Every finding on record at Loving Care LLC

Purpose of Visit: A Re-Licensure survey. Entrance conference was conducted on 03/07/2025. Agency Census: Licensed and Certified Home Health (L&CHH) –11 Abbreviations: QAPI (Quality Assessment and Performance Improvement Program) DON (Director of Nursing) LVN (Licensed Vocational Nurse) HHA (Home Health Aide) The agency was in compliance with 42 CFR part 484.102, Emergency Preparedness Requirements for Home Health Agencies.

Purpose of Visit: A Recertification survey. Entrance conference was conducted on 03/07/2025. Agency Census: Licensed and Certified Home Health (L&CHH) – 11 Abbreviations: QAPI (Quality Assessment and Performance Improvement Program) DON (Director of Nursing) LVN (Licensed Vocational Nurse) HHA (Home Health Aide)

Participate in the HHA's QAPI program; CFR(s): 484.75(b)(8) Participation in the HHA's QAPI program; and This ELEMENT is not met as evidenced by: Based on record review and interview, the agency failed to establish a QAPI (Quality Assessment and Performance Improvement) Committee that included the required membership. The committee did not include a representative from the scope of services the agency provided, in that, the committee did not include representation from the agency’s therapist in the 04/30/2024 QAPI committee meeting. The failure of the agency to have appropriate representation on the QAPI committee placed the agency’s clients at risk of not having their problems and/or concerns regarding therapy services addressed. The Findings Included: Review of a QAPI report dated 04/30/2024 and titled “Quality Assessment/Performance Improvement Report” revealed no documented evidence that an individual representing therapy services attended the meeting. The signature page included the signatures of the Administrator, Alternate Administrator, DON (Director of Nursing), Alternate DON, LVN (Licensed Vocational Nurse) and HHA (Home Health Aide). During an interview on 03/10/2025 at 1:30 p.m. with the Administrator/DON, the above findings were reviewed and discussed. He confirmed that there was no documented evidence that an individual representing therapy services (Physical Therapy) attended the meeting which placed the agency's clients that were receiving Physical Therapy services at risk of receiving inadequate care and services. He stated he thought the signatures were there and stated it was an oversight on his part. Review of the agency’s policy titled, “QAPI.1 Quality Assessment Performance Improvement Program”, with a review date of 011318, revealed in part, “…D. The QAPI committee consisting of, at a minimum, the Administrator, supervising nurse for therapist, and individuals representing the scope of services provided by the agency will meet at least twice a year or more often as needed…”

Purpose of Visit: Recertification Entrance Conference: 3/7/22 at 10:55 a.m. with the Administrator Agency Census: Licensed and Certified (L&C): 19 Exit Conference: 3/11/22 at 9:50 p.m. with the Administrator and the Office Manager The preliminary findings were discussed. The agency was afforded the opportunity to provide additional information. Written instructions were provided for submitting a plan of correction within 10 days of receipt of the Statement of Deficiencies. Admin – Administrator Director of Nurses – DON Registered Nurse - RN Licensed Vocational Nurse – LVN POC – Plan of Care SOC – Start of Care SN – Skilled Nurse NS – Normal Saline HHA – Home Health Aide s/s – Signs and Symptoms CDC – Centers for Disease Control and Prevention QAPI – Quality Assessment Performance Improvement ADLs – Activities of Daily Living COPD – Chronic Obstructive Pulmonary Disease prn – when needed B/P – Blood Pressure FM – Family Member PT – Physical Therapy OT – Occupational Therapy N/A – Not Applicable mg – Milligram tab – tab po – by mouth q – every hs – at night qd – every day HCL – Hydrogen Chloride cap – cap bid – twice a day OTC – Over-the-Counter lpm – liters per minute COPD – Chronic Obstructive Pulmonary Disease mcg – microgram GM – gram ml – milliliters cc – cubic centiliters OASIS – Outcome Assessment and Information Set TULIP – Texas Unified Licensure Information Portal

Purpose of Visit: Recertification Entrance Conference: 3/7/22 at 10:55 a.m. with the Administrator Agency Census: Licensed and Certified (L&C): 19 Exit Conference: 3/11/22 at 9:50 p.m. with the Administrator and the Office Manager The preliminary findings were discussed. The agency was afforded the opportunity to provide additional information. Written instructions were provided for submitting a plan of correction within 10 days of receipt of the Statement of Deficiencies. Admin – Administrator Director of Nurses – DON Registered Nurse - RN Licensed Vocational Nurse – LVN POC – Plan of Care SOC – Start of Care SN – Skilled Nurse NS – Normal Saline HHA – Home Health Aide s/s – Signs and Symptoms CDC – Centers for Disease Control and Prevention QAPI – Quality Assessment Performance Improvement ADLs – Activities of Daily Living COPD – Chronic Obstructive Pulmonary Disease prn – when needed B/P – Blood Pressure FM – Family Member PT – Physical Therapy OT – Occupational Therapy N/A – Not Applicable mg – Milligram tab – tab po – by mouth q – every hs – at night qd – every day HCL – Hydrogen Chloride cap – cap bid – twice a day OTC – Over-the-Counter lpm – liters per minute COPD – Chronic Obstructive Pulmonary Disease mcg – microgram GM – gram ml – milliliters cc – cubic centiliters OASIS – Outcome Assessment and Information Set TULIP – Texas Unified Licensure Information Portal

A review of all current medications CFR(s): 484.55(c)(5) A review of all medications the patient is currently using in order to identify any potential adverse effects and drug reactions, including ineffective drug therapy, significant side effects, significant drug interactions, duplicate drug therapy, and noncompliance with drug therapy. This ELEMENT is not met as evidenced by: Based on observation, record review and interview, the agency failed to have a current medication list in each patient record as applicable to the services provided for three of three patients (Patients #1, #2, and #3) who had home visits performed, in that: 1. Patient #1’s medication list did not include Diclofenace Sodium Topical Gel (relieves joint pain) OTC, Duloxetine (anti-depressant), Simvastatin (lowers cholesterol levels) and Oxygen therapy and included Mirtazapine (antidepressant), Risperidone (anti-psychotic), Fluoxetine (anti-depressant) HCL and Trazadone (for sleep/depression) HCl. 2. Patient #2’s medication list did not include Multivitamin Centrum Silver (vitamin supplement), Iron (vitamin supplement) and Bethamethasone Dipropionate Cream 0.5 % (for itching) and included Amitiza. 3. Patient #3’s medication list was inaccurate in that Carvedilol (lowers blood pressure) was listed twice and Lorsantan (for blood pressure) was not listed. This deficient practice places the active patients at risk of medication errors, drug-drug interaction, and duplication of therapy when the medication list is not accurate and/or updated. The findings included: 1. Review of Patient #1’s SOC OASIS (initial RN assessment) dated 9/17/21 revealed the client had a diagnosis of COPD (inability to breathe) and had oxygen therapy at 2 lpm prn via nasal cannula (a method of delivering oxygen through the nose) at night and when lying down. Review of Patient #1’s Recertification OASIS (reassessment) dated 1/14/22 revealed Patient #1 had COPD, was dependent on supplemental oxygen, and used oxygen at night when lying down at 2 lpm nasal cannula Review of the Patient #1’s clinical record revealed a SOC date on 9/17/21 for a POC certification from 1/15/22 through 3/15/22 with a diagnosis of Diabetes (high blood sugar), high blood pressure, COPD, and dependence on supplemental oxygen. Further review of the POC revealed the SN was to visit the client once a week for nine weeks (1 w 9) and two visit (2) prn. Review of the section titled “Medications” revealed no documented evidence of Diclofenace Sodium Topical Gel, Duloxetine, and Simvastatin were included. In addition, Mirtazapine (antidepressant) 7.5 mg 1-tab po qhs, Risperidone (anti-psychotic) 0.5 mg 1 tab po qd, Fluoxetine (anti-depressant) HCL 40 mg 1 cap po bid, and Trazadone (for sleep/depression) HCl 100mg 1-tab po hs were listed. Finally, there was no oxygen therapy included in the POC and/or the Medication section. Review of the handwritten “Medication List” dated 1/14/22 (provided by the agency) revealed no documented evidence that Diclofenace Sodium Topical Gel, Duloxetine, and Simvastatin were included. Further review revealed Mirtazapine 7.5 mg 1-tab po qhs, Risperidone 0.5 mg 1-tab po qd, Fluoxetine HCL 40 mg 1 cap po bid, and Trazodone HCl 100 mg tab hs 30 minutes before bedtime were listed. Finally, Oxygen was not listed on the medication list. Review of the handwritten “Medication List” (undated) provided by Patient #1 in a notebook revealed the “Simvastatin 20 mg (for cholesterol), Duloxetin 30 mg and Duloxetin 60 mg (for depression)” were listed. There was no documented evidence that Mirtazapine, Risperidone, Trazadone, and Fluoxetine were listed. 2. During a concurrent home visit and interview on 3/8/22 at 9:00 a.m. with Patient #1 and the Admin/DON, the patient was not wearing oxygen but had an oxygen concentrator by her side which was turned off. The patient provided the surveyor with the handwritten medication list and provided a bag of medications. Further review revealed a medication bottle of Duloxetine with a label affixed that read “30 mg po daily, take 60 mg for a total of 90 mg daily with a fill date on 2/28/22” and a medication bottled with a label affixed that read “Simvastatin 40 mg po daily with a fill dated on 12/23/21.” Patient #1 stated that she used the Diclofenace Sodium Topical Gel for her left shoulder pain and that she took the medications that were on her handwritten list that she developed. She stated that she stopped taking the Mirtazapine a year ago, Trazadone, Risperidone, and Fluoxetine. Finally, she added that the nurses did not “go through her medication bottles” like the Surveyor did and that she wears the oxygen at night and when she gets short of breath. 3. During an interview on 3/10/22 at 9:20 a.m., with the Admin/DON he stated that he performed a visit last week and reviewed the medications. He further stated that he did not know why these medications were not listed on her medication list and that he would have to look for his notes. He stated it was important to keep an updated list of medications to prevent medication errors. Finally, he stated that oxygen should be listed in the medication list and on the POC. 4. Review of the form titled “Document Worksheet” dated 3/3/22 (visit note written by Admin/DON) revealed no documented evidence that medications were reviewed at that visit. 5. During an interview on 3/11/22 at 5:46 p.m., with LVN B she stated that she did not know that Patient #1 received oxygen because the patient never wore it during her visits. She stated that she asked the patient about her medication and the patient denies that she had any changes but would review the medication bottled if it was a new medication. She further stated that she did could not account for the difference in the medication lists. 6. Review of Patient #2’s clinical record revealed a SOC dated 4/5/21 for a POC certification period from 1/30/22 to 3/30/22 with a diagnosis of Cerebral Palsy (abnormal brain and muscle tone developed before birth). Further review of the SN visit revealed a frequency of one visit weekly for nine weeks. In the section titled “Medication” revealed “Enulose (brand name) (laxative) 10 GM/15 ml take 60 cc po bid was listed and no documented evidence that patient was ordered Multivitamin Centrum Silver (vitamin supplement), Iron and Bethamethasone Dipropionate Cream 0.5 % (for itching). In addition, Amitiza (laxative) 24 mcg 1 cap po daily was listed. Review of Patient #2’s handwritten medication list (provided by the agency) dated 1/28/22 revealed no documented evidence of Multivitamin Centrum Silver (vitamin supplement), Iron, and Bethamethasone Dipropionate Cream 0.5 % (for itching). In addition, Amitiza 24 mcg 1 cap po daily was listed. 8. During a concurrent interview and home visit on 3/8/22 at 3:00 p.m., with Patient #2 revealed the patient was non-verbal and Patient #2’s FM provided the Surveyor with the medications to review. Further review revealed a tube of Bethamethosone Dipropionate Cream 5% with a label affixed that read “Apply to buttocks (bottom) once a day with a fill date on 12/14/21, an OTC bottle of Centrum Silver, and an OTC bottled of Nature’s Bounty (brand name) Iron 325 mg tab. Patient #2’s FM stated that she gave the Centrum Silver and the Iron every day. Further review revealed there was no Amitiza. Patient #2’s FM stated she did not remember the medication Amitiza. During a second interview (via phone) on 3/10/22 at 8:29 a.m., with Patient #2’s FM she stated that the “Amitiza was for his poop” and that he no longer was taking it anymore and stopped it about a year ago. She stated that the client was taking Lactulose/Enulose instead. 9. During an interview on 3/10/22 at 10:30 a.m., with the Admin/DON he stated that the medication list was inaccurate and not current. 10. Review of Client #3’s clinical record revealed a SOC on 1/3/22 for a POC certification from 1/3/22 through 3/3/22 with a diagnosis of Diabetes, and Hypertension. Further review revealed SN visit frequency 1 visit for nine weeks. In the section titled “Medication” revealed Carvedilol 6.25 mg 1-tab qhs was listed twice and Lorsantan was not listed. Review of the Client #3’s “Medication Profile” dated 1/3/22 through 3/3/22 revealed in part “Carvedilol was listed twice and there was no documentation of Lorsantan order. 11. During a concurrent home visit and interview on 3/9/22 at 8:45 a.m., with Client #3 the client provided the Surveyor with her medications. Review of the medication bottled with the label affixed to it read “Lorsantan Potassium 100 mg tab daily with a fill date on 2/7/22” and the bottle of “Carvedilol 6.25 mg take 1-tab qhs. Client #3 stated that she just took one Carvedilol a day and that she had been on the Lorsantan. 12. During an interview on 3/10/22 at 10:25 a.m., with the Admin/DON he stated that the repeated Carvedilol was an error and could not explain why the Lorsantan was not on the medication list. He stated that the nurses should be reviewing the medications with the bottles with the clients at every visit and that an incorrect medication list could lead to medication errors. He added that a inaccurate medication list to lead to medication errors. During an interview on 3/11/22 at 9:30 a.m., with LVN A she stated that she checked the client’s medication list with the actual medication bottles and checked that the dosage and frequency matched with the physician’s orders. She further stated that she checked date filled and expiration date and made sure the client had enough medications. She could not explain why the medications were listed like that on the medication list. 13. Review of the agency’s policy titled “Medication List and Monitoring” dated 5/4/07 revealed in part “Agency will maintain a current, accurate list of all prescriptions and over-the-counter (OTC) medications taken by the patient (Medication Profile0. Oxygen therapy including liters per minutes, route, and frequency will be documented on the medication profile.”

Plan of care must include the following CFR(s): 484.60(a)(2)(i-xvi) The individualized plan of care must include the following: (i) All pertinent diagnoses; (ii) The patient's mental, psychosocial, and cognitive status; (iii) The types of services, supplies, and equipment required; (iv) The frequency and duration of visits to be made; (v) Prognosis; (vi) Rehabilitation potential; (vii) Functional limitations; (viii) Activities permitted; (ix) Nutritional requirements; (x) All medications and treatments; (xi) Safety measures to protect against injury; (xii) A description of the patient's risk for emergency department visits and hospital re-admission, and all necessary interventions to address the underlying risk factors. (xiii) Patient and caregiver education and training to facilitate timely discharge; (xiv) Patient-specific interventions and education; measurable outcomes and goals identified by the HHA and the patient; (xv) Information related to any advanced directives; and (xvi) Any additional items the HHA or physician or allowed practitioner may choose to include. This ELEMENT is not met as evidenced by: Based on record review and interview the agency failed to ensure that the POC included all medications and treatments, all nutritional requirements and safety measures for three of five active patients (Patients #1, #2, and #4), whose records were reviewed, in that: Patient #1’s POC did not include oxygen therapy.Patient #2’s POC did not include Ensure (brand name) (dietary supplement).Patient #4’s POC did not include safety measures for a client receiving Eliquis (prolongs bleeding). This deficient practice places the active patients at risk of receiving inadequate care and negative outcomes when the POC is not current. The findings included: 1. Review of Patient #1’s SOC OASIS (initial RN assessment) dated 9/17/21 revealed the client had a diagnosis of COPD (inability to breathe) and had oxygen therapy at 2 lpm prn via nasal cannula (a method of delivering oxygen through the nose) at night and when lying down. Review of Patient #1’s Recertification OASIS (reassessment) dated 1/14/22 revealed Client #1 had COPD, was dependent on supplemental oxygen, and used oxygen at night when lying down at 2 lpm nasal cannula Review of the Patient #1’s clinical record revealed a SOC date on 9/17/21 for a POC certification from 1/15/22 through 3/15/22 with a diagnosis of Diabetes (high blood sugar), high blood pressure, COPD, and dependence on supplemental oxygen. Further review of the POC revealed there was no oxygen therapy included in the POC and/or the Medication section. Review of Client #1’s “SN Visits” (nurse’s notes) dated 1/19/22, 2/2/22, 2/9/22, and 2/16/22 revealed the client’s oxygen saturation (amount of oxygen in the blood) was within normal limits and was on room air (receiving no oxygen). Review of the handwritten “Medication List” dated 1/14/22 (provided by the agency) oxygen was not listed on the medication list. 2. During a concurrent home visit and interview on 3/8/22 at 9:00 a.m. with Patient #1 and the Admin/DON, the client was not wearing oxygen but had an oxygen concentrator by her side which was turned off. Client #1 stated that she wears the oxygen at night and when she gets short of breath. 3. During an interview on 3/10/22 at 9:20 a.m., with the Admin/DON he stated that oxygen should be listed in the medication list and on the POC. He further stated the POC needed to be complete and individualized to assure the care provided according to the physician’s orders. During an interview on 3/11/22 at 5:46 p.m., with LVN B she stated that she did not know that Patient #1 received oxygen because the patient never wore it during her visits. She further stated that she reviewed the POC before she performed her visits. 4. Review Patient #2’s clinical record revealed a SOC dated 4/5/21 for a POC certification period from 1/30/22 to 3/30/22 with a diagnosis of Cerebral Palsy (abnormal brain and muscle tone developed before birth). Further review of the SN visit revealed a frequency of one visit weekly for nine weeks. In the section titled” Nutritional Requirements” in the visit note revealed no added salt and the client was to receive a heart healthy diet including Ensure. There was no documented evidence that the client received Ensure 1 can per day. 5. During a concurrent interview and home visit on 3/8/22 at 3:00 p.m. with Patient #2, the patient’s FM revealed the patient was non-verbal and Patient #2’s FM reported that she provided a can of Ensure every day. 6. During an interview on 3/10/22 at 10:30 a.m., with the Admin/DON, he stated that Ensure was not listed in the POC and nutritional supplements should be included in the POC. 7. Review of Patient #4’s “SOC OASIS” (RN initial assessment) dated 9/13/21 revealed in section titled “Safety Measures” revealed Standard Precautions (to prevent transmission of bloodborne pathogens, Fall Precautions, Use of Assistive Devices, and Keep Pathways Clear.” There was no documented evidence of safety precautions for bleeding. Review of the “OASIS Reassessment” (reassessment done by the RN) dated 1/10/22 revealed in section titled “Safety Measures” there was no documented evidence of bleeding precautions. Review of Patient #4’s clinical record revealed a SOC on 9/13/21 for a POC certification from 1/11/22 through 3/11/22 with a diagnosis of Diabetes and Unspecified combined systolic and diastolic Congestive Heart Failure (the heart is not pumping blood effectively throughout the body). Further review revealed SN frequency of one visit a week for nine weeks. In section titled “Medications” revealed Eliquis 5 mg 1-tab po bid. Further review of the section titled “Safety Measures” revealed no documented evidence of safety precautions for bleeding. Review of the handwritten “Medication List” dated 1/10/22 (provided by the agency) revealed the patient received “Eliquis 5 mg 1-tab po bid.” 8. During an interview on 3/10/22 at 10:55 a.m. with the Admin/DON, he stated that the care plan did not have bleeding precautions and it should have listed it. He further stated that this could lead to errors in care when the POC was not accurate. During an interview on 3/11/22 at 9:30 a.m., with LVN A she stated that she reviewed with the patient about not bumping into things and about bleeding, but she did not remember documenting that she provided teaching on bleeding precautions. 9. Review of the agency’s policy titled “Plan of Care” dated 11/3/18 revealed in part “C. The individualized Plan of Care will specify the care and services necessary to meet the patient specific needs as identified in the comprehensive assessment…The POC will contain the following elements: 9. Nutritional requirements, 10. All medications and treatment, and 11. Safety measures to protect against injury…” 10. Review of "Journal of Pharmacy Education and Practice" dated 2018 June 6 (2):34 Published on line April 20, 2018 titled "Patient Education on Oral Anticoagulation" revealed common side effects of anticoagulation include signs and s/s of bleeding.

Only as ordered by a physician CFR(s): 484.60(b)(1) Drugs, services, and treatments are administered only as ordered by a physician or allowed practitioner. This ELEMENT is not met as evidenced by: Based on record review and interview, the agency failed to ensure that drugs, services and treatments were administered only as ordered by the physician such as wound dressing changes and urinary catheter (a hollow tube inserted into the bladder to drain urine into a bedside urinary collection bag) irrigation (flush) (a procedure to wash out the inside of the bladder) for one of two inactive patient’s (Patient #6) whose records were reviewed, in that: 1. There was no documentation of the solution used to irrigate/flush the bladder according to the physician’s orders for three of seven skilled nurse’s notes reviewed and the incorrect amount of vinegar was used to flush the catheter for one of seven notes reviewed. 2. There was no documentation of the type of wound dressing used according to the physician’s order for five of the seven skilled nurse’s notes reviewed. This deficient practice places the active patients at risk of receiving inadequate care and services and could cause a delay in wound healing and bladder impairment. The findings included: 1. Record review of Patient #6’s clinical record revealed a SOC on 4/5/21 for a POC certification from 6/4/21 through 8/2/21 with a diagnosis of “Encounter for Change or Removal of Non-Surgical Wound Dressing and Retention of Urine.” Further review revealed SN visits daily for wound care and suprapubic (inserted in front of and bellow the bladder to drain urine) foley (brand name for indwelling urinary catheter) care “till wound heals. In addition, “Wound to buttocks (bottom) area: Cleanse with NS/wound cleaner, pat dry with gauze, apply collagen (may use triple antibiotic ointment), cover with gauze and hold with tape daily till healed…SN to flush suprapubic (hollow tube) catheter with ration 1/10 vinegar and 9/10 of sterile NS twice weekly to prevent infection, clogging, residue/sediment.” Review of the “SN Visit” (nurse’s notes) dated 6/8/21 revealed “SN changed suprapubic catheter via sterile (free from germs) technique and flushed suprapubic catheter with 1:3 vinegar/distilled water solution via sterile technique.” Review of the “SN Visit dated 6/21/21 revealed “Suprapubic catheter flushed using 100 cc of sterile water prepared with vinegar…” There was no documented evidence as to the amount of vinegar used. Review of the “SN Visit” notes dated 7/2/21, 7/5/21, and 7/12/21, revealed “Catheter flushed.” There was no documented evidence of the type and amount of solution used for the catheter flush. Review of the “SN Wound Care” notes dated 7/2/21, 7/5/21, 7/12/21, 7/14/21, and 7/16/21 revealed no documented evidence of the type of wound care dressing performed. 2. During an interview on 3/10/22 at 12:00 noon with the Admin/DON, he stated that the note on 6/8/21 was the incorrect amount of vinegar and the nurse did not follow the orders. He further stated that it was “best” or “better” when the nurse’s documented the name and the amount of solution that was used. He added that the nurses should have documented what dressing was used when they performed wound care. He further added that this could impact the clients because this could lead to improper healing when the nurse did not follow the physician’s orders. During an interview on 3/11/22 at 9:30 a.m. with LVN A and at 5:46 p.m. with LVN B, she stated that the policy was to document wound care that you provided and document the bladder flush that was used. LVN B further stated that the client already had prepared the solution that she used for the bladder flush and she did not know how much vinegar to NS was mixed. 3. Review of the “Lippincott Manual Nursing Procedures” seventh edition, 2013 revealed in part “Wound Management” section titled “Documentation” page 730 read in part “Documentation of application of a topical medication; type and amount of new dressing applied. Review of the “Lippincott Manual Nursing Procedures” seventh edition, 2013 revealed in part” Indwelling Urinary Catheter Irrigation” section titled “Documentation” page 398 read in part “Document the date and time the irrigation was performed as well as the type and volume of irrigant (solution) instilled.”

Coordination of Care CFR(s): 484.60(d) Standard: Coordination of care. The HHA must: This STANDARD is not met as evidenced by: Based on record review and interview, the agency failed to document in the patient record the steps it took to make sure each patient’s care was coordinated among all service providers for two of five active patient charts reviewed (Patients #1 and #3), in that: 1. The nurse did not coordinate care with the physician or the DON when Patient #1’s vital signs were out of parameters (acceptable range). 2. The nurse did not coordinate with the Admin/DON that Patient #3 had a paid provider from another home health agency to assist her in ADLs (grooming, bathing, toileting, meal preparation) and did not inform the physician or the DON of a high blood pressure reading. This deficient practice could place the patients at risk of receiving inadequate care and services when the agency does not effectively communicate with all healthcare providers. The findings included: 1. Review of the Patient #1’s clinical record revealed a SOC date on 9/17/21 for a POC certification from 1/15/22 through 3/15/22 with a diagnosis of Diabetes (high blood sugar), high blood pressure, and COPD (inability to breathe). Further review of the POC revealed the SN was to visit the client once a week for nine weeks (1 w 9) and two visit (2) prn. In addition, the SN was to notify the physician of “Pulse (heartbeat) greater than 120 or less than 50, Blood pressure (the pressure in the arteries when the heart beats and pushes blood through the body) Systolic B/P (heart at work) greater than 170 or less than 90, and Diastolic (heart at rest) B/P greater than 90 or less than 50. Review of the “SN Visit Note” (nurse’s visit note) dated 2/2/22 revealed Patient #1’s blood pressure was 147/96 (above parameter). There was no documented evidence that the nurse informed the physician, or the DON and she did not retake the blood pressure to see if the diastolic number went down. Review of the “SN Visit Note” dated 2/9/22 revealed Patient #1’s apical pulse (pulse taken by listening to the heartbeat with the use of a stethoscope) was 124 (high and out of parameter). There was no documented evidence that the nurse retook the apical pulse or called the physician and/or the DON. Review of the “SN Visit” dated 2/16/22 revealed Patient #1’s diastolic blood pressure was 97 (high and out of parameter). Further review revealed “B/P elevated. Denies any symptoms related to BP elevation.” Further review revealed that the client went to see her physician and administered a steroid injection (reduces inflammation and pain) for pain in her left shoulder. There was no documented evidence that the nurse re-took the blood pressure and informed the physician and/or the DON. Review of the form titled “Reports Vital Signs” dated 1/19/22 through 2/16/22 revealed on 2/9/22 Patient #1’s pulse was 124, on 2/2/22 the patient’s blood pressure was 147/96, and on 2/16/22 the patient’s blood pressure was 140/97. 2. During a concurrent home visit and interview on 3/8/22 at 9:00 a.m. with Patient #1, she stated that she took her blood pressure every morning and she wrote it down on paper. She further stated that she got dizzy when her blood pressure was high, and she waited and rested some before she continued her activity. She confirmed that the nurse had told her it was high, and she thought that the nurse re-took her blood pressure, but the nurse had not called the physician. 3. During the interview on 3/10/22 at 9:20 a.m. with the Admin/DON, he stated the nurses were to call him and the physician if the vital signs were out of parameters. He stated that the nurses should wait awhile and re-take the vital signs to see if issue resolved. 4. During an interview on 3/11/22 at with LVN B, she stated she thought she texted the DON about Patient #1’s elevated heart rate and could not get a hold of the physician and/or the DON. She further stated that she thought she documented her actions. She added that normally she stayed with the patient and re-took the blood pressure, heart rate, or blood glucose to see if she got a different reading and perhaps the patient calmed down. She further added that sometimes the patients called her after she left the home to let her know that the patient re-took their pressure, and it was fine. She stated that often the patients told her that they just took their blood pressure medication and realized it was too soon for the medication to be effective. Finally, she stated she would let the DON know and did not know why she did not document it. 5. Review of Patient #3’s clinical record revealed a SOC on 1/3/22 for a POC certification from 1/3/22 through 3/3/22 with a diagnosis Diabetes and for the SN to visit once a week for nine weeks (1 w 9) and for two prn visits. In addition, the SN was to notify the physician of “Pulse (heartbeat) greater than 120 or less than 50, Blood pressure (the pressure in the arteries when the heart beats and pushes blood through the body) Systolic B/P (heart at work) greater than 170 or less than 90, and Diastolic (heart at rest) B/P greater than 90 or less than 50. Review of the Start of Care Outcome Assessment and Information Set (OASIS) (admission assessment by the RN) dated 1/3/22 revealed in section titled “Type of Assistance Patient Receives – other than from home health agency staff and in Section titled “Supportive Assistance” both were found blank. Review of the “SN Visit” note dated 1/17/22 revealed the client’s blood pressure was 135/101 and there was no documented evidence that the nurse re-took the blood pressure, called the physician, or called the DON. 6. During a concurrent home visit and interview on 3/9/22 at 8:45 a.m. with Patient #3 and Patient #3’s FM, Patient #3’s FM stated that she was the patient’s paid provider and that she worked Monday through Wednesday from 9 a.m. through 3 p.m., and on Thursday and Friday she worked from 9:00 a.m. through 2 p.m. The FM stated that she helped with the patientt’s cooking, meal preparation, bathing, grooming, and toileting assistance. She stated that she had been here when the agency staff visited and that she had worked for Agency B for a while. Patient #3 stated that the nurse had to call the physician for refills because the nurse did her weekly medication box refill but did not think it was due to her blood pressure. 7. During an interview on 3/10/22 at 10:25 a.m. with the Admin/DON, he stated that normally the agency coordinated with the provider services and that the staff should have let him know if the family member was the provider. He further stated that the agency should know all healthcare providers to coordinate client care. During an interview on 3/10/22 at 9:30 a.m. with LVN A, she stated that she would call the primary care physician and Admin/DON if the vital signs were out of range. She further stated that she would stay with the client and wait awhile and re-check the vital sign. She stated that once stable she would continue with the visit. She stated she did not know why she did not document it. Finally, she stated that she would tell the Admin/DON if the client had a paid provider and did not know that the caregiver was a paid provider. 8. Review of the agency’s policy titled “Coordination of Care” dated 9/24/18 revealed in part “A. The Agency will use an interdisciplinary approach to coordinate services with all healthcare providers, disciplines, and physicians involved in the plan of care from the initial assessment through discharge and periodic interactive, discussion regarding the status and recommendations for the plan of care…B. Agency will exchange information, report to and coordinate patient services among: 3.The agency and other providers of health care services involved in the care of a patient, it known by the agency…”

Infection Prevention CFR(s): 484.70(a) Standard: Infection Prevention. The HHA must follow accepted standards of practice, including the use of standard precautions, to prevent the transmission of infections and communicable diseases. This STANDARD is not met as evidenced by: Based on record review and interview, the agency failed to follow written policies to control infections including how to keep infections and communicable diseases from spreading for five of five active Patients (Patients #1, #2, #3, #4, #5) and for two inactive patients (Patients #6 and #7) whose records were reviewed in that, there was no documented evidence that the nurses screened for Covid-19 (worldwide respiratory infection) prior to making visits. This deficient practice places the active patients at risk for spreading Covid-19 to the community when pre-screening patients and family members at the time of the visit is not performed. The findings included: 1. Review of the “Covid-19 Patient Screening questionnaire” (blank form) revealed a section for the client’s name, screening date, screening by, and checklist of signs and symptoms (cough, fever, shortness of breath…) and in bold “Patients that answer “yes” to any of these questions may schedule a visit with their Primary Care Provider or Covid-19 testing facility for Covid-19 testing, Nurses are not to visit patient prior to agency receiving a Negative Covid-19 result…” 2. Review of Patient #1’s SN notes (nurse’s clinical visit notes) for 1/19/22, 1/26/22, 2/2/22, 2/9/22, and 2/16/22 revealed no documented evidence that a Covid-19 pre-screening was done. Review of Patient #2’s SN visit notes dated 1/31/22, 2/7/22, 2/14/22, 2/22/22, and 2/28/22 revealed no documented evidence that a Covid-19 pre-screening was done. Review of Patient #3’s SN visit notes dated 1/3/22, 1/10/22, 1/17/22, 1/24/2, 1/31/22, 2/7/22, and 2/14/22 revealed no documented evidence that a Covid-19 pre-screening was done. Review of Patient #4’s SN visit notes dated 1/17/22, 1/24/22, 1/31/22, 2/7/22, 2/14/22, 2/21/22, and 2/28/22 revealed no documented evidence that a Covid-19 pre-screening was done. Review of Patient #5’s SN visit notes dated 2/7/22, 2/15/22, and 2/22/22 revealed no documented evidence that a Covid-19 pre-screening was done. Review of Patient #5’s HHA visit notes dated 2/7/22, 2/10/22, 2/15/22, 2/17/22, 2/22/22, and 2/24/22 revealed no documented evidence that a Covid-19 pre-screening was done. Review of inactive Patient #6’s SN visit notes dated 7/2/21, 7/5/21, 7/6/21, 7/7/21, 7/8/21, 7/9/21 /12/21, 7/13/21, 7/14/21, and 7/16/21, revealed no documented evidence that a Covid-19 pre-screening was done. Review of inactive Patient #7’s SN visit votes dated 8/17/21 revealed no documented evidence that a Covid-19 pre-screening was done. 2. During an interview on 3/9/22 at 12:45 p.m., with the Admin/DON he stated when the pandemic started the staff used the Covid-19 Patient Screening form and brought the completed form back to the agency. He further stated that he stopped that practice and the nurses were to continue to do the pre-visit screen and document it in their notes. He added that “I guess they got used to asking the questions but have not documented it.” During a second interview on 3/9/22 at 3:00 p.m., with the Admin/DON he stated that the agency did not have a specific policy on documenting the pre-screening prior to the visit. He further stated that prior to the visit the nurse called the client and/family to see if they had any s/s. He added that the agency followed CDC guidelines. During a third interview on 3/9/22 at 3:50 p.m., with the Admin/DON he stated that the agency found the Covid Screening policy. During a fourth interview and record review on 3/11/22 at 8:40 a.m., with the Admin/DON he stated that the staff used the “Covid Screening Questionnaire” and completed it prior to the visit. He further stated that at the beginning of the pandemic (worldwide infection) staff completed the Questionnaire and returned them to the agency, but the agency stopped that practice because he did not want the forms to come back from the client’s home which could spread the infection. At the same time the Admin/DON provided the Surveyor completed “Covid-19 Patient Screening Questionnaire” for Client #1 dated 3/8/22, Client #2 dated 3/8/22, and Client #3 dated 3/9/22 and stated that this was proof that he called the clients and pre-screened them prior to the Surveyor’s home visit. During an interview on 3/11/22 at 9:00 a.m., with HHA C, she stated that she performed the Covid-19 screen prior to the visit and made sure the patients and families did not have any s/s. She denied that she documented it on her notes and stated that she kept a folder with the questionnaire forms in her car. During an interview on 3/11/22 at 9:30 a.m., with LVN A she stated that she checked the patient’s lungs and temperature and called the patient prior to the visit but she did not document the Covid-19 screening. During an interview on 3/11/21 at 5:46 p.m., with LVN B she stated that she pre-screened the patients prior to the visit but stopped documenting the Covid-screening because it was “repetitive.” 3. Review of the agency’s policy titled “Covid-19 Screening Policy” date 10/7/20 revealed in part “A. Screening/documentation requirements will be implemented by July 22, 2020. 4. During exit conference on 3/11/22 at 9:50 a.m. with the Administrator and the OM, the OM provided the agency’s policy titled “Covid-19 Screening Policy” dated 10/7/20 which read “A. Screening/documentation requirements will be implemented by January 11, 2021.”

Contents of clinical record CFR(s): 484.110(a) Standard: Contents of clinical record. The record must include: This STANDARD is not met as evidenced by: Based on record review and interview, the agency failed to keep patient record entries current and accurate for two of the five active patient records (Patient #4 and Patient #5), whose records were reviewed, in that: Patient #4’s OASIS recertification form was inaccurate.HHA D’s clinical notes did not list the ADL activities that she performed for Patient #5 for four of six HHA visit notes reviewed. This deficient practice places the active patients at risk for miscommunication among all care providers and can lead to errors in patient care when the clinical record is inaccurate. The findings included: 1. Review of Patient #4’s clinical record revealed a SOC on 9/13/21 for a POC certification period from 1/11/22 through 3/11/22 with a diagnosis of Diabetes. Further review revealed SN visits were to be performed one visit a week for nine weeks and 2 prn visits. There was no documented evidence that Patient #4 received HHA services. Review of Client #4’s OASIS Recertification (SN reassessment) dated 1/10/22 revealed in section titled “Aide Supervisory Visit” dated 1/10/22 that the patient rated the HHA as “Excellent” in all categories such as competency, honors patient rights, follows client plan of care as instructed, and documents appropriately. 2. During an interview on 3/10/22 at 10:55 a.m., with the Admin/DON he stated that the patient did not receive aide services, and that the OASIS recertification was incorrect. He further stated that he had a problem with the Electronic Medical Record (EMR) “auto populating” (the EMR system automatically computes the data in the fields.) He stated that he’ll have to get it fixed and that this could lead to errors in patient care when the record was not correct. 3. Review of Patient #5’s clinical record revealed a SOC on 6/1/21 for a POC certification period from 2/7/22 through 4/7/22 with a diagnosis of Diabetes. Further review of the POC revealed SN visit frequency one visit for nine weeks (1 w 9) and two prn visits and two visits a week for nine weeks for the HHA to assist with showers, bathing, and hygiene. Review of Patient#5’s “HHA Care Plan” dated 2/7/22 through 4/7/22 revealed the HHA provided personal care at every visit and prn for assistance with dressing, back rub, grooming, oral care, bathing, skin care, and light housekeeping. Review of the HHA visit notes dated 2/7/22, 2/10/22, 2/15/22, an2/17/22 revealed the HHA recorded the patient’s vital sign (B/P, pulse, respirations, and temperature) but there was no documented evidence of the activities the HHA to assist patient in his ADLs. 4. During an interview on 3/10/22 at 11:05 a.m., with the Admin/DON, he stated that the HHA should document all the activities that she had done for Patient #5, otherwise, the agency did not know whether the HHA followed the POC and could give inappropriate care to the patient. During an interview on 3/11/22 at 9:00 a.m. with HHA D, she stated that she took her tablet home and sometimes had bad internet service and perhaps her documentation did not get recorded. She further stated that perhaps her notes did not get saved and did not know this was a problem. 5. Review of the agency’s policy titled “Medical Record Content” dated 2/13/18 revealed in part “A. Agency will retain an accurate and complete medical record for each patient receiving care in compliance with agency policy and all federal and state regulations.”