Every finding on record at Lhcg Xxxviii, LLC

RN performs assessment CFR(s): 484.55(a)(1) A registered nurse must conduct an initial assessment visit to determine the immediate care and support needs of the patient; and, for Medicare patients, to determine eligibility for the Medicare home health benefit, including homebound status. The initial assessment visit must be held either within 48 hours of referral, or within 48 hours of the patient's return home, or on the physician or allowed practitioner - ordered start of care date. This ELEMENT is not met as evidenced by: Based on interview and record review the facility failed to complete an initial assessment within 48 hours after the physician ordered home health services for four of nine patients, (Patient 1, 6, 7, and 8). This failure resulted in not providing the immediate necessary care and services needed for Patients 1, 6, 7, and 8. Findings: 1. A review of a policy revised (01/01/23), titled “Admission Process,” indicated the admission/initial visits are made within 48 hours of the referral unless there is a specific physician ordered start of care, (SOC) date. During a record review of Patient 1’s clinical record, a referral dated 10/14/22 indicated the Veteran’s Administration physician ordered Physical Therapy and Skilled Nursing home health services for generalized weakness and prolonged hospitalizations. A record review indicated Patient 1 was admitted to home health services on 10/19/22 for spinal stenosis, (a condition when the small spinal canal containing nerve roots and the spinal cord become compressed), congestive heart failure, (a condition when the heart has difficulty pumping blood throughout the body), dependent edema, and high blood pressure. During an interview on 3/15/23 at 10:40 am, the Patient Care Manager, (PCM) confirmed Patient 1’s SOC visit was five days later than the referral date. 2. A record review indicated Patient 6 was admitted to home health services on 3/12/22 for the diagnoses of cervicalgia, (neck pain and stiffness), muscle weakness, and hypothyroidism, (an underactive thyroid gland). During a record review of Patient 6’s clinical record, a referral dated 3/8/22 indicated Physical Therapy was ordered for Patient 6 for home health services for generalized weakness. During a record review of Patient 6’s clinical record, Patient 6 was admitted to home health services on 3/12/22, four days later than the physician ordered. During a review of Patient 6’s clinical record, there were no physician updates, via fax or call to notify the physician there was a delay in the ordered home health services. During an interview on 3/14/23 at 3:44 pm, the PCM confirmed the SOC visit was four days late for Patient 6. 3. A record review indicated Patient 7 was admitted to home health services on 12/2/22 for lung cancer, active C-Diff, (a highly contagious bacterial infection that causes infection of the colon), high blood pressure, nausea and vomiting, and hypokalemia, (low potassium). During a record review of Patient 7’s clinical record, a referral was dated 11/28/22 for Skilled Nursing to evaluate and treat as indicated after a hospitalization. During an interview on 3/16/23 at 11:30 am, the PCM confirmed there was a delay for the SOC visit, six days after the referral date for Patient 7. 4. A record review indicated Patient 8 was admitted to home health services on 2/14/23 for diagnoses of acquired absence of left eye, aftercare surgery of neoplasm of left eye, asthma, (a condition when the air ways narrow making breathing difficult), and high blood pressure. During a record review of Patient 8's clinical record, a referral dated 2/10/23 was for Skilled Nursing to complete wound care as ordered two times weekly to the left orbital cavity. During an interview on 3/16/23 at 2:20 pm, the PCM confirmed a late SOC for Patient 8, requiring wound care needed. The SOC visit was four days after the referral date.

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 observation, interview, and record review the facility failed to ensure that two of nine sampled patients (Patient 7 and 8) had an updated medication profile. This failure had the potential for the patient to experience adverse medication interactions and negative side effects and the potential to be hospitalized for wrong medication administration. Findings: A policy revised, (05/01/19) titled “Monitoring Medications,” indicated the purpose of this policy is to provide a process to ensure continuous monitoring of medications in the patient’s home. A drug regimen review will be performed on all patients in conjunction with all assessments. Additionally, all clinicians will participate in medicine review and reconciliation throughout the episode. A policy revised, (02/01/23) titled “High Risk Medications,” indicated the purpose of this policy is to promote and maximize patient health and safety when reconciling or administering high risk medications. This policy indicated the agency plans, supports and coordinates patient and care giver education designed to promote optimal patient health and safety. Patients receive oral and written information regarding high-risk medications prescribed for the patient on an ongoing basis while being cared for by the agency. A record review indicated Patient 7 was admitted to home health services on 12/2/22 for lung cancer, active C-Diff, (a highly contagious bacterial infection that causes infection of the colon), high blood pressure, nausea and vomiting, and hypokalemia, (low potassium). During an observation on 3/15/23 at 12:40 pm, a home visit was completed at Patient 7’s home with Licensed Nurse (LN) A. Patient 7 had severe nausea and verbalized she did not know she had two separate medications for nausea. Patient 7 stated, “I take only the one medication Compazine because I can take it more often, but I did not know I could take the two medicines separately for nausea. I have been up all night nauseated and unable to sleep. I just had chemotherapy and it is bad for a few days, it is hard to eat with nausea." During an observation on 3/15/23 at 12:50 pm, Licensed Nurse (LN) A checked medications for Patient 7 which had not been reconciled in weeks per the medication list and an old bottle of an antibiotic not used since the initial assessment on 12/2/22. During an interview on 3/15/23 at 1:20 pm, LN A confirmed the medication list in the home was not up to date, and Patient 7 needed more education on how to take medications prescribed for nausea and to update clinicians on all supplements taken to obtain approval from the physician. LN A stated she will call the physician and obtain clarification for the supplements in the home and request a sublingual medication for the nausea. A review of a record dated 3/15/23, titled “Narrative,” LN A documented the following, “Medication reconciliation completed. Patient reported that she was now taking over the counter, (OTC) medications, Zinc, Vitamin C, and a Multivitamin. Skilled nurse called the physician for clarification and new verbal order to discontinue Compazine and all supplements at this time, OTC Pepcid approved and Senexon approved by the physician. Sublingual Zofran ordered and sent to the pharmacy. Patient had an expired vancomycin prescription that I advised her to throw away. Medication list updated to reflect new orders and will be placed in the home folder and one additional copy for Patient for personal use. Patient’s caregiver updated with medication changes.” A review of a record dated 3/15/23, titled “Physician Order” indicated the following order was added to the clinical record: Pepcid Complete 10/mg-800 mg-165 mg-chewable tablet oral two times daily as needed (prn), Senexon-S 8.6 mg-50mg 1 tablet two times daily prn. Discontinue prochlorperazine maleate 10 mg tablet every six hours prn. Goal: Medication list will remain updated and free of discrepancy.” During an interview on 3/15/23 at 2:05 pm, the Patient Care Manager (PCM) confirmed the present medication list is not up to date. PCM confirmed education should be provided to Patient 7 and care givers for all medications, especially to a patient on chemotherapy to control symptoms such as nausea. PCM also confirmed all medications are supposed to be checked at each home visit and they have a new process they are starting using different colored bags in the home, one clear and one red for current and discontinued medications to help sort out all the medications and keep changes updated in the home. 2. A record review indicated Patient 8 was admitted to home health services on 2/14/23 for diagnoses of acquired absence of left eye, aftercare surgery of neoplasm of left eye, asthma, (a condition when the air ways narrow making breathing difficult), and high blood pressure. During an observation on 3/15/23 at 3:44 pm of a home visit for Patient 8, the medication list was not accurate, and the pill minder box was not filled correctly. The Registered Nurse (RN) A called the physician while in the home for clarification of losartan medication related to two separate doses documented on the medication list. RN A changed the pill minder during the home visit for safety and to fix the medication error and will update the medication list in the clinical record for Patient 8. RN A also stated she would call the daughter who fills the pill minder to make sure the medications are properly administered. A review of a record for Patient 8 dated 3/15/23 titled “Narrative,” indicated RN A documented the following, “Medication list reviewed with actual prescription bottles and assessed with Medi-set. Discrepancy noted on losartan dose and frequency. Called physician and received clarification via telephone order and medication reconciliated to update and reflect changes. Medication list in home folder updated and called daughter who is responsible for filling medication. Advised of clarification, Medi-set assessed, and medications removed to reflect accuracy.” A review of a record for Patient 8 dated 3/15/23, titled “Physician Order,” indicated Losartan 25 mg 1 tablet PO (by mouth) daily. During an interview on 3/15/23 at 4:40 pm, RN A stated, “I know that was a medication error, but I added the new verbal order and will update the medical record.” During an interview on 3/16/23 at 8:45 am, the PCM confirmed there was a medication error in the home of Patient 8 for a blood pressure medication and the pill minder box was changed during the home visit on 3/15/23 by RN A after the physician was called while in the home for clarification. PCM confirmed this medication error could have caused hypotension and the potential for injury for Patient 8. PCM stated, “Yes, RN A called me after the home visit yesterday and updated me of the medication error.”

Within 48 hours of the patient's return CFR(s): 484.55(d)(2) Within 48 hours of the patient's return to the home from a hospital admission of 24 hours or more for any reason other than diagnostic tests, or on physician or allowed practitioner - ordered resumption date; This ELEMENT is not met as evidenced by: Based on interview, and record review the agency failed to complete a resumption of care within 48 hours after returning home from the hospital for one of nine Patients, (Patient 6). This failure had the potential for Patient 6 to have a negative medical outcome and was a high risk for another hospitalization. Findings: A record review indicated Patient 6 was admitted to home health services on 3/12/22 for the diagnoses of cervicalgia, (neck pain and stiffness), muscle weakness, and hypothyroidism, (an underactive thyroid gland). During a record review of Patient 6’s clinical record, there were documented falls on 3/13/22, 3/14/22, 4/7/22, and 4/11/22 for the certification period (a period of 60 days from the start of care) of 3/12/22 through 5/9/22. During a record review of Patient 6’s clinical record, there were missed visits from Physical Therapy (PT) and Physical Therapy Assistant (PTA) on 3/22/22, 3/30/22, and 4/4/22. During a record review of Patient 6’s clinical record, there was a documented skilled nursing discipline discharge on 4/15/22. During a record review of Patient 6’s clinical record, Patient 6 was hospitalized from 4/18/22 through 4/20/22 to rule out a Cerebral Vascular Accident, (CVA or commonly called stroke), altered mental status, and high blood pressure. During a record review of Patient 6, the resumption of care, (ROC) was not completed until 4/27/22, seven days after a hospitalization. During an interview on 3/14/23 at 3:44, the Patient Care Manager confirmed the ROC was seven days after a hospitalization for Patient 6, five days late. PCM also confirmed the missed visits, late SOC, and falls at home.

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 interview and record review, the agency failed to promptly alert one of nine sampled patients’ physician when she had a change of condition. Patient 2 was assessed to have a low blood pressure during a Licensed Nurse (LN) home visit. This had the potential for failed communication, physician involvement in an altered plan of care, and planed outcomes to not be achieved for patients. Findings: A review of Patient 2’s record indicated she was admitted to the agency on 2/17/23 with diagnoses that included hypertension (high blood pressure), heart failure, and a history of falling. A review of Patient 2’s plan of care (Physician’s orders) dated 2/17/23, prescribed nursing visits for four times a week for one week (4W1), and one time a week for eight weeks (1WK8). The orders also included a prn (as needed) visit for heart complications. A review of a Licensed Nurse (LN) “Visit Note Report” dated 2/20/23 at 12:54, the LN documented Patient 2’s blood pressure was 70/40 (abnormal lower than 90/60). The LN additionally documented that she called EMS (Emergency Medical Staff) and Patient 2 agreed to be sent to a local hospital. There was no documentation that Patient 2’s Physician had been notified of her low blood pressure or her transfer to the hospital. On 3/16/23 at 2:15 pm, an interview and record review was conducted with Patient Care Manager (PCM). PCM acknowledged Patient 9 was sent to the hospital on 2/20/23 for low blood pressure and the nurse failed to document she notified Patient 2’s physician of her low blood pressure and that she was sent to the hospital. A review of a “Significant Change In Condition (Other Follow-Up) Assessment" policy revised 12/1/13, described a significant change is a major decline requiring an extensive alteration in a patients plan of care.

Patients receive education and training CFR(s): 484.60(d)(5) Ensure that each patient, and his or her caregiver(s) where applicable, receive ongoing education and training provided by the HHA, as appropriate, regarding the care and services identified in the plan of care. The HHA must provide training, as necessary, to ensure a timely discharge. This ELEMENT is not met as evidenced by: Based on observation, interview, and record review the agency failed to educate five of nine sampled patients (Patient 1, 2, 6, 7, and 9) and care givers to follow the plan of care (physician orders), to manage disease processes and medications to achieve optimum quality of life while living at home. This failure resulted in a hospitalization, poor symptom management, and medication errors with the potential for injury. Findings: 1. A review of a policy revised (11/01/21), titled “Physician Orders,” indicated services are provided according to the most recent orders updating the patient’s Plan of Care. All care and services are provided within acceptable standards of practice. A policy revised, (02/01/23) titled “High Risk Medications,” indicated the purpose of this policy is to promote and maximize patient health and safety when reconciling or administering high risk medications. This policy indicated the agency plans, supports and coordinates patient and care giver education designed to promote optimal patient health and safety. Patients receive oral and written information regarding high-risk medications prescribed for the patient on an ongoing basis while being cared for by the agency. A record review indicated Patient 1 was admitted to home health services on 10/19/22 for spinal stenosis, (a condition when the small spinal canal containing nerve roots and the spinal cord become compressed), congestive heart failure, (a condition when the heart has difficulty pumping blood throughout the body), dependent edema, and high blood pressure. A review of Patient 1’s record indicated the medication furosemide (a diuretic medication) 20 milligrams 1 tablet PO (by mouth) daily was ordered for edema/heart failure. A review of Patient 1’s clinical record indicated the Registered Nurse (RN) add on visit was completed on 11/2/22 and weights/measurements was added to the plan of care. A review of Patient 1’s clinical record indicated weight or measurements were not obtained on the following skilled nurse visit on 11/9/22 or any follow up visits through 12/17/22. During an interview on 3/14/23 at 2:20 pm, PCM confirmed measurements should be taken every week for Patient 1’s calves to compare edema, (increased swelling due to the inability of the heart to effectively pump fluids throughout the body) from week to week since the patient is unable to stand. The Registered Nurse (RN) did complete measurements of Patient 1’s calves, but no there was no follow up with the LNs visits. PCM confirmed weekly measurements are on the plan of care to obtain and update the physician as indicated. PCM also stated, “There was no RN case management follow up or coordination of care for updates between clinicians.” 2. A review of Patient 2’s record indicated she was admitted to the agency on 2/17/23 with diagnoses that included hypertension (high blood pressure), heart failure, and a history of falling. A review of Patient 2’s plan of care (Physician’s orders) dated 2/17/23, prescribed nursing visits for four times a week for one week (4W1), and one time a week for eight weeks (1WK8). The orders also included a prn (as needed) visits for cardiac complications to include chest pain, dyspnea (labored breathing), edema (swelling) and a five-pound increase in weight in a week. An interview and record review was conducted with Patient Care Manager (PCM) on 3/16/23 at 2:32 pm. PCM stated Patient 2 had only been weighed once on her start of care on 2/17/23, and no other weights were obtained during her visits. She stated if Patients are not able to stand to be weighed it is her expectation that staff measure the patients’ calves to evaluate edema (increased swelling due to the inability of the heart to effectively pump fluids throughout the body). 3. During a record review of Patient 6’s clinical record, there were documented falls on 3/13/22, 3/14/22, 4/7/22, and 4/11/22 for the cert period of 3/12/22 through 5/9/22. During a record review of Patient 6’s clinical record, there were missed visits from Physical Therapy (PT) and Physical Therapy Assistant (PTA) on 3/22/22, 3/30/22, and 4/4/22. During a record review of Patient 6’s clinical record, there was a documented skilled nursing discipline discharge on 4/15/22. During a record review of Patient 6’s clinical record, Patient 6 was hospitalized from 4/18/22 through 4/20/22 to rule out a Cerebral Vascular Accident, (CVA or commonly called stroke), altered mental status, and high blood pressure. During an interview on 3/15/23 at 11:05 am, the Patient Care Manager (PCM) confirmed Patient 6 needed more frequency of skilled nursing visits, update to physician for multiple falls with etiology unknown, missed PT visits for gait and balance, poor coordination of care for clinicians and no revision to the plan of care for a declining patient. PCM stated, "We need more education and more case managers, we do not have any full time Registered Nurse (RN) case managers, our RNs are part time or per diem. I try to case manage, but it is a lot, especially with the work flow I do and visits I need to complete. I agree, even communication with the care givers could have helped Patient 6 and I do not know why the resumption of care was so late." 4. A record review indicated Patient 7 was admitted to home health services on 12/2/22 for lung cancer, active C-Diff, (a highly contagious bacterial infection that causes infection of the colon), high blood pressure, nausea and vomiting, and hypokalemia, (low potassium). During an observation on 3/15/23 at 12:40 pm, a home visit was completed at Patient 7’s home with Licensed Nurse (LN) A. Patient 7 had severe nausea and verbalized she did not know she had two separate medications for nausea. Patient 7 stated, "I have been up all night nauseated and unable to sleep. I just had chemotherapy and it is bad for a few days, it is hard to eat with nausea." During an interview on 3/15/23 at 2:05 pm, the Patient Care Manager (PCM) confirmed the present medication list is not up to date. PCM confirmed education should be provided to Patient 7 and care givers for all medications, especially to a patient on chemotherapy to control symptoms such as nausea. PCM confirmed this was poor symptom management and more coordination of care should have been provided with care givers to educate on when to call the physician if symptoms continue, and all nurses should update the physician on visits if the patient is unable to eat or sleep due to prolonged nausea. PCM stated, "We will provide more education to our staff for symptom management, and the physician needs more updates." 5. A review of Patient 9’s plan of care indicated she was admitted to home health services on 1/25/23 for diagnoses that include history of cerebral infarction (a stroke due to lack of blood flow in the brain), transient ischemic attack (TIA, a short episode of mini strokes caused by a temporary disruption of the blood flow), and frequent falls. A review of Patient 9’s 1/25/23 plan of care prescribed nursing visits for one time a week for one week (1wk1), then one visit every three weeks for 3 weeks, then one visit every two weeks for 4 weeks. There was also prn orders that included one visit for an increase in edema, dyspnea and a weight gain of five pounds in a week (cardiac complications). Physical Therapy was also ordered one time a week for 9 weeks (1wk9). A home visit was made on 3/15/23 at 2:15 pm, with Physical Therapy Assistant (PTA). During an interview with Patient 9’s Family Member (FM) on the same day at 3:17 pm, she stated Patient 9 can be weighed in the home, and they have a scale. FM stated Patient 9 usually gets weighed every three months at the Doctors office. FM stated Patient 9 does not have a good appetite. FM stated she is not sure if Patient 9 has gained or lost weight. During an interview and record review with PCM on 3/16/23 at 2:50 pm she acknowledged Patient 9 had cardiac diagnoses and had only been weighed once on her start of care (1/25/23). PCM acknowledged staff should have weighed Patient 9 per the agency practice.

Visit schedule CFR(s): 484.60(e)(1) Visit schedule, including frequency of visits by HHA personnel and personnel acting on behalf of the HHA. This ELEMENT is not met as evidenced by: Based on interview and record review, the agency did not ensure that they followed two of nine sampled patients (Patient 1 and 6) plan of cares (physician's orders), when the facility did not notify the physician when there was a change to the patient's plan of care. This failure had the potential for the physician to not be fully involved and approve of changes with their ordered treatment plans, which could lead to patients not achieving their treatment goals. Findings: 1. A review of a policy revised (11/01/21), titled “Physician Orders,” indicated services are provided according to the most recent orders updating the patient’s Plan of Care. All care and services are provided within acceptable standards of practice. A review of a process revised (2022), titled “Processing Missed Visits” indicated a visit should not be missed if it can be rescheduled to other days within the Medicare week. The Medicare week is Sunday through Saturday. If a visit is missed a coordination note should be completed and with the discipline, date, reason, name of the physician and today’s date, and how the update was submitted. These visits should not be missed without communication to the Patient Care Manager (PCM). A record review indicated Patient 1 was admitted to home health services on 10/19/22 for spinal stenosis, (a condition when the small spinal canal containing nerve roots and the spinal cord become compressed), congestive heart failure, (a condition when the heart has difficulty pumping blood throughout the body), dependent edema, and high blood pressure. A review of Patient 1’s clinical record indicated the frequency of the plan of care, (physician orders) for the certification period of 10/19/22 through 12/17/22 were Skilled Nursing one time weekly for seven weeks. This plan of care had Physical Therapy (PT) ordered as follows: PT one time a week for two weeks, three times a week for three weeks, and PT one time a week for four weeks. During a review of Patient 1's visit record, it was noted that no PT visits were completed the week of 10/23/22, and only two PT visits the week of 11/13/22 and there was no documentation that the physician had been notified regarding this change to Patient 1's plan of care for two separate weeks. During an interview on 3/14/23 at 2:40 pm, the PCM confirmed Patient 1 had two missed PT visits and the physician was not updated of this change in plan of care. 2. A record review indicated Patient 6 was admitted to home health services on 3/12/22 for the diagnoses of cervicalgia, (neck pain and stiffness), muscle weakness, and hypothyroidism, (an underactive thyroid gland). A review of Patient 6’s clinical record indicated the frequency of the plan of care, (physician orders) for the certification period of 3/12/22 through 5/9/22 were SN one time weekly and SN once every five weeks, one SN visit as needed. This plan of care had PT ordered as follows: PT one time a week for eight weeks. During a review of Patient 6’s clinical record, it was noted that PT did not complete a visit the week of 3/27/22, and PT did not complete a visit the week of 4/3/22. There was no documentation that the physician had been notified regarding this change to Patient 6's plan of care for two separate weeks. During an interview on 3/16/23 at 8:45 am, the PCM confirmed Patient 6 had two missed PT visits and the physician was not updated of this change in plan of care.

Infection control CFR(s): 484.70(b)(1)(2) Standard: Control. The HHA must maintain a coordinated agency-wide program for the surveillance, identification, prevention, control, and investigation of infectious and communicable diseases that is an integral part of the HHA's quality assessment and performance improvement (QAPI) program. The infection control program must include: (1) A method for identifying infectious and communicable disease problems; and (2) A plan for the appropriate actions that are expected to result in improvement and disease prevention. This STANDARD is not met as evidenced by: Based on observation, interview, and record review, the agency failed to ensure infection control measures were implemented for two of nine patients, (Patient 7, and 9) when: 1-Patient 7 was admitted to home health services with a highly transmissible infection and no education was provided to the patient or multiple care givers in the home. 2-An unvaccinated employee completed a home visit with Patient 9 and did not wear a mask. Findings: 1. A review of a policy revised 11/01/21 titled “Infection Control Plan,” indicated the purpose of this policy is to enhance the safety and quality of patient care provided by the agency and to decrease the risk of infections and transmission of communicable diseases. The agency will establish a comprehensive infection control program to ensure that there is a functioning, coordinated process in place to reduce the risk of endemic, epidemic, and home acquired infections. In this policy page four indicated Highly Transmissible/Communicable Employee Infections must be confirmed by physician diagnosis and may include but not be limited to Herpes Zoster, Tuberculosis, Scabies, Enterocolitis due to Clostridium Difficile, (C-Diff), Influenza, Rubella, Rubeola and Covid19. A record review indicated Patient 7 was admitted to home health services on 12/2/22 for lung cancer, active C-Diff, (a highly contagious bacterial infection that causes infection of the colon), high blood pressure, nausea and vomiting, and hypokalemia, (low potassium). A record review for Patient 7 indicated on the initial assessment dated 12/2/22 the number one diagnosis is C-Diff and noted the following: Symptoms poorly controlled, patient needs frequent adjustments in treatment and dose monitoring. A record review for Patient 7 indicated on the initial visit note completed on 12/2/22 patient was referred to home care by physician for aftercare following active C-diff and plans for next visit was documented, “Plans for next visit: Assessment of C-Diff” which was not documented in any of the following visit notes. A record review of Patient 7’s clinical record indicated from 12/2/22 through 3/16/23 there was no education provided on C-Diff precautions to patient or care givers going in and out of the home to include but not limited to education for the specific contagious disease process, taking all the antibiotics prescribed, personal hygiene such as handwashing with soap and water or prevention of transmission to other care givers. No education provided for signs and symptoms to report immediately. No documentation present of appropriate Personal Protective Equipment (PPE) for clinicians to be worn to prevent the spread of active C-Diff communicated to patient or other clinicians. The plan of Care (physician orders) was not followed to provide education for prevention, transmission, and the disease process. A review of a record dated 12/2/22 titled “SOC Clinical Summary” indicated Patient 7 was recently hospitalized from 11/20/22 through 11/24/22 for C-Diff. A review of a record dated 12/2/22 titled “Client Medication Report,” indicated the medication Vancomycin 125 milligrams, (mg a unit of measure) 1 capsule oral every six hours for 14 days, an anti-infective agent. End date documented 12/13/22 for the antibiotic ordered to treat the C-Diff infection. A review of a record dated 3/15/23 titled “Narrative” LN A documented for Patient 7, “Patient had an expired bottle of Vancomycin prescription and advised to throw away.” During an interview on 3/16/23 at 2:10 pm, the Patient Care Manager (PCM) confirmed all PPE should have been worn by the clinicians for an admission for C-Diff and communication notes entered for all staff to be updated for C-Diff precautions. PCM also confirmed the plan of care, physician orders were not followed to provide education to patient and caregivers. PCM added “Precautions and education should have been provided at all visits and clinicians should know to teach use of proper handwashing of soap and water and not hand sanitizer for C-Diff.” During an Interview on 3/17/23 at 10:50 am, the Executive Director (ED) confirmed all the education was missed for C-diff precautions for Patient 7 and the PPE should have been worn to prevent the transmission of a highly contagious disease. ED also stated, “They need to teach C-Diff education, teach proper hand washing to all the care givers and patient 7. It is in our Infection Control policy for C-Diff and we will start the education for our staff." 2. A record review indicated Patient 9 was admitted to home health services on 1/25/23 for diagnoses including repeated falls, cerebral vascular accident or stroke, and a history of transient ischemic attacks (TIA is a short episode of mini strokes caused by a temporary disruption of the blood flow). During an observation on 3/15/23 at 2:15 pm, a home visit was completed at Patient 9’s home with a Physical Therapy Assistant (PTA). Prior to entering the home, PTA was asked if a mask would be worn in patient 9’s home. PTA stated it is the agency’s policy they do not have to wear a mask if they are not having Covid19 symptoms, and they do a self-test for symptoms recorded in the tablet daily. PTA stated she does have an exemption, is not vaccinated, and did not wear a mask throughout the visit. During an interview on 3/17/23 at 9:30 am, the ED confirmed the policy of the agency is to wear a mask in all patient’s home if the employee is unvaccinated and any type of exemption would not excuse protecting the patient in their homes. The ED also added, “We have immuno-compromised patients, and the staff knows to wear a mask in all homes and facilities if they choose not to be vaccinated.”

Governing body CFR(s): 484.105(a) Standard: Governing body. A governing body (or designated persons so functioning) must assume full legal authority and responsibility for the agency's overall management and operation, the provision of all home health services, fiscal operations, review of the agency's budget and its operational plans, and its quality assessment and performance improvement program. This STANDARD is not met as evidenced by: Based on observation, interview and record review, the agency failed to have an effective governing body (GB) legally responsible for establishing and implementing management and operational policies to ensure effective administration of the agency to provide care and services within acceptable standards of practice when the agency failed to: 1-Ensure there were full time Registered Nurse (RN) Case Managers. 2-Ensure the Executive Director or Director of Patient Care Services provided oversight to make decisions on accepting new home health referrals. 3-Ensure there is a Director of Patient Care Services on site in the Redding office to provide oversight for education and train RN case managers. 4-Ensure implementation of Infection Control Measures for two of nine patients and clinicians. This failure resulted in poor symptom management, hospitalizations, medication errors, and no education provided to the patients or caregivers. Findings: 1-During a review of a policy revised (8/01/19) titled “Coordination Of Care, From Admit to Discharge,” indicated the purpose of this policy is to establish processes and criteria so that the coordination of patient care will be optimal from admit through discharge. Section two indicated the Executive Director and Clinical Director coordinate care and services. During an interview with the Patient care manager on 3/15/23 at 2:05 pm, the Patient Care Manager confirmed there are no full time Registered Nurses (RN), but they have hired two RNs to case manage for oversight and care coordination. PCM also stated, “We do not have a Director for Patient Care, I am not sure why, maybe it is because our census is low. I am still completing visits needed, and I cannot case manage all patients until we can provide coverage for the nursing visits.” During an interview on 3/17/23 at 10:10 am, the Executive Director (ED) confirmed they do not have any full time RN case managers, they did hire two RNs, but they do not have home health experience. ED stated, “I agree we need more RN oversight and to teach our clinicians, we are going to start this process.” 2. A review of a policy revised (01/01/23), titled “Admission Process,” indicated the admission/initial visits are made within 48 hours of the referral unless there is a specific physician ordered start of care, (SOC) date. During a review of a policy revised (01/01/21) titled “Admission Process,” indicated once nursing staff receives a referral, the Executive Director or Clinical Director is notified, and a qualified clinician is scheduled to make the initial assessment or admit visit. During record reviews for Patient 1, 6, 7, and 8 it was documented all initial visits were late and the physician was not updated within 48 hours of the referral. During an interview on 3/17/23 at 10:20 am, the ED confirmed she does not make the decision to accept the referrals but will start to review all home services ordered for RN oversight per policy. ED also stated during their internal audit it was determined initial assessments were late with no physician update and they have started a new process for all referrals to be initiated within 48 hours or the physician will be updated. 3. During an observation on 3/15/23 at 12:40 pm, a home visit was completed at Patient 7’s home with Licensed Nurse (LN) A. Patient 7 had severe nausea and stated, “I have been up all night nauseated and unable to sleep. I just had chemotherapy and it is bad for a few days, it is hard to eat with nausea.” During an interview on 3/15/23 at 2:05 pm, the Patient Care Manager (PCM) confirmed the present medication list is not up to date. PCM confirmed education should be provided to Patient 7 and care givers for all medications, especially to a patient on chemotherapy to control symptoms such as nausea. PCM confirmed some patients with a higher acuity should be seen more often and more education is needed for clinicians for symptom management to improve patients’ quality of life. PCM stated the agency will provide more education to their staff for symptom management and educate the new clinicians to prevent and possible complications that can occur in the home with all disease processes. PCM agreed education to the patients and caregivers in the home is a way to prevent hospitalizations, reduce medication errors, reduce the patient and family’s anxiety, provide support, and deliver coordinated care in the home. 4. A review of a policy revised 11/01/21 titled “Infection Control Plan,” indicated the purpose of this policy is to enhance the safety and quality of patient care provided by the agency and to decrease the risk of infections and transmission of communicable diseases. The agency will establish a comprehensive infection control program to ensure that there is a functioning, coordinated process in place to reduce the risk of endemic, epidemic, and home acquired infections. A record review of Patient 7’s clinical record indicated from 12/2/22 through 3/16/23 there was no education provided on C-Diff precautions to patient or care givers going in and out of the home to include but not limited to education for the specific contagious disease process, taking all the antibiotics prescribed, personal hygiene such as handwashing with soap and water or prevention of transmission to other care givers. No education provided for signs and symptoms to report immediately. No documentation present of appropriate Personal Protective Equipment (PPE) for clinicians to be worn to prevent the spread of active C-Diff communicated to patient or other clinicians. The plan of Care (physician orders) was not followed to provide education for prevention, transmission, and the disease process. During an interview on 3/16/23 at 2:10 pm, the PCM confirmed all PPE should have been worn by the clinicians for an admission for C-Diff and communication notes entered for all staff to be updated for C-Diff precautions. PCM also confirmed the plan of care, physician orders were not followed to provide education to patient and caregivers. PCM added “Precautions and education should have been provided at all visits and clinicians should know to teach use of proper handwashing of soap and water and not hand sanitizer for C-Diff.” During an Interview on 3/17/23 at 10:50 am, the ED confirmed all the education was missed for C-diff precautions for Patient 7 and the PPE should have been worn to prevent the transmission of a highly contagious disease. ED also stated, “They need to teach C-Diff education, teach proper hand washing to all the care givers and patient 7. It is in our Infection Control policy for C-Diff, and we will start the education for our staff.” During an interview on 3/17/23 at 10:30 am, the ED confirmed more RN oversight and education will help with all areas of patient care. ED agreed some of the areas included late initial assessments, late resumptions of care, not obtaining weights or measurements as ordered, poor symptom management, medication errors, no medication reconciliations on all home visits, hospitalizations, missed visits (not following the plan of care), and infection control practices will be taught with each new clinician and the current staff. Ed stated, "We have a lot of support with our corporate office who gives us time to learn and provide good patient care before they rush increasing the census, they are very supportive to educate us as we grow. We have learned a lot and will start processes immediately."

Assure patient needs are continually assessed CFR(s): 484.105(c)(4) Assuring that patient needs are continually assessed, and This ELEMENT is not met as evidenced by: Based on interview and record review, the agency failed to assure one of nine sampled patients needs were continually assessed. A Medical Social Worker (MSW) was assessed as needed during Patient 5's admission to the home health agency. This service was never followed up on or provided to Patient 5. This failed action had the potential for patient needs not to be met and negative outcomes to occur to patients. Findings: A review of Patient 5's record indicated she was admitted to the Home Health Agency on 1/5/22 with diagnoses that included Parkinson's disease (progressive disease of the nervous system), lung cancer, diabetes (elevated glucose in the blood stream), chronic pain and blindness. A review of Patient 5's start of care OASIS (Outcome and Assessment Information Set, an assessment tool) dated 1/5/22, a Licensed Nurse (LN) documented that Patient 5 needed MSW services for an Advanced Directive (legal document that specifies health care actions if a patient can no longer make their own decisions) and in home support. A review of Patient 5's physician's orders and visit notes showed no visits by a MSW from 1/5/22 to 3/5/22. During an interview and record review with Patient Care Manager (PCM), on 3/16/23 at 3:12 pm, she confirmed the documented need for MSW Services on 1/5/22 for Patient 5. She stated the LN on 1/5/22 did send a fax to the physician for the MSW services but the request was never followed up on by nursing. She stated the visiting nurses need to review what the previous nurse documents and follow up on the recommendations and needed orders. PCM stated the nurses need to write a narrative note and follow up on patient needs. She stated Patient 5 should have received MSW services.

Assure implementation of plan of care CFR(s): 484.105(c)(5) Assuring the development, implementation, and updates of the individualized plan of care. This ELEMENT is not met as evidenced by: Based on interview and record review, the agency failed to assure the development, implementation, and updates of the plans of care (physician's orders) for one of nine sampled patients (Patients 4) when the plan of care was not signed and returned by the physician within thirty (30) working days as required by State law. This failure had the potential for staff not to be aware of changes to the plans of care and for inappropriate or incorrect care to be rendered, which could lead to negative clinical outcomes. Patient 4 was referred to the facility on 2/1/23 with diagnoses that included bilateral (both sides of the body) osteoarthritis of the knees, hypertension (high blood pressure), and a history of falling. The Plan of Care, dated 2/2/23, was reviewed. The physician had not signed the Plan of Care. During an interview and concurrent record review, conducted on 3/14/23 at 3:30 pm, with Patient Care Manager (PCM) she reviewed the Plan of Care for Patient 4. PCM confirmed that the document had not been signed by the physician and that this should have been completed within 30 days. Findings: During a review of a policy revised (11/01/21) titled “Physician Orders,” indicated the Plan of Care, (physician orders) must be signed and dated within 30 days by the physician or authorized practitioner per state regulation.