNR) dated 2/25/22 revealed documentation the SN obtained the specimen for the CBC. There was no documentation of the urine specimen being obtained as ordered. Further review revealed a physician order dated 3/2/22 at 4:03 PM for the RN (Registered Nurse) to collect tobramycin trough (30 minutes prior to dose), CBC with Diff (differential), CMP (comprehensive metabolic profile), CRP (c-reactive protein), ESR (erythrocyte sedimentation rate), and CPK (creatine phosphokinase) on Friday 3/4/22 and Tue (Tuesday) 3/8/22. Review of the SNVNR dated 3/8/22 revealed no documentation the ordered labs were obtained. In an interview conducted 3/24/22 at 10:40 AM, the surveyor asked Employee Identifier (EI) # 1, RN, Clinical Director, if the labs had been collected as ordered on SN visits 2/25/22 and 3/8/22? EI # 1 provided documentation of lab results for both of the requested dates, but confirmed the SN did not document the labs were obtained during those visits, how they were obtained, patient response, or where the labs were taken for processing, and should have.