Every finding on record at Medical Services of America, Inc.

An onsite, unannounced recertification survey was conducted 7/15/24-7/17/24. No deficiencies to the Emergency Preparedness Plan was identified.

An unannounced, onsite recertification survey was conducted 7/15/24-7/17/24. Standard level deficiencies to the Medicare CoP were identified.

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 agency policy, clinical record review, direct observation, and staff interviews the agency failed to obtain orders for wound care for 3 of 4 patients with a wound [#1, 7 and 10]. The findings included: 3. Patient #10 had a start of care date of 04/12/2024 with admitting diagnoses of pressure ulcer (damage to an area of the skin caused by constant pressure on the area for a long time) of left buttock, stage 3 (full thickness skin loss), chronic obstructive pulmonary disease ( a group of lung diseases that block airflow and make it difficult to breathe), chronic atrial fibrillation (an irregular heart rate), pulmonary hypertension (a type of high blood pressure that affects arteries in the lungs and in the heart), peripheral vascular disease (narrowed blood vessels reduce blood flow to the limbs), venous insufficiency (a condition in which the veins fail to return blood efficiently to the heart). Review of the Plan of Care for certification period 06/11/2024-08/09/2024 revealed orders for SN (skilled nursing) 1 time a week for one week, effective 06/11/2024, and two times a week for eight weeks effective 06/17/2024, with 4 PRN (as needed) visits effective 06/11/2024. The plan of care also included orders for the left buttock to clean with Anasept (skin and wound cleanser) and gauze, apply Prisma (a dressing that creates a moist wound bed and supports wound healing) to wound bed and cover with border foam dressing (a foam dressing that absorbs fluid that leaks out of tissue), change every 2-3 days and PRN for soiling/coming off. On 7/16/24 at 12:30 pm a joint visit was conducted with the Registered Nurse (Employee #4), to observe wound care provided to the patient (Patient #10). During the visit, The RN completed wound care to the patient’s left buttock in accordance to the Plan of Care. The RN assessed the patient’s skin and observed a pressure ulcer to the patient’s right buttock and completed wound care to the right buttock. The RN cleaned the right buttock wound with Anasept and gauze, applied Prisma, and covered it with a border foam dressing. A review of the clinical record revealed no physician’s order for wound care to the right buttock. During an interview with Employee #1 and Employee #2 on 07/17/24 at approximately 1:00 pm, Employee #2 confirmed the RN completed wound care to the right buttock without a physician’s order. The policy, Physician Telephone/Verbal Orders HH2018 [3/24] was provided by the agency administrator on 7/17/24 at 8:30 am. The policy stated, "______[name of agency] provides care, treatment and/or services to patients according to a physician's or licensed practitioners most recent order..." 1. Patient # 1 had a Start of Care date of 6/11/24 with admitting diagnoses of copd [chronic obstructive pulmonary disease-lung disease making it difficult to breath], atrial fibrillation [abnormal heart rhythm], heart failure, type 2 diabetes without complications, pressure ulcer right buttock, stage 2 [shallow open wound that indicates partial thickness loss of the skin’s epidermis and dermis], and pressure ulcer left buttock, stage 2. Review of the plan of care [POC] for the certification period 6/11/24-8/9/24 included orders for SN [skilled nursing] 2 times a week for 2 weeks, 1 time a week for 7 weeks and “SN to apply zinc barrier cream to stage 2 on buttocks...apply zinc barrier cream to affected area bilateral groins...” Review of the clinical record revealed on 6/13/24 RN # 5 conducted a routine visit and documented the following information, “...Rt [right] groin...area cleaned and antifungal applied...left groin...area cleaned and antifungal applied...buttocks...optifoam applied to open area...”Further review of the clinical record revealed on 6/19/24 and 6/21/24 RN # 5 documented “antifungal applied to bilateral groin”. During an interview with RN # 1 on 7/17/24 at approximately 1pm, the RN confirmed there was no physician’s order for an optifoam or antifungal cream. 2. Patient # 7 had a start of care date of 4/14/24 and admitting diagnoses of unspecified severe protein-calorie malnutrition, pneumonia, unspecified open wound right lower leg, and unspecified open wound, left lower leg. Review of the plan of care [poc] for the certification period 6/15/24-8/13/24 included orders for SN [skilled nursing] 1 time a week for 9 weeks. On 7/15/24, at approximately 3 pm, a joint visit was conducted with LPN # 6 . During the visit, the patient expressed a fall earlier which resulted in 4 new skin tears. The new skin tears were on the bilateral lower legs, right upper arm, and right shoulder. During the visit, the LPN applied a dry dressing. Review of the clinical record revealed no order for a dry dressing. The clinical record revealed the LPN sent a communication note to the physician after the visit asking for wound care orders. During an interview with RN # 1 on 7/17/24 at approximately 1 pm, the RN confirmed the LPN applied the dry dressing without a physician’s order.

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 SN [skilled nurse] failed to ensure the nursing bag was closed after removing equipment for the visit for 3 of 6 home visits #6, 7, and 10]; and failed to perform hand hygiene for 2 of 6 patients who received home visits [# 7 and 10]; and failed to place wound care supplies on a barrier for 1 of 2 home visits [#7]; and failed to place syringes/needle used to obtain blood and a syringe full of wasted blood [first blood sample obtained from PICC [type of catheter used to access the large veins in your chest] line is discarded] in a proper receptacle for 1 of 1 patient having PICC line [# 9]. The findings included: 3. Patient #10 had a start of care date of 04/12/2024 with admitting diagnoses of pressure ulcer (damage to an area of the skin caused by constant pressure on the area for a long time) of left buttock, stage 3 (full thickness skin loss), chronic obstructive pulmonary disease ( a group of lung diseases that block airflow and make it difficult to breathe), chronic atrial fibrillation (an irregular heart rate), pulmonary hypertension (a type of high blood pressure that affects arteries in the lungs and in the heart), peripheral vascular disease (narrowed blood vessels reduce blood flow to the limbs), venous insufficiency (a condition in which the veins fail to return blood efficiently to the heart). Review of the Plan of Care for certification period 06/11/2024-08/09/2024 revealed orders for SN (skilled nursing) 1 time a week for one week, effective 06/11/2024, and two times a week for eight weeks effective 06/17/2024, with four PRN (as needed) visits effective 06/11/2024. The plan of care also included orders for the left buttock to clean with Anasept (skin and wound cleanser) and gauze, apply Prisma (a dressing that creates a moist wound bed and supports wound healing) to wound bed and cover with border foam dressing (a foam dressing that absorbs fluid that leaks out of tissue), change every 2-3 days and PRN for soiling/coming off. On 7/16/24 at 12:30 pm a joint visit was conducted with the Registered Nurse (Employee #4), to observe wound care provided to the patient (Patient #10). During the visit, Employee #4 donned a pair of clean gloves from the nursing bag. Employee #4 removed the old dressing from the wound and removed the gloves. Employee #4 placed a clean pair of gloves on and did not use hand sanitizer between glove changes. In speaking with Employee #4, she was aware that she needed to use hand sanitizer when removing gloves. During an interview with Employee #1 and Employee #2 on 7/17/24 at approximately 1:00 pm, they confirmed Employee #4 should have used hand sanitizer after removing dirty gloves. 4. Patient #10 had a start of care date of 04/12/2024 with admitting diagnoses of pressure ulcer (damage to an area of the skin caused by constant pressure on the area for a long time) of left buttock, stage 3, chronic obstructive pulmonary disease, chronic atrial fibrillation, pulmonary hypertension, peripheral vascular disease, venous insufficiency. Review of the Plan of Care for certification period 06/11/2024-08/09/2024 revealed orders for SN (skilled nursing) 1 time a week for one week, effective 06/11/2024, and two times a week for eight weeks effective 06/17/2024, with four PRN (as needed) visits effective 06/11/2024. The plan of care also included orders for the left buttock to clean with Anasept (skin and wound cleanser) and gauze, apply Prisma (a dressing that creates a moist wound bed and supports wound healing) to wound bed and cover with border foam dressing (a foam dressing that absorbs fluid that leaks out of tissue), change every 2-3 days and PRN for soiling/coming off. On 7/16/24 at 12:30 pm a joint visit was conducted with Employee #4, to observe wound care provided to the patient (Patient #10). During the visit, Employee #4 retrieved supplies for the visit out of her home health bag and kept the home health bag open during the entire visit. 5. Patient #9 had a start of care date of 06/20/2024 with admitting diagnoses of osteomyelitis (inflammation of bone caused by infection) of vertebrae ( a series of small bone forming the backbone), cervical region (the neck region of your spinal column or backbone), intraspinal abscess (a buildup of pus in the spine caused by infection) and granuloma ( a tiny cluster of white blood cells and other tissue), retropharyngeal and parapharyngeal abscess (infection in the lymph nodes behind the throat and a deep neck infection), extrapyramidal movement disorder (involuntary movements you cannot control), Stiff-man Syndrome (a rare neurological disorder with symptoms of muscle stiffness), type I diabetes mellitus with hyperglycemia, type 1 diabetes mellitus ( a disorder in which the body does not produce enough insulin or respond normally to insulin, that result in too much sugar in the blood) with diabetic neuropathy (nerve damage that can occur with diabetes), and chronic obstructive pulmonary disease (a group of lung diseases that block airflow and make it difficult to breathe). Review of the Plan of Care for certification period 06/20/2024-08/18/2024 revealed orders for SN (skilled nursing) one time a week for nine weeks, with 3 PRN (as needed) visits and “SN for IV (intravenous) line care, labs weekly, education on meds and disease process”. A visit was conducted with the Registered Nurse (Employee #3) at the patient’s home on 7/16/24 at 9:20 am. The RN was visiting to perform PICC line (one type of catheter used to access the large veins in your chest) care, dressing change and venipuncture for lab work ordered by the physician. During the visit, the Registered Nurse was observed recapping the needle several times that was used to place blood into the blood collection tubes. The Registered Nurse did not have a sharps container (a container made of rigid plastic to ensure safe containment of sharp objects) available to place the used needle in and placed the recapped needle in a glove and carried it out of the patient’s home in the glove. During the patient visit, the Registered Nurse placed the syringe containing the blood waste from the PICC line directly on the counter and not on the barrier. At the end of the visit, the Registered Nurse carried the syringe containing the blood waste into the patient’s bathroom and disposed of the blood in the patient’s commode and flushed. The RN did not have a mask, eye protection, or a face mask to protect against splashing while disposing of the blood. An interview was conducted with Employee #1 and Employee #2 on 7/17/24 at 1:00 pm, both stated that employees are provided sharps container to dispose of syringes and non-penetrable containers to transport blood. The policy, Hand Hygiene HH4012 [6/24], was provided by the human resource director on 7/16/24 at 11:06 am. The policy stated, "...Indications for Hand Hygiene: Before and after having direct contact with the patient...Before and after use of gloves (or other PPE)…Before and after treatments/procedures..." The policy, Bag Technique HH4020 [6/24], was provided by the human resource director on 7/16/24 at 11:06 am. The policy stated, "...After performing hand hygiene, all the clean supplies and equipment needed for the visit are moved from the bag. The bag is then closed..." Review of the CDC [Centers for Disease Control] best practice guidelines related to sharps container use revealed the following information, " immediately place the connected needle and syringe into the sharps disposal container. Place contaminated dressings, gauze, cotton materials, tubing, and contaminated cleanup items in biohazard waste disposal bags. Place uncontaminated non-sharps in a standard trash can". 1. Patient # 6 had a start of care date of 6/22/24 with admitting diagnoses of encounter for orthopedic aftercare following surgical amputation and type 2 diabetes with diabetic polyneuropathy [condition that affects nerves in diabetics]. Review of the plan of care for the certification period 6/22/24-8/20/24 included orders for SN [skilled nursing] 1 time a week for 5 weeks and “SN to obtain wound measurements weekly...Cleanse the wound with wound cleanser daily, apply xeroform to the incision site, wrap with kerlix and ace wrap using figure 8 method. On 7/15/24 at approximately 4 pm, a joint visit was conducted with RN # 7 to observe wound care. After arriving in the patient’s home, the RN placed the nursing bag on a barrier and removed the vital sign equipment. The vital sign equipment was placed on the barrier. The RN failed to close the nursing bag and the nursing bag remained open the entire visit. During an interview with RN # 1 on 7/17/24 at approximately 1 pm, the RN confirmed the nursing bag should have been zipped up after removing the equipment. 2A. Patient # 7 had a start of care date of 4/14/24 and admitting diagnoses of unspecified severe protein-calorie malnutrition, pneumonia, unspecified open wound right lower leg, and unspecified open wound, left lower leg. Review of the plan of care [poc] for the certification period 6/15/24-8/13/24 included orders for SN [skilled nursing] 1 time a week for 9 weeks and “RLE [right lower extremity] trauma wounds clean with anesept, pry dry, apply xeroform, gauze to wound bed...” On 7/15/24, at approximately 3 pm, a joint visit to observe wound care was conducted with LPN # 6. During the visit, the LPN was noted to wash hands upon arrival to the patient’s home. The LPN applied gloves to do the dressing change. After removing the old dressings, the LPN removed the gloves. After removing the old gloves, she applied a new pair of gloves to clean the wounds. She did not do hand hygiene with hand sanitizer. After cleaning the wounds, she removed the old gloves and applied new gloves. She did not use hand sanitizer. During an interview with RN # 1 on 7/17/24 at approximately 1 pm, the RN confirmed the LPN should have used hand sanitizer each time she removed a used pair of gloves. 2B. Patient # 7 had a start of care date of 4/14/24 and admitting diagnoses of unspecified severe protein-calorie malnutrition, pneumonia, unspecified open wound right lower leg, and unspecified open wound, left lower leg. Review of the plan of care [poc] for the certification period 6/15/24-8/13/24 included orders for SN [skilled nursing] 1 time a week for 9 weeks. On 7/15/24, at approximately 3 pm, a joint visit to observe wound care was conducted with LPN # 6. Upon entering the patient’s home, LPN # 6's nursing bag was unzipped. The LPN placed the nursing bag on a barrier. LPN # 6 removed vital sign equipment and placed it on the barrier. The nursing bag remained open the entire visit. During an interview with RN # 1 on 7/17/24 at approximately 1 pm, the RN confirmed the nursing bag should have been zipped shut after removing the equipment needed for the visit.

Responsibilities of skilled professionals CFR(s): 484.75(b) Standard: Responsibilities of skilled professionals. Skilled professionals must assume responsibility for, but not be restricted to, the following: This STANDARD is not met as evidenced by: Based on agency policy, clinical record review, and staff interviews the SN [skilled nurse] failed to initial/weekly wound measurements for 2 of 4 patients with a wound [ #1 and 6]; and failed to place wound care supplies on a barrier for 1 of 3 home visits receiving wound care [#7]; and failed to use an unused syringe/needle when transferring a blood sample to a blood collection tube for several samples [#9];and failed to clean PICC [a long, flexible plastic tube that's inserted into a vein in the upper arm and threaded into a large vein above the heart used for long term medication or to obtain blood] line insertion site correctly when doing a PICC line dressing change for 1 of 1 patients [#9]. The findings included: 5. Patient #9 had a start of care date of 06/20/2024 with admitting diagnoses of osteomyelitis (inflammation of bone caused by infection) of vertebrae ( a series of small bone forming the backbone), cervical region (the neck region of your spinal column or backbone), intraspinal abscess (a buildup of pus in the spine caused by infection) and granuloma ( a tiny cluster of white blood cells and other tissue), retropharyngeal and parapharyngeal abscess (infection in the lymph nodes behind the throat and a deep neck infection), extrapyramidal movement disorder (involuntary movements you cannot control), Stiff-man Syndrome (a rare neurological disorder with symptoms of muscle stiffness), type I diabetes mellitus with hyperglycemia, type 1 diabetes mellitus ( a disorder in which the body does not produce enough insulin or respond normally to insulin, that result in too much sugar in the blood) with diabetic neuropathy (nerve damage that can occur with diabetes), and chronic obstructive pulmonary disease (a group of lung diseases that block airflow and make it difficult to breathe). Review of the Plan of Care for certification period 06/20/2024-08/18/2024 revealed orders for SN (skilled nursing) one time a week for nine weeks, with 3 PRN (as needed) visits. Per Plan of Care, “SN for IV (intravenous) line care, labs weekly, education on meds and disease process”. A visit was conducted with the Registered Nurse (Employee #3) at the patient’s home on 7/16/24 at 9:20 am. The RN was visiting to perform the PICC line dressing change and venipuncture for lab work ordered by the physician. During the PICC line dressing change, the nurse cleaned the pick line insertion area using a scrubbing motion as opposed to an outward circular motion. The policy, Wound Care Standards [8/23], was provided by the human resource director on 7/16/24 at 11:06 am. The policy stated, "...Any patient with an open area will have the sites measured and documented weekly..." The policy, Central Venous Catheters and Midline Catheters, last revised 2/2023, received from Human Resources 7/16/24 at 11:06 am, stated “open the package of one alcohol swab stick. Clean the area, beginning at the insertion site and working in an outward circular motion about 3 inches (this removes natural oils from the patient’s skin).” 1. Patient # 1 had a Start of Care date of 6/11/24 with admitting diagnoses of copd [chronic obstructive pulmonary disease-lung disease making it difficult to breath], atrial fibrillation [abnormal heart rhythm], heart failure, type 2 diabetes without complications, pressure ulcer right buttock, stage 2 [shallow open wound that indicates partial thickness loss of the skin’s epidermis and dermis], and pressure ulcer left buttock, stage 2. Review of the plan of care [POC] for the certification period 6/11/24-8/9/24 included orders for SN [skilled nursing] 2 times a week for 2 weeks, 1 time a week for 7 weeks and “SN to apply zinc barrier cream to stage 2 on buttocks...” Review of the clinical record revealed the SN made routine visits on 6/13/24, 6/19/24, 6/21/24, 6/26/24, 7/2/24. There were no wound measurements noted in 5 of 5 SN visits. During an interview with RN # 1 on 7/17/24 at approximately 1 pm, RN # 1 confirmed the SN failed to measure the stage 2 decubitus. 2. Patient # 6 had a start of care date of 6/22/24 with admitting diagnoses of encounter for orthopedic aftercare following surgical amputation and type 2 diabetes with diabetic polyneuropathy [condition that affects nerves in diabetics]. Review of the plan of care for the certification period 6/22/24-8/20/24 included orders for SN [skilled nursing] 1 time a week for 5 weeks and “SN to obtain wound measurements weekly...Cleanse the wound with wound cleanser daily, apply xeroform to the incision site, wrap with kerlix and ace wrap using figure 8 method...” Review of the clinical record revealed SN visits on 6/22/24, 6/27/24, 7/5/24, 7/11/24, 7/15/24. Review of the documentation for the visits revealed no wound measurements for 5 of 5 SN visits. During an interview with RN # 1 on 7/17/24 at approximately 1 pm, the RN confirmed the SN failed to obtain wound measurements. 3. Patient # 7 had a start of care date of 4/14/24 and admitting diagnoses of unspecified severe protein-calorie malnutrition, pneumonia, unspecified open wound right lower leg, and unspecified open wound, left lower leg. Review of the plan of care [poc] for the certification period 6/15/24-8/13/24 included orders for SN [skilled nursing] 1 time a week for 9 weeks and “RLE [right lower extremity] trauma wounds clean with anesept, pry dry, apply xeroform, gauze to wound bed...” On 7/15/24, at approximately 3 pm, a joint visit to observe wound care was conducted with LPN # 6 . During the visit, the LPN placed the barrier for her nursing bag on the floor to the left of the patient. The LPN placed plastic bags with wound care supplies directly on the floor without a barrier. During the visit the gauze wrapping came out of the bag and was directly on the floor. The LPN continued with the wound care, using the gauze that was on the floor. During an interview with RN # 1 on 7/17/24 at approximately 1 pm, the RN confirmed the wound supplies should have been on a barrier and the LPN should not have used the rolled gauze that was on the floor. 4. Patient # 9 had a start of care date of 6/20/24 with admitting diagnoses of osteomyelitis [infection of the bone] and stiff man syndrome [progressive neurological disorder that causes muscle stiffness and spasms]. Review of the plan of care for the certification period 6/20/24-8/18/24 included orders for SN [skilled nursing] 1 time a week for 9 weeks and “...SN to obtain labs per orders via PICC [peripherally inserted central catheter used to obtain blood or administer medication over a period of time] …obtain weekly on Monday or Tuesday...” On 7/16/24 at approximately 9:20 am a joint visit was conducted with RN # 3 to observe PICC line care. During the visit RN # 3 was noted to be obtaining blood for the lab sample using a 10 cc syringe and then transferring the blood into the blood tubes using a large bore needle. The RN accessed the PICC line numerous times [3-4] using the same syringe and transferring the blood sample into collection tubes with the same needle. During an interview with RN # 1 on 7/17/24 at approximately 1 pm, the RN confirmed RN # 3 should not have consistently used the same syringe to obtain the blood sample or the same needle to transfer the blood.

Onsite supervisory visit every 14 days CFR(s): 484.80(h)(1)(i) (1)(i) If home health aide services are provided to a patient who is receiving skilled nursing, physical or occupational therapy, or speech language pathology services— (A) A registered nurse or other appropriate skilled professional who is familiar with the patient, the patient's plan of care, and the written patient care instructions described in paragraph (g) of this section, must complete a supervisory assessment of the aide services being provided no less frequently than every 14 days; and (B) The home health aide does not need to be present during the supervisory assessment described in paragraph (h)(1)(i)(A) of this section. This ELEMENT is not met as evidenced by: Based on policy review, client record review, and staff interview the agency failed to provide accurate home health aide supervision for 1 of 3 home health aide records reviewed (#8). Findings included: Review of policy “Clinical Supervision HH2036”, revised 11/2023 was received from agency administrator on 07/17/24 at 8:30 a.m. The policy stated,” …shall be supervised by a qualified staff member at least, but not to exceed, every 14 days as specified in the Conditions of Participation…” Patient #8 had a SOC (start of care) of 06/08/24 and included diagnoses of major depressive disorder, atrial flutter, hypertensive heart disease, heart failure, and unspecified hearing loss. Home health aide orders were for 1 time a week for 8 weeks. Review of the weekly home health aide visits revealed a supervisory visit was completed on 06/07/24 by the registered nurse and was not completed again until 07/15/24. Interview with agency administrator on 07/17/24 at 1:51 p.m. revealed, “the aide supervisory visit should have been completed by 07/12/24, we were out of compliance on that one”.

An onsite recertification survey was conducted 1/10/22-1/14/22. No deficiencies to the Emergency Preparedness Plan was identified.

An onsite recertification survey was conducted 1/10/22-1/14/22. Standard level deficiencies to the Medicare CoP were identified.

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 agency policy, virtual visit observation, clinical record review and interviews with staff and patients/caregivers, the plan of care failed to include all medications the patient was using for 6 of 17 records [#1, 2, 7, 3, 6, 14 ]; failed to include complete blood sugar parameters [when to notify the physician] for 7 of 17 records [# 2, 7, 3, 4, 11, 12, 14 ]; failed to include all pertinent diagnoses on the plan of care for 1 of 17 records [#14]The findings included: 4A. Patient #3 was admitted on 12/23/21 with diagnoses of chronic myeloproliferative disease and type 2 diabetes with chronic kidney disease. The Plan of Care (POC) for 12/23/21-2/20/22 included orders for Physical Therapy (PT) one time for one week, two times per week for four weeks, and one time per week for three weeks; Occupational Therapy (OT) one time per week for four weeks, then two times per week for three weeks. A virtual home visit was conducted with OT #32 on 1/11/22 at approximately 11:00 a.m. During the visit it was revealed the daughter prefills medications for the patient. The daughter was not present during the visit. The “Patient Medication Record” provided by the agency prior to the virtual visit included Tresiba 200 units/ml 60 units given subcutaneous in the evenings for diabetes. An interview RN #28 on 1/14/22 at 3:20 p.m. revealed a call was placed to the patient’s daughter to verify the Tresiba dose. The daughter confirmed the medication had changed from 60 units to 30 units approximately 1 month ago. 4B. Patient #3 was admitted on 12/23/21 with diagnoses of chronic myeloproliferative disease and type 2 diabetes with chronic kidney disease. The Plan of Care (POC) for 12/23/21-2/20/22 included orders for Physical Therapy (PT) one time for one week, two times per week for four weeks, and one time per week for three weeks; Occupational Therapy (OT) one time per week for four weeks, then two times per week for three weeks. The POC also included to “Notify physician of…Fasting blood sugar greater the (>) 400 or less than (Potassium Chloride ER (extended release) was listed on the Patient Medication Record as 10 meq (milli-equivalents) twice daily for an electrolyte supplement. The patient stated she was taking this once daily. The patient confirmed this was not a new dosage.Topiramate 200 mg at bedtime for headaches was listed on the Patient Medication Record. The patient confirmed the dose is 100 mg-200 mg. She stated, “He [the physician] lets me judge the dose.”Biotin Maximum Strength Oral 10000 mcg daily for hair, skin and nails and Folic Acid 800 mcg daily for a supplement was listed on the Patient Medication Record. The patient stated, the medications had been “stopped for quite a while.” AN interview with RN #4 revealed the home visit on 1/11/22 was her first visit with the patient. The medication profile was updated and sent to the physician for signature. 6. Patient #4 was admitted on 9/23/21 for dressing changes following an amputation and type 2 diabetes. The Plan of Care (POC) for 11/22/21-1/20/22 included orders for skilled nursing (SN) weekly for nine weeks. The POC also included to “Notify physician of…Fasting blood sugar greater the (>) 400 or less than () 400 or less than() 400 or less than () 400 or less than() 400 or less than () 400 or less than() 400 or less than () 400 or less than () 400 or less than (Care Planning and Coordination [12/2021], was provided by the clinical manager on 1/14/22 at approximately 4:30 pm. The policy stated, “…The initial plan of care includes at least the following information…Treatments/Orders…All medications including dose/frequency and route…” 1. Patient # 1 had a Start of Care [SOC] date of 12/1/21 and an admitting diagnosis of unilateral primary osteoarthritis [right hip]. A review of the Plan of Care [POC] for the certification period 12/1/21 to 1/29/22 revealed orders for SN [skilled nursing] 1 time a week for 6 weeks; PT [physical therapy] 1 time a week effective 12/2/21 then 1 time a week beginning 12/14/21. On 1/11/22 at approximately 9:30 am a virtual visit was conducted with PT # 9. During the visit, a medication review was conducted using the Patient Medication Record provided by the agency. The following discrepancies were noted: Patient # 1 reports she was using Flonase [nasal spray] 1 spray each nostril each day. The Patient Medication Record provided by the agency did not include the Flonase. An interview was conducted with the patient after the medication review. The patient reported she had been using the Flonase since “around 11/22/21”. During the medication review the patient reported taking Vitamin B 12 [supplement] 1000 mcg daily. Vitamin B 12 was not included on the Patient Medication Record. The Patient Medication Record included Senna-Plus [stool softener] 8.6-50 mg. Take 2 tablets twice a day for constipation. During the interview with the patient, the patient reported “I haven’t used that since I got home from the nursing home.” During an interview with PT # 9 on 1/14/22 the PT reported, “I realize we are supposed to look at the medications each visit. Honestly, I would just ask the patient if there had been any new or changed medications.” During an interview with the agency clinical manager on 1/14/22 the clinical manager confirmed the POC did not include the current medications the patient was using. 2A. Patient # 2 had a Start of Care [SOC] date of 12/20/21 with an admitting diagnosis of unspecified open wound, right lower leg. A review of the Plan of Care [POC] for the certification period 12/20/21 to 2/17/22 revealed orders for SN [skilled nursing] 1 time a week for 9 weeks. A virtual visit was conducted on 1/11/22 at approximately 10:30 am with LPN # 32. During the visit, a medication review was conducted using the Patient Medication Record provided by the agency. The following discrepancies were noted: A review of the ALF [assisted living facility] medication administration record revealed Patient # 2 was taking Escitalopram [antidepressant] 5 mg daily with a start date of 11/15/19, Tricor [high cholesterol] 145 mg daily with a start date of 6/19/17, Jardiance [for diabetes] 10 mg daily with a start date of 6/25/20, Lisinopril + HCTZ [blood pressure] 20-25mg daily with a start date of 11/12/15, Metoprolol ER [blood pressure] 50 mg daily with a start date of 11/12/15, Zyprexa [used for mental disorders] 25 mg at bedtime with a start date of 7/17/19, Omega 3 [supplement] 1 capsule daily with a start date of 4/24/21, Prilosec [stomach medication] 20 mg daily with a start date of 10/4/18, Potassium CL ER [supplement] 20 meq 2 times per day with a start date of 4/24/20, Simethicone [gas] 80 mg 3 times per day with a start date of 2/1/21, Ambien [sleep] 10 mg at bedtime with a start date of 5/11/17, Acetaminophen [pain] 500 mg take 1 tablet every 4 hours as needed for pain with a start date of 2/19/19, Calcium Carbonate [indigestion] 500 mg 1-2 tablets every 2 hours as needed for ingestion with a start date of 1/23/19, Nitroglycerin [chest pain] .4 mg dissolve 1 under tongue every 5 minutes for chest pain with a start date of 3/9/16, Novolog [insulin] 100 unit/ml give 4 units for blood sugar 200-250, 6 units for blood sugar 251-300, 8 units for blood sugar 301-350, 10 units for 351-400, 12 units for blood sugar 401-450, 14 units for blood sugar of 451-500 with a start date of 9/13/21, Trulicity [insulin] 1.5 mg/0.5 ml pen inject 1.5 mg weekly with a start date of 8/24/21 and Bactroban [topical ointment] to wound on right leg with a start date of 3/4/21. The Patient medication Report did not list any of the medications above. An interview was conducted with the agency director on 1/14/22 at approximately 11:30 am. During the interview the director confirmed the POC did not include medications the patient was using. 2B. Patient # 2 had a Start of Care [SOC] date of 12/20/21 with an admitting diagnosis of unspecified open wound, right lower leg. A review of the Plan of Care [POC] for the certification period 12/20/21 to 2/17/22 revealed orders for SN [skilled nursing] 1 time a week for 9 weeks and “Notify physician of…fasting blood sugar greater than 400 and less than…” [There was no lower end parameter included on the POC]. An interview was conducted with RN # 23 on 1/14/22 at approximately 2 pm. During the interview the RN confirmed the POC did not include the lower number related to reporting blood sugars. “I was told we didn’t have to have that number on the POC.” 3A. Patient # 7 had a Start of Care [SOC] date of 11/23/21 and admitting diagnoses of unspecified open wound, right knee, unspecified open wound, left knee, type 1 diabetes mellitus with foot ulcer, non-pressure chronic ulcer other part of right foot and type 1 diabetes mellitus with hyperglycemia. A review of the Plan of Care [POC] for the certification period 11/23/21 to 1/21/22 revealed orders for SN [skilled nursing] 1 time a week for 1 week; 2 times a week for 8 weeks. A virtual visit was conducted on 1/12/22 with RN # RN # 24. During the visit a medication review was conducted using The Patient Medication Record provided by the agency. The following discrepancies were noted: The Patient Medication Record listed Sulfamethoxazole-Trimethoprim Intravenous Solution 400-80 Mg/5 ml, Novolog [insulin] FlexPen 100 unit/ml 120 subcutaneous, three times daily [no dosage]. During an interview with Patient # 7 after the medication review the patient stated she was not taking any IV [intravenous] mediation and the Sulfamethoxazole-Trimethoprim is pills. An interview was conducted with RN # 24 on 1/14/22. The RN confirmed the POC did not include the current/correct medications. 3B. Patient # 7 had a Start of Care [SOC] date of 11/23/21 and admitting diagnoses of unspecified open wound, right knee, unspecified open wound, left knee, type 1 diabetes mellitus with foot ulcer, non-pressure chronic ulcer other part of right foot and type 1 diabetes mellitus with hyperglycemia. A review of the Plan of Care [POC] for the certification period 11/23/21 to 1/21/22 revealed orders for SN [skilled nursing] 1 time a week for 1 week; 2 times a week for 8 weeks and “…Clinicians will assess vital signs…call MD if vital signs are out of agency parameters…Fasting blood sugars greater than 400 or less than [no number]/random blood sugar greater than 400 or less than [no number]”. Further review of the POC revealed no lower number for blood sugar parameters. An interview was conducted with RN # 24 on 1/14/22 at approximately 12:15 pm. During the interview RN # 24 stated, “I was never taught that I had to have a bottom number for parameters related to blood sugars. I educate my patients on the signs of hyper and hypoglycemia.”

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 interviews the agency failed to follow the Plan of Care [POC] related to notifying the physician for an oxygen saturation outside the given parameters for 1 of 7 patients who received a home visit [#5]; failed to obtain lab work in accordance with the POC for 1 of 17 records reviewed [#9]; failed to conduct evaluations for services for 3 of 17 records [#13. 16, 17[; failed to monitor blood sugar readings for 2 of 17 records [# 3 and 15]. The findings included: 3. Patient #13 was admitted on 8/5/21 with a diagnosis drug induced pancytopenia. The Plan of Care for 8/5/21-10/3/21 included orders for skilled nursing weekly for 9 weeks; physical therapy (PT) two times per week for four weeks, then weekly for four weeks. PT #10 conducted the evaluation visit on 8/9/21. The evaluation note stated, “Patient notes new difficulty with swallowing/choking on thin liquids. PT requested order for ST [speech therapy] consult to address.” The order for ST was obtained on 8/9/21. The physical therapy assistant (PTA) note on 8/11/21 stated, “Pt [patient] presenting with increased difficulty swallowing when pt takes a drink of water causing pt to cough repeatedly. Plan to follow-up with supervising PT on ST recommendation/order.” PT #10 conducted a re-evaluation visit on 8/31/21. The note stated, “No longer having difficulty with swallowing. [Due to] this family okay with discontinuing order for ST evaluation.” There was no evidence the ST evaluation was conducted between the order 8/9/21 and 8/31/21 when the PT identified the patient no longer needed the ST evaluation. 4. Patient #16 was admitted on 8/6/21 with trochanteric bursitis. The Plan of Care included orders for physical therapy one time for one week, twice weekly for four weeks, then one time for one week. On 8/9/21, a communication stated, “Received phone call from patient’s family members that he has been living with ________. Family member very distraught and crying. States that she is unable to care for the patient any longer and that he is very constipated/impacted. States he is also lethargic and much more weak. States the patient is stating “I just can’t do this anymore” and that he is not doing well. ______ [family member states that she needs placement for the patient and is unable to care for him like this. Instructed _______ [family member] to call ambulance to take patient to the ED to be assessed due to these new [signs/symptoms]. She states the patient is too weak to get in the care and she will call the ambulance to take him to the ER.” On 8/11/21, an order was received for a nursing and medical social work evaluation. A Missed Visit Form was completed by the medical social worker on 8/25/21. The note stated, “This social worker called patient’s home to try to set up an appointment and his daughter _______ answered the phone. I introduced myself to her and advised her why I was calling and would like to set up an appointment to see patient to help with connecting with local resources. [Daughter] stated that the nurse from ______ [assisted living facility] and I think one other person may be the administration had come and she is trying to get patient into __________ [ALF] for respite care and then possibly long-term care. The social worker asked if there was anything I could do to help she stated no but that if in the future she would need help she would call and let us know if she needed help [sic].” There was no evidence that the medical social worker contacted the patient/caregiver between 8/11/21 and 8/25/21. An interview with RN #28 on 1/14/22 at 3:00 p.m. confirmed the was no evidence of MSW visit attempt between 8/11/21 and 8/25/21. 5. Patient #17 was admitted on 2/21/21 with a diagnosis of type 1 diabetes. The Plan of Care for 2/21/21-4/21/21 included orders for skilled nursing weekly for 9 weeks; physical therapy weekly for 6 weeks; and occupational therapy weekly for seven weeks. The POC stated, “SN requested MSW consult to see if there are any resources for available to assist patient.” An order on 2/24/21 stated, “…MSW eval week of 3/1/21 due to patient having dialysis today as SW will not be available until next week.” There was no evidence of MSW follow up until the evaluation visit on 3/11/21. An interview with RN #28 on 1/14/22 at 3:15 p.m. confirmed the was no evidence of MSW visit until 3/11/21. 6. Patient #3 was admitted on 12/23/21 with diagnoses of chronic myeloproliferative disease and type 2 diabetes with chronic kidney disease. The Plan of Care (POC) for 12/23/21-2/20/22 included orders for Physical Therapy (PT) one time for one week, two times per week for four weeks, and one time per week for three weeks; Occupational Therapy (OT) one time per week for four weeks, then two times per week for three weeks. The POC also included to “Notify physician of…Fasting blood sugar greater the (>) 400 or less than (Daughter reports that in the mornings she is usually on the lower side and in the evenings on the higher side. She only takes insulin in the evenings now.” There was no evidence that the physical therapy staff reviewed the patient’s blood sugar in 6 of 7 PT visits and 3 of 3 OT visits. An interview with PT #1 was conducted on 1/14/22 at 9:00 a.m. The PT stated, “The patient monitors. We don’t monitor blood sugars. I don’t believe therapy is asking on a regular basis about blood sugar.” 7. Patient #15 was admitted on 5/3/21 with diagnoses of aftercare following a joint replacement and type 2 diabetes. The Plan of Care for 5/3/21-7/1/21 included orders for physical therapy three times per week for 2 weeks. The POC also included to “Notify physician of…Fasting blood sugar greater the (>) 400 or less than (<).” Between 5/3/21-5/19/21 there was no evidence of blood sugar monitoring in 7 of 7 therapy visits. The PTA documented on 5/14/21, “[Patient] also asks me about the sugars in milk and reports that he drinks a half gallon/day.” An interview with PT #1 was conducted on 1/14/22 at 9:15 a.m. The PT stated, “The patient monitors. We don’t monitor blood sugars. I don’t believe therapy is asking on a regular basis about blood sugar.” 1A. Patient # 5 had a Start of Care [SOC] date of 11/21/21 and an admitting diagnosis of chronic pain. A review of the Plan of Care [POC] for the certification period 11/21/21 to 1/19/22 revealed orders for SN [skilled nursing] 1 time a week for 7 weeks and “Notify physician of…O2 sat less than 88%...” A review of the clinical record revealed LPN # 31 made a routine visit on 11/30/21. Further review revealed the following documentation, “…Pt [patient] stable at home with chronic conditions, assisted by family. Patients oxygen [sic] sat [saturation] was 74% upon SNs arrival this morning…” There was no evidence the LPN notified the physician of the oxygen saturation reading in accordance with the POC. An interview was conducted with LPN # 31 on 1/14/22. During the interview the LPN stated, “I did call the office, but I may not have documented it”. 2. Patient # 9 had a Start of Care [SOC] date of 11/18/21 with admitting diagnoses of encounter for attention to colostomy and encounter for change or removal of surgical wound dressing, aftercare following surgery for neoplasm. A review of the Plan of Care [POC] for the certification period 11/18/21 to 1/16/22 revealed orders for SN [skilled nursing] 1 time a week for 9 weeks. A review of the Plan of Care revealed the following order “Due in December…SN to obtain fasting lipid, TSH, T4, CBC, Iron, TIBC, Magnesium and CMP”. Further review of the clinical record revealed no evidence the lab work was obtained in accordance with the POC. An interview was conducted with the clinical manager on 1/14/22 at approximately 9 am. During the interview the clinical manager confirmed the lab work was not obtained.

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 clinical record review and staff interviews the agency failed to obtain an order for home health aide services for 1 of 1 records with a SCIC [Significant Change in Condition] completed [#5]. The findings included Patient # 5 had a Start of Care [SOC] date of 11/21/21 and an admitting diagnosis of chronic pain. A review of the Plan of Care [POC] for the certification period 11/21/21 to 1/19/22 revealed orders for SN [skilled nursing] 1 time a week for 7 weeks. A review of the clinical record revealed a SCIC [Significant Change in Condition] was conducted on 12/9/21 due to a decline in condition related to a urinary tract infection. A review of the POC associated with the SCIC revealed no order for home health aides. Further review of the clinical record revealed the patient received aide services 2 times per week from 12/9/21 until 12/20/21 without an order. An interview was conducted with the clinical manager on 1/14/22 at approximately 1:30 pm. During the interview the clinical manager confirmed there was no order for aide services on the SCIC POC.

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 agency policy, clinical record review and staff interviews the agency failed to communicate with the physician a missed visit for 1 of 17 records [#1];failed to notify the physician when no medical social work visit was made in accordance with physician’s order for 1 of 3 patients with an order for social work services [#7]; failed to communicate with the physician related to “noncompliance” issues related to diabetic diet and insulin for 1 of 7 patients with a virtual visit [#7]; failed to communicate with the physician when labs were not obtained in accordance with the physician’s order for 1 of 17 records reviewed [# 9]; failed to report changes in a wound for 2 of 17 records [#6 and 8]; failed to report noncompliance with obtaining blood sugars for 1 of 17 records [#12]; failed to report the presence of a new wound in 2 of 17 records [#14 and 17]; failed to communicate when a patient was out of a medication for 1 of 17 records [#14] 4. Patient #6 was admitted on 11/9/21 with a diagnosis of an infection following a procedure. The Plan of Care (POC) for 11/9/21-1/7/22 included orders for skilled nursing (SN) two times per week for 9 weeks. The POC also included orders for the nurse to “instruct Patient/caregiver on signs/symptoms of infection to include Increased [sic] temp > than 101.4 (increased temperature greater than 101.4), Increased redness swelling, pain drainage, odor…” A visit was conducted on 12/23/21 by RN #33. The tissue surrounding the wound was reddened. There was no evidence the nurse notified the physician of the redness. The next visit was conducted on 12/27/21. The patient was noted to have a moderate purulent drainage with a pungent odor. The RN documented the physician’s office was notified of “Wound changes, tunnel at 4 cm and green drainage.” An interview with RN #28 at 1/14/22 at 3:00 p.m. confirmed there as not evidence the physician was notified of the redness noted on 12/23/21. 5A. Patient #8 was admitted on 4/13/21 with diagnoses of stage 4 pressure ulcer left hip and stage 2 pressure ulcer left buttock. The Plan of Care (POC) for 12/9/21-2/6/22 included orders for skilled nursing one time for one week, then twice weekly for eight weeks. The POC also include “SN to assess/evaluate wound(s) at each dressing change and as needed for signs/symptoms of infections. Instruct patient signs/symptoms of infection to include increased redness, drainage, swelling, fever or other significant changes…” The visit notes included the following assessment for the wound on the left trochanter:12/17/21—Stage 4 pressure area measuring 1.4cm X 1.4cm X 2.3cm, Wound Bed: Red, Pink/Red: 100%, Wound Edges: Non-Attached, Drainage: Serosanguineous, Amount: Small, Odor: None, Tissue: Intact 12/20/21—Stage 4 pressure area measuring 1.4cm X 1.4cm X 2.3cm, Wound Bed: Tan, Tan: 100%, Wound Edges: Attached, Drainage: Serosanguineous, Amount: Small, Odor: None, Surrounding Tissue: Erythema 12/22/21-- Stage 4 pressure area measuring 1.4cm X 1.4cm X 2.3cm, Wound Bed: Red, Pink/Red: 90%, Slough: 10%, Wound Edges: Non-Attached, Drainage: Serosanguineous , Amount: Small, Odor: None, Surrounding Tissue: Intact There was no evidence the physician was notified of the changes in the color of the wound bed or the presence of slough. An interview was conducted with RN #4 on 1/14/22 at 9:30 p.m. The RN confirmed there was no notification to the physician of the changes. The patient was seen by the wound care center on 12/27/21. 5B. The visit notes included the following assessment for the wound on the left ischium: 12/17/21—Stage 3 pressure area measuring 4cm X 1.5cm x1.2cm, Wound Bed: Red, Pink/Red: 100%, Wound Edges: Non-Attached, Drainage: Serous, Amount: Moderate, Odor: Foul, Surrounding Tissue: Intact, Fragile12/20/21—Stage 3 pressure area measuring 4cm X 1.5cm x1.2cm, Wound Bed: Pink, Pink/Red: 75%, Eschar: 25%, Wound Edges: Attached, Drainage: Serous, Amount: Moderate, Odor: Foul, Surrounding Tissue: Intact, Excoriated, Fragile12/22/21—Stage 3 pressure area measuring 5cm X 5cm X 2cm, Wound Bed: Red, Pink/Red: 100%, Wound Edges: Non-Attached, Drainage: Serous, Amount: Moderate, Odor: Foul, Surrounding Tissue: Intact, Fragile12/24/21—Stage 3 pressure area measuring 5cm X 5cm x 1.8cm, Wound Bed: Red, Pink/Red: 60%, Eschar: 40%, Wound Edges: Non-Attached, Drainage: Serous, Amount: Moderate, Odor: Foul, Surrounding Tissue: Intact, Fragile There was no evidence the physician was notified of the changes in the wound bed. An interview was conducted with RN #4 on 1/14/22 at 9:30 p.m. The RN confirmed there was no notification to the physician of the changes. The patient was seen by the wound care center on 12/27/21. 6. Patient #12 was admitted on 12/19/21 with diagnoses of hypertensive heart disease with heart failure and type 2 diabetes. The Plan of Care (POC) for 12/19/21-2/16/22 included orders for skilled nursing (SN) weekly for nine weeks. The POC also included to “Notify physician of…Fasting blood sugar greater the (>) 400 or less than () 400 or less than(wound. An interview with RN #28 on 1/14/22 at 3:00 p.m. revealed there was no evidence the physician was notified of the wound. 7B. On 7/28/21, the PTA conducted a visit and stated, “Med [medication] reconciliation performed no issues noted [sic]. On 7/30/21, PT #1 visit documentation stated, “Med reconciliation, no issues noted…Pt [patient] informs me that he has run out of Metformin [medication used to treat diabetes] and he does not yet have his prescriptions move here from the VA. Pt cannot recall who his PCP is for me to call to inform them so this PT contacted his daughter to see if she knows who the PCP is/if she can contact them about getting the prescription refilled here locally.” There was no evidence of physician notification of the patient being out of Metformin. On 1/14/22 at 9:15 a.m. PT #1 stated in an interview, “Looking back, I did not do a good job with communicating that.” 8. Patient #17 was admitted on 2/21/21 with a diagnosis of type 1 diabetes. The Plan of Care (POC) for 2/21/21-4/21/21 included orders for skilled nursing weekly for nine weeks. A visit note on 4/6/21 revealed, “He has new wounds on his feet related to a flash burn. He reports that he is attending an appointment with the wound care center tomorrow and will discuss wound treatment for the burns, at that time.” New wound was noted to the left inner foot measuring 3.5 X 1.5 X 0. There was no evidence the physician was notified of the new wound. An interview was conducted on 1/14/22 at 12:00 p.m. with RN #19. The nurse was not aware of how the patient obtained the wounds. The nurse confirmed the physician was not notified of the wounds because the patient had an appointment the following day. The policy, Care Planning and Coordination [12/2021], was provided by the clinical manager on 1/12/22 at approximately 9:00 am. The policy stated, “…The physician is contacted with reports of changes..." The policy, Scheduling [8/2021], was provided by the clinical manager on 1/12/22 at 9:00 am. The policy stated, “…When a visit is missed and cannot be rescheduled during the current Medicare week, the clinician will notify the MD of the missed visit and the reason for the missed visits.” 1. Patient # 1 had a Start of Care [SOC] date of 12/1/21 and an admitting diagnosis of unilateral primary osteoarthritis, right hip. A review of the Plan of Care for the certification period 12/1/21 to 1/29/22 revealed orders for SN [skilled nursing] 1 time a week for 6 weeks. A review of the clinical record revealed a missed visit note dated 12/27/21 by RN # 2. The noted stated, “Patient will wait till next week to be seen. Patient agreed to phone visit. Prepped for discharge.” An interview was conducted with RN # 2 on 1/14/22. During the interview the RN reported the patient family visiting from out of town and had requested a phone visit. “I went over the discharge items that would be discussed the next week. I do not think there was an order for phone visits, and I didn’t let the physician know.” 2A. Patient # 7 had a Start of Care [SOC] date of 11/23/21 and admitting diagnoses of unspecified open wound, right knee, unspecified open wound, left knee, type 1 diabetes mellitus with foot ulcer, non- pressure chronic ulcer other part of right foot and type 1 diabetes mellitus with hyperglycemia. A review of the Plan of Care [POC] for the certification period 11/23/21 to 1/21/22 revealed orders for SN [skilled nursing] 1 time a week for 1 week; 2 times a week for 8 weeks. A review of the SOC assessment revealed the following documentation by RN # 24, “Patient needs assistance with insulin and checking BS [blood sugar] …Patient is non-compliant with insulin and diet.” Further review of the clinical record revealed no evidence the RN notified the physician of her findings related to the patient’s noncompliance issues. An interview was conducted RN # 24 on 1/14/22 at approximately 2 pm. During the interview the RN stated, “No, I didn’t notify the physician of the patient's noncompliance with insulin and diet.” 2B. Patient # 7 had a Start of Care [SOC] date of 11/23/21 and admitting diagnoses of unspecified open wound, right knee, unspecified open wound, left knee, type 1 diabetes mellitus with foot ulcer, non-pressure chronic ulcer other part of right foot and type 1 diabetes mellitus with hyperglycemia. A review of the Plan of Care [POC] for the certification period 11/23/21 to 1/21/22 revealed orders for SN [skilled nursing] 1 time a week for 1 week; 2 times a week for 8 weeks. A review of the admission visit on 11/23/21 revealed the following documentation by RN # 24, “MSW [medical social work] referral indicated for: patient difficulty caring for herself.” Further review of the clinical record revealed the order for a MSW visit was not written until 12/13/21. Further review of the clinical record revealed the MSW failed to make a visit, and the physician was not notified the MSW never made a visit. An interview was conducted with employee # 25 on 1/14/22. During the interview employee # 24 stated, “I thought I had sent an email about the referral out, but I can’t go back to my emails to see”. 3. Patient # 9 had a Start of Care [SOC] date of 11/18/21 with admitting diagnoses of encounter for attention to colostomy and encounter for change or removal of surgical wound dressing, aftercare following surgery for neoplasm. A review of the Plan of Care [POC] for the certification period 11/18/21 to 1/16/22 revealed orders for SN [skilled nursing] 1 time a week for 9 weeks. A review of the Plan of Care revealed the following order “Due in December…SN to obtain fasting lipid, TSH, T4, CBC, Iron, TIBC, Magnesium and CMP”. A review of the clinical record revealed no evidence the lab work was obtained in accordance with the POC. Further review of the clinical record revealed the physician was not notified related to the missing lab work. An interview was conducted with the clinical manager on 1/14/22 at approximately 3 pm. During the interview the clinical manager confirmed the physician was not notified.

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 policy review, observation, clinical record, and staff interview the RN failed to change gloves between multiple wounds for 1 of 4 virtual wound care observations (#7). Findings include: Patient #7 was admitted on 11/23/21 with diagnoses of unspecified open wound right knee and left knee, type 1 diabetes with foot ulcer, and hyperglycemia. The Resumption of Care orders on 12/15/21 included orders for wound care—cleanse all wounds with Anasept and gauze, cover with pink polymem. A virtual home visit was conducted on 1/12/22 at approximately 9:30 with RN #24. The RN provided wound care for wounds on the right foot, left foot, and right knee. The RN removed dressing from both feet with one pair of gloves. The gloves removed and a clean pair donned. All three wounds were cleaned while wearing one pair of gloves. The gloves were removed and a clean pair donned. Dressing were applied to all three sites while wearing on pair of gloves. There was no evidence of precautions to prevent wound cross-contamination. An interview with RN #24 on 1/14/22 at 1:00 p.m. revealed she was unsure of the policy of changing gloves between wounds.

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 interviews the home health aide care plan failed to include frequency of the assigned tasks for 4 of 5 records with home health aide orders [# 5, 10, 3, 11] The findings included: 3. Patient #3 was admitted on 12/23/21 with diagnoses of chronic myeloproliferative disease and type 2 diabetes with chronic kidney disease. The Plan of Care (POC) for 12/23/21-2/20/22 included orders for Occupational Therapy (OT) one time per week for four weeks, then two times per week for three weeks. OT #32 conducted an evaluation on 12/28/21 and revealed a request would be made for a home health aide. A verbal order was taken on 12/29/21 for home health services. There was no frequency for service included in the order. A late entry for 12/29/21 was entered on 1/11/22 for aide services to begin the week of 1/3/22 with a frequency of two times per week for six weeks. An interview with the agency director on 1/11/22 at 9:00 a.m. confirmed there was no frequency for aide services on the plan of care. 4. Patient #11 was admitted on 12/17/21 with diagnoses on hypertensive heart and chronic kidney disease and type 2 diabetes. The home health aide care plan was completed by OT #6 on 1/4/22. The tasks included: assist to dress, back rub/massage, check pressure areas, comb hair, complete bath, foot care, nail care, oral hygiene denture care, partial bath/sponge, pericare, shampoo hair, shave, skin care, tub, and shower. There was no frequency for the personal care tasks listed on the home health aide care plan. An interview with OT #6 on 1/14/22 at 10:00 a.m. revealed the intent was for the home health aide to complete each task identified each visit. 1. Patient # 5 had a Start of Care [SOC] date of 11/21/21 and an admitting diagnosis of chronic pain. A review of the Plan of Care [POC] for the certification period 11/21/21 to 1/19/22 revealed orders for SN [skilled nursing] 1 time a week for 7 weeks and HHA [home health aide] 2 times a week for 4 weeks. A review of the clinical record revealed RN # 22 completed the aide care plan on 11/29/21. Further review of the aide care plan revealed no frequency for the type of bath. An interview was conducted with the clinical manager on 1/14/22 at approximately 12:30 pm. During the interview the clinical manager confirmed there was no frequency for the assigned tasks. 2. Patient # 10 had a Start of Care [SOC] date of 12/3/21 and an admitting diagnosis atherosclerotic heart disease of native coronary artery without angina pectoris [chest pain]. A review of the Plan of Care [POC] for the certification period 12/3/21 to 1/31/22 revealed orders for home health aide [HHA] 2 times a week for 4 weeks. A review of the clinical record revealed the aide care plan was completed by PT # 10 on 12/3/21. A review of the aide care plan “Personal Care” section revealed no frequency for activities of daily living. An interview was conducted with the clinical manager on 1/14/22 at approximately 12:30 pm. During the interview the clinical manager confirmed there was no frequency for the tasks assigned to the aide.

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 agency policy, clinical record review and staff interviews the clinical record failed to include weekly wound measurements for 2 of 12 charts with a wound [# 2 and 9]. The findings included: The policy, Wound Care Standards [8/2021], was provided by the clinical manager on 1/12/22 at approximately 2 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 # 2 had a Start of Care [SOC] date of 12/20/21 with an admitting diagnosis of unspecified open wound, right lower leg. A review of the Plan of Care [POC] for the certification period 12/20/21 to 2/17/22 revealed orders for SN [skilled nursing] 1 time a week for 9 weeks and “Clean wound [right lower leg] with normal saline, apply topical ointment and cover with allevyn bandage…” A review of the clinical record revealed RN # 23 completed the start of care visit on 12/20/21 and recorded wound measurements to the right lower leg as 5 cm x 2 cm x 0. RN # 23 made a routine visit on 12/30/21. Further review of the clinical record revealed no wound assessment/measurement for the wound on the right leg. An interview was conducted with RN # 23 on 1/14/22 at approximately 2 pm. During the interview RN # 23 stated, “it must be a glitch in my computer. I am pretty sure I documented those.” 2. Patient # 9 had a Start of Care [SOC] date of 11/18/21 with admitting diagnoses of encounter for attention to colostomy and encounter for change or removal of surgical wound dressing, aftercare following surgery for neoplasm. A review of the Plan of Care [POC] for the certification period 11/18/21 to 1/16/22 revealed orders for SN [skilled nursing] 1 time a week for 9 weeks and “SN to obtain wound measurements weekly and as needed…” A review of the clinical record revealed the following information RN # 20 completed the SOC on 11/18/21 and documented the following information, “Location-Rectal, Status-Open…Size-Length-NA, Width-NA, Depth-NA…” RN # 20 completed a routine visit on 11/22/21 and documented “…Status-Open… Size-Length-NA, Width-NA, Depth-NA…” An interview was conducted with RN # 20 on 1/14/22. During the interview the RN confirmed there was not wound measurements/assessment documented. RN # 29 made a routine visit on 11/29/21 and did not document any wound measurements or any wound assessment. RN # 29 made a routine visit on 12/9/21 and documented the following information, ““…Status-Open… Size-Length-NA, Width-NA, Depth-NA…Pinpoint opening only visible with a flashlight…” RN # 29 made a routine visit on 12/14/21 and did not document a wound assessments or wound measurements. RN # 29 was no longer employed by the agency. An interview was conducted with the agency administrator on 1/14/22. During the interview the administrator stated, “Sometimes when the clinicians document on the wound, you will have to open the visit note to make sure it is there.” LPN # 30 made a routine visit on 12/21/22. LPN # 30 did not record any wound measurements or a wound assessment. An interview was conducted with LPN # 30 on 1/14/22 at approximately 1:30 pm. During the interview the LPN stated, “If I didn’t document the wound measurements, I guess I didn’t get them.” LPN # 31 made routine visits on 12/28/21 and 1/5/22 and did not record any wound measurements or a wound assessment. An interview was conducted with LPN # 31 on 1/14/22 at approximately 1:50 pm. During the interview the LPN stated, “I think it was healed and maybe that’s the reason I didn’t measure it.”