Every finding on record at Life Fountain Health Care, Inc.

The Emergency Preparedness regulations were reviewed as part of the Medicare recertification survey completed on 09/18/2025. During the survey it was determined the home health provider is in compliance with the requirements of 42 CFR 484.102 Condition of Participation: Emergency Preparedness for Home Health Providers.

A partial extended survey for Medicare recertification for the home health provider was completed on 09/18/2025. The provider had 10 current patients.

Accuracy of encoded OASIS data CFR(s): 484.45(b) Standard: The encoded OASIS data must accurately reflect the patient's status at the time of assessment. This STANDARD is not met as evidenced by: Based on policy review, clinical record review, and interview, the home health provider failed to ensure the accuracy of the Outcome and Assessment Information Set (OASIS- Outcome and Assessment Information Set; a standardized data collection tool) data in one of five full records reviewed (Record/Patient #1). This deficient practice has the potential to affect accurate OASIS data collection for all the provider’s patients. Findings included: Review of the provider’s policy titled, “Assessment, Comprehensive,” revised “10/2018”, showed, in part: - “Named provider” will ensure timely (timeliness) and accuracy of the OASIS data; and - The Director of Patient Services and/or designee will consult the qualified clinician who conducted and completed the comprehensive assessment for purposes of collaboration, clarification or to complete missing OASIS data items. RECORD/PATIENT #1: Review of the clinical record showed the patient was admitted to home health services on 09/13/2025 with a primary diagnosis of alcoholic cirrhosis of the liver with ascites (a chronic liver disease caused by excessive alcohol consumption, leading to scarring (fibrosis) of the liver and the accumulation of fluid in the abdominal cavity (ascites). The patient resided at home with their spouse. Review of the OASIS Start of Care (SOC) initial assessment, dated 09/13/2025, showed: - Item M1306: Does this patient have at least one unhealed pressure ulcer injury at stage 2 (two) (a partial thickness loss of the skin caused by pressure) or higher (worse) or designated unstageable (the depth of the wound cannot be determined because it is covered)? This was marked as no; - Item M1324: Stage of most problematic unhealed pressure ulcer/injury that is stageable: This was marked as N/A (not applicable)– “Patient has no pressure ulcers/injuries or no stageable pressure ulcers/injuries”; and - Under the wound care worksheet portion: wound 1- location: coccyx, status: open, present on admission, type: left blank, wound bed: pink, drainage: none, odor: left blank, surrounding tissue: intact, treatment: apply barrier cream. (There failed to be any measurements of the coccyx wound). During an interview on 09/18/2025 at 9:40 AM the clinical manager stated that the OASIS data entry was inaccurate, and they should have marked Item M1306: yes.

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 policy review, clinical record review, and interview, the home health provider failed to complete the initial assessment of the patient within 48 hours of the referral to home care, or 48 hours after the patient's return home, or on the physician ordered start of care date in one of five full records reviewed (Record/Patient #1). This deficient practice has the potential to affect the immediate needs of all the provider’s patients. Findings included: Review of the provider’s policy titled, “Assessment, Comprehensive,” revised “10/2018”, showed, in part, a registered nurse, or qualifying clinician, must conduct an initial assessment within 48 hours of referral or patient’s return to home, or on the physician ordered start of care date. RECORD/PATIENT #1: Review of the patient profile sheet showed, under the comments section, the following: “9/9/2025: Received completed referral and report from “named employee”, marketer, that patient contact made for verification and referral is now ready for staffing. “Named clinical manager” 9/9/2025: Call made to verify “named physician” (PCP) (primary care physician) will follow for home care orders. Return call received, “named physician” to follow for home care orders. ” named clinical manager””. Review of the start of care (SOC) OASIS (Outcome and Assessment Information Set; a standardized data collection tool) initial assessment, and the first skilled nurse (SN) visit to the patient showed, in part: - The assessment was dated 09/13/2025 (ninety-six hours after the referral and 120 hours after inpatient discharge); - Item M0102 (Physician ordered start of care date), was answered with N/A- No specific SOC/ROC (resumption of care) date ordered by the physician; - Item M0104 (Date of Referral), was answered with 09/08/2025; and – Item M1005 (Inpatient discharge date) was answered with 09/08/2025. Further review of the clinical record failed to show physician orders for a specific SOC date. During an interview on 09/18/2025 at 9:40 AM, the clinical manager stated, “there should have been an order put in for a late SOC, but it wasn't put in, so that was one that was missed”.

Health, psychosocial, functional, cognition CFR(s): 484.55(c)(1) Standard: Content of the comprehensive assessment. The comprehensive assessment must accurately reflect the patient's status, and must include, at a minimum, the following information: (1) The patient's current health, psychosocial, functional, and cognitive status; This ELEMENT is not met as evidenced by: Based on policy review, clinical record review, and interview, the home health provider failed to ensure the comprehensive assessment accurately reflected the patient’s current health status in one of five full records reviewed (Record/Patient #1). This deficient practice has the potential to affect all the patients served by the provider. Findings included: Review of the provider’s policy titled, “Assessment, Comprehensive,” revised “10/2018”, showed, in part: - The comprehensive assessment must accurately reflect the patient's status and serve as a purpose to provide the home health agency with a complete picture of the patient’s status to assist the home health agency in developing the patient's plan of care; and - The comprehensive assessment must include at a minimum the following patient information: assessment of the patient’s current health status includes relevant past medical history as well as all active health and medical problems. RECORD/PATIENT #1: Review of the clinical record showed the patient was admitted to home health services on 09/13/2025 with a primary diagnosis of alcoholic cirrhosis of the liver with ascites (a chronic liver disease caused by excessive alcohol consumption, leading to scarring (fibrosis) of the liver and the accumulation of fluid in the abdominal cavity (ascites). The patient resided at home with their spouse. Review of the OASIS (Outcome and Assessment Information Set; a standardized data collection tool) Start of Care initial assessment, dated 09/13/2025, showed: - Under the wound care worksheet portion: wound 1- location: coccyx, status: open, present on admission, type: left blank, wound bed: pink, drainage: none, odor: left blank, surrounding tissue: intact, treatment: apply barrier cream; and - The initial assessment documentation failed to show any measurements of the coccyx wound. During an interview on 09/18/2025 at 9:40 AM, the clinical manager stated that there were no coccyx wound measurements, but they usually did measure the wounds on admission (if present) and weekly.

Services by skilled professionals CFR(s): 484.75(a) Standard: Provision of services by skilled professionals. Skilled professional services are authorized, delivered, and supervised only by health care professionals who meet the appropriate qualifications specified under §484.115 and who practice according to the HHA's policies and procedures. This STANDARD is not met as evidenced by: Based on clinical practice guidelines, clinical record review, and interview, the home health provider failed to maintain professional standards when wound measurements were not obtained/documented according to the clinical practice guidelines and interview, in one of two records with wounds (Record/Patient #3). This deficient practice has the potential to affect all the patients with wounds served by the provider. Findings included: Review of the provider’s policies showed the provider failed to have a wound care/management policy. Review of the article by Karen S. Clay, RN, BSN, CWCN Copyright 2008 titled, "Evidence-Based Pressure Ulcer Prevention: A Study Guide for Nurses," showed the following: "The standard of practice requires at least weekly measurement of the wound. In addition, every time you change the dressing, assess peri-wound skin, wound margins, wound tissue, drainage, odor, pain, and any other relevant issues. On a weekly basis, assess those macroscopic (i.e., visible to the naked eye) indices, measure the wound, assess the effectiveness of the treatment, and determine any treatment plan changes." (http://www.hcpro.com/content/76944.pdf Chapter 9-Wound Healing-Page 95) RECORD/PATIENT #3: Review of the clinical record showed the patient was admitted to home health services on 08/22/2025 with a primary diagnosis of stage two (2) pressure ulcer (an injury with partial-thickness skin loss caused by unrelieved pressure) of the left ankle, type 2 diabetes mellitus (DM- a chronic disease that affects how the body uses sugar for energy) with foot ulcer (discontinuity or break in a bodily membrane that impedes normal function of the affected organ), non-pressure chronic (condition that persists over a long time, generally at least a year, or recurs frequently) ulcer on parts of left foot and right foot. The patient lived at home with his/her adult children. Review of the OASIS (Outcome and Assessment Information Set; a standardized data collection tool) start of care (SOC) skilled nurse (SN) initial assessment, dated 08/22/2025, showed the following wound measurements: - Wound 1 (one), right heel - 6-centimeters (cm) x 3.4-cm x 0-cm; - Wound 2, posterior left lower leg – 4.5-cm x 1.5-cm x 0.3-cm; and - Wound 3 (three), anterior left foot – 2.0-cm x 2.9-cm x 0-cm. Review of the plan of care (POC), dated 08/22/2025 to 10/20/2025, showed in part: - The patient’s primary diagnosis was a pressure ulcer of the left ankle, stage 2; - SN visit frequency of one time a week for one week, then starting on 08/25/2025, three times a week for six weeks; and - Interventions included SN assessment of patient with stage 2 pressure ulcer of left ankle, type 2 DM with foot ulcer, and non-pressure chronic ulcer of other parts of left and right foot. Review of clinical record showed the skilled nurses failed to measure the patient's wound the week of 08/24/2025 to 08/30/2025 and from 09/07/025 to 09/16/2025. During an interview on 09/18/2025, beginning at 10:57 AM, the clinical manager stated that he/she would expect that wounds were measured weekly.

Provide services in the plan of care CFR(s): 484.75(b)(3) Providing services that are ordered by the physician or allowed practitioner as indicated in the plan of care; This ELEMENT is not met as evidenced by: Based on policy review, clinical record review, and interview, the home health provider failed to provide skilled nursing services as ordered by the physician on the plan of care (POC) in one of five full records reviewed (Record/Patient #3). This deficient practice has the potential to affect the quality of nursing care to all patients served by the provider. Findings included: Review of the provider’s undated policy titled, "Plan of Care", showed, in part, the following: - The initial POC must include, at a minimum, these patient specific items; * The frequency and duration of visits to be made by all disciplines; - The POC will serve as physician’s orders for patient care and all staff providing services will be in compliance with the orders; and - The patient's physician orders for treatments and services are the foundation of the POC. If the agency (provider) misses a visit or treatment or service as required by the POC, which results in any potential for clinical impact upon the patient, then the agency will notify the responsible physician of such missed treatment or service. The physician will decide whether the treatment or service may be skipped or whether additional intervention is required by the home health agency due to the clinical impact on the patient. RECORD/PATIENT #3: Review of the clinical record showed the patient was admitted to home health services on 08/22/2025 with a primary diagnosis of stage two (2) pressure ulcer (an injury with partial-thickness skin loss caused by unrelieved pressure) of the left ankle, type 2 diabetes mellitus (a chronic disease that affects how the body uses sugar for energy) with foot ulcer (discontinuity or break in a bodily membrane that impedes normal function of the affected organ), non-pressure chronic (condition that persists over a long time, generally at least a year, or recurs frequently) ulcer on parts of left foot and right foot. The patient lived at home with his/her adult children. Review of the POC, dated 08/22/2025 to 10/20/2025, showed in part: - The patient’s primary diagnosis was a pressure ulcer of the left ankle, stage 2; - Type 2 diabetes mellitus with foot ulcer; - Non-pressure chronic ulcer on parts of left foot and right foot; - Skilled nurse (SN) visit frequency of one time a week for one week, then starting on 08/25/2025 three times a week for six weeks; and - Interventions included SN assessment of patient with stage 2 pressure ulcer of left ankle, Type 2 diabetes mellitus with foot ulcer, non-pressure chronic ulcer on parts of left foot and right foot. Review of the clinical record showed nurses notes dated 08/25/2025, 08/28/2025, 09/02/2025, and 09/05/2025. Review of clinical record showed the skilled nurse failed to make three visits a week the weeks of 08/24/2025 to 08/30/2025 and from 08/31/025 to 09/06/2025. Review of the SN missed visit form, dated 08/27/2025, showed the patient’s adult child contacted the provider to cancel SN visit for that day and wanted to reschedule SN visit for the following day (Thursday 08/28/2025). The adult child stated he/she would be going to work today (08/27/2025). Fax sent to the physician. (the provider failed to make up the missed visit on other days during the week) Review of the SN visit, dated 08/28/2025, showed: - Treatment goals and plan audits comments – Adult child was in during the visit and requested SN visit next Tuesday (09/02/2025) as they were having family event over next few days. Review of the SN missed visit form dated 09/01/2025 showed the patient and adult child stated that they preferred the SN visit on Tuesday (09/02/2025) as they were having extended family over for that day. A fax was sent to the physician (the provider failed to make up the missed visit on other days during the week). During an interview on 09/18/2025, beginning at 10:57 AM, the clinical manager stated that he/she would expect the POC to be followed.

Required items in clinical record CFR(s): 484.110(a)(1) The patient's current comprehensive assessment, including all of the assessments from the most recent home health admission, clinical notes, plans of care, and physician or allowed practitioner orders; This ELEMENT is not met as evidenced by: Based on policy review, clinical record review, and interview, the home health provider failed to provide a clinical record that was accurate and included completed nursing visits in one of five full records reviewed (Record/Patient #3). This deficient practice has the potential to affect the complete and accurate records of all the provider’s patients. Findings included: Review of the provider’s policy titled, “Contents of Clinical Records,” revised 10/2018, showed patient records must be kept current and confidential. Review of the provider’s policy titled, “Description of Services Policy, Skilled Nursing,” revised 10/2018, showed duties of the registered nurse are to keep current and adequate documentation showing assessment of the patient's current status. RECORD/PATIENT #3: Review of the clinical record showed the patient was admitted to home health services on 08/22/2025 with a primary diagnosis of stage two (2) pressure ulcer (an injury with partial-thickness skin loss caused by unrelieved pressure) of the left ankle, type 2 diabetes mellitus (DM - a chronic disease that affects how the body uses sugar for energy) with foot ulcer (discontinuity or break in a bodily membrane that impedes normal function of the affected organ), non-pressure chronic (condition that persists over a long time, generally at least a year, or recurs frequently) ulcer on parts of left foot and right foot. The patient lived at home with his/her adult children. Review of the OASIS (Outcome and Assessment Information Set; a standardized data collection tool) start of care (SOC) skilled nurse (SN) initial assessment showed the assessment was completed on 08/22/2025. Review of the plan of care (POC) dated 08/22/2025 to 10/20/2025, showed in part: - The patient’s primary diagnosis was a pressure ulcer of the left ankle, stage 2; -SN visit frequency of one time a week for one week, then starting on 08/25/2025 three times a week for 6 weeks; and - Interventions included SN assessment of patient with stage 2 pressure ulcer of left ankle, type 2 DM with foot ulcer, and non-pressure chronic ulcer of other parts of left and right foot. Review of clinical record showed visit verification signatures signed by the patient for 9/5/2025, 9/8/2025, 9/10/2025, 9/12/2025, and 9/15/2025 and failed to show visit notes and assessments documented for the visits. During an interview on 09/18/2025, beginning at 10:55 AM, the clinical manager stated that clinical record documentation should be completed within 48 hours as per Medicare, but staffing problems made her get behind.

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, clinical record review, and interview, the home health provider failed to ensure a completed comprehensive discharge summary was sent to the primary care physician or other professional who would be responsible for providing care and services to the patient after discharge from the home health provider/services within five business days of the patient’s discharge in two of two discharge records reviewed (Records/Patients #5 and #6). This deficient practice has the potential to affect the post-discharge care of all patients served by the home health provider. Findings included: Review of the provider’s policy titled, “Discharge/Transfer, Patient,” dated 10/2018, showed, in part: -The assigned staff member will document physician notification and as needed obtain a discharge/transfer order; -A completed discharge summary will be 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 home health agency (if any) within five (5) business days of the patient’s discharge; and -The discharge summary will be placed in the patient’s clinical record. RECORD/PATIENT #5: Review of the clinical record showed the patient was admitted to home health services on 03/29/2025, with a primary diagnosis of hemiplegia (paralysis affecting one side of the body) following cerebral infarction (stroke) affecting the right dominant side and functional quadriplegia (paralysis that affects all the person’s limbs). The patient resided at home with his/her spouse. Review of the patient’s discharge “Outcome and Assessment Information Set” (OASIS, a standardized data collection tool), dated 04/19/2025, showed, in part: -Reason for discharge: hospice; -Discharge from home health services; -All services notified and discontinued; -Physician notified of discharge prior to discharge date, per agency policy; and -Physician notified of discharge summary availability. Review of the clinical record failed to show the discharge summary was completed and sent to the primary care physician or to the receiving hospice provider. During an interview on 09/18/2025 at 09:41 AM, the clinical manager stated that: - There was not a discharge summary completed; therefore, no summary was sent to the patient’s primary care physician; and - He/she only had the order for the patient’s discharge. RECORD/PATIENT #6: Review of the clinical record showed the patient was admitted to home health services on 06/07/2025 with a primary diagnosis of severe dementia (decline in mental capacity), thyrotoxicosis (a rare and life-threatening condition that occurs when the thyroid gland releases a large amount of thyroid hormones), and bilateral cortical age-related cataract (develops in the outer layers of the eye’s lens causing clouding of the lens, leading to blurred vision). The patient resided in the home with his/her adult children. Review of the OASIS discharge, dated 06/27/2025, showed in part: - The physician was notified of discharge prior to discharge date; and - The OASIS discharge was completed by the registered nurse. Review of the clinical record failed to show the discharge summary was sent to the primary care physician. During an interview on 09/17/2025 at 11:28 AM, the clinical director stated that: - The discharge summary was not sent; and - The order was sent to the physician for the patient to be discharged and the physician signed the order.

A partial extended survey for Medicare recertification for the home health provider was completed on 10/19/2022. The agency had 26 current patients. A Covid-19 vaccination survey was completed on 10/19/2022. One standard level deficiency was identified related to the Covid-19 vaccination survey. The Emergency Preparedness regulations were reviewed as part of the Medicare recertification survey completed on 10/19/2022. One standard level deficiency was identified.

EP Training Program CFR(s): 484.102(d)(1) §403.748(d)(1), §416.54(d)(1), §418.113(d)(1), §441.184(d)(1), §460.84(d)(1), §482.15(d)(1), §483.73(d)(1), §483.475(d)(1), §484.102(d)(1), §485.68(d)(1), §485.625(d)(1), §485.727(d)(1), §485.920(d)(1), §486.360(d)(1), §491.12(d)(1). *[For RNCHIs at §403.748, ASCs at §416.54, Hospitals at §482.15, ICF/IIDs at §483.475, HHAs at §484.102, "Organizations" under §485.727, OPOs at §486.360, RHC/FQHCs at §491.12:] (1) Training program. The [facility] must do all of the following: (i) Initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles. (ii) Provide emergency preparedness training at least every 2 years. (iii) Maintain documentation of all emergency preparedness training. (iv) Demonstrate staff knowledge of emergency procedures. (v) If the emergency preparedness policies and procedures are significantly updated, the [facility] must conduct training on the updated policies and procedures. *[For Hospices at §418.113(d):] (1) Training. The hospice must do all of the following: (i) Initial training in emergency preparedness policies and procedures to all new and existing hospice employees, and individuals providing services under arrangement, consistent with their expected roles. (ii) Demonstrate staff knowledge of emergency procedures. (iii) Provide emergency preparedness training at least every 2 years. (iv) Periodically review and rehearse its emergency preparedness plan with hospice employees (including nonemployee staff), with special emphasis placed on carrying out the procedures necessary to protect patients and others. (v) Maintain documentation of all emergency preparedness training. (vi) If the emergency preparedness policies and procedures are significantly updated, the hospice must conduct training on the updated policies and procedures. *[For PRTFs at §441.184(d):] (1) Training program. The PRTF must do all of the following: (i) Initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles. (ii) After initial training, provide emergency preparedness training every 2 years. (iii) Demonstrate staff knowledge of emergency procedures. (iv) Maintain documentation of all emergency preparedness training. (v) If the emergency preparedness policies and procedures are significantly updated, the PRTF must conduct training on the updated policies and procedures. *[For PACE at §460.84(d):] (1) The PACE organization must do all of the following: (i) Initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing on-site services under arrangement, contractors, participants, and volunteers, consistent with their expected roles. (ii) Provide emergency preparedness training at least every 2 years. (iii) Demonstrate staff knowledge of emergency procedures, including informing participants of what to do, where to go, and whom to contact in case of an emergency. (iv) Maintain documentation of all training. (v) If the emergency preparedness policies and procedures are significantly updated, the PACE must conduct training on the updated policies and procedures. *[For LTC Facilities at §483.73(d):] (1) Training Program. The LTC facility must do all of the following: (i) Initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected role. (ii) Provide emergency preparedness training at least annually. (iii) Maintain documentation of all emergency preparedness training. (iv) Demonstrate staff knowledge of emergency procedures. *[For CORFs at §485.68(d):](1) Training. The CORF must do all of the following: (i) Provide initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles. (ii) Provide emergency preparedness training at least every 2 years. (iii) Maintain documentation of the training. (iv) Demonstrate staff knowledge of emergency procedures. All new personnel must be oriented and assigned specific responsibilities regarding the CORF's emergency plan within 2 weeks of their first workday. The training program must include instruction in the location and use of alarm systems and signals and firefighting equipment. (v) If the emergency preparedness policies and procedures are significantly updated, the CORF must conduct training on the updated policies and procedures. *[For CAHs at §485.625(d):] (1) Training program. The CAH must do all of the following: (i) Initial training in emergency preparedness policies and procedures, including prompt reporting and extinguishing of fires, protection, and where necessary, evacuation of patients, personnel, and guests, fire prevention, and cooperation with firefighting and disaster authorities, to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles. (ii) Provide emergency preparedness training at least every 2 years. (iii) Maintain documentation of the training. (iv) Demonstrate staff knowledge of emergency procedures. (v) If the emergency preparedness policies and procedures are significantly updated, the CAH must conduct training on the updated policies and procedures. *[For CMHCs at §485.920(d):] (1) Training. The CMHC must provide initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles, and maintain documentation of the training. The CMHC must demonstrate staff knowledge of emergency procedures. Thereafter, the CMHC must provide emergency preparedness training at least every 2 years. This STANDARD is not met as evidenced by: Based on policy review, employee record review, and interview, the agency failed to provide training in emergency preparedness policies and procedures to new and existing staff and to individuals providing services under arrangement upon orientation and at least every two years in, but not limited to, three (Employees #1, #2, and #3) of three employee files reviewed. This deficient practice has the potential to affect the safety and well-being of all patients served by the agency. Findings included: Review of the agency's policy titled, "Emergency Preparedness Plan - Training and Testing Program," dated/revised 03/2019, showed, in part: - Emergency preparedness training is provided to personnel; - Training is documented, including the dates, participants, and the content covered; - The training program will consist of initial training in emergency preparedness policies and procedures to all new and existing agency staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles; - The agency will provide at least annual emergency preparedness training; - All training will be documented and kept on file at the agency; -The expectation is that each individual knows the facility's emergency program and their role during emergencies; and - Furthermore, if a surveyor asks one of these individuals what their role is during a disaster, the expectation is that the individual can describe the emergency plans and their role. Review of the agency's policy titled, "Mandatory Training," dated/revised 10/2018, showed, in part; - The agency will provide all staff members with annual educational training in order to ensure the competency of all staff; - The agency will show evidence of compliance with documentation and/or monitoring as required; and - Annual training will include emergency preparedness. Review of the agency's personnel file for employee #1 showed: - The employee's hire date was 06/20/2020; - The employee completed a test that contained some emergency preparedness (EP) content on 06/30/2020; and - The personnel file failed to contain documentation that showed EP training was completed since orientation. Review of the agency's personnel file for employee #2 showed: The employee's hire date was 05/17/2021; and The personnel file failed to contain documentation that EP training was completed during orientation. Review of the agency's personnel file for employee #3 showed: The employee's hire date was 06/09/2022; and The personnel file failed to contain documentation that EP training was completed during orientation. During an interview on 1019/2022 at 10:00 AM, the administrator and operations manager stated that employee #1 had not completed any EP education since their orientation. Employees #2 and #3 are working under arrangement and the agency does not have documentation of EP education on file for them but the contracting agency may have something. They suggested that the clinical manager call the contracting entity and ask if they have anything on file. They were not aware the agency was supposed to provide EP education during orientation and every two years thereafter for all staff including those working under arrangement. During an interview on 10/19/2022 at 10:10 AM, the clinical manager stated that he/she called the contracting entity and was told they do not provide any education because it is up to each individual agency to provide the education they need to stay in regulatory compliance. He/she was not aware the agency was supposed to provide EP education during orientation and every two years thereafter for all staff including those working under arrangement.

Accuracy of encoded OASIS data CFR(s): 484.45(b) Standard: The encoded OASIS data must accurately reflect the patient's status at the time of assessment. This STANDARD is not met as evidenced by: Based on policy review, clinical record review, and interview, the agency failed to ensure the accuracy of the Outcome and Assessment Information Set (OASIS) data in, but not limited to, one (Record/Patient #1) of five full records reviewed. This deficient practice has the potential to affect accurate OASIS data collection for all of the agency’s patients. Findings included: Review of the agency’s policy titled, “OASIS Data Entry and Transmission,” dated/revised 10/2018, showed, in part: - Personnel completing OASIS forms, paper or computerized, will enter accurate and complete information that reflects the patient’s status at the time of assessment; - Accurate means that the OASIS data transmitted to Centers for Medicare & Medicaid Services (CMS) is consistent with the current status of the patient at the time the OASIS was completed; and - Data entry audits will be conducted to assure that the OASIS data is accurate. RECORD/PATIENT #1: Review of the physician’s order for home health showed the referral was dated 09/26/2022. Review of the document titled, "OASIS Start of Care," dated 09/29/2022, showed that: - M0110 was answered as no specific start of care date ordered by physician; - The question, “from which of the following inpatient facilities was the patient discharged within the past 14 days,” (M1000) was answered as “patient was not discharged from an inpatient facility;” and - The date the written or verbal referral for initiation of care was received by the home health agency (M0104) was answered as 09/29/2022 (referral was dated/received on 09/26/2022). Review of the unsigned physician’s order, dated 09/29/2022 at 12:06 PM, showed: - Starting on 09/21/22 SN (skilled nurse) made two phone call attempts to patient’s wife with messages left on voicemail; - Return call received from wife on 09/28/2022 requesting visit on Thursday 09/29/2022; and - Start care visit for skilled home care services for Thursday 09/29/2022. During an interview on 10/19/2022 at 10:15 AM, the clinical manager stated that he/she understands that the OASIS data entry was inaccurate and they should have contacted the physician within 48 hours of receiving the referral to notify that they were having trouble getting a response from the patient’s spouse.

Written notice within 4 business days CFR(s): 484.50(a)(4) Provide written notice of the patient's rights and responsibilities under this rule and the HHA's transfer and discharge policies as set forth in paragraph (d) of this section to a patient-selected representative within 4 business days of the initial evaluation visit. This ELEMENT is not met as evidenced by: Based on policy review, review of the agency’s current patient rights information and interview, the agency failed to provide written notice of patient rights regarding their right to have a copy of the patient’s rights and responsibilities provided to a patient-selected representative within four business days of the initial evaluation visit. This deficient practice has the potential to adversely affect all patients served by the agency. Findings included: Review of the agency’s policy titled, “Patient Rights and Responsibilities”, dated most recently revised 11/2019, showed it failed to contain information that the home health agency must provide written notice of the patient’s rights and responsibilities under this rule and the HHA’s (home health agency) transfer and discharge policies as set forth in paragraph (d) of this section to a patient-selected representative within 4 (four) business days of the initial evaluation visit. Review of the agency’s current patient rights information located in the patient handbook, provided to this surveyor on 10/17/2022 by the administrator, showed it failed to contain written information regarding the home health agency must provide written notice of the patient’s rights and responsibilities under this rule and the HHA’s (home health agency) transfer and discharge policies as set forth in paragraph (d) of this section to a patient-selected representative within 4 (four) business days of the initial evaluation visit. During an interview on 10/17/2022 at 1:56 PM, when discussing the portion of the rights regarding providing written notice of the patient’s rights and responsibilities to a patient-selected representative within 4 business days, the clinical manager stated that: - He/she knew that the 4 business days isn’t in there; and - Is it supposed to be written just like that? .

State toll free HH telephone hotline CFR(s): 484.50(c)(9) Be advised of the state toll free home health telephone hot line, its contact information, its hours of operation, and that its purpose is to receive complaints or questions about local HHAs. This ELEMENT is not met as evidenced by: Based on policy review, review of the agency’s current patient rights information and interview, the agency failed to provide written notice of the correct state toll free home health hotline number and its hours of operation. This deficient practice has the potential to adversely affect the knowledge and comprehension of the rights and responsibilities of all the agency’s patients. Findings included: Review of the agency’s policy titled, “Patient Rights and Responsibilities,” dated most recently revised 11/2019, showed: - Policy- [company] recognizes, respects, and supports patients’ rights and develops policies and procedures to ensure all patients/caregivers, representatives (if any), and staff acknowledge, observe and implement the patients’ rights and responsibilities to participate in their ongoing care; - Procedure- Ensure patients receive appropriate notification of their rights and responsibilities as well as the transfer and discharge policies by providing written notice to the patient or their representative of their rights and responsibilities via hard copy unless the patient requests that the document be provided electronically. Review of the agency’s current admission folder, provided by the administrator, included an insert with a resource directory that showed “NEW MISSOURI ADULT ABUSE AND NEGLECT HOTLINE AND ONLINE REPORTING SYSTEM 800-392-0210. The website and hotline operate 24/7. Review of the agency’s current patient handbook, provided by the administrator, showed: - On page 5, If you feel that your complaint is not resolved to your satisfaction, you may also contact the State toll free Hotline 1-800-392-0210 which receives complaints between 7:00 am to 12:00 am; - On page 15, State Department of Public Health toll free Hotline 1-800-392-0210, Calls are accepted 7 days a week, 7:00 am to 12:00 am; and - On page 21, If you feel satisfactory action has not been taken, you may contact the state’s home care hotline which receives “complains” or questions about local home care agencies. Their hours of operation are 7 days a week, 7:00 am to 12:00 am, and they may be reached at 1-800-392-0210. During an interview on 10/17/2022 at 1:56 PM, the clinical manager stated that he/she was unaware of the time change from midnight to 8:00 PM. .

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 clinical record review, and interview, the agency failed to complete the initial assessment of the patient within 48 hours of the referral to home health care or within 48 hours of the physician ordered start of care in, but not limited to, two (Records/Patient’s #1 and #2) of five full records reviewed. This deficient practice has the potential to affect the immediate care needs of all patients served by the agency. RECORD/PATIENT #2: Review of the clinical record showed: - Referral information from a local hospital with fax confirmation dates and times of 09/16/2022 3:33 PM and “09/18/2022 5:37:26 PM” printed on the top of the pages; - A missed visit form dated 09/21/2022 (Wednesday) showed unable to contact patient by phone until late afternoon. Patient states his/her meds make him/her sleep and he/she missed the call. This SN was able to contact the patient after he/she called the home health office. He/she states that he/she has steps in the home that are difficult for him/her to navigate. He/she requests that the SN visit be made on Friday when someone is available to open the door (that Friday would have been 09/23/2022); - An undated referral form with a planned SOC (start of care) date of 09/29/2022 with MD (medical doctor) orders/requested services for SN (skilled nurse), PT (physical therapy), and OT (occupational therapy); - A Start of Care OASIS (Outcome and Assessment Information Set- a standardized evaluation) with a visit date of 09/29/2022 documented and digitally signed by the RN 09/29/2022; - A Start of Care OASIS with item M0104 (date of referral) with a date of 09/26/2022 (three days prior to the SOC); - A Start of Care OASIS with item M0110 (date of physician ordered start of care) marked NA- no specific SOC date ordered by physician; - A Start of Care OASIS with item M1005 (Inpatient discharge date) with a date of 09/18/2022; and - A Plan of Care (POC) dated 09/29/2022 to 11/27/2022, showed orders for SN 1xwkx4wk (one time a week for four weeks), and PT (Physical Therapy) and OT (Occupational Therapy) to evaluate and treat. Findings included: Review of CFR: 484.55(a)(1) showed 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 the referral, or within 48 hours of the patient’s return home, or on the physician or allowed practitioner-ordered start of care date. RECORD/PATIENT #1: Review of the clinical record showed a physician’s order for home health services dated 09/26/2022 (electronic upload of referral into the agency’s medical record software was also dated 09/26/2022). Review of the document titled, "OASIS (Outcome Assessment Information Set) Start of Care," showed the start of care date was 09/29/2022 (72 hours after referral received). Review of the unsigned physician’s order, dated 09/29/2022 at 12:06 PM, showed: - Starting on 09/21/22 SN (skilled nurse) made two phone call attempts to patient’s wife with messages left on voicemail; - Return call received from patient’s wife on 09/28/2022 requesting visit on Thursday 09/29/2022; and - Start of care visit for skilled home care services for Thursday 09/29/2022. During an interview on 10/18/2022 at 1:30 PM, the clinical manager stated that an order was sent to the physician on 09/29/2022 showing they tried to make contact on 09/21/2022 but didn’t get a response until 09/28/2022. He/she sees that they should have made contact with the physician while within the 48 hour window of receiving the referral. Stated their software system will not usually allow documents to be dated prior to the admission date but will have to find out how the referral was uploaded with the earlier 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 policy review, record review, home visit observation, and interview, the agency failed to ensure the registered nurse performed an accurate review/update of all medications the patient was currently using in, but not limited to, two (Records/Patients #1 and #6) of five full records reviewed. This deficient practice has the potential to affect the agency’s ability to ensure safe and effective use of medications for all patients served by the agency. PATIENT/RECORD #6: Review of an after visit summary from a local hospital dated printed 9/21/2022 7:41PM, with a fax date and time on top of the pages of Sep 23, 2022 2:28 PM, show a medication list that stated take these meds: - Acetaminophen 500mg (milligram) tablet: “take 1-2 tablets (500-1,000mg total)by mouth every 6 (six) hours as need for pain (1 tablet for mild to moderate pain, 2 tablets for severe pain) for up to 120 doses’; - Albuterol HFA 90mcg (microgram)/actuation inhaler: inhale 2 puffs every 6 (six) hours as needed for wheezing; - Atorvastatin 40mg tablet: take 40mg by mouth daily (for cholesterol); - Carvedilol 12.5mg tablet: take 1 tablet by mouth twice daily with meals (used to treat high blood pressure and heart failure); - Cholecalciferol 1,000 unit capsule: take 1,000 units by mouth daily (vitamin D supplement); - Cyanocobalamin 1,000mcg tablet extended release: Take by mouth daily (vitamin B12 supplement); - Fluticasone propionate 110mcg/actuation inhaler every 12 (twelve) hours, (no further directions provided) (steroid inhaler); - Furosemide 20mg tablet: take 1 (one) tablet by mouth daily (fluid pill to reduce swelling); - Gabapentin 300mg capsule: take 1 capsule by mouth two times daily as needed (pain) (anticonvulsant and nerve pain medication); - Losartan 50mg tablet: take 50mg by mouth daily (high blood pressure medication); - Nitroglycerin 0.4mg SL (sublingual (under tongue)) tablet: place 0.4mg under the tongue every 5 (five) minutes as needed for chest pain; - Polyethylene glycol 17 gram/dose powder: take 17 g (gram) by mouth daily, mix 1 scoop (17g) in 8oz (ounce) of water and drink daily (stool softener); - Senna docusate 8.6-50mg: take 1 tablet by mouth daily (stool softener/laxative); and - White petrolatum-mineral oil cream: Apply topically daily. Review of the plan of care dated 09/23/2022 to 11/21/2022 showed the following discrepancies: - Furosemide 20mg 1 tablet: take 1 tablet by mouth two times daily; - Gabapentin oral 300mg take 1 capsule two times daily; - Losartan failed to be listed; - Polyethylene glycol failed to be listed; - Senna docusate failed to be listed; and - White petrolatum-mineral oil cream failed to be listed. Review of the Start of Care OASIS (Outcome and Assessment Information Set- a standardized evaluation), dated with a visit date of 09/23/2022 showed: - Item M2001 Drug regimen review: Did a complete drug regimen review identify potentially clinically significant medication issues? Marked Yes- Issues found during review; - Item M2003 Medication follow-up: Did the agency contact a physician (or physician designee) by midnight pf the next calendar day and complete prescribed/recommended actions in response to the identified potentially clinically significant medication issues? Marked Yes (no further clarification provided); and - Physician contacted re: home care start of care and plan, clarify meds and wound care orders. Observation on 10/18/2022 at 12:29 PM, during the patient’s home visit showed: - The RN (registered nurse) asked the patient if he/she had any medication changes (the patient replied no); - The RN did not review the medications with the patient or review the list in the home; - Surveyor reviewed medications (bottles and agency list left in the home) after RN confirmed completion of the visit and found the following medication discrepancies: * Furosemide bottle contains 40mg tablets; patient stated that takes one daily; *Losartan potassium 50mg; patient stated that takes one daily (same as on referral but missing from plan of care and patient’s medication list in the home); * Nitroglycerin 0.4mg SL (sublingual (under tongue)) tablet: place 0.4mg under the tongue every 5 (five) minutes as needed for chest pain (same as on referral but missing from plan of care and patient’s medication list in the home); and *Patient had a bottle of amlodipine 5m 1 daily last filled 09/26/2022 that patient stated is taking (not on referral or on plan of care). Per interview conducted during observation, RN stated that he/she doesn’t look at the bottles every visit if the patient says no changes and would look into the discrepancies and contact the doctor. During an interview on 10/18/2022 at 11:42 AM the clinical manager stated that: - There is documentation that discrepancies were found on admission; and - The discrepancies found were not listed. Findings included: Review of the agency’s policy titled, “Medication, Regimen Review Comprehensive,” dated/revised 08/2017, showed, in part, the following: - All required comprehensive assessments wit include 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; - The clinician will compare the medication list to those on the referral or other documents provided to the agency; - Any discrepancies will be reconciled with the physician and documented in the clinical record; and - Nursing staff will assess on an ongoing basis the patient’s response to the medication and the patient/caregiver’s compliance with the medication regimen. RECORD/PATIENT #1: Review of the clinical record showed the patient was admitted to home health services on 09/29/2022 with a primary diagnosis of seizures (a burst of uncontrolled electrical activity between brain cells that causes temporary abnormalities in muscle tone or movements, behaviors, sensations or states of awareness) and additional diagnoses of a cerebrovascular accident (CVA, a stroke - damage to the brain occurring from a blockage of blood supply to part of the brain or when a blood vessel in the brain bursts, can cause lasting brain damage, long-term disability or death), hypertensive heart disease (heart problems that occur because of high blood pressure) and heart failure (a chronic condition in which the heart doesn’t pump blood as well as it should). Observation and interview on 10/18/2022 beginning at 10:00 AM, during the patient’s home visit, showed the following medication discrepancies with the agency’s medication profile: - The medication profile showed an order for atorvastatin calcium (used to treat high cholesterol) 40 milligrams (mg) one tablet at bedtime and an order for atorvastatin 40 mg ½ tablet (20 mg) at bedtime; - Two duplicate orders for divalproex sodium (used to treat epileptic seizures) 500 mg three tablets at bedtime; - Two duplicate orders for Aspirin 81 mg daily; - Two duplicate orders for levetiracetam (used to treat seizures) 1000 mg two times a day; - Two duplicate orders for cyclobenzaprine hydrochloride (a muscle relaxant) 10 mg daily for up to three doses as needed for muscle spasms; - Two duplicate orders for famotidine (used to treat acid reflux) 20 mg two times a day; - Two duplicate orders for metoprolol tartrate (used to control heart rate and lower blood pressure) 25 mg every morning and bedtime; - Two duplicate orders for cholecalciferol (Vitamin D2) 1.25 mg one time weekly on Saturdays; - Two duplicate orders for losartan potassium (used to treat high blood pressure) 50 mg daily; - Two duplicate orders for amlodipine besylate (used to treat high blood pressure) 5 mg daily; - Two duplicate orders for sertraline hydrochloride (used to treat depression and anxiety) 25 mg daily; - Two duplicate orders for acetaminophen 325 mg two tablets every four hours as needed for pain; - Two duplicate orders for polyethylene glycol (used to treat constipation) 17 grams daily and the medication was not located in the home; - Two duplicate orders for prochlorperazine maleate (used to treat nausea and vomiting) 10 mg every six hours as needed and the medication was not located in the home; - Nayzilam nasal (used to treat seizures) spray 5 mg/0.1 milliliter spray into one nostril once as needed four up to two times was on the agency’s medication list but was not located in the home; - Eliquis 5 mg (a blood thinner) two times a day was on the agency’s medication list but was not located in the home; - Folic acid (a nutritional supplement) 1 mg daily was on the agency’s medication list but was not located in the home; - The patient’s spouse stated that they have not gotten the missing medications filled at the pharmacy and patient has not been taking them. He/she stated that they have been having financial trouble; and - The patient has nitroglycerine (used to treat chest pain) 0.4mg taken under the tongue every five minutes up to three times as needed. The medication was not included on the agency’s medication list. During an interview on 10/18/2022 at 1:30 PM, the clinical manager stated that the nurses are expected to check the patient’s medication bottles in the home against the agency’s medication list at every visit. In regards to the duplicate medication orders on the medication list, he/she stated that it sounded like they have not been reviewing the care plans like they are supposed to. The agency had just recently held an in-service on the importance of reconciling medications. He/she would expect any medication discrepancies or duplicate medications to be clarified with the physician. He/she would also expect the physician to be notified that the patient is not taking all of their medications as ordered and the reason they were not taking them.

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, clinical record review, and interview the agency failed to ensure that each patient received the home health services that are written in the individualized plan of care in, but not limited to, three (Records/Patients #1, #2 and #6) of five full records reviewed. This deficient practice has the potential to affect all patients served by the agency. RECORD/PATIENT #2: Review of the clinical record showed the patient was admitted to the agency on 09/29/2022 with hypertensive chronic kidney disease (high blood pressure caused by the narrowing of your arteries that carry blood to your kidneys). The agency was, in part, to instruct/teach on importance of attending appointments, following physician orders and not to change or discontinue medications without physician orders, and instruct/teach disease process education. Review of the plan of care dated 09/29/2022 to 11/27/2022 showed SN (skilled nurse) 1x wk x 4 wk (one time a week for four weeks). Review of the clinical record showed: - An SN visit for the third week (Week of 10/10/2022) failed to be documented; and - A physician order for a missed visit failed to be documented. During an interview on 10/18/2022 at 11:00 AM, when questioned regarding no SN visit documented the third week (week of 10/10/2022, the clinical manager stated that: - I want to say it was a missed visit, but I want to check and see; - It looks like it was a missed visit; and - I do not have documentation where they notified the doctor. RECORD/PATIENT #6 Review of the plan of care dated 09/23/2022 to 11/21/2022 showed SN 2x2w x 2wk then 1x wk x3wk (two times a week for two weeks, then one time a week for three weeks). Review of the clinical record showed: - Only one SN visit documented the first week; - A physician order for a missed visit failed to be documented. During an interview on 10/18/2022 at 11:52 AM, when questioned regarding only one SN visit documented the first week, the clinical manager stated that: - It (the admission day) was a Friday; and - It (the plan of care) should have said 1 week one (one time a week for one week) for the first week. Findings included: Review of the agency’s policy titled, “Plan of Care,” dated/revised 10/2018, showed, in part: - The plan of care (POC) will serve as physician’s orders for patient care and all staff providing services will be in compliance with the orders; - The patient’s physician orders for treatments and services are the foundation of the POC; - If the agency misses a visit or a treatment or service as required by the POC, which results in ant potential for clinical impact upon the patient, then the agency will notify the responsible physician of such missed treatment or service; - The physician will decide whether the treatment or service may be skipped or whether additional intervention is required by the agency due to the clinical impact on the patient; - If the patient or the patient’s representative refuses care that could impact the patient’s clinical wellbeing on more than one occasion, then the agency will attempt to identify the reason for the refusal; and - If the agency is unable to identify and address the reason for the refusal, then the agency will communicate with the patient’s responsible physician to discuss how to proceed with patient care. RECORD/PATIENT #1: Review of the POC, dated 09/29/2022 through 11/27/2022, showed skilled nursing (SN) to visit the patient one time weekly for four weeks. Review of the SN notes showed the agency failed to make a visit during the week of 10/10/2022 through 10/16/2022. Review of the clinical record showed the agency failed to document the reason for the missed visit and failed to communicate with the physician about the missed visit. During an interview on 10/18/2022 at 1:30 PM, the clinical manager stated that he/she would expect the clinician to notify the physician of the missed visit and the reason for the missed visit.

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 policy review, clinical record review, home visit observation and interview, the agency failed to promptly alert the physician of changes in the patient’s condition or needs that suggest outcomes are not being achieved and/or that the plan of care should be altered in two (Records/Patients #1 and #6) of five full records reviewed. This deficient practice has the potential to affect all patients served by the agency. RECORD/PATIENT #6: Review of the plan of care dated 09/23/2022 to 11/21/2022 showed the patient was admitted to the agency with, in part, lymphedema (swelling in an arm or leg caused by a lymphatic system blockage), and chronic peripheral venous insufficiency (occurs when your leg veins don’t allow blood to flow back up to your heart which can lead to swelling and skin changes of the legs). Review of the clinical record showed: - A physician order #975963323, dated and electronically signed by the RN (registered nurse) 09/23/2022 showed , in part, SN (skilled nurse) to assess LE (lower extremity) raised blistering and apply moisturizing cream/lotion such as Eucerin daily after bathing. May apply tubi grips (a tubular bandage that provides continuous support for the management of strains, sprains and swelling) starting from the base of the toes and pull up towards the knees stopping at the bend of the knee daily during the day and remove at night to decrease edema (swelling); - A SN visit note dated 10/13/2022 with documentation that stated patient has no reliable caregiver to assist in donning her support wraps and stockings. Patient continues to decline PT (physical therapy) and OT for evaluation for exercises and functioning in the home. Patient educated on OT (occupational therapy) visit for assistance in managing edema in legs will discuss further on next visit; and - There failed to be any documentation with the physician in regards to the patient’s inability/noncompliance with his/her tubi grips. During an interview on 10/18/2022 at 11:42 AM the clinical manager stated that: - The doctor was not notified; and - He/she would expect the doctor to be contacted if not following physician orders. Findings included: Review of the agency’s policy titled, “Physician Plan of Care/ Physician Orders,” dated/revised 10/2018, showed the relevant physician must be notified of any changes in the patient condition or needs that suggest that outcomes are not being met and/or the plan of care (POC) should be revised. Review of the agency’s policy titled, “Medication, Regimen Review Comprehensive,” dated/revised 08/2017, showed, in part: - The nursing staff will assess, on an ongoing basis, the patient’s response to the medication and the patient/caregiver’s compliance with the medication regimen; and - Adverse patient response, lack of patient response, and/or compliance concerns will be communicated to the physician as well as documented in the clinical record. Review of the agency’s policy titled, “Plan of Care,” dated/revised 10/2018, showed, in part: - The plan of care will serve as physician’s orders for patient care and all staff providing services will be in compliance with the orders; and - The agency must promptly alert the relevant physician 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. RECORD/PATIENT #1: Review of the POC, dated 09/29/2022 through 11/27/2022, showed the patient had orders for the following medications: - Vosevi oral (a combination drug used to treat chronic hepatitis C) 400-100-100 milligrams (mg) take one tablet daily for 12 weeks; - Nayzilam nasal spray (used to treat seizures) 5 mg / 0.1 milliliter spray into one nostril once as needed for seizure for up to two times. Administer in alternate nostril for the second dose; and - Eliquis (a blood thinner) 5 mg two times a day. Review of the patient’s medications on 10/18/2022, during the patient’s home visit, showed the patient did not have the Vosevi, Nayzilam, or Eliquis in the home. Per an interview conducted during the home visit, the patient’s spouse stated that the medications had never been filled and the patient has not been taking them. He/she stated that the patient had a small short seizure episode since the last physical therapist visit. Review of the clinical record showed the agency failed to notify the physician of the patient’s non-compliance with the ordered medications. During an interview on 10/18/2022 at 1:30 PM, the clinical manager stated that he/she would expect the clinicians to review the patient’s medication against the agency’s medication list and to notify the physician of any non-compliance with the patient’s ordered medications.

Infection control education CFR(s): 484.70(c) Standard: Education. The HHA must provide infection control education to staff, patients, and caregiver(s). This STANDARD is not met as evidenced by: Based on policy review, employee record review, and interview, the agency failed to provide infection control education to staff on orientation and annually, thereafter in, but not limited to, three (Employees #1, #2, and #3) of three employee records reviewed. This deficient practice has the potential to affect the health and safety of all patients served by the agency. Findings included: Review of the agency’s policy titled, “Infection Control Program,” dated/revised 03/2019, showed, in part: - The goal for this program is to prevent and control the spread of infections and communicable diseases; - The agency will provide access to information needed to support infection prevention, control, and education activities; and - A minimum of an annual in-service update on exposure and post-exposure, communicable disease and infection control will be provided to the direct care staff. Review of the agency’s policy titled, “Mandatory Training,” dated/revised 10/2018, showed, in part: - The agency will provide all staff members with annual educational training in order to ensure the competency of all staff; - The agency will show evidence of compliance with documentation and/or monitoring as required; and - Annual training will include, at a minimum, infection control training. Review of the agency’s policy titled, “Employment Process,” dated/revised 08/2017, showed, in part: - All hired staff shall have an orientation to the agency and to their respective position; - The orientation will be completed within the introductory period; - All staff shall be informed of any and all associated risks including, but not limited to, job duties and responsibilities related to safety and infection control; - All staff shall be in-serviced according to the agency’s mandatory training; - The agency will conduct ongoing in-services for all staff that both comply with law and are appropriate to the needs of the population served; and - All ongoing in-services and training will be documented in the personnel file. Review of the agency's personnel file for employee #1 showed: - The employee's hire date was 06/20/2020; - The personnel file contained a check-off sheet that had infection control listed as an item that was reviewed for competency; and - The file failed to contain any documentation of annual infection control education. Review of the agency’s personnel file for employee #2 showed: - The employee worked under arrangement and was hired on 05/17/2021; - The personnel file failed to contain documentation that infection control education was provided during orientation; and - The personnel file failed to contain documentation that infection control education was provided annually. Review of the agency’s personnel file for employee #3 showed: - The employee worked under arrangement and was hired on 06/09/2022; and - The personnel file failed to contain documentation that infection control education was provided during orientation. During an interview on 10/19/2022 at 10:00 AM, the administrator and operations manager stated that employee #2 and employee #3 are working under arrangement and they do not have infection control training for these employees in their employee files but the contracting agency may have something on file. During an interview on 10/19/2022 at 10:10 AM, the clinical manager stated that he/she was not aware that infection control training was required on orientation and then annually. He/she stated that he/she had called the contracted therapy agency and they did not provide the required infection control education upon hire and annually stating that it is up to each individual agency to provide education needed to stay in regulatory compliance. He/she stated it is a learning process and they will do better going forward.

COVID-19 Vaccination of Home Health Agency staff CFR(s): 484.70 (d)-(d)(3)(i-x) § 484.70 Condition of Participation: Infection Prevention and Control. (d) Standard: COVID-19 Vaccination of Home Health Agency staff. The home health agency (HHA) must develop and implement policies and procedures to ensure that all staff are fully vaccinated for COVID-19. For purposes of this section, staff are considered fully vaccinated if it has been 2 weeks or more since they completed a primary vaccination series for COVID-19. The completion of a primary vaccination series for COVID-19 is defined here as the administration of a single-dose vaccine, or the administration of all required doses of a multi-dose vaccine. (1) Regardless of clinical responsibility or patient contact, the policies and procedures must apply to the following HHA staff, who provide any care, treatment, or other services for the HHA and/or its patients: (i) HHA employees; (ii) Licensed practitioners; (iii) Students, trainees, and volunteers; and (iv) Individuals who provide care, treatment, or other services for the HHA and/or its patients, under contract or by other arrangement. (2) The policies and procedures of this section do not apply to the following HHA staff: (i) Staff who exclusively provide telehealth or telemedicine services outside of the settings where home health services are directly provided to patients and who do not have any direct contact with patients, families, and caregivers, and other staff specified in paragraph (d)(1) of this section; and (ii) Staff who provide support services for the HHA that are performed exclusively outside of the settings where home health services are directly provided to patients and who do not have any direct contact with patients, families, and caregivers, and other staff specified in paragraph (d)(1) of this section. (3) The policies and procedures must include, at a minimum, the following components: (i) A process for ensuring all staff specified in paragraph (d)(1) of this section (except for those staff who have pending requests for, or who have been granted, exemptions to the vaccination requirements of this section, or those staff for whom COVID-19 vaccination must be temporarily delayed, as recommended by the CDC, due to clinical precautions and considerations) have received, at a minimum, a single-dose COVID-19 vaccine, or the first dose of the primary vaccination series for a multi-dose COVID-19 vaccine prior to staff providing any care, treatment, or other services for the HHA and/or its patients; (ii) A process for ensuring that all staff specified in paragraph (d)(1) of this section are fully vaccinated for COVID-19, except for those staff who have been granted exemptions to the vaccination requirements of this section, or those staff for whom COVID-19 vaccination must be temporarily delayed, as recommended by the CDC, due to clinical precautions and considerations; (iii) A process for ensuring the implementation of additional precautions, intended to mitigate the transmission and spread of COVID-19, for all staff who are not fully vaccinated for COVID-19; (iv) A process for tracking and securely documenting the COVID-19 vaccination status of all staff specified in paragraph (d)(1) of this section; (v) A process for tracking and securely documenting the COVID-19 vaccination status of any staff who have obtained any booster doses as recommended by the CDC; (vi) A process by which staff may request an exemption from the staff COVID-19 vaccination requirements based on an applicable Federal law; (vii) A process for tracking and securely documenting information provided by those staff who have requested, and for whom the HHA has granted, an exemption from the staff COVID-19 vaccination requirements; (viii) A process for ensuring that all documentation, which confirms recognized clinical contraindications to COVID-19 vaccines and which supports staff requests for medical exemptions from vaccination, has been signed and dated by a licensed practitioner, who is not the individual requesting the exemption, and who is acting within their respective scope of practice as defined by, and in accordance with, all applicable State and local laws, and for further ensuring that such documentation contains (A) All information specifying which of the authorized COVID-19 vaccines are clinically contraindicated for the staff member to receive and the recognized clinical reasons for the contraindications; and (B) A statement by the authenticating practitioner recommending that the staff member be exempted from the HHA's COVID-19 vaccination requirements for staff based on the recognized clinical contraindications; (ix) A process for ensuring the tracking and secure documentation of the vaccination status of staff for whom COVID-19 vaccination must be temporarily delayed, as recommended by the CDC, due to clinical precautions and considerations, including, but not limited to, individuals with acute illness secondary to COVID-19, and individuals who received monoclonal antibodies or convalescent plasma for COVID-19 treatment; and (x) Contingency plans for staff who are not fully vaccinated for COVID-19. This STANDARD is not met as evidenced by: Based on employee vaccination record review, and interview, the agency failed to develop and implement policies and procedures to ensure that all staff are fully vaccinated for COVID-19 in, but not limited to, five (Employees #3, #4, #5, #6, and #7) of 16 employee vaccination records reviewed. This deficient practice has the potential to affect the health and safety of all patients served by the agency. Findings included: Review of the agency’s vaccination records for employees #3, #4, #5, #6, and #7, showed the agency failed to have any documentation regarding whether the COVID-19 vaccination was administered or if a medical or religious exemption was approved. Review of the agency’s policies showed the agency failed to have a COVID-19 vaccination policy. During an interview on 10/18/2022 at 12:45 PM, the clinical manager stated that they do not have a policy for COVID-19 vaccination. They follow their infection control program policy but it does not have any guidance for ensuring that staff COVID-19 vaccination status is monitored. Their process has been informal and they verbally encourage the vaccine and have vaccination records on most of the staff but there are no written policy and procedures in place regarding COVID-19 vaccinations, or any additional measures to be taken by unvaccinated staff.

Interdisciplinary assessment of the patient CFR(s): 484.75(b)(1) Ongoing interdisciplinary assessment of the patient; This ELEMENT is not met as evidenced by: Based on record review, and interview, the agency failed to ensure ongoing interdisciplinary assessment of patient, in one (Record/Patient #2) of five full records reviewed. This deficient practice has the potential to affect the coordination of care and services for all patients on service with the agency. Findings included: RECORD/PATIENT #2 Review of the clinical record showed: - An undated referral form with a planned SOC (start of care) date of 09/29/2022 with MD (medical doctor) orders/requested services for SN (skilled nurse), PT (physical therapy), and OT (occupational therapy); - A Start of Care OASIS (Outcome and Assessment Information Set- a standardized evaluation) with a visit date of 09/29/2022 documented and digitally signed by the RN 09/29/2022; - A Start of Care OASIS with item M0104 (date of referral) with a date of 09/26/2022; - A Plan of Care (POC) dated 09/29/2022 to 11/27/2022, showed orders for SN 1xwkx4wk (one time a week for four weeks), and PT (Physical Therapy) and OT (Occupational Therapy) to evaluate and treat; - An OT evaluation visit note dated 10/14/2022 (fifteen days later); and - A late OT evaluation order failed to be documented within five days of the SOC. During an interview on 10/18/2022 at 11:00 AM, the clinical manager stated that he/she would expect the OT evaluation visit within five days of the SOC or an order for a late evaluation (beyond 5 days of SOC). .

Provide services in the plan of care CFR(s): 484.75(b)(3) Providing services that are ordered by the physician or allowed practitioner as indicated in the plan of care; This ELEMENT is not met as evidenced by: Based on policy review, clinical record review, and interview, the agency failed to provide services that are ordered by the physician or allowed practitioner as indicated in the plan of care in, but not limited to, two (Records/Patients #3 and #4) of five full records reviewed. This deficient practice has the potential to affect all patients served by the agency. RECORD/PATIENT # 4 Review of the clinical record showed the patient was admitted to the agency on 08/04/2022 with spondylosis with radiculopathy, lumbar (low back) region (age related degeneration of the vertebrae and disks of the lower back with injury or damage to nerve roots in the lumbar area.) Review of the plan of care dated 08/04/2022 to 10/02/2022 showed admit to home health for SN (skilled nurse) visits 1x wk x 4wk (one time a week for four weeks). Review of the clinical record showed: - SN visits documented one time each week for five weeks (08/04/2022, 08/13/2022, 08/18/2022, 08/24/2022, and 08/30/2022; and - There failed to be a physician order for the SN visit for the fifth week. During an interview on 10/19/2022 at 9:30 AM, the clinical manager stated that: - He/she saw on the 08/18/2022 SN visit documentation that the doctor was contacted for need of support stockings and need to see patient for two more visits before discharging; - I do not see an order for the extra visit; and - He/she would expect the clinician to follow the orders on the plan of care. Findings included: Review of the agency’s policy titled, “Plan of Care,” dated/revised 10/2018, showed, in part: - The plan of care (POC) will serve as physician’s orders for patient care and all staff providing services will be in compliance with the orders; - The patient’s physician orders for treatments and services are the foundation of the POC; and - Authorized clinician staff members may only administer treatments as ordered by the physician. RECORD/PATIENT #1: Review of the POC, dated 09/22/2022 through 11/20/2022 showed an order for occupational therapy (OT) for evaluation and treatment. Review of the clinical record failed to show that an OT evaluation was performed. During an interview on 10/18/2022 at 1:30 PM, the clinical manager stated that he/she could not find any documentation showing that the OT evaluation was completed. He/she stated that they would have to do further investigation. No further documentation was provided to explain why the order for the OT evaluation was not completed.

In accordance with current clinical practice CFR(s): 484.105(f)(2) All HHA services must be provided in accordance with current clinical practice guidelines and accepted professional standards of practice. This ELEMENT is not met as evidenced by: Based on review of the Missouri code of state regulations (CSR) and rules (RSMo), policy review, personnel record review, and interview, the agency failed to: - Ensure that personnel received the required Alzheimer’s disease and related dementias training on orientation and annually in three (Employees #1, #2, and #3) of three employee files reviewed; and - Ensure that the employee disqualification list (EDL) was checked prior to hire in, but not limited to, one (Employee #1) of three employee files reviewed. These deficient practices have the potential to affect all patients served by the agency. Findings included: Review of 19 CSR 30-26.010 (1) (B) required: “Licensed home health agencies shall provide dementia-specific training about Alzheimer’s disease and related dementias to their employees and those persons working as independent contractors who provide direct care to or may have daily contact with residents, patients, clients or consumers with Alzheimer’s disease or related dementias. 1. The training for persons providing direct care shall address the following areas, at a minimum: (A) An overview of Alzheimer's disease and related dementias; (B) Communicating with persons with dementia; (C) Behavior management; (D) Promoting independence in activities of daily living; and (E) Understanding and dealing with family issues. 2. Employees or independent contractors who do not provide direct care for, but may have daily contact with, persons with Alzheimer's disease or related dementias shall receive dementia-specific training that includes, at a minimum: (A) An overview of Alzheimer's disease and related dementias; and (B) Communicating with persons with dementia. 3. Dementia-specific training about Alzheimer's disease and related dementias shall be incorporated into orientation for new employees with direct patient contact and independent contractors with direct patient contact. The training shall be presented by an instructor who is qualified by education, experience, and knowledge in the current standards of practice regarding individuals with Alzheimer's disease and other related dementias. The training shall be provided annually and updated as needed.” Review of Section 192.2490.12 RSMo: “No person, corporation, organization, or association who received the employee disqualification list under subdivisions (1) to (7) of subsection 11 of this section shall knowingly employ any person who is on the employee disqualification list.” Review of the agency’s policy titled, “Employment Process,” showed, in part: - Application and authorization for criminal background check, Family Care Registry, and EDL will be completed prior to hire; - The agency will check the EDL maintained by the Missouri Department of Health and Senior Services EDL before hiring an individual; and - The agency will not continue to employ a person whose name appears on the EDL. Review of employee #1’s personnel file showed: - The employee was hired on 06/20/2020; - The employee was hired to provide services as a registered nurse; - The requested date for the EDL check was 07/01/2020; - The personnel file failed to contain documentation that Alzheimer’s disease and related dementias training was provided during orientation; and - The personnel file failed to contain documentation that Alzheimer’s disease and related dementias training was provided annually. Review of employee #2’s personnel file showed: - The employee was hired on 05/17/2021; - The employee was hired under arrangement to provide services as a certified occupational therapy assistant; - The personnel file failed to contain documentation that Alzheimer’s disease and related dementias training was provided during orientation; and - The personnel file failed to contain documentation that Alzheimer’s disease and related dementias training was provided annually. Review of employee #3’s personnel file showed: - The employee was hired on 06/09/2022; - The employee was hired under arrangement to provide services as a certified occupational therapy assistant; and - The personnel file failed to contain documentation that Alzheimer’s disease and related dementias training was provided during orientation. During an interview on 10/18/2022 at 12:20 PM, the clinical manager provided an undated document titled, “Alzheimer’s Post Test,” that contained 15 true or false questions about Alzheimer’s disease and dementia. He/she stated that the agency provided the test as their Alzheimer’s education. He/she stated that they were not aware that there were required topics that must be provided to staff on orientation and updated annually. They give the clinician the post-test to see what they know regarding Alzheimer’s disease and dementia. They do not provide or include education on the required topics. During an interview on 10/19/2022 at 10:00 AM, the administrator and the operations manager stated that they were not aware that the EDL needed to be checked prior to the employees hire date.

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, clinical record review and interview, the agency failed to send a discharge summary to the primary care practitioner or other healthcare professional within five business days of the discharge in one (Record/Patient #4) of six applicable records reviewed. This deficient practice has the potential for unmet care needs for all patients discharged from the agency. Findings included: Review of the agency’s undated policy titled “Discharge/Transfer, Patient” showed: - “Named agency” will discharge and/or transfer patients in a timely, coordinated manner when the agency meets the agency discharge/transfer criteria; - “Named agency” may discharge a patient if the physician who is responsible for the home health plan of care agree that “Named Agency” the measurable outcomes and goals set forth in the plan of care have been achieved and that the patient no longer needs “Named Agency” services; - A completed discharge summary will be sent to the primary care practitioner or other healthcare professional who will be responsible for providing care and services to the patient after discharge from the HHA (home health agency) (if any) within five business days of the patient’s discharge; - Appropriate OASIS (Outcome and Assessment Information Set- patient specific, standardized assessment used in home health care to; plan care, determine reimbursement, and measure quality) Discharge Summary will be completed; and - The discharge summary will be placed in the patient’s clinical record. RECORD/PATIENT #4: Review of the clinical record showed: - The patient was admitted to the agency 08/04/2022 with orders for SN (skilled nurse) one time a week for four weeks, PT (physical therapy) two times a week for three weeks, then one time a week for one week, and OT (occupational therapy) to evaluate and treat week of 08/09/2022; - A physician signed OT evaluation dated 08/11/2022 with an order frequency of one time a week for one week, two times a week for two weeks, then one time a week for one week; - A physician signed OT evaluation dated 09/08/2022 with an order frequency of one time a week for four weeks; - A completed discharge OASIS dated 09/29/2022 (which was not sent to the physician); - It failed to contain a discharge summary completed upon discharge. During an interview on 10/19/2022 at 9:30 AM with the clinical manager, while reviewing the electronic medical record, he/she stated that: - There is a care summary portion on the discharge OASIS; - The discharge OASIS is not sent to the physician; and - I don’t see a discharge summary completed upon discharge from the agency, just a discharge OASIS. .

Authentication CFR(s): 484.110(b) Standard: Authentication. All entries must be legible, clear, complete, and appropriately authenticated, dated, and timed. Authentication must include a signature and a title (occupation), or a secured computer entry by a unique identifier, of a primary author who has reviewed and approved the entry. This STANDARD is not met as evidenced by: Based on policy review, clinical record review, and interview, the agency failed to ensure that entries into the clinical records are legible, clear, complete, and appropriately authenticated, dated, and timed in two (Records/Patients #3 and #6) of five full records reviewed. This deficient practice has the potential to affect all patients served by the agency. RECORD/PATIENT #6 Review of the clinical record showed: - A POC (plan of care) dated 09/23/2022 to 11/21/2022 showed SN (skilled nurse) visit frequency of 2x2w x 2wk then 1x wk x3wk (two times a week for two weeks, then one time a week for three weeks); - Review of EMR (electronic medical record) under the episode manager: view: nursing: showed visit date 10/07/2022 RN- skilled nursing visit status as saved and an icon with a house with a checkmark (software visit verify icon that occurs after obtaining the patient signature with GPS, cellular, and Wi-Fi technology used to record the location and time the visit was made); and - Review of EMR (electronic medical record) under the episode manager: view: nursing: showed visit target date 10/11/2022 RN- skilled nursing visit status as not started and an icon with a house with a checkmark (software visit verify icon that occurs after obtaining the patient signature with GPS, cellular, and Wi-Fi technology used to record the location and time the visit was made). During an interview on 10/18/2022 at 11:42 AM, while reviewing the EMR, the clinical manager stated that: - The SN visits were made (10/07/2022 and 10/11/2022); - The visit notes (10/07/2022 and 10/11/2022) are not complete; and - They (the clinicians) have to have them completed within forty eight hours of the visit. During an interview on 10/19/2022 at 9:20 AM, after requesting copies of the SN visit notes for 10/07/2022 and 10/11/2022, the office manager stated that there were no notes available for those dates. Findings included: Review of the agency’s policy titled, “Submission of Patient Documentation,” dated/revised 07/2022, showed, in part: - The agency will ensure timely and accurate submission of patient documentation to the medical record; and - Ongoing visit documentation will be documented within 48 hours of the visit. RECORD/PATIENT #3: Review of the plan of care (POC) dated 09/22/2022 through 11/20/2022 showed an order for skilled nurse (SN) to visit one time a week for four weeks. Review of the SN notes showed no documentation for a nursing visit during the week of 10/10/2022 through 10/16/2022. During an interview on 10/18/2022 at 1:30 PM, the clinical manager stated this would have been the nursing discharge summary visit and he/she has a folder in his/her desk drawer with paperwork that tracks the visits. It showed the nurse completed the visit but the nurse failed to complete the visit documentation. He/she stated that the expectation is for documentation to be completed within 48 hours of the visit.