Every finding on record at Maxim Healthcare Services, Inc

The following reflects the findings of the Department of Public Health during a recertification survey. Representing the Department of Public Health: Surveyor: 43929 Surveyor: 43979 Census: 42 Unduplicated admissions: 49 Sample Size: 7 Home Visits: 3 Closed Record review: 2

Participate in care CFR(s): 484.50(c)(4)(i,ii,iii,iv,v,vi,vii,viii) Participate in, be informed about, and consent or refuse care in advance of and during treatment, where appropriate, with respect to-- (i) Completion of all assessments; (ii) The care to be furnished, based on the comprehensive assessment; (iii) Establishing and revising the plan of care; (iv) The disciplines that will furnish the care; (v) The frequency of visits; (vi) Expected outcomes of care, including patient-identified goals, and anticipated risks and benefits; (vii) Any factors that could impact treatment effectiveness; and (viii) Any changes in the care to be furnished. This ELEMENT is not met as evidenced by: Based on interview and record review, the Home Health Agency (HHA, an organization that delivers skilled nursing and other therapeutics service to a patient at home) failed to ensure two of seven sampled patients (Patient 1 and Patient 2) were informed about nursing care schedule changes, in advance. This deficient practice resulted in emotional discomfort for Patient 1 and Patient 2 their caregivers. 1.A review of Patient 1’s Face Sheet (admission record) indicated, Patient 1 was admit to the agency on 6/21/2022 with diagnoses including Cerebral palsy (a group of disorders that affect a person’s ability to move and maintain balance and posture). A record review of Patient 1’s “Plan of Care”, for certification period 12/13/2023 to 2/10/2024, indicated the skilled nurse was to provide the following: 32 to 40 hours week for 60 days. 40 hours a month for respite care for 60 days. 6 hours a day Monday through Friday and 4 hours a day Saturday and Sunday for 60 days. During an interview on 12/20/2023, at 4:30 p.m., with Patient 1’s caregiver (CG 1), CG 1 stated, the HHA did not provide information on what the nursing care/services covered for all the hours approved. CG 1 stated the nurse who provided care on Thursdays, Fridays, and Saturdays was out on medical leave and the HHA has not provided coverage. CG 1 stated it was stressful for her when care was not provided because Patient 1 requires 24-hour care. CG 1 stated, “I get no break”. CG 1 stated HHA has not provided hours for respite (relieve family members from the responsibility of providing care) care. 2. A review of Patient 2’s “Face Sheet” indicated, Patient 2 was admitted to HHA dated 2/2/2015 with diagnoses including pulmonary hypertension (high blood pressure in the lungs causing your heart to work harder). A record review of Patient 2’s “Plan of Care”, for certification period 12/17/2023 to 2/14/2024, indicated the skilled nurse was to provide the following: 32 to 40 hours week for 60 days 30 hours a month or 90 hours a quarter for respite care for 60 days. 6 hours a day Monday through Friday and 4 hours a day Saturday and Sunday for 60 days. During an interview on 12/20/2023, at 2:02 p.m., with Patient 2’s caregiver (CG 2), CG 2 stated the agency did not notify her that the nurse who normally covered Thursday and Friday shift would be out on medical leave. CG 2 stated the agency had not provided staff coverage for Thursday and Friday. CG 2 stated Patient 2 required 24 hour a day care because she was a threat to herself. CG 2 stated that whenever the nursing care was not provided, CG 2 must take over the care. CG 2 stated she felt “frustrated” when the HHA could not provide the approved care/services. CG 2 stated the HHA has not referred her to another agency who could provide the nursing care hours. During an interview on 12/22/2023, at 11:31 a.m., with the Administrator (ADM), ADM stated, the HHA was trying to hire new staff. The ADM stated nurses could not work too much overtime hours because the agency does not get reimbursed for overtime. During an interview on 12/22/2023, at 11:53 a.m., with the ADM, ADM stated, information about nursing care schedules were communicated verbally to the patient/caregiver and nothing in writing. When asked about the importance of providing written information about the schedule to the patients/caregiver, the ADM stated, so the family know what their schedule is for the week. 3. A review of Patient 5’s “Face Sheet” indicated, Patient 5 was admitted on 5/10/2022 with diagnoses including gen idiopathic epilepsy (group of seizures, childhood seizures), chronic respiratory distress and tracheostomy (tube inserted into the trachea to facilitate breathing). A review of Patient 5’s “Plan of Care” dated 11/1/2023 to 12/30/2023, indicated “Frequency and duration (agency) to provide skilled nursing for 123-154 hours per week throughout the 60-day certification period authorized by…” During a concurrent interview and record review on 12/22/2023 at 10:30 a.m. with the Administrator (ADM) of Patient 5’s medical record, record indicated Patient 5 was seen 407.35 hours in the month of November 2023. It also indicated Patient 5 received 113.07 hours of care the week of December 3 to 9, 2023. During a joint home visit on 12/20/2023 at 2 p.m. with License Vocational Nurse 3 (LVN3) to Patient 5’s home, Patient 5’s Care Giver 3 (CG3), CG3 stated, Patient 5 qualified for 24-hour care in 2021 after being placed on a ventilator (breathing machine). CG3 stated she had difficulty finding skilled nursing service coverage when one of the regular LVNs were off. During an interview on 12/22/2023 at 10:30 a.m. with the Administrator (ADM), ADM stated when there was a missed visit the, the agency would call the family and made aware of the missed visit. ADM stated if there were any documentation of the family being aware of the missed visit, it would be under the patient communication notes. During a concurrent interview and record review on 12/22/2023 at 12 p.m. with the Administrator (ADM) of Patient 5’ s medical record, ADM stated there was no documentation of CG3 being made aware of missed visits. ADM stated caregivers need to be made aware to be able to assume care for the patient. A record review of the HHA’s policy and procedure titled, “Patient/Client Rights and Responsibilities”, dated 10/7/2022, indicated, “5. Patient/Client Rights…Participate in, be informed about and consent or refuse care in advance of and during treatments, with respect to…Any factors that could impact treatment effectiveness. Receive all services outlined in the plan of care and be informed, in advance, of any changed to the plan of care. A review of facility’s policy and procedure titled “Reassessments/Recertifications” revised 7/14/2023, indicated “Any revision to the plan of care due to a change in patients’ health status must be communicated to the patient, representative, caregiver, and all physicians issuing orders for the plan of care.

Contact info Federal/State-funded entities CFR(s): 484.50(c)(10)(i,ii,iii,iv,v) Be advised of the names, addresses, and telephone numbers of the following Federally-funded and state-funded entities that serve the area where the patient resides: (i) Agency on Aging (ii) Center for Independent Living (iii) Protection and Advocacy Agency, (iv) Aging and Disability Resource Center; and (v) Quality Improvement Organization. This ELEMENT is not met as evidenced by: Based on interview and record review the Home Health Agency (HHA, an organization that delivers skilled nursing and other therapeutics service to a patient at home) failed to ensure seven of seven sampled patients (Patients 1, Patient 2, Patient 3, Patient 4, Patient 5, Patient 6, and Patient 7) received information on Federal and State funded entities available in the areas they reside. This deficient practice had the potential to prevent patients be familiar with the services that are available and could provide assistance with care and services they need. A review of Patient 1’s “Face Sheet” indicated an admit date of 6/21/2022 with diagnoses including Cerebral palsy (a group of disorders that affect a person’s ability to move and maintain balance and posture). A review of Patient 2’s “Face Sheet” indicated an admit date of 2/2/2015 with diagnoses including pulmonary hypertension (high blood pressure in the lungs causing your heart to work harder). A review of Patient 3’s “Face Sheet” indicated an admit date of 4/27/2009 with diagnoses including anoxic brain damage (lack of oxygen to the brain). A review of Patient 4’s “Face Sheet” indicated an admit date of 9/11/2020 with diagnoses including acute transverse myelitis in demyelinating disease of CNSL (inflammation of both sides of one section of the spinal cord). A review of Patient 5’s “Face Sheet” indicated an admit date of 5/10/2022 with diagnoses including gen idiopathic epilepsy (group of seizures, childhood seizures). A review of Patient 6’s “Face Sheet” indicated an admit date of 1/1/2022 with diagnoses including cellulitis of right lower limb (bacterial skin infection causing pain and swelling). A review of Patient 7’s “Face Sheet” indicated an admit date of 11/3/2023 with diagnoses including respiratory disorder (group of conditions that affect the lungs). During a concurrent interview and record review on 12/21/2023, at 2:08 p.m., the Administrator (ADM) reviewed the HHA’s booklet titled, “Patient Information”. The ADM stated the booklet did not have the information (name, address, phone number) of state and federal funded information and did not know why. The ADM stated it was important for patients to have the information, so they are aware of the resources available to them. The HA can help the patients advocate and help coordinate their resources. A record review of the HHA’s policy and procedure titled, “Patient/Client Rights and Responsibilities”, dated 10/7/2022, indicated, “5. Patient/Client Rights…Be advised of…The names, addresses, and telephone numbers of the following Federally funded and state-funded entities that serve the area where the patient resides…”

A review of all current medications CFR(s): 484.55(c)(5) A review of all medications the patient is currently using in order to identify any potential adverse effects and drug reactions, including ineffective drug therapy, significant side effects, significant drug interactions, duplicate drug therapy, and noncompliance with drug therapy. This ELEMENT is not met as evidenced by: Based on observation, interview, and record review, the Home Health Agency (HHA, an organization that delivers skilled nursing and other therapeutics service to a patient at home) failed to review and document all the medications and treatments the patient was currently using for three of seven sampled patients (Patient 1, Patient 2, and Patient 5). This deficient practice placed the patients at risk of drug-to-drug interaction and harm by not knowing which medications the patients were taking and could place Patient 1, Patient 2, and Patient 5, at risk for medication errors and adverse side effect. 1. A review of Patient 1’s “Face Sheet” indicated an admit date of 6/21/2022 with diagnoses including Cerebral palsy (a group of disorders that affect a person’s ability to move and maintain balance and posture). During an observation of the home visit on 12/20/2023, at 4:30 p.m., Licensed Vocational Nurse 1 (LVN 1) provided care to Patient 1. During a concurrent observation, interview, and record review on 12/20/2023, at 5:02 p.m., LVN 1 reviewed Patient 1’s record titled, “Patient Medication Profile”, printed on 12/19/2023. LVN 1 stated the following discrepancies, the label on the medication bottles were not matching the profile for: “Lactulose” (a laxative, helps with bowel movements). LVN 1 stated the label indicated to give the medication by mouth. LVN 1 stated it was supposed to be given through the gastrointestinal tube (GT-a tube inserted through the belly that brings nutrition directly to the stomach). The risk of the label indicating a different route can place Patient 1 at risk of aspiration (medication going to the lungs) by accidently giving the medication by mouth instead of the GT. “Trileptal” (to prevent convulsions-involuntary movements caused by the brain). LVN 1 stated the label indicated to give the medication by mouth. The profile indicated the route to be oral (by mouth) LVN 1 stated, she gave the medication through the GT. LVN 1 stated the medication profile was supposed to say GT. “Baclofen” (a muscle relaxer). LVN 1 stated the label indicated to take by mouth. LVN 1 stated she crushed the medication, dissolve it with water and give it through the GT. “Diazepam” (for anxiety). LVN 1 stated the label indicated to take it by mouth. LVN 1 stated the medication was given through the GT. “Erythromycin” (an antibiotic). LVN 1 stated the label indicated to take it by mouth. LVN 1 stated to give it by GT. During a concurrent observation, interview, and record review on 12/20/230, at 5:14 p.m., LVN 1 reviewed Patient 1’s record titled, “Patient Medication Profile”, printed on 12/19/2023. “Famotidine” (reduces stomach acid) was expired. LVN 1 stated pharmacy usually gives it as a powder, and we (nurse) mix it. Looks like this time they mixed it. If we mix it, we mix with water and have 30 days to five it from the time it was mixed. Based on the label, its expired. The label says to use by 11/25/2023. LVN 1 stated the medication had to be taken in timely manner to make sure it is effective. Checking for expiration dates was part of the medication review. LVN 1 stated Patient 1's medications should have been reviewed when the registered nurse came, medications were checked for right patient, right time, right to refuse, right route, right dose. A record review of Patient 1’s record at the home titled, “Medications”, for date ranges 12/17/2023 to 12/23/2023, indicated the HHA staff gave the expired Famotidine on 12/17/2023, 12/18/2023, and 12/19/2023. “Diastat” (prevents seizures). LVN 1 stated the medication was expired. The label of the medication indicated an expiration date of August 2023. LVN 1 stated the medication could accidently be given if Patient 1 has a seizure. A possible outcome was getting sick. Since this medication is for seizures, it might not help at all. The following medications were listed on the medication profile, but Patient 1 was no longer taking: “Acetaminophen” (pain/fever reducer). “Diphenhydramine” (for allergies). 2. A review of Patient 2’s medical record form title “Face Sheet” indicated an admit date of 2/2/2015 with diagnoses including pulmonary hypertension (high blood pressure in the lungs causing your heart to work harder). During an observation of the home visit on 12/20/2023, at 2:00 p.m., Licensed Vocational Nurse 2 (LVN 2) provided care to Patient 2. During an concurrent observation, interview, and record review on 12/20/230, at 2:28 p.m., LVN 2 reviewed Patient 2’s record titled, “Patient Medication Profile”, printed on 12/19/2023. LVN 2 stated the following discrepancies: Medication titled, “First Aid antibiotic” was listed on the profile, but Patient 2 was no longer taking. Medications being taken by Patient 2, but not listed on the profile: “Neosporin” ointment (an antibiotic). LVN 2 stated Patient 2 was taking this medication for her skin boils and bumps. It is taken as needed. Medication does not listed correctly: “digoxin (heart medication) powder gram”. LVN 2 stated it is not a powder, it’s a tablet. This is a potent drug. It can be confusing if it’s not clear how the medication comes (powder versus tablet). “Levothyroxine” (thyroid medication). LVN 2 stated the profile indicated is was a powder. Patient 2 was taking a pill. “Hydrocortisone (medication for itching)” dosage was listed as 2.5%. Patient 1 was taking 1%. LVN 2 stated it was not listed correctly. During an interview on 12/20/2023, at 2:42 p.m., LVN 2 stated the medication profile was reviewed for accuracy every 3 months. LVN 2 stated the Registered Nurse manager was responsible in updating the medication profile. The medication profile needed to be accurate because if a nurse comes without prior knowledge of the patient, she needs an accurate record to give meds, to make sure the patient has right medication, right time, right reaction, so the patient is not put at risk. During an interview on 12/21/2023, at 11:39 p.m., the Clinical Manager (CM) stated the licensed vocational nurse (LVN) was supposed to review the medications every shift at the home. The LVN was supposed to look at the Plan of Care, Medication Profile, prescription bottles, and supplemental orders (because sometimes changes are made, and it’s not reflected in the plan of care) to make sure everything matched. The importance of checking the medications is for the safety of the patient. To make sure patient is receiving treatment from doctor. To make sure the nurses are following the orders. That they have everything that they need for that patient. A potential outcome of not following medication review process: It would be a patient safety issue. We don’t want a nurse to give a medication that is not on the plan of care. It could be a potential sentinel event if the nurse gave the wrong medication. It would be considered a medication error. During an interview on 12/21/2023, at 1145 a.m., the CM stated the nurse should have called her, the doctor, or the pharmacy to clarify the route. The CM stated the nurse did not report. Otherwise, the HHA would have caught the discrepancy. A review of Patient 5’s “Face Sheet” indicated an admit date of 5/10/2022 with diagnoses including gen idiopathic epilepsy (group of seizures, childhood seizures), chronic respiratory distress and tracheostomy (tube inserted into the trachea to facilitate breathing). A review of Patient 5’s “Plan of Care” dated 11/1/2023 to 12/30/2023, indicated “Famotidine (stomach acid medication) two times daily oral”. It also indicated “Nutritional Req. GT (gastrostomy tube – soft hollow tube inserted into the stomach through the abdominal wall to provide feeding and medication). During a joint home visit on 12/20/2023 at 2 p.m. with License Vocational Nurse 3 (LVN3) to Patient 5’s home, Patient 5’s medication bottle label indicated “Famotidine… two times daily oral.” LVN3 stated label should indicate GT not oral. A record review of the HHA’s policy and procedure titled, “Administration and Documentation of Medications”, dated 10/7/2022, indicated, “Policy: All medications require a physician order. The contest of the physician order for medication shall include: the name, the dosage…the route…All medications will be recorded on the Medication Profile…prior to medication administration, the nurse will…check all medications for stability by visually examining the medication and observing…expiration date… A review of facility’s policy and procedure titled “Medication Profile” revised 4/9/2021, indicated “Patient receiving medications will have a current and accurate medication profile maintained in the medical record and the home folder. A registered nurse (RN) shall review all prescriptions and non-prescription medications including herbal remedies. The medication profile, when complete and updated, should be used as the primary source of reference when pre-pouring medication sin the home for self-administration by a caregiver. The patient’s medications are reviewed and compared to the medication profile during each skilled shift/visit. The medication profile will be reviewed at every comprehensive assessment or reassessment.”

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 interview and record review the Home Health Agency (HHA) failed to ensure a Plan of Care (POC – individualized patient care plan) were followed and patients received treatments or services in accordance with their written plan of care for two of seven sample patients (Patient 5 and Patient 6): The weekly hours indicated for Patient 5 The wound treatment as indicated for Patient 6 This deficient practice resulted in the physician not being aware of the services being provided and not being provided to the patients by the HHA. A review of Patient 5’s “Face Sheet” indicated an admit date of 5/10/2022 with diagnoses including gen idiopathic epilepsy (group of seizures, childhood seizures), chronic respiratory distress and tracheostomy (tube inserted into the trachea to facilitate breathing). A review of Patient 5’s “Plan of Care” dated 11/1/2023 to 12/30/2023, indicated “Frequency and duration Maxim Healthcare Services to provide skilled nursing for 123-154 hours per week throughout the 60-day certification period authorized by…” During a concurrent interview and record review on 12/22/2023 at 10:30 a.m. with the Administrator (ADM) of Patient 5’s medical record, record indicated Patient 5 was seen 407.35 hours in the month of November 2023. It also indicated Patient 5 received 113.07 hours of care the week of December 3 to 9, 2023. During a joint home visit on 12/20/2023 at 2 p.m. with License Vocational Nurse 3 (LVN3) to Patient 5’s home, Patient 5’s Caregiver 3 (CG3) stated Patient 5 qualified for 24-hour care in 2021 after being placed on a ventilator (breathing machine). CG3 stated she had difficulty finding skilled nursing coverage when one of the regular LVNs were off. During an interview on 12/22/2023 at 10:30 a.m. with the Administrator (ADM), ADM stated when there was a missed visit, the family was called and made aware of the missed visit. ADM stated if there were any documentation of the family being aware of the missed visit, it would be under the patient communication notes. During a concurrent interview and record review on 12/22/2023 at 12 p.m. with the Administrator (ADM) of Patient 5’ s medical record, ADM stated there was no documentation of CG3 being made aware of missed visits. ADM stated caregivers need to be made aware to be able to assume care for the patient. A review of Patient 6’s “Face Sheet” indicated an admit date of 1/1/2022 with diagnoses including cellulitis of right lower limb (bacterial skin infection causing pain and swelling). A review of Patient 6’s “Plan of Care” dated 10/23/2023 to 12/21/2023, indicated “Right and left leg wound care daily. Document wound measurements weekly and as needed for change in appearance.” A review of Patient 6’s “Wound Care Flow Sheet” dated from 10/29/2023 to 12/10/2023, indicated wound site to right leg above ankle. During an interview on 12/20/2023 at 12 p.m. with the Administrator (ADM), ADM stated Patient 6’s nursing notes were not in their electronic medical record because Patient 6 has once a day visits and was not on continuous care. During a concurrent interview and record review on 12/22/2023, with Clinical Manager (CM) or Patient 6’s medical record, CM provided one sheet of Patient 6’s wound measurements documentation dated from 10/29/2023 to 12/10/2023. CM stated she did not know where the other wound care flow sheets were. CM provided nursing documentation that did not have wound measurements. CM stated it was important to document wound measurements to know the progress of the wound or to know if the treatment needs to be changed. A review of HHA policy and procedure titled “Missed Shift/Visit’ revised 4/9/2021, indicated “If at any time the services provided do not match the ordering practitioner order a missed Shift/Visit note and notification of the ordering practitioner is required.” A review of HHA policy and procedure titled “Home Health Certification and Plan(s) of Care” revised 7/14/2023, indicated “The Home Health Certification and Plan of Care is the ordering practitioners order for home care services.”

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 interview and record review, the Home Health Agency (HHA, an organization that delivers skilled nursing and other therapeutics service to a patient at home), failed to ensure the Plan of Care (POC, individualized patient care plan) included information on acceptable parameters for vital signs (VS, clinical measurements which include but are not limited to blood pressure, temperature, respirations, heart rate, pain, signs that indicate the status of the body’s functions) for two of seven sampled patients (Patient 1 and Patient 4). This deficient practice has the potential to result in decline in health status and/or hospitalization when the POC did not have information of VS when to notify the physician. A review of Patient 1’s “Face Sheet” indicated an admit date of 6/21/2022 with diagnoses including Cerebral palsy (a group of disorders that affect a person’s ability to move and maintain balance and posture). During a concurrent interview and record review on 12/21/2023, at 2:01 p.m., with the Clinical Manager (CM), the CM reviewed Patient 1’s “Plan of Care”, for certification period 12/13/2023 to 2/10/2024. The CM stated the POC did not have parameters for Patient 1’s VS. CM stated, VS parameters were important to include in the POC so the nurse knows when to call the doctor and best practice for the patient. A review of Patient 4’s “Face Sheet” indicated an admit date of 9/11/2020 with diagnoses including acute transverse myelitis in demyelinating disease of CNSL (inflammation of both sides of one section of the spinal cord). During a concurrent interview and record review on 12/21/2023, at 2:03 p.m., the CM reviewed Patient 4’s “Plan of Care”, for certification period 12/30/2022 to 2/27/2023. The CM stated the POC did not have parameters for Patient 4’s VS.

Patients receive education and training CFR(s): 484.60(d)(5) Ensure that each patient, and his or her caregiver(s) where applicable, receive ongoing education and training provided by the HHA, as appropriate, regarding the care and services identified in the plan of care. The HHA must provide training, as necessary, to ensure a timely discharge. This ELEMENT is not met as evidenced by: Based on observation, interview, and record review, the Home Health Agency (HHA) failed to ensure to provide and the the patient's caregiver received ongoing education about medication management for one of seven sampled patients (Patient 1). This deficient practice resulted in Patient 1 receiving expired medication and had the potential for ineffective medication and treatment. A review of Patient 1’s “Face Sheet” indicated an admit date of 6/21/2022 with diagnoses including Cerebral palsy (a group of disorders that affect a person’s ability to move and maintain balance and posture). During an observation of the home visit on 12/20/2023, at 4:30 p.m., Licensed Vocational Nurse 1 (LVN 1) provided care to Patient 1. During an interview on 12/20/2023, at 4:30 p.m., Patient 1’s caregiver (CG 1) stated she cared for Patient 1 and administered medications, when the HHA nurse not there. During a concurrent observation, interview, and record review on 12/20/230, at 5:14 p.m., LVN 1 reviewed Patient 1’s “Patient Medication Profile”, printed on 12/19/2023 and observed “Famotidine” (reduces stomach acid) was expired. During an an interview with LVN 1, LVN 1 stated, pharmacy usually on Famotidine in a powder form, and we (nurse) mix it. Looks like this time they mixed it. If we mix it, we mix with water and have 30 days to five it from the time it was mixed. Based on the label, its expired. The label says to use by 11/25/2023. LVN 1 stated the medication had to be taken in timely manner to make sure it is effective and checking for expiration dates was part of the medication review." During an interview on 12/20/2023, at 5:20 p.m., with CG 1, CG 1 stated, Famotidine was given by the pharmacy on 10/26/2023. CG 1 stated she received 5 bottles and had two bottles left. The bottles were labeled 1 of 5, 2 of 5, 3 of 5, 4 of 5, and 5 of 5. CG 1 stated the one that says of 4 of 5 and 5 of 5 were the ones remaining at home because the other bottles were already given to Patient 1. During an interview on 12/20/2023, at 5:22 p.m., CG 1 stated she always got confused with the label. CG 1 stated, “so many dates, I don’t understand what the dates mean”. A record review of Patient 1’s record at the home titled, “Medications”, for date ranges 12/17/2023 to 12/23/2023, indicated the HHA staff gave the expired Famotidine on 12/17/2023, 12/18/2023, and 12/19/2023. A record review of Patient 1’s record titled, “Plan of Care”, for certification period 12/13/2023 to 2/10/2024, indicated, “Education: Educate PCG (primary care giver) on all care and related …medications…” During a concurrent interview and record review on 12/21/2023, at 12:42 p.m., the Clinical Manager (CM) reviewed Patient 1’s record titled, “Skilled Nursing Note”, dated 11/30/2023. The CM stated the record indicated CG 1 was educated on medications. However, the document did not detail what aspects of medications she was educated on. There was no documentation the HHA provided ongoing education for current certification period of 12/13/2023 to 2/10/2024. A record review of the HHA’s policy and procedure titled, “Administration and Documentation of Medications”, dated 10/7/2022, indicate, “Procedure: The nurse will provide instruction to the patient and/or family/caregiver regarding current medications on a continuing basis. This instruction will include medication administration, route…contraindications…” Documentation in the medical record will describe the education provided…For medications that are dispensed as multi-dose vials, unless the manufacturer instructions state otherwise, once a vial is opened, it must be discarded after 28 days. The nurse will instruct the patient and/or family to record the date the vial was opened on the vial and to discard as directed by the manufacturer or after 28 days.” A review of facility’s policy and procedure titled “Patient Education” revised 4/9/2021, indicated “Each patient/client admitted for care will receive education and training specific to needs identified during the initial and ongoing evaluation.”

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 interview and record review, the Home Health Agency (HHA) failed to provide all necessary medical information to the primary care practitioner within 5 days of discharge for one of eight sampled patients (Patient 4). This deficient practice resulted in the primary care practitioner not receiving information regarding the services and care provided by the HHA. A review of Patient 4’s “Face Sheet” indicated an admit date of 9/11/2020 with diagnoses including acute transverse myelitis in demyelinating disease of CNSL (inflammation of both sides of one section of the spinal cord). During a concurrent interview and record review on 12/22/2023, at 11:59 a.m., the Clinical Manager (CM) reviewed Patient 4’s “Discharge Summary”, dated 1/26/2023. The CM stated it was not the HHA’s policy to send the summary to the doctor but it was important to send the summary of information of care and services Patient 4 received , so the doctor know what services were provided.