Every finding on record at Medi Home Health Agency

An onsite recertification and follow up survey was conducted on 03/13/23-03/15/23. No deficiencies to the Emergency Preparedness Program were identified. ABH

An onsite recertification and follow up survey was conducted on 03/13/23-03/15/23. Deficiencies to the Medicare Conditions of Participation were identified. The following tags were put back into compliance effective 03/15/23- G708 and G800. ABH

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 policy review, observation, clinical record review, and staff interview, the agency failed to include all medications on the plan of care for 4 of 7 home visits (#12,16,17,and 11) failed to have the psychosocial status for 5 of 18 records reviewed (#7,6,11,13, and 14) failed to include weight bearing restrictions for 1 of 17 records reviewed (#10), and failed to include indications for PRN (as needed) visits for 1 of 7 patients with a home visit (#15). Findings included: 4A. Patient # 11 had a Start of Care date of 1/30/23 and an admitting diagnosis of infection or inflammatory reaction due to internal left knee prosthesis. Review of the Plan of Care [POC] for the certification period 1/30/23 to 3/30/23 included orders for SN [skilled nursing] 1 time a week for 4 weeks; PT [physical therapy] 1 time a week for 4 weeks. The patient was admitted to the hospital on 2/27/23 and was discharged home on 3/3/23. Review of the ROC [resumption of care – orders/visit after the patient has had an inpatient stay] orders included orders for SN 2 times a week for 2 weeks; PT 3 times a week for 2 weeks. A joint home visit was conducted with PT # 17 on 3/14/23 at approximately 10 am. During the joint visit a medication review was conducted using a medication profile provided by the agency. The following discrepancies were noted: The patient presented a tube of Diclofenac Sodium 1% [topical nonsteroidal anti-inflammatory] use to affected area three times a day [patient stated he was using on his “sore joints”]. During an interview with the patient during the visit the patient reported he had been using the medication since before his admission to home health. During an interview with the director of professional services on 3/14/23 at approximately 4 pm, it was confirmed the POC did not include all the medications the patient was using at the time of admission. 4B. Patient # 11 had a Start of Care date of 1/30/23 and an admitting diagnosis of infection or inflammatory reaction due to internal left knee prosthesis. Review of the Plan of Care [POC] for the certification period 1/30/23 to 3/30/23 revealed the Psychosocial section of the POC was blank. During an interview with the director of professional services on 3/14/23 at approximately 3 pm, it was confirmed the Psychosocial section of the POC should have been addressed. 5A. Patient # 15 had a Start of Care date of 1/24/23 with an admitting diagnosis of appendicitis with perforation [infection from the appendix may cause a hole that allows the infection from the appendix to spread to the rest of the abdomen], cutaneous abscess of abdominal wall [collection of pus in the abdomen] and hypertensive heart disease with heart failure [heart problems that occur because of high blood pressure that is present for an extended period of time, to include affecting the pumping ability of the heart]. Review of the Plan of Care [POC] for the certification period 1/24/23 to 3/24/23 included orders for SN [skilled nursing] 2 times a week for 3 weeks, 1 time a week for 6 weeks; PT [physical therapy] 1 time a week for 7 weeks. On 3/14/23 at approximately 11:30 am a joint visit was conducted with RN # 3. During the visit a medication review was conducted using a medication profile provided by the agency. The following discrepancies were noted: Iron [supplement] 324 mg. Take 1 daily was not included on the medication profile. The patient stated she had been using the medication since admission to the agency. Diltiazem [blood pressure] 30 mg each day was not included on the medication profile. The patient states she has been using this since admission to the agency. During an interview with the agency administrator on 3/14/23 at approximately 12 pm, the administrator confirmed the POC did not include all the medications the patient was using. 5B. Patient # 15 had a Start of Care date of 1/24/23 with an admitting diagnosis of appendicitis with perforation [infection from the appendix may cause a hole that allows the infection from the appendix to spread to the rest of the abdomen], cutaneous abscess of abdominal wall [collection of pus in the abdomen] and hypertensive heart disease with heart failure [heart problems that occur because of high blood pressure that is present for an extended period of time, to include affecting the pumping ability of the heart]. Review of the Plan of Care [POC] for the certification period 1/24/23 to 3/24/23 included orders for SN [skilled nursing] 2 times a week for 3 weeks, 1 time a week for 6 weeks 1 PRN [as needed]. Further review of the POC no indications for the PRN visit. During an interview with the director of professional services on 3/14/23 at approximately 4 pm, it was confirmed the order for nursing services failed to include indications for the PRN visit. 6. Patient # 6 had a Start of Care date of 2/14/23 and an admitting diagnosis of ataxia [lack of voluntary coordination of muscle movement] following cerebral infarction [stroke]. Review of the Plan of Care [POC] for the certification period 2/14/23 to 4/14/23 revealed the Psychosocial section of the POC was blank. During an interview with the director of professional services on 3/14/23 at approximately 3 pm, it was confirmed the Psychosocial section of the POC should have been addressed. 7. Patient # 13 had a Start of Care date of 3/3/23 and an admitting diagnosis of unspecified open wound to left lower leg. Review of the Plan of Care [POC] for the certification period 3/3/23 to 5/1/23 revealed the Psychosocial section of the POC was blank. During an interview with the director of professional services on 3/14/23 at approximately 3 pm, it was confirmed the Psychosocial section of the POC should have been addressed. 8. Patient # 14 had a Start of Care date of 2/7/23 and an admitting diagnosis of hypertensive heart disease with heart failure [heart problems that occur because of high blood pressure that is present for an extended period of time, to include affecting the pumping ability of the heart]. Review of the Plan of Care [POC] for the certification period 2/7/23 to 4/7/23 revealed the Psychosocial section of the POC was blank. During an interview with the director of professional services on 3/14/23 at approximately 3 pm, it was confirmed the Psychosocial section of the POC should have been addressed. 9. Patient # 10 had a Start of Care date of 2/3/23 and admitting diagnoses of encounter for surgical after care following surgery on the circulatory system and essential hypertension [high blood pressure]. Review of the Plan of Care [POC] for the certification period 2/3/23 to 4/3/23 included orders for PT [physical therapy] 1 time a week for 1 week, 2 times a week for 6 weeks; OT [occupational therapy] 1 time a week for 6 weeks; home health aide 1 time a week for 4 weeks. Review of the hospital discharge note from _____ [name of hospital] revealed the patient had a pacemaker [small device used to treat some arrhythmias -abnormal heartbeat] placed on 1/9/23. The patient was discharged from the hospital on 1/13/23 with orders for “Left shoulder restrictions for 8 weeks. Do not lift that arm above shoulder height for 2 months…No more lifting or pushing more than 5-10 pounds with arm for 2 months…” The POC did not include the information related to the left shoulder precautions. During an interview with PT # 10 on 3/15/23 at approximately 11 am, the PT confirmed this information should have been included on the POC. Review of policy, “Reducing Medication Errors HH3009”, revised 08/22, was received from the Employee #1 on 03/15/23 at 8:35 a.m. The policy stated”, …to further reduce medication errors staff must review medications on each visit by physically looking at medication bottles/dispensers…”. 1. Patient #12 was admitted was admitted on 03/01/23 with diagnoses of cholecystostomy (removal of gall bladder), and afib (atrial fibrillation) heart flutters. The plan of care for 03/01/23 to 04/29/23 had orders for skilled nursing 2 times a week for 1 week, and 1 time a week for 4 weeks. Physical therapy 1 time a week for 1 week, 2 times a week for 1 week, and 1 time a week for 4 weeks. Occupational therapy 1 time a week for 7 weeks. A home visit with the occupational therapist was observed on 03/13/23 at 3:35 p.m. The medication review during the home visit revealed the following discrepancies: vitamin D3 1000 IU (international units) daily by mouth, and magnesium 250 mg(milligrams) 1 daily by mouth were not included on the medication profile. Interview with the patient confirmed she takes both supplements daily. 2. Patient #16 was admitted on 03/01/23 with diagnoses of essential hypertension, bipolar disorder, and tremor. The plan of care for 03/01/23 to 04/29/23 had orders for physical therapy 1 time a week for 1 week, 2 times a week for 3 weeks, and 1 time a week for 4 weeks. A home visit with the physical therapist assistant was observed on 03/14/23 at 1:28 p.m. The medication review during the home visit revealed the following discrepancy: omeprazole (heartburn) 20 mg 1 tablet by mouth daily was not included on the medication profile. Interview with the patient confirmed she has been taking this medication for 2 months. 3. Patient #17 was admitted on 01/30/23 with diagnoses of parkinson’s disease, essential hyptertension, and depression. The plan of care for 01/30/23 to 03/30/23 had orders for physical therapy 2 times a week for 4 weeks, 1 time a week for 4 weeks. Occupational therapy 1 time a week for 6 weeks. A home visit with the physical therapist was observed on 03/14/23 at 2:47 p.m. The medication review during the home visit revealed the following discrepancy: ginkgo biloba (supplement for memory) 60 mg 1 tablet by mouth daily was not included on the medication profile. Interview with the patient confirmed she has been taking this supplement for several years. 4. Patient #7 was admitted on 02/20/23 with diagnoses of cva (cerebral vascular accident) stroke, weakness, copd (chronic obstructive pulmonary disease) and hypertension. The plan of care for 02/20/23 to 04/20/23 had orders for physical therapy 1 time a week for 1 week, 2 times a week for 4 weeks, and 1 time a week for 2 weeks. Review of the plan of care revealed the psychosocial status was missing. Interview with the agency director on 03/15/23 at approximately 9:10 a.m. revealed, “it’s not flowing over from the oasis to the plan of care with the oasis update”.

Conformance with physician orders CFR(s): 484.60(b) Standard: Conformance with physician or allowed practitioner orders. This STANDARD is not met as evidenced by: Based on agency policy, clinical record review and staff interviews the agency failed to follow physician’s orders for visit frequencies for 3 of 17 patients [#2, 8, 15]. The findings included: The policy, Managing Physician Orders HME019C [1/2023], was provided by the director of professional services on 3/15/23 at 8:20 am. The policy stated, “…It is the policy of _______ [agency name] to provide care, treatment…with physician orders…” 1. Patient # 2 had a Start of Care date of 11/27/21 and an admitting diagnosis of type 2 diabetes mellitus with other specified complications, other acute osteomyelitis [infection of bone] of right ankle and foot, and diabetes mellitus with foot ulcer. Review of the Plan of Care [POC] for the certification period 11/27/21 to 1/25/22 included orders for SN [skilled nursing] 1 time a week for 1 week, 2 times a week for 1 week, 1 time a week for 7 weeks. Review of the clinical record revealed only 1 SN visit was made the week of 11/28/21 [2 times a week for 1 week]. Further review of the clinical record revealed no missed visit information. During an interview with the director of professional services on 3/15/23 at approximately 12:25 pm, the director confirmed the SN visits were not made in accordance with the physician’s order. 2. Patient # 8 had a Start of Care date of 2/3/23 and an admitting diagnosis of dysphagia [difficulty swallowing] following cerebral infarction [stroke]. Review of the Plan of Care for the certification period 2/3/23 to 4/3/23 included orders for ST [speech therapy] 1 time a week for 1 week, 2 times a week for 1 week, 1 time a week for 2 weeks, 0 times a week for 2 weeks, 1 time a week for 3 weeks. Review of the clinical record revealed the ST made a visit the week of 3/5/23 [0 times a week for 2 weeks]. During an interview with ST # 7 on 3/15/23 at 11:10 am, the ST confirmed there was not order for a visit that week. The ST stated, “The visit must have been plotted wrong.” 3. Patient # 15 had a Start of Care date of 1/24/23 with an admitting diagnosis of appendicitis with perforation [infection from the appendix may cause a hole that allows the infection from the appendix to spread to the rest of the abdomen], cutaneous abscess of abdominal wall [collection of pus in the abdomen] and hypertensive heart disease with heart failure [heart problems that occur because of high blood pressure that is present for an extended period of time, to include affecting the pumping ability of the heart]. Review of the Plan of Care [POC] for the certification period 1/24/23 to 3/24/23 included orders for SN [skilled nursing] 2 times a week for 3 weeks, 1 time a week for 6 weeks 1 PRN [as needed]. Review of the clinical record revealed only 1 SN visit was made the week of 1/24/23 [should have been 2 SN visits that week]. Further review of the clinical record revealed 2 SN visits were made the week of 2/12/23 [order string was for 1 SN visit the week of 2/12/23]. During an interview with the director of professional services on 3/15/23 at approximately 10:30 am she confirmed the SN visits were not made in accordance with physician’s orders.

Promptly alert relevant physician of changes CFR(s): 484.60(c)(1) The HHA must promptly alert the relevant physician(s) or allowed practitioner(s) to any changes in the patient's condition or needs that suggest that outcomes are not being achieved and/or that the plan of care should be altered. This ELEMENT is not met as evidenced by: Based on agency policy, clinical record review and staff interviews the agency failed to document notifying the physician of a vital sign outside of parameters for 1 of 17 records reviewed (#9) and failed to notify the physician for a new onset of shortness of breath for 1 of 7 patients receiving a home visit (#15). Findings included: 2. Patient # 15 had a Start of Care date of 1/24/23 with an admitting diagnosis of appendicitis with perforation [perforation [infection from the appendix may cause a hole that allows the infection from the appendix to spread to the rest of the abdomen], cutaneous abscess of abdominal wall [collection of pus in the abdomen] and hypertensive heart disease with heart failure [heart problems that occur because of high blood pressure that is present for an extended period of time, to include affecting the pumping ability of the heart]. Review of the Plan of Care [POC] for the certification period 1/24/23 to 3/24/23 included orders for SN [skilled nursing] 2 times a week for 3 weeks, 1 time a week for 6 weeks; PT [physical therapy] 1 time a week for 7 weeks. Review of the clinical record revealed PTA [physical therapy assistant] # 9 made a routine visit on 2/10/23 and documented the following information, “Pt [patient ]reports she feels very short of breath lately. She has trouble sleeping and has been having to sit up at the side of the bed to breath better.” The clinical record revealed the PTA contacted PT # 8 to report her findings, but the physician was not contacted related to the patients complaints of shortness of breath. During an interview with PTA # 9 on 2/15/23 at 12:30 pm, the PTA confirmed the physician was not notified of the new onset of shortness of breath. Review of policy “Care Plan Implementation HH2015”, was revised 12/2022, was received from Employee #1 on 03/15/23 at 8:35 a.m. The policy stated” …the home health agency will notify the physician promptly to any changes in the patients’ condition or needs that suggest outcomes are not being achieved and /or that the plan of care should be altered…”. Patient #9 was admitted on 01/30/23 with diagnoses of sepsis due to e coli (blood infection), chronic pyelonephritis (kidney infection), and essential hypertension. The plan of care for 01/30/23 to 03/30/23 had orders for skilled nursing 1 time a week for 6 weeks. Order for skilled nursing were to notify the physician of pulse greater than 110 or less than 60. Review of the skilled nursing visit note for 03/09/23 revealed a pulse of 58. No other documentation was in the record aside from the vital signs. The visit note was not completed at the time of review on 03/14/23. Interview with the registered nurse on 03/15/23 at 9:10 a.m. revealed, “yes, I did call the doctor and I extended her services, and she had med changes as well”.

Communication with all physicians CFR(s): 484.60(d)(1) Assure communication with all physicians or allowed practitioners involved in the plan of care. This ELEMENT is not met as evidenced by: Based on clinical record review and staff interviews the speech therapist failed to communicate with the physician related to a medication for 1 of 2 patient receiving speech therapy services [#8]; failed to communicate the possible need for a follow up BNP [B-Type Natriuretic Peptide-blood work used to help diagnosis congestive heart failure] for 1 of 1 patient with elevated BNP [#15]; failed to report patient’s confusion related to medications for 1 of 7 patients with a home visit [#15]. The findings included: 1. Patient # 8 had a Start of Care date of 2/3/23 and an admitting diagnosis of dysphagia [difficulty swallowing] following cerebral infarction [stroke]. Review of the Plan of Care for the certification period 2/3/23 to 4/3/23 included orders for ST [speech therapy] 1 time a week for 1 week, 2 times a week for 1 week, 1 time a week for 2 weeks, 0 times a week for 2 weeks, 1 time a week for 3 weeks. Review of the clinical record revealed the following documentation by ST #7 during the visit on 2/10/23, “…Plavix [blood thinner] for CVA [stroke] prevention noted in chart [at the facility where patient resided]. As of 3/15/23 at 9 am, there was no documentation related to coordination with the physician related to the Plavix. During an interview with ST # 7 on 3/15/23 at approximately 11:10 am, the ST stated, “I wanted to follow up to see if the patient should be taking the medication since the medication wasn’t on his profile. I haven’t been able to catch up with the physician to follow up on that.” 2A. Patient # 15 had a Start of Care date of 1/24/23 with an admitting diagnosis of appendicitis with perforation [infection from the appendix may cause a hole that allows the infection from the appendix to spread to the rest of the abdomen], cutaneous abscess of abdominal wall [collection of pus in the abdomen] and hypertensive heart disease with heart failure [heart problems that occur because of high blood pressure that is present for an extended period of time, to include affecting the pumping ability of the heart]. Review of the Plan of Care [POC] for the certification period 1/24/23 to 3/24/23 included orders for SN [skilled nursing] 2 times a week for 3 weeks, 1 time a week for 6 weeks. Review of the clinical record revealed a B-Type Natriuretic Peptide [BNP-lab test [via blood] which is often use to diagnosis exacerbation of heart failure] reading of 3,988 [normal 0-450] resulted on 2/17/23. There was no evidence the physician was contacted to request a repeat of the BNP. An interview was conducted with the director of professional services on 3/14/23 at approximately 4 pm. During the interview the director of professional services confirmed the BNP had not been repeated. The director of professional services stated, “I will call over and follow up on that right now.” 2B. Patient # 15 had a Start of Care date of 1/24/23 with an admitting diagnosis of appendicitis with perforation [infection from the appendix may cause a hole that allows the infection from the appendix to spread to the rest of the abdomen], cutaneous abscess of abdominal wall [collection of pus in the abdomen] and hypertensive heart disease with heart failure [heart problems that occur because of high blood pressure that is present for an extended period of time, to include affecting the pumping ability of the heart]. Review of the Plan of Care [POC] for the certification period 1/24/23 to 3/24/23 included orders for SN [skilled nursing] 2 times a week for 3 weeks, 1 time a week for 6 weeks; PT [physical therapy] 1 time a week for 7 weeks. Review of the clinical record revealed PT # 8 made a routine visit on 2/24/23 and documented the following information, “…Patient reports some confusion with medications and reached [patient] out to SN for advice. Patient reports some discomfort in legs due to swelling…” Further review of the clinical record revealed no evidence PT # 8 communicated the patient’s confusion related to her medications to the physician. During an interview with PT # 8 on 3/15/23 at approximately 10:45 am, PT # 8 stated, “This had been an ongoing problem with the patient. I didn’t put that in the note.”

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 agency policy, direct observation and staff interviews the physical therapist failed to follow accepted standards of practice [failure to place bag on a barrier] during 1 of 7 home visits [#11]. The findings included: The policy, Bag Technique HH4020 [12/2022], was provided by the director of professional services on 3/15/23 at 8:20 am. The policy stated, “…The bag should be placed on a barrier…in the employee’s car and in the patient’s home…” Patient # 11 had a Start of Care date of 1/30/23 and an admitting diagnosis of infection or inflammatory reaction due to internal left knee prosthesis. Review of the Plan of Care [POC] for the certification period 1/30/23 to 3/30/23 included orders for SN [skilled nursing] 1 time a week for 4 weeks; PT [physical therapy] 1 time a week for 4 weeks. The patient was admitted to the hospital on 2/27/23 and was discharged home on 3/3/23. Review of the ROC [resumption of care – orders/visit after the patient has had an inpatient stay] orders included orders for SN 2 times a week for 2 weeks; PT 3 times a week for 2 weeks. A joint visit was made with PT # 17 on 3/14/23 at 10 am. During the visit, PT # 17 was noted to have 2 bags [1 bag had vital sign equipment and the 2nd bag contained a measuring wheel]. When entering the home PT # 17 placed the bag containing the vital sign equipment on a barrier on the patient’s couch. The 2nd bag was placed directly on the patient’s couch with no barrier. The bag remained on the couch with no barrier for the entire visit. An interview was conducted with PT # 17 on 3/15/23 at approximately 9:30 am. During the interview, PT # 17 confirmed both bags should have been placed on a barrier since the bags are used in other patients’ homes.

Provide services in the plan of care CFR(s): 484.75(b)(3) Providing services that are ordered by the physician or allowed practitioner as indicated in the plan of care; This ELEMENT is not met as evidenced by: Based on agency policy, clinical record view and staff interviews the SN [skilled nurse] failed to provide services/treatments ordered by the physician for 1 of 1 patient with a PICC [peripherally inserted central catheter] [#11]; and failed to provide wound care as ordered by the physician for 1 of 5 patients with a wound [#13]; The findings included: The policy, Care Plan Implementation HH2015 [12/2022], was provided by the director of professional services on 3/15/23 at 8:20 am. The policy stated, “…_______ [name of agency] provides care, treatment and/or services for each patient according to accepted professional standards and applicable laws and regulations…” 1. Patient # 11 had a Start of Care date of 1/30/23 and an admitting diagnosis of infection or inflammatory reaction due to internal left knee prosthesis. Review of the Plan of Care [POC] for the certification period 1/30/23 to 3/30/23 included orders for SN [skilled nursing] 1 time a week for 4 weeks. The patient was admitted to the hospital on 2/27/23 and was discharged home on 3/3/23. Review of the ROC [resumption of care – orders/visit after the patient has had an inpatient stay] orders included orders for SN 2 times a week for 2 weeks and “…SN to draw draw [sic] weekly labs while on IV [intravenous-directly into the veins] antibiotics on Monday or Tuesdays…” Review of the clinical record revealed the patient would continue IV antibiotics for 38 days. Review of the patient’s calendar for visits revealed the patient was seen on 3/9/23 [Thursday] and lab work was obtained during the Thursday visit. Further review of the clinical record revealed weekly labs [for week of 3/12/23] had not been obtained as of 3/15/23 [Wednesday]. During an interview with LPN # 6 on 3/15/23 at approximately 11:15 am, the LPN stated, “I don’t know why the nursing visits for lab work were not scheduled on Monday or Tuesday. I guess it’s a scheduling issue. I plan to see the patient today to obtain the lab work.“ 2. Patient # 13 had a Start of Care date of 3/3/23 and an admitting diagnosis of unspecified open wound left lower leg. Review of the Plan of Care [POC] for the certification period 3/3/23 to 5/1/23 included orders for SN [skilled nursing] 1 time a week for 1 week, 2 times a week for 1 week, 1 time a week for 6 weeks and “Wound care to left shin as follows: Cleanse with Vashe [brand of wound cleanser] , apply xeroform, cover with non adhesivefoam [sic] wrap in kerlix, secure with tape. Change every other day, SN to change at visits, caregiversto [sic] perform in SN absence…” On 3/13/23 at approximately 11 am a joint visit was made with RN # 15. During the visit, RN # 15 completed wound care to the left lower leg. After the wound care was completed, the patient stated, “How often should my family be doing these dressing changes.” RN # 15 stated, “Let’s do the dressing changes every day to keep the dressings from drying out and sticking to the wound.” During an interview with RN # 15 on 3/15/23 at approximately 12 pm, the RN confirmed the orders on the POC were for every other day. “I called and got an order this morning to do the dressing changes every day.”

Home health aide assignments and duties CFR(s): 484.80(g)(1) Standard: Home health aide assignments and duties. Home health aides are assigned to a specific patient by a registered nurse or other appropriate skilled professional, with written patient care instructions for a home health aide prepared by that registered nurse or other appropriate skilled professional (that is, physical therapist, speech-language pathologist, or occupational therapist). This STANDARD is not met as evidenced by: Based on clinical record review and staff interviews the agency failed to include shoulder precautions on the aide care plan for 1 of 2 patients receiving aide services [#10]; failed to include specific type of bath patient should receive for1 of 2 patients receiving aide services [#10]. The findings included: 1A. Patient # 10 had a Start of Care date of 2/3/23 and admitting diagnoses of encounter for surgical after care following surgery on the circulatory system and essential hypertension [high blood pressure]. Review of the Plan of Care [POC] for the certification period 2/3/23 to 4/3/23 included orders for PT [physical therapy] 1 time a week for 1 week, 2 times a week for 6 weeks; home health aide 1 time a week for 4 weeks. Review of the hospital discharge note from _____ [name of hospital] revealed the patient had a pacemaker [small device used to treat some arrhythmias -abnormal heartbeat] placed on 1/9/23. The patient was discharged on 1/13/23 with the following orders “Left shoulder restrictions for 8 weeks. Do not lift that arm above shoulder height for 2 months…No more lifting or pushing more than 5-10 pounds with that arm for 2 months…” Review of the clinical record revealed PT # 10 completed the aide care plan on 2/3/23. Review of the aide care plan revealed the information related to the left shoulder precautions were not placed on the aide care plan. During an interview with home health aide # 12 on 3/15/23 at 9 am, the aide stated "she had no knowledge of the left shoulder restrictions". During an interview with PT # 10 at 11 am, the PT confirmed the information related to the left shoulder restrictions should have been included on the aide care plan. 1B. Patient # 10 had a Start of Care date of 2/3/23 and admitting diagnoses of encounter for surgical after care following surgery on the circulatory system and essential hypertension [high blood pressure]. Review of the Plan of Care [POC] for the certification period 2/3/23 to 4/3/23 included orders for PT [physical therapy] 1 time a week for 1 week, 2 times a week for 6 weeks; home health aide 1 time a week for 4 weeks. PT # 10 completed the aide care plan on 2/3/23. Review of the aide care plan revealed the following tasks “…partial bath/sponge bath every visit…shower every visit…” The aide care plan did not specify which type of bath the aide should complete. During an interview with PT # 10 on 3/15/23 at approximately 11 am, the PT confirmed the task should have been specific related to the type of bath.

Required items in clinical record CFR(s): 484.110(a)(1) The patient's current comprehensive assessment, including all of the assessments from the most recent home health admission, clinical notes, plans of care, and physician or allowed practitioner orders; This ELEMENT is not met as evidenced by: Based on clinical record review and staff interviews the agency failed to include missed visit notes in the clinical record for 1 of 4 discharged charts [#4]. The findings included: Patient # 4 had a Start of Care date of 3/25/22 and an admitting diagnosis of pressure ulcer of left ankle, stage 3 [full thickness of the skin]. Review of the Plan of Care for the certification period 3/25/22 to 5/23/22 included order for SN [skilled nursing] 1 time a week for 1 week, 2 times a week for 5 weeks. Review of the clinical record revealed SN visits were made 4/5/22, 4/7/22, 4/12/22, 4/19/22 and 4/21/22. Further review of the clinical record revealed no SN visits were made or attempted after 4/21/22. The patient was discharged from the agency on 4/28/22. The discharge OASIS [Outcome Assessment Information Set stated the patient/caregiver was consistently not available for visits. During an interview with the director of professional services on 3/15/23 at approximately 11:20 am, the director of professional services stated, “ There should have been missed visits in the chart. It looks like the missed visit notes have been deleted. It may have been a system’s issue.”

An onsite recertification survey was conducted February 15-17, 2021. No deficiencies to Emergency Preparedness program were identified.

An onsite recertification survey was conducted February 15-17, 2021. Standard level deficiencies to the Medicare Conditions of Participation were identified.

Conformance with physician orders CFR(s): 484.60(b) Standard: Conformance with physician or allowed practitioner orders. This STANDARD is not met as evidenced by: Based on clinical record review and staff interview, the agency failed to provide Home Health Aide services as ordered for 1 of 6 patients (Patient #13) receiving Home Health Aide Services. Findings include: Patient #13 was admitted to the agency on 01/08/21 with diagnoses including Type 2 diabetes, multiple wounds to the legs and feet, heart failure and chronic obstructive pulmonary (lung) disease. The Plan of Care dated 01/08/21-03/08/21 revealed orders for a Home Health Aide 2 times per week for 4 weeks effective 01/11/21. There was no evidence of Home Health Aide visits in clinical record. In an interview with Employee #11, Quality Nurse Manager, on 02/17/21 at 12:30 pm she stated that she was unable to locate evidence of any Home Health Aide visits for Patient #13. Employee #11 stated, "(insurance) authorization was obtained but the visits were not scheduled."

Development and evaluation of plan of care CFR(s): 484.75(b)(2) Development and evaluation of the plan of care in partnership with the patient, representative (if any), and caregiver(s); This ELEMENT is not met as evidenced by: Based on agency policy review, clinical record review and staff interviews the agency failed to provide ongoing evaluation of the plan of care by failing to measure wounds in accordance with agency policy for 2 of 11 patients with a wound [#20 and 24]; and failed to obtain central line [a catheter inserted in a large vein and often used to administer medications] measurement for 2 of 2 charts [#19 and 14]. The findings included: The policy, Wound Care Standards [revised date 7/20/20] was provided on 2/16/20 by RN # 11 at approximately 12:30 pm. The policy stated, "After the initial assessment, skin integrity will be assessed at every visit. Any patient with an open area will have the sites measured and documented weekly ..." 1. Patient # 20 had a Start of Care date of 8/3/20 and admitting diagnoses of Pressure Ulcer of Right Buttock-Ischium [stage 4], Pressure Ulcer of Sacral Region [stage 4], Pressure Ulcer of Left Ankle [stage 3] and Encounter for change or removal of nonsurgical wound dressings. A review of the Plan of Care for the certification period 8/3/20-10/1/20 revealed orders for SN [skilled nursing] 3 times a week for 9 weeks; Negative pressure wound therapy to right ischium 150 mm HG via negative pressure, change 2-3 times per week and as needed; SN to instruct patient/caregiver on wound care as follows; cleanse wound to left ankle and sacrum with normal saline or soap and water, apply aquacel ag to wound bed and cover with dry gauze and then kerlix and secure with tape; SN to perform wound care at nursing visits and patient/caregiver to perform in absence of nurse. A review of the clinical record revealed the following wound measurements were documented by RN # 12: 8/3/20- Sacrum- 1cm x 1.5cm x 1.5cm; Left lateral ankle - 0.3cm x 0.4cm x 0.1cm; Right ischium - 1.5cm x 0.5cm x 1.0cm. The clinical record revealed no further wound measurements until 8/21. RN # 12 was no longer employed with the agency. An interview was conducted with RN # 11 at approximately 1 pm on 2/17/21 . During the interview RN # 11 confirmed the wound measurements were not obtained in accordance with agency policy. 2. Patient # 24 had a Start of Care [SOC] date of 5/4/20 and admitting diagnoses of Pressure Ulcer of Right Heel [unstageable] and Pressure Ulcer of Right Hip [unstageable]. A review of the Plan of Care [POC] for the certification period 5/4/20 to 7/20/20 revealed orders for SN [skilled nursing] 3 times a week for 2 weeks and 2 times a week for 7 weeks. Other orders included were: "SN for wound care to right heel every visit as follows: clean with NS [normal saline] and gauze, apply skin prep cover with thin hydrocolloid, SN for wound care to right hip as follows ever visit clean with NS and gauze, cover with foam cover dressing; SN for wound care to sacrum as follows each visit: clean with NS and gauze, apply dermaginate ag [type of dressing] and cover." SN to assess/evaluate wounds at each dressing change and as needed ..." A review of the clinical record revealed no wound measurements the week of 6/6/20-6/13/20. RN # 16 was not available for interview. An interview was conducted with RN # 11 on 2/17/21 at approximately 1:10 pm. During the interview RN # 11 confirmed RN # did not obtain weekly wound measurements in accordance with agency policy Review of the agency policy titled "Central Venous Catheters and Midline Catheters," provided by Nurse #11 on 2/17/21 at 8:38 a.m. last revised 09/2020, revealed that the clinician should "measure and document the length of the catheter visible from the insertion site to the hub" with each dressing change. 3. Patient # 19 had a Start of Care [SOC] date of 9/16/20 and admitting diagnoses of Encounter for Adjustment and Management of Vascular Access Device [VAD] and Pressure Ulcer of Left Upper Back [stage 2]. A review of the Plan of Care for the certification period 1/14/20 to 3/14/20 revealed orders for SN [skilled nursing] 1 time a week for 9 weeks. A review of the routine visit made on 1/20/21 by RN # 10 revealed no measurement for the central line catheter length. A review of the 1/27/21 visit by RN # 10 revealed an assessment and central line dressing change. A review of the clinical record revealed a section labeled, "Infusion Addendum", In this section the line was identified as a central line located in the patient's right chest. The section of external length of catheter was left blank. A phone interview was conducted with RN # 10 on 2/17/21 at approximately 12:30 pm. During the interview the RN confirmed if the documentation was not included in the note, she may have failed to record it. An interview was conducted with RN # 11 on 2/17/21 at approximately 1:25 pm. During the interview RN # 11 stated the clinicians were expected to measure any exposed line each week. 4. Review of an open clinical record revealed Patient #14 was had a start of care (SOC) of 1/25/21 and a diagnosis of adjustment and management of VAD [vascular access device, also known as a central line]. Review revealed orders to be seen by skilled nursing once per week for 9 weeks to change the central line dressing and assess and evaluate the site. Review revealed Nurse #3 documented dressing changes on 1/26/21, 2/2/21, and 2/9/21. Dressing change documentation did not include measurements of the length of the central line. Interview with Nurse #3 on 2/17/21 at 10:25 a.m. revealed that he was unsure whether to measure central lines during dressing changes. Interview revealed he did not measure the central line with dressing changes.

Provide services in the plan of care CFR(s): 484.75(b)(3) Providing services that are ordered by the physician or allowed practitioner as indicated in the plan of care; This ELEMENT is not met as evidenced by: Based on agency policy review, clinical record review and staff interviews the agency failed to follow the plan of care in relation to wound care orders for 3 of 11 patients with a wound [#20, 21 and 1]; failed to obtain weights in accrodance with the plan of care for 1 of 1 patients [#9]; failed to obtain lab work in accordance with the plan of care for 1 of 1 patients [#11]. The findings included: The policy, Care Plan Implementation [revised date 2/2019], was provided by RN # 11 on 2/16/21 at 12:30 pm. The policy stated, "______[name of agency] provides care, treatment and or services for each patient according to accepted professional standards and applicable laws and regulations ..." 1. Patient # 20 had a Start of Care date of 8/3/20 and admitting diagnoses of Pressure Ulcer of Right Buttock-Ischium [stage 4], Pressure Ulcer of Sacral Region [stage 4], Pressure Ulcer of Left Ankle [stage 3] and Encounter for change or removal of nonsurgical wound dressings. A review of the Plan of Care for the certification period 8/3/20-10/1/20 revealed orders for SN [skilled nursing] 3 times a week for 9 weeks; Negative pressure wound therapy to right ischium 150 mm HG via negative pressure, change 2-3 times per week and as needed; SN to instruct patient/caregiver on wound care as follows; cleanse wound to left ankle and sacrum with normal saline or soap and water, apply aquacel ag to wound bed and cover with dry gauze and then kerlix and secure with tape; SN to perform wound care at nursing visits and patient/caregiver to perform in absence of nurse. A review of the visit note by RN # 12 dated 8/5/20 revealed the following information, " ...Wound care to left ankle and sacrum done by caregiver prior to home visit ..." During the 8/7/20 and 8/10/20 visit RN # 12 did not address wound care to the left ankle or sacrum in the visit note. During the 8/12/20 visit RN # 12 documented the wound to the left ankle was "closed" and documented the dressing change to the sacral area was done in accordance with plan of care. During the 8/14/20 visit, RN # 12 documented the following information, "Patient's cg [caregiver] changed wound to sacral area". A review of the 8/17/20, 8/19/20 , 8/28/20, 9/2/20 visit notes revealed the RN did not address the wound to the sacral area. During the 9/9/20 visit RN # 12 documented the following information, "Patient was seen by Md yesterday and wound vac was discontinued. Family states that patient will be seen at the Md office weekly to manage wound care and wound care orders have changed ..." Patient was discharged from the agency on 9/9/20. RN # 12 was no longer employed with the agency. An interview was conducted with RN # 11 at approximately 1 pm on 2/17/21. During the interview RN # 11 confirmed the wound care listed on the Plan of Care was not followed. 2. Patient # 21 had a Start of Care [SOC] date of 8/31/20 and an admitting diagnosis of Pressure Ulcer of Other Site [stage II]. A review of the Plan of Care [POC] for the certification period 8/31/20 to 10/29/20 revealed orders for SN [skilled nursing] 3 times a week for 1 week and 2 times a week for 8 weeks. SN to clean left and right posterior thigh with normal saline, apply medi honey [used in wound care] and cover with allevyn foam [type of dressing]. A review of the SN visit notes by RN # 12 dated 9/2/20 and 9/8/20 revealed the nurse documented the following information related to wound care for left and right posterior thigh, " ...SN cleaned wound with normal saline/soap and applied aquacel ag to wound bed cover [sic] with allevyn foam dressing ..." RN # 12 was no longer employed by the agency. An interview was conducted with RN # 11 on 2/17/21 at approximately 1 pm. During the interview RN # 11 confirmed the Plan of Care was not followed related to wound care as the nurse had not applied medi honey. 3. Patient #1 was admitted to the agency on 01/11/21 with diagnoses including pressure ulcer of right buttock, in-growing nail (right great toe), and Type 2 diabetes. The Plan of Care dated 01/11/21-03/11/21 revealed skilled nursing visits were ordered 3 times per week for 1 week, 2 times per week for 4 weeks and 2 visits PRN (as needed) for wound complications. Clinical record review revealed a wound care note dated 01/14/21 for cellulitis of the right great toe. A home health resumption of care occurred on 01/20/21. Clinical record review of the Resumption of Care (ROC) on 01/20/21 included nursing skilled interventions for betadine (a topical antiseptic agent) paint and non-adherent dressing application to the right great toe daily. Nursing documentation (Employee #3) on 01/20/21 revealed " ...patient will get betadine today." The next nursing visit occurred on 01/27/21. Employee # 3 ' s documentation on 01/27/21 revealed "Patient still has not gotten betadine but will do this today." A Missed Visit Form of 02/05/21 for skilled nursing from Employee #3 revealed "Patient to MD yesterday but toe not healing as expected and MD made referral to wound clinic which patient is going today." In an interview with Employee #3, the Registered Nurse Case Manager, on 02/17/21 at 10:30 AM, Employee #3 stated that he did not notify the physician that the patient was not performing wound care as ordered. Employee #3 stated, "I would think there would be some Betadine in the home now but things went in a different direction for her. The wound care orders changed when she went back to the wound clinic." 4. Patient #9 was admitted to the agency on 01/15/21 with diagnoses including hypertensive heart disease, chronic congestive heart failure, chronic kidney disease, rheumatoid arthritis, and chronic obstructive pulmonary (lung) disease. The Plan of Care dated 01/15/21-03/15/21 included orders for skilled nursing visits 1 time per week for 2 weeks, 2 times per week for 2 weeks, 1 time per week for 2 weeks and 2 visits PRN (as needed) for change in status. Skilled nursing interventions included "instruct patient on weighing self and maintaining weight log ...daily weigh at same time of day and with same clothing." On 01/20/21, Employee #5, Registered Nurse Case Manager, documented that Patient #9 was "unable to stand safely to do daily weights." On 01/22/21, Employee #5 documented, "Patient (#9) unsafe to stand on scales. DC (discontinue) intervention." There was no evidence in the patient record that the physician was notified. In an interview with Employee #5 on 02/17/21 at 10:50 AM, she stated that Patient #9 was "not safe to stand on scales." Employee #5 stated that she did not remove the intervention from the plan of care during her 01/20/21 and 01/22/21 visits because she wanted to "give her (Patient #9) the benefit of the doubt" and felt it might have been too soon to remove the intervention. When asked about notifying the physician, employee #5 stated "I did not notify the physician on this one, but I guess I should have." In an interview with Employee #10, Quality Nurse Manager, on 02/17/21 at 10:55 AM she stated that the case manager would typically remove interventions that should be removed. Employee #10 further stated "there should have been some questions about whether the intervention was appropriate..." 5. Review of an open clinical record revealed Patient #11 had a start of care (SOC) of 1/18/21 and diagnoses of scalp laceration, right hand wound, and Parkinson's disease. Review of the clinical record revealed an order on 2/2/21 from the patient's primary care provider which read, "Sn [skilled nurse] to draw labs week of 2/7 ...please call [MD] from patient home next week when drawing labs." Review of the visit schedule revealed missed visit notifications on 2/9/21 and 2/14/21. Review revealed skilled nursing had not seen the patient the week of 2/7/21 or the week of 2/14/21 and ordered labs had not been drawn. Nurse #12 documented on 2/14/21 that the patient would be discharged from skilled nursing. Review failed to reveal notification to the doctor or the patient of the discharge. Nurse #12 was not available for interview. Interview with Nurse #11, a clinical manager, on 2/17/21 at 12:00 p.m. revealed that the discharge process had not been performed appropriately and that Nurse #12 should have obtained an order to extend nursing visits. Interview with the agency director on 2/17/21 at 3:00 p.m. revealed that the agency had requested an order from the doctor to extend visits to draw the ordered labs and plan for discharge. Review of the clinical record confirmed the order for skilled nursing to extend visits was received on 2/16/21 at 4:35 p.m.

Services provided by HH aide CFR(s): 484.80(g)(2) A home health aide provides services that are: (i) Ordered by the physician or allowed practitioner; (ii) Included in the plan of care; (iii) Permitted to be performed under state law; and (iv) Consistent with the home health aide training. This ELEMENT is not met as evidenced by: Based on clinical record review and staff interview, the home health aide failed to follow the Plan of Care for 1 of 4 patients with a home health aide assigned (#9). Findings include: Patient #9 was admitted to the agency on 01/15/20. The Plan of Care dated 01/15/21-03/15/21 included orders for skilled nursing visits 1 time per week for 2 weeks, 2 times per week for 2 weeks, 1 time per week for 2 weeks and 2 visits PRN (as needed). Home Health Aide visits were ordered 2 times per week for 4 weeks effective 01/25/21. The Home Health Aide Plan of Care included an order for range of motion activity to be completed every visit. The aide visited on 01/27/21, 02/03/21, 02/09/21, and 02/15/21. For each visit, range of motion exercises is documented as not performed. In an interview on 02/17/21 at 11:15 AM, Employee #6, Home Health Aide, reported "She complained of pain every time and she would not let me do it." Employee #6 stated that she notified the Occupational Therapist (OT) and was unsure if she documented this information in the patient record. She stated "I wrote it on paper every time and I told (OT). In an interview on 02/27/21 at 11:30 AM, with Employee #10, Quality Nurse Manager, she reported that there are different places in the patient record where a Home Health Aide can record communication. On 02/17/21 at 2:00 PM, Employee #10 reported that she was unable to locate evidence in the patient record of the communication reported by Employee #6.