Every finding on record at Loving Care and More Inc

An unannounced Medicare recertification visit was conducted at your home health agency on 7/22/2024 through 7/23/2024. The following deficiencies were identified: The following abbreviations were used in this report: COPD - Chronic Obstructive Pulmonary Disease DON - Director of Nursing HHA - Home Health Agency LPN - Licensed Practical Nurse OT - Occupational Therapist POC - Plan of Care PT - Physical Therapist pt/pcg - patient/patient caregiver RA - Rheumatoid Arthritis RN - Registered Nurse r/t - related to SN - Skilled Nurse ST - Speech Therapist

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 review of patient records and staff interview, it was determined the agency failed to provide accurate contact information for the Department of Health and Welfare and the home health agency hotline. This had the potential to affect all patients at the agency who wished to file a complaint with the state regarding their home health agency care. Findings include: The Patient Bill of Rights was included in the admission packet for all patients. Within this document, it stated, "The patient has the right to be advised of the availability of the toll free HHA hotline in the state...The HOTLINE number is: 1-800-377-3529". This number was incorrect. There was no mailing address or email listed as an alternate contact. The Administrator was interviewed on 7/22/24, beginning at 3:00 PM. The Patient Bill of Rights was reviewed in his presence. The Administrator confirmed the hotline number printed on the form was incorrect. He stated the document had been updated 2 years ago, apparently with this incorrect hotline number. Patients were not provided a contact number to file complaints regarding the agency.

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, medical record review, and staff interview, it was determined the facility failed to follow the POC for 2 of 11 patients (Patient #6 and #7) whose records were reviewed. This created a lack of pain assessment and potential for pain to be unrecognized and not addressed in a timely fashion. Findings include: A facility policy titled, “Pain Assessment/Management” dated 2018, stated, “Pain is assessed on every home visit and documented on a pain or symptom flow sheet.” The policy further documented, “the nurse/therapist will use a standardize agency accepted pain assessment tool that evaluates …severity (rating scale) … and response to treatment.” This policy was not followed. Examples include: Patient #6 was a 66-year-old female admitted to the agency 5/08/24 with a primary diagnosis of pressure ulcer of right buttock, stage 3. Additional diagnoses included pressure ulcer of sacral region, fitting and adjustment of urinary device, chronic pain syndrome and mild cognitive impairment, major depressive disorder, essential hypertension, Type II diabetes and COPD. She received SN, OT, ST and PT services. Patient #6’s POC documented that interventions and goals included “Assess: Pain level” as well as goal “Pt will verbalize/demonstrate measures to manage pain r/t chronic pain/RA”. Patient #6’s medical record had no pain assessment documented for visits on 5/17/24, 5/20/24, 5/30/24, 6/04/24, and 6/11/24. The DON was interviewed beginning at 7/23/24 at 11:35 AM and Patient #6’s record was reviewed with him. The DON confirmed that pain was not assessed at every visit for Patient #6. 2. Patient #7 was a 79-year-old male admitted to the agency 5/29/24 with a primary diagnosis of pressure ulcer of other site, stage 3. Additional diagnoses included non-pressure ulcer of low leg, localized edema, unspecified atrial fibrillation, COPD, essential hypertension and hypokalemia. He received SN services. Patient #7’s POC documented that interventions and goals included “Pain levels r/t chronic pain” and “Pt/pcg will verbalize/demonstrate measures to manage pain.” Patient #7’s medical record had no pain rating documented for visits on 6/21/24, 6/28/24, or 7/05/24. Additionally, on visit days 7/17/24 and 7/19/24, pain ratings of 8 were documented with no discussion, intervention or contact to doctor documented. The DON was interviewed beginning at 7/23/24 at 11:35 AM and Patient #7’s medical record was reviewed with him. The DON confirmed that pain was not assessed at every visit for Patient #7. When asked what follow up was needed for a pain rating of 8, the DON reported the doctor would need to be contacted. The DON confirmed the doctor was not contacted when the pain rating was documented at 8 for Patient #7. The agency failed to ensure pain was fully assessed at each visit.

Nursing services supervised by RN CFR(s): 484.75(c)(1) Nursing services are provided under the supervision of a registered nurse that meets the requirements of §484.115(k). This ELEMENT is not met as evidenced by: Based on medical record review, policy review, observation, and staff interview, it was determined the HHA failed to ensure the LPN was supervised by a Registered Nurse and documented on a regular and consistent basis to ensure patient care was followed according to the individual plan of care. This had the potential to affect all patients seen by an LPN. Findings include: Policy C-320, Licensed Practical Nurse Supervision, updated 2018, was reviewed. The policy stated, "Supervisory visits are to be documented in the patient's chart. The patient/caregiver will be notified of any changes in care. The supervision will occur at a minimum of every to(sic) 14 days." This policy was not followed. Example included: Patient #9 was a 70 year old female admitted to the agency on 2/07/24 for wound care. Patient #9 received SN and PT services. An observation visit by the surveyor was conducted with the LPN on 7/23/24 at 10:40 AM. Patient #9's chart was reviewed. LPN visits occurred on the following dates: 6/17/24, 6/21/24, 6/24/24, 6/27/24, 7/02/24, 7/08/24, 7/15,24, and 7/23/24. Patient #9 was seen by an RN on 7/05/24, 7/13/24 and 7/20/24. There was no note regarding the supervision of the LPN in these documented visits. The DON was interviewed on 7/23/24, beginning at 2:00 PM. He confirmed there were no documented supervisory visits completed for Patient #9. LPN visits were not provided under the direction and supervision of an RN.

No deficiencies were cited during the Emergency Preparedness survey conducted at your agency from 11/15/21 to 11/18/21. Surveyors conducting the survey were: Surveyor 40733 -Team Lead Surveyor 44100

The following deficiencies were cited during the Medicare recertification and COVID-19 focused infection control surveys of your hospice agency from 11/15/21 to 11/18/21. Surveyors conducting the survey were: 44100 40733 Acronyms used in this report include: CHF - Congestive Heart Failure COVID-19 - Coronavirus Disease 2019 DON - Director of Nursing HTN - Hypertension MSW - Medical Social Worker OT – Occupational Therapy POC - Plan of Care PT – Physical Therapy RN - Registered Nurse SN – Skilled Nursing SOC - Start of Care UTI – Urinary Tract Infection

5 calendar days after start of care CFR(s): 484.55(b)(1) The comprehensive assessment must be completed in a timely manner, consistent with the patient's immediate needs, but no later than 5 calendar days after the start of care. This ELEMENT is not met as evidenced by: Based on record review, policy review, and staff interview, it was determined the agency failed to complete the OT portion of the comprehensive assessment within 5 calendar days of the SOC for 1 of 5 patients (Patient #8) who had orders for OT and whose records were reviewed. This resulted in a delay in completion of the comprehensive assessment. Findings include: Patient #8 was a 78 year old female admitted to the agency 9/28/21 with a primary diagnosis of orthopedic after care. Additional diagnoses included atrial fibrillation, HTN, and hypomagnesemia. She received SN, PT, and OT services. Her record, for the certification period 9/28/21 to 11/26/21, was reviewed. A referral order, dated 9/28/21, included an order for OT evaluation of Patient #8 for 9/29/21. The SOC OT evaluation of Patient #8 was conducted on 10/05/21, 6 days after the date ordered. The reason for the delay could not be determined. The DON was interviewed on 11/17/21 at 4:40 PM. He confirmed the delay in OT services for Patient #8 and stated he did not see any documented reason for the delay. Patient #8's comprehensive assessment was not completed within 5 calendar days of the SOC visit.

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 record review, patient interview, and staff interview, it was determined the agency failed to ensure medications were reconciled and medication lists were kept current for 2 of 10 patients (Patients #4 and #8) whose records were reviewed. These failures had the potential to compromise patient safety. Findings include: 2. Patient #4 was an 80 year old male admitted to the agency 2/09/21 with a primary diagnosis of malignant neoplasm of head and neck. Additional diagnoses included prostate cancer and chronic obstructive pulmonary disease. Patient #4 received SN services for wound care. An SN observation visit was performed on 11/16/21 with this patient. Patient #4's record, for the certification period of 10/07/21 to 12/02/21, was reviewed. Patient #4's record included a medication profile. Medications were reconciled in the patient home with the patient and RN. Patient #4 stated that he takes amoxicillin prophylactically for wound infection. Patient #4 produced the bottle of amoxicillin. Amoxicillin was not on the medication profile. The RN was interviewed after the visit on 11/16/21 at 11:45 AM. She confirmed that she was aware the patient was taking amoxicillin but that it "fell off the med list at some point". Patient #4's plan of care did not include a current medication profile. The agency's policy, "MEDICATION PROFILE (MAR)", stated, "If the physician changes the medication orders the nurse must add newly ordered drugs or medications changed to the Medication Profile (MAR)." This policy was not followed. 1. Patient #8 was a 78 year old female admitted to the agency 9/28/21, with a primary diagnosis of orthopedic after care. Additional diagnoses included atrial fibrillation, HTN, and hypomagnesemia. She received SN, PT, and OT services. Her record, for the certification period 9/28/21 to 11/26/21, was reviewed. Patient #2's record included an ADVERSE EVENT REPORTING form, dated 10/21/21, signed by the Physical Therapist. The Physical Therapist documented Patient #8 had been diagnosed with a UTI and was prescribed the antibiotic, Cephalexin. Her medication list did not include Cephalexin. The DON was interviewed on 11/17/21 at 4:40 PM. He confirmed Patient #8’s Cephalexin had not been added to her medication list. Patient #2's plan of care did not include all of her medications.

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 medical record review and staff interview, it was determined the agency failed to ensure SNs assumed responsibility for ongoing and complete assessments of patients for 1 of 10 patients (Patient #7) whose records were reviewed. This failure had the potential to result in the inability to identify changes in patients' condition and intervene to address those changes. Findings include: Patient #7 was a 70 year old male admitted to the agency on 6/04/21 with a diagnosis of an achilles injury and wound care. Additional diagnoses included chronic obstructive pulmonary disease. He required disciplines of SN, PT and OT. His record, including the POC, was reviewed. The assessments lacked consistency and frequently omitted a numeric rating for pain and also a note documenting how the patient tolerated wound care. SN visit 5/29/21 did not rate patient's pain and did not document in the provided section of "Patient response to treatment". SN visit 6/02/21 did not rate patient's pain and did not document in the provided section of "Patient response to treatment". OT visit 6/11/21, in section for "Evaluation/Clinical Findings:" documented "Pt faces chronic pain limitations" but did not document in Pain section for Quality, location or severity. SN visit 6/15/21 did not rate patient's pain and did not document in the provided section of "Patient response to treatment". SN visit 6/22/21 did not rate patient's pain and did not document in the provided section of "Patient response to treatment". SN visit 6/28/21 did not document in the provided section of "Patient response to treatment". SN visit 7/06/21 did not rate patient's pain and did not document in the provided section of "Patient response to treatment" SN visit 7/12/21 did not document in the provided section of "Patient response to treatment". SN visit 7/16/21 did not document in the provided section of "Patient response to treatment". The Administrator was interviewed on 11/18/21 beginning at 2:00 PM. Patient #7's record was reviewed in his presence. The Administrator confirmed there were incomplete assessments by staff. Patient #7 did not consistently receive complete assessments. l

Services provided by HH aide CFR(s): 484.80(g)(2) A home health aide provides services that are: (i) Ordered by the physician or allowed practitioner; (ii) Included in the plan of care; (iii) Permitted to be performed under state law; and (iv) Consistent with the home health aide training. This ELEMENT is not met as evidenced by: Based on record review, policy review, and staff interview, it was determined the agency failed to ensure the home health aide provided services in accordance with the written aide care plan for 1 of 2 patients (Patient #2) who received aide services and whose records were reviewed. This resulted in care omitted that was included in the aide care plan. This had the potential to interfere with quality, consistency, and coordination of patient care and result in unmet patient needs. Findings include: An agency policy C-751, "HOME HEALTH AIDE CARE PLAN," dated 2017, stated, "A complete and appropriate Care Plan, identifying duties to be performed by the Home Health Aide, shall be developed by a Registered Nurse or Therapist. All home health aide staff will follow the identified plan." Agency policy C-220, "HOME HEALTH AIDE SERVICES," dated 2018, stated, "The Aide will follow the care plan and will not initiate new services or discontinue services without contacting the supervising Nurse/therapist." Patient #2 was a 91 year old female admitted to the agency on 8/10/21, with a primary diagnosis of COVID-19. Additional diagnoses included HTN and CHF. She received SN, PT, OT, and aide services. Her record, including the POC for certification period that began 10/09/21 was reviewed. Patient #2's aide care plan included blood pressure to be taken every visit. Aide documentation for visits on 10/14/21, 10/28/21, and 11/04/21 were reviewed. Patient #2's blood pressure was not documented for these 3 visits. The DON was interviewed on 11/18/18 at 11:30 AM. He reviewed Patient #2's record and confirmed her blood pressure was not documented as ordered by the aide care plan. Aide care provided to Patient #2 was not consistent with the written plan of care.