Every finding on record at Maxim Healthcare Services, Inc

An Emergency Preparedness Survey was conducted by the California Department of Public Health on behalf of the Centers for Medicare & Medicaid Services (CMS) from to 07/29/2024 to 08/01/2024. The facility was found to be in compliance with 42 CFR 484.102. Total Patients: 40 Representing the Department: 42744, HFEN 14748, HFEN

The following reflects the findings of the California Department of Public Health during a Home Health Agency survey conducted 7/29/24 to 8/1/24. Representing the Department: 42744, HFEN 14748, HFEN Number of Unduplicated Admissions: 53 Census: 40 Sample Size: 7 Record review with home visits: 3 Record review with no home visits: 4

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 agency failed to correctly review the medications for one of three sampled patients (Patient 3). This failure had the potential to result in decreased identification of adverse effects, drug reactions, side effects, drug interactions, duplicate drug therapy, and noncompliance. Findings: During a concurrent observation and record review on 7/30/2024 at 10:15 a.m. in Patient 1's home, the following medications were found in the home but were not found on the patient's physician orders: Maximum Strength X-Lax (laxative) KY Jelly (lubricant) Triple Antibiotic Ointment Sodium Chloride Inhalation (used to produce sputum from the mouth to help improve lung function). The following medications were found on the physician orders but not found in the home: Docusate Sodium (laxative) Vicodin 5/325 milligrams (pain relief) Astepro nasal spray (antihistamine). During an interview on 7/31/24, at 11 a.m. with Clinical Manager (CM), CM stated a complete medication reconciliation happens weekly, but staff "aren't doing a thorough enough job at the weekly reconcile." During a review of the facility's policy and procedure (P&P) titled, "In Home Medication Reconciliation," dated 1/11/2016, the P&P indicated, "Collect patient's medications...Collect paperwork...Compare listed medications to medications found in the home...Document all discrepancies...Contact the physician for clarification...Update the MAR (medication administration record) with the clarified information if applicable." Findings: During a concurrent interview and record review on 7/30/24 at 11:40 a.m. with Licensed Vocational Nurse (LVN) 2, Patient 3’s Patient Medication Profile (PMP), dated 7/30/24, and MAR, dated 7/28/24 to 8/3/24, were reviewed. Patient 3’s PMP indicated Carbidopa 25 mg- Levodopa 100 mg 1 tab was to be given three times a day Gastrostomy tube (G-tube- feeding tube inserted through the abdomen to the stomach to provide nutrition, fluids, and medications). Patient 3’s MAR indicated Carbidopa 25 mg- Levodopa 100 mg “2 tabs” was crossed out and “1 tab” was handwritten in, and medication was only given twice a day at 10 a.m. and 4 p.m. LVN 2 stated the PMP should have been updated. During a concurrent interview and record review on 7/30/24 at 11:42 a.m. with LVN 2, Patient 3’s PMP, dated 7/30/24, and MAR, dated 7/28/24 to 8/3/24, were reviewed. Patient 3’s PMP indicated two capsules of Gabapentin 300 mg (600 mg) were to be given three times daily via G-tube. The MAR indicated “Three Times a Day” was crossed out and “2x Daily” was handwritten in with Order Date: “10/23/2023” crossed out and 4/2/24 handwritten in. The MAR indicated Gabapentin was being given twice a day. LVN 2 stated the Gabapentin order had been changed on 4/2/24 from three times a day to twice a day. LVN 2 stated she updates the wrong information on the MAR weekly. During a concurrent interview and record review on 7/30/24 at 11:43 a.m. with LVN 2, Patient 3’s PMP, dated 7/30/24, and MAR, dated 7/28/24 to 8/3/24, were reviewed. Patient 3’s PMP indicated Nitrofurantoin was not on the PMP and was written on the MAR as under “Orders” as “Nitro” with no further instructions. Patient 3’s PMP indicated Bupropion 100 mg tablets, give 1.5 tablets one time daily. Patient 3’s MAR indicated Bupropion was to be given twice a day. LVN 2 stated the orders were changed on 4/2/24. During a review of Patient 3’s Medical Record (MR), Patient 3’s POC, dated 6/16/24 to 8/14/24, and MAR, dated 7/28/24 to 8/3/24, were reviewed. The POC indicated Lorazepam (medication used to treat anxiety was to be given “As Needed Every Four Hours” The MAR indicated, “As Needed Every Four Hours” was crossed out and “Q2H” (every 2 hours) was handwritten on the MAR. During a concurrent interview and record review on 7/30/24 at 12:12 p.m. with LVN 2, Patient 3’s MAR, dated 7/28/24 to 8/3/24, was reviewed. The MAR indicated Lorazepam was changed to every 2 hours. LVN 2 reviewed her Supplemental Physician’s Orders and could not find the Lorazepam order change. LVN 2 stated she did not know when the order was changed. During a concurrent interview and review on 7/30/24 at 3:21 p.m. with Clinical Manager (CM), Patient 3's Patient Medication Profile (PMP), dated 7/30/24, and Medication Administration Record (MAR), dated 7/14/24 to 7/20/24, were reviewed. Patient 3’s PMP indicated Carbidopa 25 mg- Levodopa 100 mg 1 tab was to be given three times a day via G-tube. Patient 3’s MARs, dated 7/14/24 to 7/20/24, indicated Carbidopa 25 mg- Levodopa 100 mg “2 tabs” was crossed out and “1 tab” was handwritten in, and medication was only given twice a day at 10 a.m. and 4 p.m. CM stated MARs should be updated to match Medication Profiles. During an interview on 7/30/24 at 3:22 p.m. with CM, Patient 3’s PMP, dated 7/30/24, and MAR, dated 7/28/24 to 8/3/24, were reviewed. The PMP and MAR indicated Nitrofurantoin was not listed under orders. CM stated, “Chances are we haven’t received it (the physician order).” During a concurrent interview and review on 7/30/24 at 3:23 p.m. with CM, Patient 3’s POC, dated 6/16/24 to 8/14/24, and MARs, dated 7/14/24 to 7/20/24 and 7/28/24 to 8/3/24, were reviewed. Patient 3’s POC indicated, “Gabapentin (used to treat seizures or nerve pain) 300 mg capsule . . . 2 cap (600 mg) Three Times Daily G-tube.” The MARs indicated “Three Times a Day” was crossed out and “2x Daily” was handwritten in with Order Date: “10/23/2023” crossed out and 4/2/24 handwritten in. The MARs indicated Gabapentin was being given twice a day. CM verified findings and stated MARs, POCs, and Medication Profiles should all match. During an interview on 7/30/24 at 4:28 p.m. with CM, CM stated MARs are sent out to patient’s homes four weeks in advance. CM stated LVNs should be checking the MARs against the PMPs when they get the new MARs and weekly for any changes. CM stated LVNs should be checking medications every day prior to giving them. CM stated the facility uses a mobile app on the phone that LVNs are supposed to scan new orders into. New orders are written on the Supplemental Physician’s Orders duplicate form. The yellow copy was to be kept in the home and the white copy was to go into the patient’s paper chart. During an interview on 7/31/24 at 4:10 p.m. with Patient 3’s LVN 2, LVN 2 stated, “I know most of the orders I write. I know what has been changed if it is not on the MAR.” LVN 2 stated most of Patient 3’s orders come through hospice. LVN 2 stated the hospice nurse calls the physician in front of me. During a review of the facility’s policy and procedure (P&P) titled, “Administration and Documentation of Medications,” dated 4/11/24, the P&P indicated, “3.3 All medications administered will be listed on the Medication Administration Record. 3.3.1 The Medication Profile, when complete and updated, should be used as the primary source of reference for the medication pre-pours in the home. The physician orders should always be used as the ultimate source. The Medication Administration Record will be reconciled with the medication profile in all cases.”

All orders recorded in plan of care CFR(s): 484.60(a)(3) All patient care orders, including verbal orders, must be recorded in the plan of care. This ELEMENT is not met as evidenced by: Based on interview and record review, the facility failed to ensure for one of seven sampled patients (Patient 3) physician's orders, including verbal orders, were included in the Plan of Care. This failure had the potential to result in confusion and medication errors. Findings: During a concurrent interview and record review on 7/30/24 at 3:22 p.m. with Clinical Manager (CM), Patient 3’s "Patient Medication Profile," dated 7/30/24, and "Medication Administration Record (MAR)," dated 7/28/24, were reviewed. The PMP and MAR indicated Nitrofurantoin was not listed under medication orders. CM stated, “Chances are we haven’t received it (the physician order).” During a review of Patient 3’s "Plan of Care (POC)," dated 6/16/24 to 8/14/24, the "POC" indicated it did not contain a medication order for Nitrofurantoin. During a review of Patient 3’s "Plan of Care (POC)," dated 6/16/24 to 8/14/24, the "POC" Indicated the following: Carbidopa- Levodopa 25 mg (milligram) /100 mg tablet, 2 tablets three times a day Gabapentin 300 mg capsule, 2 capsules three times a day Bupropion 100 mg tablet, 1.5 tablets, one time a day Lorazepam 2 mg/ml concentrate, 0.5 to 1 ml every 4 hours as needed for anxiety. During a concurrent interview and record review on 7/31/24 at 10:05 a.m. with Clinical Manager (CM), Patient 3’s “Hospice Plan of Care (HPOC),” dated 7/31/24, was reviewed. The HPOC indicated the following orders: 5/10/24: Carbidopa- Levodopa 25 mg/100 mg tablet. 1 tablet three times a day. 5/10/24: Gabapentin 300 mg capsule. 2 capsules two times a day. 4/2/24: Bupropion 100 mg tablet. 1 tablet, two times a day. May titrate up to 150 mg twice a day in one week if depression not improved. 9/12/23: Lorazepam 2 mg/ml concentrate. Give 0.5 to 1 ml every 2 hours as needed for anxiety. 5/17/24: Macrobid (Nitrofurantoin) 100 mg capsules. Give 1 capsule once a day. CM stated LVNs should have uploaded supplemental hospice orders (verbal orders made by hospice providers and documented on the Supplemental Physician's Order form) to the app or mailed the paper orders to the office for upload. CM stated there were no copies of orders in the paper chart or uploaded in the electronic medical records. CM stated the Plan of Care, Medication Profile, and MARs do not match. During an interview on 7/31/24 at 2:25 p.m. with Clinical Manager (CM), CM stated the changes to Bupropion were not reflected in the Patient Medication Profile were not made because the facility was not aware of the changes. The LVN did not upload the orders. During an interview on 8/1/24 at 1:34 p.m. with CM, CN stated the facility had not received supplemental orders for changes to the POC for Carbidopa-Levodopa, Gabapentin, or Bupropion. During a review of the facility’s policy and procedure (P&P) titled, “Home Health Certification and Plan(s) of Care,” dated 7/0/18, the P&P indicated, “PURPOSE: 2. To provide direct care staff with the ordering practitioner’s ordered treatments, procedures, medications, and services required to meet the patient’s home care needs. 3. POLICY: 3.1 The Home Health Certification and Plan of Care (485) is the ordering practitioner’s order for home care services. 3.1.1 The Plan of Care will be individualized to include, but not limited to all treatments, procedures, medications, and services authorized to be provided by direct care staff(s) . . . 5.3 The Plan of Care shall include, but not limited to: . . .5.3.4 Listing of all medications, including over-the-counter.”

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 interview and record review, the facility failed to ensure for two of seven sampled patients (Patient 2 and Patient 3) medication was given according to physician’s orders. These failures resulted in lack of assessment, reassessment, documentation for administering medications meant to be given for specific symptoms, and the potential for medication errors causing harm to the patient. Findings: During a review of Patient 2’s “Plan of Care (POC),” dated 7/15/24 to 9/12/24, the "POC" indicated to give Aspirin (prevents blood clots) 81 mg (milligram) chewable tablet (TABLET CHEWABLE) 81 mg One Time Daily Oral Monitor for signs and symptoms of bleeding and Lansoprazole (for gastric reflux) 15 mg delayed release, disintegrating tablet (TABLET, DISINTEGRATING, DELAYED RELEASE) 15 mg (1 capsule) One Time Daily Oral *Prevacid.* During a concurrent interview and record review on 7/30/24 at 10:30 a.m. with Licensed Vocational Nurse (LVN) 1, Patient 2’s Medication Administration Record (MAR), dated 7/7/24 through 7/13/24, was reviewed. The MAR indicated Aspirin 81 mg chewable tablet (81 mg) TABLET CHEWABLE Oral One Time Daily. LVN 1 stated Aspirin was being given via Gastrostomy tube (G-tube- feeding tube inserted through the abdomen to the stomach to provide nutrition, fluids, and medications) and not by mouth. LVN 1 stated, “I’ll call to correct it.” During a concurrent interview and record review on 7/30/24 at 10:34 a.m. with LVN 1 and Family Member, Patient 2’s "MAR," dated 7/7/24 through 7/13/24, was reviewed. The MAR indicated Lansoprazole DR 15 mg CAP (capsule) generic for Prevacid 15 mg DR cap Take 1 (one) capsule by mouth once daily before meals. Family Member stated she was taught to give Lansoprazole through the G-tube. LVN 1 stated Lansoprazole was being given via G-tube and not by mouth. LVN 1 stated physician orders and MAR should be changed to indicate Lansoprazole should be given via G-tube. During a concurrent interview and record review on 7/30/24 at 3:21 p.m. with Clinical Manager (CM), Patient 2’s "MAR" was reviewed. Patient 2’s MAR indicated Aspirin and Lansoprazole were to be given by mouth. CM stated the order should be to give these medications by G-tube to reflect how they were being given by staff. During a review of Patient 3’s “Supplemental Physician’s Order (SPO),” dated 1/19/24, the "SPO," indicated, “Metronidazole (antibiotic to treat infections) Topical 1% Solution Spray Wound at G-tube site two times a day.” During a concurrent interview and record review on 7/30/24 at 11:45 a.m. with LVN 2, Patient 3’s "MAR," dated 7/28/24 to 8/3/24, was reviewed. The MAR indicated, “Metronidazole 1% topical gel . . . Topical Two Times Daily.” The MAR indicated there were no nurse’s signatures showing Metronidazole had been administered. LVN 2 stated the medication was being given only as needed and not two times a day. LVN 2 stated they did not want to discontinue the medication in case it was needed. During a review of Patient 3’s "MAR," dated 7/28/24 to 8/3/24, the "MAR" indicated, “Morphine (narcotic used to treat severe pain) concentrated 20 mg/ml oral syringe . . . (10mg to 20 mg) SYRINGE (ML) G-tube As Needed Every One Hour . . . Notes: PRN (as needed)- SOB (shortness of breath), pain.” The MAR indicated under “Schedule” that “7AM, 10 AM, 1 PM, and 4 PM” were handwritten onto the MAR. LVN 2’s initials indicated morphine was given routinely on 7/29/24 at 7:17 a.m., 10 a.m., 1:02 p.m., and 4:05 p.m., and on 7/30/24 at 7:24 a.m. and 10:01 a.m. The MAR did not indicate how much morphine was administered. During a review of Patient 3’s "MAR," dated 7/28/24 to 8/3/24, the "MAR" indicated, “Guaifenesin (used to relieve chest congestion) 100 mg/5/ml oral liquid (10 ml to 20 ml) LIQUID (ML) G-tube As Needed Every Four Hours . . . PRN-cough, oral secretions.” The MAR indicated under “Schedule” that “10 AM” and “4 PM” were handwritten onto the MAR. LVN 2’s initials indicated Guaifenesin was given routinely on 7/29/24 at 10 a.m. and 4:05 p.m., and on 7/30/24 at 7:24 a.m. and 10:01 a.m. The MAR did not indicate how much Guaifenesin was administered. During a review of Patient 3’s "POC," dated 6/16/24 to 8/14/24, and "MAR," dated 7/28/24 to 8/3/24, were reviewed. The "POC" indicated, “Lorazepam (used to treat anxiety) 1 mg/0.5.ml. . . (1 mg (0.5 mL) to 2 mg (1 mL) SYRINGE . . . G-tube. . . Notes: PRN- Anxiety/ SOB.” The POC indicated “As Needed Every Four Hours” The "MAR" indicated, “As Needed Every Four Hours” was crossed out and “Q2H” (every 2 hours) was handwritten on the MAR. The MAR indicated under “Schedule” that “7 AM, 10 AM, 1 PM, and 4 PM” were handwritten onto the MAR. LVN 2’s initials indicated Lorazepam was given routinely on 7/29/24 at 7:17 a.m., 10 a.m., 1:02 p.m., and 4:05 p.m., and on 7/30/24 at 7:24 a.m. and 10:01 a.m. The MAR did not indicate how much Lorazepam was administered. During an interview on 7/30/24 at 11:50 a.m. with LVN 2, LVN 2 stated the routine schedule of medications was worked out with Patient 3’s wife. LVN 2 stated Patient 3 was not able to adequately verbalize his needs until they manifested in extreme behavioral outburst. LVN stated she was also able to give the medication as needed based on the orders if the interval between the routine medication and prn medication administration times met the physician order. During a concurrent interview and record review on 7/30/24 at 3:23 p.m. with CM, Patient 3’s "MAR," dated 7/28/24 to 8/3/24, was reviewed. The MAR indicated medications were being given routinely by staff as evidenced by changing the schedule to routine times. CM verified findings and stated nurses should have made recommendations to the physician for order changes to give medication routinely, and then write new orders to reflect any changes. During a concurrent interview and record review on 7/31/24 at 10:05 a.m. with CM, Patient 3’s “Skilled Nursing Note (SNN),” dated 7/29/24 and 7/30/24, were reviewed. The SNN indicated there were no nursing notes related to assessment or reassessment of pain, anxiety, SOB, excess secretions, or cough after administration of morphine, lorazepam, or guaifenesin. CM stated when a nurse gives a prn medication, they should document the reason for giving the medication and the results in nurse’s notes. CM verified there was no documentation in Patient 3’s SNN indicating prn medication was given, validating LVNs were giving prn medications routinely. CM stated the prn orders should have been changed to routine and separate orders written for prn. During a review of the facility’s policy and procedure (P&P) titled, “In Home Medication Reconciliation,” dated 1/11/16, the P&P indicated, “Documentation of discrepancies . . . Any/all discrepancies should be documented in the nurses’ notes. Contact the physician for clarification. Create a Supplemental Order for the clarification, if applicable. Update the MAR with the clarified information, if applicable.”

Revised plan of care CFR(s): 484.60(c)(2) A revised plan of care must reflect current information from the patient's updated comprehensive assessment, and contain information concerning the patient's progress toward the measurable outcomes and goals identified by the HHA and patient in the plan of care. This ELEMENT is not met as evidenced by: Based on interview and record review, the facility failed to ensure for one of seven sampled patients (Patient 4) Plan of Care was updated. This failure had the potential to result in confusion related to conflicting orders. Findings: During a concurrent interview and record review on 8/1/24 at 10:35 a.m. with Clinical Manager (CM), Patient 4’s "Plan of Care (POC)," and "Plan of Treatment (POT)," dated 6/27/24 to 8/25/24 were reviewed. The POC indicated, Famotidine 40 mg/ 5 ml, give 0.3 ml twice a day. The POC indicated, Famotidine 40 mg/ 5 ml, give 0.6 ml twice a day. CM stated the order for Famotidine 0.3 ml twice a day should have been discontinued and the POC should have been updated. During a review of the facility's policy and procedure (P&P) titled, "Home Health Certification and Plan(s) of Care," dated 7/9/18, the P&P indicated,"2. PURPOSE: 2.2 To provide direct care staff with the ordering practitioner's ordered treatments, procedures, medications, and services required to meet the patient's home care needs. 3. POLICY: 3.1 The Home Health Certification and Plan of Care (485) is the ordering practitioner's order for home care services. 3.1.1 The Plan of Care will be individualized to include, but not limited to, all treatments, procedures, medications, and services authorized to be provided by direct care staff."

Integrate all orders CFR(s): 484.60(d)(2) Integrate orders from all physicians or allowed practitioners involved in the plan of care to assure the coordination of all services and interventions provided to the patient. This ELEMENT is not met as evidenced by: Based on interview and record review, the facility failed to coordinate care for one of seven sampled patients (Patient 3) with their hospice provider. This failure resulted in medication orders from the hospice provider not being integrated into the facility’s Plan of Care and the potential for medication errors. Findings: During a review of Patient 3’s "Hospice Plan of Care (HPOC)," dated 6/16/24 to 8/14/24, the "POC" Indicated the following: Carbidopa- Levodopa 25 mg/100 mg tablet. 2 tablets three times a day Gabapentin 300 mg capsule. 2 capsules three times a day Bupropion 100 mg tablet. 1.5 tablets, one time a day Lorazepam 2 mg/ml concentrate. 0.5 to 1 ml every 4 hours as needed for anxiety. During a review of Patient 3’s "HPOC," dated 6/16/24 to 8/14/24, the "HPOC," did not include a medication order for Nitrofurantoin. During a concurrent interview and record review on 7/31/24 at 10:05 a.m. with Clinical Manager (CM), Patient 3’s “Hospice Plan of Care (HPOC),” dated 7/31/24, was reviewed. The HPOC indicated the following medication orders: 9/12/23: Lorazepam 2 mg/ml concentrate. Give 0.5 to 1 ml every 2 hours as needed for anxiety. 4/2/24: Bupropion 100 mg tablet. 1 tablet, two times a day. May titrate up to 150 mg twice a day in one week if depression not improved. 5/10/24: Carbidopa- Levodopa 25 mg/100 mg tablet. 1 tablet three times a day. 5/10/24: Gabapentin 300 mg capsule. 2 capsules two times a day. 5/17/24: Macrobid (Nitrofurantoin) 100 mg capsules. Give 1 capsule once a day. CM stated LVNs should have uploaded supplemental hospice orders to the app or mailed the paper orders to the office for upload. CM stated there were no copies of orders in the paper chart or uploaded in the electronic medical records. CM stated the Plans of Care, Medication Profile, and MARs do not match. During a review of the facility’s policy and procedure (P&P) titled, “Care Coordination/ Case Conference,” the P&P indicated, “2. PURPOSE: 2.1 To ensure the coordination of services for each patient and to minimize the potential for missed, conflicting, or duplicated services. 2.2 To facilitate effective communications amongst the health care team. 3. POLICY: 3.1 Care coordination is accomplished through communication with the members of the health care team including independent contractors where applicable. 3.2 Interdisciplinary coordination of care is ensured through communication and case conferencing. . . 5. PROCEDURE: 5.1 Direct Care Staff shall communicate changes in patient status amongst the assigned personnel and the office clinical leader or clinical designee. Direct Care Staff will communicate changes in a timely manner via telephone, one-on-one meetings, case conferences and/or home visits. Documentation of communications will be included in the medical record on a communication note, case conference note, clinical visit note, supervisory visit note or in the system of record. Documentation will include the date and time of the communication, individuals involved with the communication, information discussed, and the outcome of the communication.”

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 observation and interview, the agency failed to ensure for one of seven sampled patients (Patient 1) equipment was cleaned or replaced per physician recommendations. This failure had the potential to result in the overuse and/or contamination of used equipment. Findings: During a concurrent observation and interview on 7/30/24 at 10:55 a.m. with Licensed Vocational Nurse (LVN) 3, LVN 3 replaced Patient 1's tracheostomy (an opening created from outside the neck into the trachea to help oxygen reach the lungs) tubing and adaptor. The tracheostomy tubing had a blue piece of equipment next to the tracheostomy opening. LVN 3 stated the blue piece of equipment was called a "dual access swivel adapter." LVN 3 stated a replacement adapter was not in the order of new supplies, so she was going to call the company to send another one. LVN 3 stated she was going to reuse the current adaptor already in place, after cleaning it. LVN 3 stated, the adaptor had already been used twice and there were two new ones available in the home. LVN 3 stated, the adapters "need to be thrown away after a while because they do get dirty." LVN 3 stated she did not know how many times this adaptor had been cleaned and reused. LVN 3 stated she did not know the policy for cleaning and reusing adaptors. LVN 3 stated, "I can get back to you." LVN 3 was then observed replacing the used adapter onto the new tracheostomy tubing after cleaning it. During an interview on 7/30/24 at 2:45 p.m. with CM, CM stated, staff do reuse equipment. CM stated they do not really have a policy about it. During an interview on 7/31/24 at 9:15 a.m. with CM, CM stated, the doctor told her they can use the same adapter for a month and dual access swivel adapters can be cleaned up to three times. CM stated the facility did not have a procedure for tracking how many times the adaptor had been cleaned or when it was changed with a new one. CM stated, "We used to have a DME (durable medical equipment) sheet. It went away when we went online...a few months ago." During an interview on 7/31/24 at 11 a.m. with Clinical Manager (CM), CM stated they did not have a policy regarding expired equipment. CM stated, "We will come up with a process to have a spread sheet and check weekly" for expiration dates. During a review of the facility's policy and procedure (P&P) titled, "Infection Control Program," dated 10/8/18, the P&P indicated, "Methods to reduce the risks associated with procedures, medical equipment, and medical devices include manufacturer's recommendations for storage, cleaning, disinfection, and sterilization, or specific ordering practitioner order will be researched, reviewed and incorporated into services provided and in the training of personnel."

Services by skilled professionals CFR(s): 484.75(a) Standard: Provision of services by skilled professionals. Skilled professional services are authorized, delivered, and supervised only by health care professionals who meet the appropriate qualifications specified under §484.115 and who practice according to the HHA's policies and procedures. This STANDARD is not met as evidenced by: Based on interview and record review, facility failed to ensure for one of seven sampled patients (Patient 3) Gastrostomy tube (G-tube- feeding tube inserted through the abdomen to the stomach to provide nutrition, fluids, and medications) medications were administered according to agency procedure. This failure had the potential to result in G-tube clogging and medication incompatibility. Findings: During a review of Patient 3’s medication administration record (MAR), dated 7/14/24 through 7/20/24, the MAR indicated Patient 3 received the following medications scheduled for 7 a.m. daily via G-tube: Gabapentin (for nerve pain) 300 mg capsule, Docusate Sodium (for constipation) 50 mg/5 ml, Pepcid (for stomach acid) 40 mg tablet, Nitrofurantoin (for urinary tract infection) capsule, Bupropion (for depression) 100 mg tablet, Quetiapine (for mood disorders) 50 mg tablet, Senna (for constipation) 176 mg/5 ml oral syrup, Morphine (for pain) concentrate 20 mg/ ml (10 mg to 20 mg), and Lorazepam (for anxiety) 1 mg/ 0.5 ml (1 mg to 2 mg). The MAR indicated the medications were given by Licensed Vocational Nurse (LVN) 2. During an interview on 7/30/24 at 12 p.m. with Licensed Vocational Nurse (LVN) 2, LVN 2 stated she gave Patient 3’s G-tube medications by crushing them together, mixing them with water, and pushing them slowly down the G-tube via syringe using the plunger. During an interview on 8/1/24 at 9:55 a.m. with Clinical Manager (CM), CM stated nurses should be administering medications one at a time through the G-tube via gravity. CM stated the facility follows Visiting Nurses of America (VNAA) Guidelines for administration of medications via G-tube. During a review of the facility’s policy and procedure (P&P) titled, “Competency Assessment-Direct Care Staff,” dated 1/14/19, the P&P indicated, “3.4 An established protocol will be used as a guideline for competency assessment. . . 3.4.2 The reference for the protocols is the Visiting Nurses of America (VNNA) Nursing Procedure Manual. 3.4.2.1 The Use of the VNNA protocols is mandatory and will be utilized to guide scenario based competencies.” During a review of the facility’s VNAA guidelines, dated 9/12, the VNAA guidelines indicated, “CONSIDERATIONS: . . . 3. Due to incompatibilities leading to occlusion [clogging], medications: . . . b. Should be prepared and administered individually. . . 10. Remove plunger from oral/ enteral [G-tube] syringe so medications can be delivered via gravity.”

Interventions and patient response CFR(s): 484.110(a)(2) All interventions, including medication administration, treatments, and services, and responses to those interventions; This ELEMENT is not met as evidenced by: Based on interview and record review, the facility failed to ensure for one of seven sampled patients (Patient 3) all medications were documented in the clinical record on the Patient Medication Profile (PMP) and Medication Administration Record (MAR). This failure had the potential to result in medication errors. Findings: During a review of Patient 3’s “Supplemental Physician’s Order (SPO),” dated 5/17/24, the "SPO" indicated, “Nitrofurantoin Mano-MCR 100 MG Take 1 capsule via g-tube (tube opening from the abdomen into the stomach/intestine used for nutrition, fluids, or medications) every day for UTI (urinary tract infection).” During a review of Patient 3’s "Patient Medication Profile (PMP)," dated 7/30/24 and "Medication Administration Record (MAR)," dated 7/28/24 to 8/3/24, the "PMP" indicated Nitrofurantoin was not on the PMP and was written on the MAR as under “Orders” as “Nitro” with no further instructions. During a concurrent interview and record review on 7/31/24 at 2:25 p.m. with Clinical Manager (CM), Patient 3’s "MAR," dated 7/28/24 to 8/3/24, was reviewed. The MAR indicated, “Nitro” under the heading “Orders.” CM stated the nurse should have completed writing the order on the MAR. CM stated “Nitro” could mean Nitroglycerin. During an interview on 7/31/24 at 4:10 p.m. with Licensed Vocational Nurse (LVN) 2, LVN 2 stated, “I know most of the orders I write. I know what has been changed if it is not on the MAR.” LVN 2 stated most of Patient 3’s orders come through hospice. During a review of the facility’s policy and procedure (P&P) titled, “Administration and Documentation of Medications,” dated 4/11/24, the P&P indicated, “3.3 All medications administered will be listed on the Medication Administration Record. 3.3.1 The Medication Profile, when complete and updated, should be used as the primary source of reference for the medication pre-pours in the home. The physician orders should always be used as the ultimate source. The Medication Administration Record will be reconciled with the medication profile in all cases.”

Authentication CFR(s): 484.110(b) Standard: Authentication. All entries must be legible, clear, complete, and appropriately authenticated, dated, and timed. Authentication must include a signature and a title (occupation), or a secured computer entry by a unique identifier, of a primary author who has reviewed and approved the entry. This STANDARD is not met as evidenced by: Based on interview and record review, the facility failed to ensure for two of seven sampled patients (Patient 3 and Patient 4) Supplemental Physician’s Orders (SPO) were signed in a timely manner. This failure resulted in Medication Administration Records (MAR), Patient Medication Profiles (PMP), and/or Plans of Care (POC) not being updated timely and had the potential for medication errors. Findings: During a review of Patient 3’s “Supplemental Physician’s Order (SPO),” dated 5/17/24, the "SPO" indicated, “Nitrofurantoin (antibiotic to treat urinary tract infections) Mano-MCR 100 MG Take 1 capsule via g-tube (tube opening from the abdomen into the stomach/intestine used for nutrition, fluids, or medications) every day for UTI (urinary tract infection).” During an interview on 8/1/24 at 11:30 a.m. with Clinical Manager (CM), CM stated Patient 3's physician’s order for Nitrofurantoin had been recorded into the system but had not yet been signed by the physician. During a review of Patient 4’s “Supplemental Physician’s Orders (SPO),” dated 2/29/24, the "SPO" indicated, “Famotidine (treats stomach reflux disease) 40 mg/5 ml (8 mg/ml) suspension Administer 0.6 ml two times daily by mouth.” During an interview on 8/1/24 at 11:53 a.m. with CM, CM stated Patient 4’s order for Famotidine 0.6 ml was written on 2/29/24 but was not placed on the Plan of Care for physician signature until 6/25/24. CM stated verbal orders were taken in the home, then the Licensed Vocational Nurse should upload them to the computer system. Once the orders were uploaded, then they were typed and faxed to the physician for signature. CM stated the orders should have been signed within 30 days of receipt. During a review of the facility’s policy and procedure (P&P) titled, “Processing of Ordering Practitioner Orders,” dated 1/13/18, the P&P indicated, “3. POLICY: 3.1 Orders will be obtained from a licensed ordering practitioner for care and services provided. . . 3.2 As applicable, orders will be signed and date within 30 days from the original date of receipt.”