Every finding on record at Medical Services of America Inc.

An onsite, unannounced recertification survey was conducted 4/20/26-4/22/26. No deficiencies to the Emergency Preparedness Plan were identified.

An unannounced, onsite recertification survey was conducted 4/20/26-4/22/26. Standard level deficiencies to the Medicare CoPs were identified.

Be free from abuse CFR(s): 484.50(c)(2) Be free from verbal, mental, sexual, and physical abuse, including injuries of unknown source, neglect and misappropriation of property; This ELEMENT is not met as evidenced by: Based on agency policy, clinical record review, and staff interviews, the agency failed to report signs of possible neglect and or unsafe living conditions to adult protective services for 1 of 21 records reviewed [#13]. Findings included: The policy, Patient Abuse, Neglect or Exploitation [4/2025], was provided by the agency administrator on 4/22/26 at approximately 8:30 am. The policy stated, “______ [agency name] is committed to maintaining a safe and abuse-free environment for all patients. Reporting suspected or confirmed abuse, neglect, exploitation, or misappropriation of property is a mandatory legal requirement in all states in which the agency operates...All employees are mandated reporters and must report suspected or confirmed cases of abuse, neglect, self-neglect, or exploitation...Reports must be made immediately....” Patient # 13 had Start of Care date of 3/18/26 with admitting diagnoses of hypertensive heart and chronic kidney disease [cardiorenal syndrome where high blood pressure damages both organs simultaneously, accelerating failure] with heart failure [heart no longer pumps effectively], type 2 diabetes mellitus with diabetic chronic kidney disease [elevated blood sugar damages kidneys], and type 2 diabetes mellitus with other specified complications. Review of the Plan of Care [POC] for the certification period 3/18/26-5/16/26 included orders for SN [skilled nursing] 2 times a week for 2 weeks, 1 time a week for 6 weeks, 1 time a week for 1 week; home health aide [hha] 2 times a week for 8 weeks; PT [physical therapy] effective 4/4/26 2 times a week for 3 weeks. Review of the clinical record revealed on 3/18/26, RN # 7 completed the admission assessment and documented the following information, “...Pnt [patient] lives at home with multple [sic] cats. Strong urine smell [sic] in the home and cats are defacating [sic] on floor. Litter box is full and pnt is unable to empty or clean it. Trash is all over the floor with the appearance of dropped items that pnt is unable to pick up. Pnt has difficulty navigating walker and oxygen tubing safely and gets tangled up in oxygen tubing...” LPN # 3 conducted a routine visit on 3/20/26 and documented the following information, “...Patient reports that she had diarrhea this morning in the guest bathroom. Guest bathroom is to the leftof [sic] the front door. Stool and paper towels are still on the bathroom floor. Cat feces on the floor throughout the home, and old food on diningtable [sic] and kitchen counters... Patient states “I’m starving, I have noessential [sic] food [sic] my son says that I can order groceries myself...” PTA # 8 conducted a visit on 4/10/26 and documented the following conversation with the patient, “Educated patient on medications. “I haven’t eaten all day. I haven’t taken my medicine. I don’t know if I’m supposed to take two of these green pills.” LPN # 3 conducted a routine visit on 4/13/26 and documented the following information, “ Patient has not had a hospital follow up appointment with PCPsince [sic] hospital discharge. SN observed patient call and schedule PCP appointment. Hospital follow up schedule [sic] for 4/14. Patient thencalled [sic] her son to ask if he would drive her. Patient son is unavailable to drive patient to hospital. Follow up on tomorrow 4/14. Patient statesthat [sic]she will try to drive herself...” PTA # 8 made a routine visit on 4/15/26 and documented the following information, “Patient upset today due to a fender bender in which she was responsible”. Further review of the clinical record revealed no report to adult protective services [APS] was made by the agency staff due for possibility of neglect/unsafe living situation. During an interview with the agency administrator on 4/22/26 at approximately 2 pm the administrator reported, “I believe APS has been involved in the past. We should have made a report.”

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, clinical record review, and staff interviews the Plan of Care [POC] failed to include all/correct medications the patient was ordered for 1 of 3 patients [#8] who received a home visit; and failed to include appropriate safety measures for 5 of 9 patients [#1, 3, 4, 6, 7] who received an anti-platelet medication [medication that inhibits blood clotting]; and failed to include the amount of insulin to be given based on sliding scale for 1 of 8 patients [#10] with a diagnosis of diabetes; and failed to include supplemental oxygen on the POC for 2 of 3 patients [#13 and 16] with orders for supplemental oxygen. The findings included: The policy, Medication Monitoring and Medication Safety [4/2025] was provided by the agency administrator on 4/21/26 at approximately 1 pm. The policy stated,” ...A system is in place to ensure that patient medications are accurate, necessary, and do not interfere with ...Medication reconciliation and medication review is conducted, at a minimum: All OASIS [Outcome and Assessment Information Set] time points...New medication addition...Any change, or update, to any medication...” The policy, Care Plan Implementation [9/2025], was provided by the agency administrator on 4/22/26 at approximately 8:30 am. The policy stated, “...Each patient shall have a written POC that specifies the care and services to be provided, measurable outcomes, responsible disciplines, and patient/caregiver education needs...” 1. Patient # 8 had a Start of Care date of 3/18/26 with admitting diagnoses of hypertensive heart and chronic kidney disease [elevated blood pressure affects blood flow to the kidneys] and acute on chronic diastolic [congestive] heart failure [the heart doesn’t pump effectively] and type 2 diabetes mellitus with diabetic chronic kidney disease [elevated blood sugars damage kidneys]. Review of the Plan of Care [POC] for the certification period 3/18/26-5/16/26 included orders for SN [skilled nursing] 1 time a week for 1 week, 2 times a week for 8 weeks. On 4/21/26 at 9 am a joint visit was conducted with RN # 10. A medication review was conducted using a medication profile provided by the agency. The following discrepancies were noted: The medication profiled listed Metoprolol Succinate ER 50 mg [blood pressure medication]. Take 1 pill daily. During the visit the patient stated, “The doctor changed that to 25 mg each day when I went for my follow-up earlier this month.” This medication was not included on the POC. The patient presented a bottle of Oxycodone 5mg/325 mg [opioid]. Take 1 pill every 6 hours as needed for pain. During the visit the patient reported, “I have taken that for a long time, but I only take it when I needed it. This medication was not included on the POC. The patient presented a bottle of Isodril 10 mg [chest pain]. Take 1 pill every 8 hours. During the visit the patient stated, “I don’t know exactly when that was ordered, but it has been a while.” This medication was not included on the POC. During an interview with RN # 5 on 4/22/26 at approximately 11:30 am, RN # 5 confirmed the POC did not include all/correct medications the patient was ordered. 2. Patient # 1 had a Start of Care date of 5/19/25 with admitting diagnoses of other cystitis [inflammation of the bladder] without hematuria [blood in the urine] and vascular dementia, unspecified severity. Review of the Plan of Care [POC] for the certification period 5/19/25-7/17/25 revealed the patient was ordered Plavix [antiplatelet-inhibits formation of blood clots] 75 mg daily. Further review of the POC revealed bleeding precautions were not listed as a safety precaution. 3. Patient # 3 had a Start of Care date of 9/5/25 with an admitting diagnosis of unspecified dementia. Review of the Plan of Care [POC] for the certification period 9/5/25-11/3/25 revealed the patient was ordered Plavix [antiplatelet-inhibits formation of blood clots] 75 mg daily. Further review of the POC revealed bleeding precautions were not listed as a safety precaution. 4. Patient # 4 had a Start of Care date of 7/18/25 with an admitting diagnosis of multiple fractures of pelvis without disruption of pelvic ring. Review of the Plan of Care [POC] for the certification period 7/18/25-9/15/25 revealed the patient was ordered aspirin [antiplatelet-inhibits clotting of blood] 81 mg every day. Further review of the POC revealed bleeding precautions were not listed as a safety precaution. 5. Patient # 6 had a Start of Care date of 4/2/26 with an admitting diagnosis of ataxia [a neurological condition characterized by a loss of muscle coordination, balance, and control] following cerebral infarction [stroke]. Review of the Plan of Care [POC] for the certification period 4/2/26- 5/31/26 revealed the patient was ordered aspirin [antiplatelet-inhibits clotting of blood] 81 mg every day. Further review of the POC revealed bleeding precautions were not listed as a safety precaution. 6. Patient # 7 had a Start of Care date of 2/8/26 with an admitting diagnosis of hypertensive chronic kidney disease [high blood pressure affects blood flow to the kidneys]. Review of the Plan of Care [POC] for the certification period 4/9/26-6/7/26 revealed the patient was ordered aspirin [antiplatelet-inhibits clotting of blood] 81 mg every day. Further review of the POC revealed bleeding precautions were not listed as a safety precaution. During an interview with the agency administrator on 4/22/26 at approximately 2:30 pm, the administrator confirmed the POCs should have included bleeding precautions. 7. Patient # 10 had a Start of Care date of 4/4/26 with admitting diagnoses of chronic respiratory failure with hypercapnia [excessive amount of carbon dioxide in the blood] and type 2 diabetes mellitus with diabetic chronic kidney disease [high blood sugars damage kidney functioning]. Preview of the Plan of Care [POC] for the certification period 4/4/26-6/2/26 included orders for PT [physical therapy] 1 time a week for 1 week, 2 times a week for 2 weeks, 1 time a week for 6 weeks. Review of the POC revealed the following medication: Humalog [insulin] KwikPen 100 units/ml. Take 0-15 units prior to meals for diabetes mellitus. Further review of the POC revealed no sliding scale numbers for guidance on the amount of insulin to take. During an interview with RN # 5 on 4/22/26 at approximately 11 am, the RN confirmed the medication order on the POC was incomplete. 8. Patient # 13 had Start of Care date of 3/18/26 with admitting diagnoses of hypertensive heart and chronic kidney disease [cardiorenal syndrome where high blood pressure damages both organs simultaneously, accelerating failure] with heart failure [heart no longer pumps effectively], type 2 diabetes mellitus with diabetic chronic kidney disease [elevated blood sugar damages kidneys], and type 2 diabetes mellitus with other specified complications. Review of the Plan of Care [POC] for the certification period 3/18/26-5/16/26 included orders for SN [skilled nursing] 2 times a week for 2 weeks, 1 time a week for 6 weeks, 1 time a week for 1 week. Review of the admission assessment completed by RN # 7 on revealed the patient was ordered supplemental oxygen at 2 liters via nasal canula as needed for shortness of breath. Review of the POC revealed oxygen was not listed with the medications. 9. Patient # 16 had a Start of Care date of 3/30/26 with admitting diagnoses of hypertensive heart and chronic kidney disease with heart failure [elevated blood pressure affects blood flow to the kidneys] and acute on chronic diastolic [congestive] heart failure [ the heart doesn’t pump effectively]. Review of the Plan of Care [POC] for the certification period 3/30/26-5/28/26 included the following nursing interventions to assess/instruct patient/caregiver on oxygen use, storage, and safety precautions...” Further review of the POC revealed oxygen was not included in the medication list. During an interview with the administrator on 4/22/26 at approximately 10 am, the administrator reported, “The patient is on oxygen at all times at home. The oxygen should have been on the POC with the flow rate.”

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 clinical record review and staff interviews, the agency failed to notify the physician of low oxygen saturation readings for 1 of 3 patients [1] on supplemental oxygen; and failed to notify the physician of a patient’s complaints of being dizzy for 1 of 5 [#4] discharged records. The findings included: . Patient # 1 had a Start of Care [SOC] date of 5/19/25 with admitting diagnoses of other cystitis [inflammation of the bladder] without hematuria [blood in the urine] and vascular dementia, unspecified severity. Review of the Plan of Care [POC] for the certification period 5/19/25-7/17/25 orders for SN [skilled nursing] 1 time a week for 1 week, 2 times a week for 3 weeks, 1 time a week for 5 weeks. The POC also included an order for supplemental oxygen 2 liters via nasal canula continuously. Review of the clinical record revealed RN # 2 conducted a routine visit on 5/27/25 and documented the following information, “...Patient wearing oxygen pernasal [sic] cannula at 2LPM‘s[liters per minute]. Vital signs taken within normal limits except O2 sats at 85%, skilled nurse increased 02 [oxygen] to 3LPM‘s and O2 satsup [sic] to 90%...” Review of the clinical record revealed no evidence the RN notified the physician of the oxygen saturations. During an interview with RN # 5 on 4/22/26 at approximately 2 pm, RN # 5 confirmed RN # 2 failed to notify the physician of the oxygen saturation readings. 2. Patient # 4 had a Start of Care date of 7/18/25 with an admitting diagnosis of multiple fractures of pelvis without disruption of pelvic ring. Review of the Plan of Care [POC] for the certification period 7/18/25-9/15/25 revealed orders for PT [physical therapy] 1 time a week for 1 week, 2 times a week for 3 weeks, 1 time a week for 4 weeks. Review of the clinical record revealed PT # 11 conducted a routine visit on 7/22/25 and documented the following information, “Patient reported, ‘I have been lightheaded today and sick on my stomach today. I’m sorry I just don’t want to get out of the bed today because I feel dizzy...” On 7/24/25, PT # 11 documented the following information, “Blood sugar was down this am and I had diarrhea this morning too. I just don’t want to stand or try to walk. I am sorry. I can’t do this today.” On 7/28/25, PT # 11 documented the following information, “Patient-I think my blood pressure has been down. Discussion with patient on BP [blood pressure] levels for systolic is 100’s and she reports this is on the lower side for her. Patient will contact cardiologist. “Review of the clinical record revealed no evidence PT # 11 notified the physician of the patient’s concerns/complaints. During an interview with the administrator on 4/22/26 at approximately 2 pm, the administrator reported, “The clinicians know they need to report changes to the physicians.”

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 review, and staff interviews, the skilled nurse increased supplemental oxygen flow to 3 liters when the physician’s order was for 2 liters per minute for 1 of 3 patients [#1] with supplemental oxygen; and the skilled nurse failed to measure a midline site [catheter inserted into an upper arm vein designed for intermediate therapy] every visit for 1 of 1 patient [#8] with a midline catheter. The findings included: The policy, Physician Telephone/Verbal Orders [11/2025], was received from the agency administrator on 4/22/26 at 8:30 am. The policy stated, “...______ [name of agency] provides all care, treatment, and services only according to current, signed, and authorized orders...” 1. Patient # 1 had a Start of Care [SOC] date of 5/19/25 with admitting diagnoses of other cystitis [inflammation of the bladder] without hematuria [blood in the urine] and vascular dementia, unspecified severity. Review of the Plan of Care [POC] for the certification period 5/19/25-7/17/25 orders for SN [skilled nursing] 1 time a week for 1 week, 2 times a week for 3 weeks, 1 time a week for 5 weeks. The POC also included an order for supplemental oxygen 2 liters via nasal canula continuously. Review of the clinical record revealed RN # 2 conducted a routine visit on 5/27/25 and documented the following information, “...Patient wearing oxygen pernasal [sic] cannula at 2LPM‘s[liters per minute]. Vital signs taken within normal limits except O2 sats at 85%, skilled nurse increased 02 [oxygen] to 3LPM‘s and O2 satsup [sic] to 90%...” RN # 2 conducted a routine visit on 6/2/25 and documented the patient’s oxygen flow was 2-3 liters per minute. Further review of the POC revealed no order for the oxygen flow to be increased. During an interview with RN # 5 on 4/22/26 at approximately 2 pm, RN # 5 confirmed the order for oxygen was for 2 liters. 2. Patient # 8 had a Start of Care date of 3/18/26 with admitting diagnoses of hypertensive heart and chronic kidney disease [elevated blood pressure affects blood flow to the kidneys] and acute on chronic diastolic [congestive] heart failure [the heart doesn’t pump effectively] and type 2 diabetes mellitus with diabetic chronic kidney disease [elevated blood sugars damage kidneys]. Review of the Plan of Care [POC] for the certification period 3/18/26-5/16/26 included orders for SN [skilled nursing] 1 time a week for 1 week, 2 times a week for 8 weeks. The POC included a nursing intervention to, “SN to access RUA [right upper arm] midline [catheter inserted into an upper arm vein designed for intermediate therapy] every visit to remain patent”. Review of the clinical record revealed LPN # 3 conducted routine visits on 3/23/26, 3/25/26 and 3/30/26. There is no evidence the LPN assessed the midline site. During an interview with RN # 5 on 4/22/26 at 2:30 pm, RN # 5 confirmed the LPN failed to assess the Midline site in accordance with the physician’s order.

Preparing clinical notes CFR(s): 484.75(b)(6) Preparing clinical notes; This ELEMENT is not met as evidenced by: Based on agency policy review, clinical record reviews, and staff interviews, the skilled nurse failed to document appropriate/consistent/or weekly wound measurements for 2 of 6 patients [#1 and 11] with a wound. The findings included: The policy, Wound Care Standards [7/2025], was provided by the agency administrator on 4/22/26 at 8:30 am. The policy stated, “...Measure and document the wound at least weekly, unless the plan of care states otherwise...Wounds must be measured consistently using length...x width...x depth...Undermining and Tunneling...Presence and depth of tunneling and undermining, noting position using the clock method...” 1A. Patient # 1 had a Start of Care [SOC] date of 5/19/25 with admitting diagnoses of other cystitis [inflammation of the bladder] without hematuria [blood in the urine] and vascular dementia, unspecified severity. Review of the Plan of Care [POC] for the certification period 5/19/25-7/17/25 orders for SN [skilled nursing] 1 time a week for 1 week, 2 times a week for 3 weeks, 1 time a week for 5 weeks and “...SN to instruct patient and caregiver on wound care as follows: rt [right] heel: apply skin prep, cover withduoderm [sic] , change [sic] weekly or as neededto [sic] right knee trauma wd [wound] - clean with saline, pat dry, apply xeroform, cover with gauze, wrap inkerlix [sic], secured with tape. change dailyto [sic] right 5th toe pressure ulcer: clean with saline, apply betadine, open to air...” Review of the clinical record revealed RN # 4 completed the SOC on 5/19/25. RN # 4 documented the wound measurements of right heel [stage 1- intact skin with non-blanchable redness that does not turn white when pressed] Length - 3.5cm, Width - 3.5cm, Depth - 0.1cm. During an interview with RN # 5 on 4/22/26 at approximately 2 pm, it was confirmed a stage I pressure ulcer cannot have a depth, as the skin is still intact. 1B. Patient # 1 had a Start of Care [SOC] date of 5/19/25 with admitting diagnoses of other cystitis [inflammation of the bladder] without hematuria [blood in the urine] and vascular dementia, unspecified severity. Review of the Plan of Care [POC] for the certification period 5/19/25-7/17/25 orders for SN [skilled nursing] 1 time a week for 1 week, 2 times a week for 3 weeks, 1 time a week for 5 weeks and, “...SN to instruct patient and caregiver on wound care as follows... 5th toe pressure ulcer: clean with saline, apply betadine, open to air...” Review of the clinical record revealed RN # 4 completed the SOC visit on 5/19/26 and staged the wound on the right 5th toe as a stage II [a partial-thickness skin injury characterized by an open, shallow wound with a red/pink, moist wound bed, or an intact/ruptured blister] pressure ulcer. Review of the documentation revealed the RN failed to document measurements of the wound to the 5th toe. RN # 6 completed a routine visit on 5/27/25. Further review of the clinical record revealed the RN failed to obtain wound measurements of the right 5th toe. RN # 2 conducted visits on 6/2/25 and 6/9/25. Review of the clinical record revealed no wound measurements for the right 5th toe. During an interview with RN # 5 on 4/22/26 at approximately 2:30 pm, RN # 5 confirmed the RN’s failed to obtain wound measurements of the stage II on the right 5th toe. 2. Patient # 11 had a Start of Care date of 3/12/26 with an admitting diagnosis of necrotizing fasciitis [life-threatening bacterial infection that destroys tissue under the skin]. Review of the Plan of Care [POC] for the certification period 3/12/26-5/10/26 included orders for SN [skilled nurse] 1 time a week for 2 weeks, 2 times a week for 7 weeks and “SN to clean wound with wound cleanser, apply barrier to periwound; skin prep [sic] apply contact layer ifordered [sic]. White foam to tunnels [narrow passageways extending from a wound bed deep into surrounding subcutaneous tissue, creating dead space and high infection risk] at 4 [sic]; 7 [sic]...” The clinical record revealed RN # 1 completed the SOC visit and documented the following wound assessment of the right buttock: “Assessment and Treatment: Size: Length - 14cm, Width - 24cm, Depth - 7cm; Thickness: Full; Edges: Non-Attached; Drainage: Type - Serous, Amount - Copious; Odor: None; Bed: Slough - 5%, Pink/Red - 95%; Surrounding Tissue: Intact; Undermining [occurs when tissue under the wound edges detaches from the underlying subcutaneous tissue, creating a pocket or "shelf" beneath the skin]:From Four O'clock - To Four O'clock - Depth: 5cm, From Seven O'clock - To Eight O'clock - Depth: 4cm; Tunneling: None;...” Further review of the visit documentation for 3/12/26 revealed the following treatment recorded by RN # 1: “Treatment Performed This Visit: Cleansed with wound cleanser, applied skin prep to peri wound, windowpanes with drape, packed 2 pieces white foam to tunnels at 4:7 o’clock, packed remainder with one-piece spiral black foam...” RN # 2 conducted a routine visit on 3/16/26 and documented the following wound assessment “...Right buttock...Assessment... Size: Length - 8cm, Width - 21.5cm, Depth - 3cm... Undermining: None; Tunneling: None...” Treatment Performed This Visit: clean with saline, pack deep depths at 4:00 [sic] and 7:00 [sic] with white foam, apply black foam, secure withocclusive [sic] dressing, connect to cont [sic] suction at 125mmhg...” LPN # 3 conducted a routine visit on 3/23/26 and documented the following wound assessment “...Right buttock...Assessment... Size: Length - 8cm, Width - 20cm, Depth - 0.3cm...Undermining: None; Tunneling:Direction[sic] - Ten O'clock, Depth - 7cm...” LPN # 3 made a routine visit on 3/25/26 and indicated the wound had no undermining or tunneling. RN # 1, RN # 2, nor LPN # 3 were available for interview. During an interview with RN # 5 on 4/22/26 at 2 pm, the RN confirmed the documentation was inconsistent related to tunnels and/or undermining.

All orders recorded in plan of care CFR(s): 484.60(a)(3) All patient care orders, including verbal orders, must be recorded in the plan of care. This ELEMENT is not met as evidenced by: Based on clinical record review and staff interviews the agency failed to include all orders in the Plan of Care for 1 of 6 patients [#6]. The findings included: 1. Patient # 6 had a Start of Care date of 7/23/23 with an admitting diagnosis of traumatic subarachnoid hematoma [presence of blood within the between the brain and the surrounding membrane] without the loss of consciousness. Review of the plan of care for the certification period 7/23/23 to 9/20/23 included orders for SN [skilled nursing] 2 times a week for 1 week, 1 time a week for 3 weeks. Review of the clinical record revealed LPN # 5 made a routine visit on 8/2/23. Review of the skilled nursing visit note dated 8/2/23 revealed the following documentation by the LPN, “…Blood pressures are concerning with some reading noted at 75/44 and 74/62. Patient was put back on Lisinopril [blood pressure medication] after most recert hospitalization…HHSN [home health skilled nurse] to call and report readings to ____ [name of physician] …” LPN # 5 made a follow up visit on 8/9/23. Review of the skilled nursing visit note dated 8/9/23 revealed the following documentation, “…Received call from MD yesterday and notified spouse to hold patients Lisinopril since BP [blood pressure] readings are low…” Further review of the clinical record revealed no written order to hold the Lisinopril. During an interview with the director of professional services on 8/29/23 at approximately 12 noon, the director stated, “I spoke with the LPN. She stated she did not write the order to hold the medication.”

An unannounced, onsite recertification survey was conducted 5/8/23-5/10/23. No deficiencies to the Emergency Preparedness Plan was identified.

An onsite, unannounced recertification survey was conducted 5/8/23-5/10/23. Standard level deficiencies to the Medicare CoP were identified.

Accuracy of encoded OASIS data CFR(s): 484.45(b) Standard: The encoded OASIS data must accurately reflect the patient's status at the time of assessment. This STANDARD is not met as evidenced by: Based on policy review, clinical record review, and staff interview, the agency failed to accurately assess patients’ status on the OASIS (Outcome and Assessment Information Set—standardized assessment) for 4 of 18 patients (#1, 11, 15, and 8). Findings included: 4. Patient #8 was admitted on 4/2/23 with a diagnosis of type 2 diabetes mellitus with chronic kidney disease. The initial assessment was conducted on 4/2/23. The patient was not identified as taking hypoglycemic medications (medication to lower blood sugar) in the OASIS (Outcome and Assessment Information Set—standardized assessment). The Plan of Care (POC) for 4/2/23-5/31/23 included orders for Lantus (long-acting insulin) and Novolin N (short acting insulin). An interview with the administrator on 5/10/23 at 2:47 p.m. confirmed the patient was prescribed anti-diabetic medications. 1. Patient # 1 had a Start of Care [SOC] date of 4/20/23 with an admitting diagnosis of aftercare following surgery for neoplasm. Review of the Plan of Care [POC] for the certification period 4/20/23 to 6/18/23 included orders for SN [skilled nursing] 1 time a week for 1 weeks, 2 times per week for 4 weeks, then 1 time per week for 4 weeks. Review of the clinical record revealed RN # 7 completed the SOC OASIS [Outcome and Assessment Information Set-comprehensive assessment] on 4/20/23. Review of the OASIS revealed RN # 7 did not answer the question at [N0415] High-Risk Drug Classes: Use and Indications correctly. RN # 7 did not indicate the patient was using an Opioid. The POC medication profile listed Oxycodone-Acetaminophen [pain medication] 5-325 mg 1 tablet every 12 hours. During an interview with RN # 7 on 5/10/23 at 1 pm, RN # 7 stated, “I guess I just missed checking that for the question.” 2. Patient # 11 had a Start of Care [SOC] date of 4/4/23 and an admitting diagnosis of type 2 diabetes mellitus with diabetic poly neuropathy [complication of diabetes resulting in damage to nerve fibers]. Review of the Plan of Care for the certification period 4/4/23-6/2/23 included order for SN [skilled nursing] 1 time a week for 4 weeks, 1 time a week every other week for 5 weeks. Review of the clinical record revealed RN # 8 conducted the SOC visit on 4/4/23. Review of the OASIS [Outcome and Assessment Information Set-comprehensive assessment – comprehensive assessment completed at the time of admission] revealed question NO415 indicated the patient was not receiving any type of anticoagulation medication. The patient was receiving aspirin 81 mg daily. During an interview with the RN on 5/10/23 at approximately 2:35 pm, the RN confirmed the OASIS question was answered incorrectly. 3. Patient # 15 had a Start of Care [SOC] date of 1/28/22 with an admitting diagnosis of acute and chronic respiratory failure with hypoxia [low oxygen levels in the blood]. Review of the Plan of Care for the certification period 1/28/22 to 3/28/22 included orders for PT [physical therapy] 1 time a week for 6 weeks; SN [skilled nursing] 1 time a week for 1 week, 2 times a week for 3 weeks, 2 PRN [as needed] for wound problems and, “SN to instruct patient and caregiver on wound care as follows: sacral stg 2[stage 2-shallow crater] pressure ulcer- cleanwith [sic] saline, pat dry, apply skin barrier, apply skin barrier paste, cover with foam border. Change 2-3 x [times] week…” Review of the clinical record revealed PT # 12 completed the SOC OASIS [Outcome and Assessment Information Set-comprehensive assessment] on 1/28/22. Review of the OASIS revealed question M1306 [Does this patient have at least one Unhealed Pressure Ulcer/Injury at Stage 2 or Higher or designated as Unstageable? (Excludes Stage 1 pressure injuries and all healed pressure ulcers/injuries) was answered incorrectly when answered “no”. PT # 12 was not available for interview. During an interview with the agency administrator on 5/10/23 at approximately 3:10 pm, the administrator confirmed the OASIS question was answered incorrectly.

Be free from abuse CFR(s): 484.50(c)(2) Be free from verbal, mental, sexual, and physical abuse, including injuries of unknown source, neglect and misappropriation of property; This ELEMENT is not met as evidenced by: Based on agency policy, clinical record review and staff interviews, the agency failed to investigate allegations of caregiver abuse for 1 of 1 patient [#15] with an allegation of abuse. The findings included: The policy, Patient Abuse, Neglect or Exploitation [reviewed 8/21] was provided by the agency administrator on 5/9/23 at approximately 8:30 am. The policy stated, “…An Abuse Assessment is to be performed immediately and appropriate action taken if the staff member has reasonable grounds to believe that an incident of abuse, neglect or exploitation or alleged abuse, neglect or exploitation has occurred…” Patient # 15 had a Start of Care date of 1/28/22 with an admitting diagnosis of acute and chronic respiratory failure with hypoxia [low oxygen levels in the blood]. Review of the Plan of Care for the certification period 1/28/22 to 3/28/22 included orders for SN [skilled nursing] 1 time a week for 1 week, 2 times a week for 3 weeks, 2 PRN [as needed] for wound problems. Review of the clinical record revealed RN # 1 documented the following information during a routine visit on 3/14/22, “Patient lying in bed resting upon SN [skilled nurse] arrival. CG [caregiver] at bedside. CG voiced concern over the large amount of bruising noted to patient's bodydue [sic] to bedbound status. Patient does have extraordinary amount of new and old bruising noted over entire body. The CG expressedconcern [sic] that the patient was being abused by the other CG. She stated that the other CG is rough with the patient, and she stated that shehad [sic] voiced her concerns to the family with no results. She also stated that when she questioned the patient about possible abuse thepatient [sic] voiced agreement… Spoke with patients [sic]son who is POA [power of attorney] about SN concerns of possibleabuse [sic] and of the documentation taken, he verbalized understanding and he stated he would speak with CG in question…” Further review of the clinical record revealed no evidence the nurse contacted the physician regarding the concern for abuse or reported the allegation to APS [adult protective services]. During an interview with RN # 1 on 5/10/23 at approximately 12:30 pm, the RN confirmed she did not notify the physician or APS. “I spoke with our clinical manager, and she told me to take pictures and talk to the son.” During an interview with the agency administrator on 5/10/23 at approximately 3 pm, the administrator confirmed no investigation was initiated related to the caregiver’s report of abuse.

Standard: Initial assessment visit. CFR(s): 484.55(a) Standard: Initial assessment visit. This STANDARD is not met as evidenced by: Based on policy review, clinical record review, and staff interview, the agency failed to conduct the initial assessment within 48 hours of referral for 3 of 18 patients (#9, 3, and 13). Findings included: 2A. Patient # 3 had a Start of Care [SOC] date of 4/3/23 and an admitting diagnosis of longstanding persistent atrial fibrillation [irregular heartbeat]. Review of the clinical record revealed a referral to home health was ordered on 3/27/23. Disciplines requested were physical therapy and occupational therapy. Further review of the medical record revealed the patient was not admitted until 4/3/23. There was no evidence the physician was notified of the delay in the SOC. During an interview with the agency administrator on 5/10/23 at approximately 3:25 pm, the administrator stated, “I see a note in the computer where the patient requested 4/3/23 for the SOC, but there is no indication we notified the physician. So, no, the SOC was not within the required timeframe”. 2B. Patient # 3 had a Start of Care [SOC] date of 4/3/23 and an admitting diagnosis of longstanding persistent atrial fibrillation [irregular heartbeat]. Review of the Plan of Care [POC] for the certification period 4/3/23 to 6/1/23 included orders for PT [physical therapy] 1 time a week for 6 weeks. Review of the clinical record revealed the patient was admitted to ________ [name of the hospital] on 4/4/23. The patient was discharged home on 4/14/23. The ROC [resumption of care-comprehensive assessment completed after inpatient stay] visit was not initiated until 4/21/23. During an interview with the agency administrator on 4/10/23 at 3:00 pm, the administrator confirmed the ROC visit was not made within the required 48 hours. 3. Patient # 13 had a Start of Care date of 8/24/21. Review of the Plan of Care [POC] for the certification period 2/20/22 to 4/20/22 revealed diagnoses of laceration without foreign body of right hand, laceration without foreign body, right lower leg, type 2 diabetes mellitus with foot ulcer, non-pressure chronic ulcer, right foot and non-pressure chronic ulcer of left heel and midfoot. Review of the clinical record revealed the patient was admitted to the hospital on 3/5/22 and was discharged home on 3/24/22. An order to do ROC [resumption of care-comprehensive assessment after in patient stay] was noted in the clinical record with a date of 3/24/22. Further review of the clinical record revealed the ROC visit was not made until 3/27/22. During an interview with the agency administrator on 5/10/23 at 3:35 pm, the administrator confirmed the ROC was not completed within the required timeframe. A policy, “Assessment” (revised 2/2023), was provided by the agency administrator on 5/9/23 at 8:30 a.m. The policy stated, “Initial Admission Assessments should be performed by a registered nurse or therapist within 48 hours of…The time of the referral…The patient’s return home…The Resumption of Care (ROC) date.” 1. Patient #9 was admitted on 3/21/23 with a diagnosis of hemiplegia (paralysis on one side of body) following a cerebral infarction (stroke). A referral for physical therapy, occupational therapy, and home health aide was received by the agency on 3/17/23. The initial assessment was not conducted until 3/21/23. The physician was notified on 3/20/23 that the initial assessment would be conducted on 3/21/23. An interview with the agency administrator on 5/10/23 at 3:26 p.m. confirmed the initial assessment was not conducted within 48 hours of referral.

5 calendar days after start of care CFR(s): 484.55(b)(1) The comprehensive assessment must be completed in a timely manner, consistent with the patient's immediate needs, but no later than 5 calendar days after the start of care. This ELEMENT is not met as evidenced by: Based on agency policy, clinical record review and staff interviews the agency failed to complete the comprehensive assessment within the 5-day timeframe for 6 of 18 patients [#1, 2, 3, 7, 11, 15]. The findings included: The policy, Assessment [revised 2/2023], was provided by the agency administrator on 5/9/23 at 8:30 am. The policy stated, “…If the physician orders therapy services, the evaluation may be completed by an appropriate rehabilitation skilled professional…within 5 days of the time of referral, the patient’s return home or the physician’s ordered Start of Care date…” 1. Patient # 1 had a Start of Care date of 4/20/23 with an admitting diagnosis of aftercare following surgery for neoplasm. Review of the Plan of Care [POC] for the certification period 4/20/23 to 6/18/23 revealed an order for OT [occupational therapy] to evaluate and treat. The OT evaluation was not initiated until 4/28/23. The clinical record contained no evidence that the physician was notified that the OT evaluation would not be completed within the 5-day timeframe. During an interview with the agency administrator on 5/10/23 at approximately 3:30 pm, the administrator confirmed the OT evaluation was not completed within the 5-day timeframe. 2. Patient # 2 had a Start of Care [SOC] date of 4/10/23 with an admitted diagnosis of neoplasm of the bladder. Review of the Plan of Care for the certification period 4/10/23 to 6/8/23 included orders for PT [physical therapy] to evaluate and treat. The PT evaluation was not conducted until 5/2/23. The clinical record included no evidence the physician was notified the PT evaluation would not be completed within the 5-day timeframe. During an interview with the agency director on 5/10/23 at approximately 3 pm, the director confirmed the PT evaluation was not completed within the required timeframe. 3. Patient # 3 had a Start of Care [SOC] date of 4/3/23 and an admitting diagnosis of longstanding persistent atrial fibrillation [irregular heartbeat]. Review of the clinical record revealed the patient was admitted to ________ [name of the hospital] on 4/4/23. The patient was discharged home on 4/14/23 with ROC [resumption of care-comprehensive assessment completed after inpatient stay] orders for OT [occupational therapy] to evaluate. Further review of the clinical record revealed the OT evaluation was not completed until 5/2/23. During an interview with the administrator on 5/10/23 at approximately 3:15 pm, the administrator confirmed the OT evaluation was not completed within the 5-day period. 4. Patient # 7 had a Start of Care date of 4/14/23 and admitting diagnoses of cellulitis of right lower limb, laceration without foreign body, right lower leg, type 2 diabetes mellitus with diabetic chronic kidney disease. The patient had an inpatient stay from 4/20/23-4/29/23. Review of the referral dated 4/28/23 indicated the disciplines desired were PT [physical therapy] and SN [skilled nursing]. The ROC [resumption of care-comprehensive assessment completed after inpatient stay] visit was initiated on 4/30/23 by the RN. Review of the clinical record revealed the Physical Therapy evaluation visit did not occur until 5/9/23. On 5/10/23 at approximately 3:35 pm, the agency administrator confirmed the PT evaluation was not within the required timeframe. 5. Patient # 11 had a Start of Care date of 4/6/23 and an admitting diagnosis of Type 2 diabetes mellitus with diabetic polyneuropathy [pain related to damaged nerves]. Review of the clinical record revealed a physician’s order dated 3/31/23. The physician’s order stated, “Please evaluate… for admission to home health. Disciplines requested: Occupational Therapy, PT, Nursing…Start of Care Date: Within 2-3 days…” The patient was admitted to the agency on 4/4/23 by nursing. Further review of the clinical record revealed the physical therapy evaluation was not completed until 4/13/23. The Occupational therapy evaluation was not completed until 5/2/23. There was no evidence the physician was notified that the therapy evaluations would not be completed within 5 days. During an interview with the agency administrator on 5/10/23 at 3 pm. The administrator confirmed the therapy evaluations were not completed within the required time frame. 6. Patient # 15 had a Start of Care [SOC] date of 1/28/22 with an admitting diagnosis of acute and chronic respiratory failure with hypoxia [low oxygen levels in the blood]. Review of the Plan of Care for the certification period 1/28/22 to 3/28/22 included orders for PT [physical therapy] 1 time a week for 6 weeks; SN [skilled nursing] 1 time a week for 1 week, 2 times a week for 3 weeks, 2 PRN [as needed] for wound problems; Speech therapy to evaluate; Occupational therapy [OT] to evaluate. Review of the clinical record revealed the speech therapy evaluation was not made until 2/4/22 and the OT visit was not made until 2/7/22. There was no evidence the physician was notified that the OT and speech therapy evaluations would not be completed within the 5-day time frame. During an interview with the agency administrator on 5/10/23 at approximately 3:20 pm, the administrator confirmed the physician was not notified of the delay.

A review of all current medications CFR(s): 484.55(c)(5) A review of all medications the patient is currently using in order to identify any potential adverse effects and drug reactions, including ineffective drug therapy, significant side effects, significant drug interactions, duplicate drug therapy, and noncompliance with drug therapy. This ELEMENT is not met as evidenced by: Based on policy review, clinical record review, and staff interview, the agency failed to assess medications for 2 of 6 patients that received an observational home visit (#5 and 6). Findings included: A policy, “Medication Management” (reviewed 8/2021), was provided by the agency administrator on 5/9/23 at 8:30 a.m. The policy stated, “During the initial assessment visit, the Registered Nurse/Therapist generates a list of the patient’s current medications, including prescription and over-the-counter (OTC) medications and herbal remedies. The information is documented in the Agency Medication Administration Record…” 1. Patient #5 was admitted on 4/16/23 with diagnoses of right femur (thigh bone) fracture, essential hypertension, type 2 diabetes, and schizophrenia. The Plan of Care (POC) was not completed until 5/8/23. On 5/9/23, a POC was provided for dates of 4/16/23-6/14/23. There were orders for physical therapy three times per week for two weeks; occupational therapy weekly for five weeks; and speech therapy (ST) weekly for six weeks. Skilled nursing visits were ordered effective 4/27/23 weekly for four weeks. A home visit was made to the patient’s home with the speech therapist on 5/9/23 at 10:30 a.m. The patient received his medications prepackaged from the pharmacy. A review of the medications revealed Levothyroxine (for thyroid), Memantine (used to slow the progression of Alzheimer’s Disease), and Omeprazole (for stomach) were not in the package but were included on the initial POC. An interview with the speech therapist on 5/10/23 at ___ p.m. revealed the ST had notified the physician office regarding the medications. The physician’s office confirmed the patient should be taking Levothyroxine, Memantine, and Omeprazole and said that the prescriptions would be sent to the pharmacy. 2. Patient #6 was admitted on 7/25/22 with diagnoses of pressure ulcer right buttock stage 3 (a wound caused by pressure that involves full-thickness skin loss and extends into the fatty tissue), pressure ulcer left buttock unstageable (a wound caused by pressure, but depth obscured) and paraplegia (paralysis of the lower body). The Plan of Care (POC) for 3/22/23-5/20/23 included nursing visits weekly for nine weeks. A home visit was conducted with RN #7 on 5/9/23 at approximately 9:00 a.m. A medication review was conducted during the visit with the caregiver. The patient was taking Prosource 1 capful twice daily for approximately one year as a protein supplement. The patient also used Flonase nasal spray for allergy symptoms as needed for approximately one year. The Prosource and Flonase were omitted from the POC. An interview with RN #7 during the visit confirmed they were not on the POC.

Plan of care CFR(s): 484.60(a)(1) Each patient must receive the home health services that are written in an individualized plan of care that identifies patient-specific measurable outcomes and goals, and which is established, periodically reviewed, and signed by a doctor of medicine, osteopathy, or podiatry acting within the scope of his or her state license, certification, or registration. If a physician or allowed practitioner refers a patient under a plan of care that cannot be completed until after an evaluation visit, the physician or allowed practitioner is consulted to approve additions or modifications to the original plan. This STANDARD is not met as evidenced by: Based on policy review, clinical record review, and staff interviews, Plans of Care were not completed timely for 12 of 13 active patients (#4, 5, 8, 9, 10, 18, 1, 2, 3, 7,11, and 12). Findings included: 7. Patient # 1 had a Start of Care date of 4/20/23 with an admitting diagnosis of aftercare following surgery for neoplasm. The Plan of Care [POC] was not completed until 5/9/23. On 5/9/23, the POC was provided for the certification period 4/20/23 to 6/18/23. 8. Patient # 2 had a Start of Care date of 4/10/23 with an admitting diagnosis of neoplasm of the bladder. The Plan of Care [POC]was not completed until 5/9/23. On 5/9/23, the POC was provided for the certification period 4/10/23-6/8/23. 9. Patient # 3 had a Start of Care [SOC] date of 4/3/23 and an admitting diagnosis of longstanding persistent atrial fibrillation [irregular heartbeat]. Review of the clinical record revealed the patient was admitted to ________ [name of the hospital] on 4/4/23. The patient was discharged home on 4/14/23. Physical therapist # 6 initiated the ROC [resumption of care-comprehensive assessment completed after inpatient stay] visit on 4/21/23. The ROC Plan of Care [POC] was not completed until 5/10/23. 10. Patient # 7 had a Start of Care date of 4/14/23 and admitting diagnoses of cellulitis [bacterial skin infection] of right lower limb, laceration without foreign body, right lower leg, type 2 diabetes mellitus with diabetic chronic kidney disease. The patient had an inpatient stay from 4/20/23-4/29/23. The ROC [resumption of care-comprehensive assessment after in patient stay] Plan of Care [POC] was not available until 5/10/23. 11. Patient # 11 had a Start of Care date of 4/4/23 and an admitting diagnosis of type 2 diabetes mellitus with diabetic poly neuropathy [complication of diabetes resulting in damage to nerve fibers]. The Plan of Care [POC] was not completed until 5/9/23. On 5/9/23, the POC was provided for the certification period 4/4/23-6/2/23. 12. Patient # 12 had a Start of Care date of 2/14/23 and admitting diagnosis of pressure ulcer of left buttock, stage 2 [Partial thickness loss of dermis presenting as a shallow open ulcer with a red or pink]. The Recertification Plan of Care [POC] was not completed until 5/10/23. On 5/10/23, the POC was provided for the dates of 4/15/23 to 6/13/23. An interview was conducted with the agency administrator on 5/8/23 at approximately 12:30 pm. During the interview, the administrator confirmed the POCs had not been processed. "We are short a clinical manager." A policy, “Care Plan Implementation” (reviewed 12/2022), was provided by the agency administrator on 5/9/23 at 8:30 a.m. The policy stated, “A written plan of care is developed in consultation with the patient, physician and agency staff…Each patient will receive an individualized plan of care including any revision or additions.” 1. Patient #4 was admitted on 4/20/23 with diagnoses of right femur fracture, speech/language deficits following other cerebrovascular disease, history of falling, dysphagia (difficulty swallowing), and dementia. The Plan of Care for 4/20/23-6/18/23 was not completed until 5/8/23. 2. Patient #5 was admitted on 4/16/23 with diagnoses of right femur (thigh bone) fracture, essential hypertension, type 2 diabetes, and schizophrenia. The Plan of Care for 4/16/23-6/14/23 was not completed until 5/8/23. 3. Patient #8 was admitted on 4/2/23 with diagnoses of type 2 diabetes mellitus with diabetic chronic kidney disease and hypertensive heart and chronic kidney disease with heart failure. The Plan of Care for 4/2/23-5/31/23 was not completed until 5/8/23. 4. Patient #9 was admitted on 3/21/23 with diagnoses of hemiplegia (paralysis on one side of body) following cerebral infarction (stroke), cellulitis (infection of inner layers of skin) both lower extremities, and hypertensive chronic kidney disease. The nurse completed an evaluation on 4/9/23. The skilled nurse Plan of Care order was not completed until 5/8/23. 5. Patient #10 was admitted on 8/19/23 with diagnoses of infection/inflammatory reaction due to internal right hip prothesis, hypertensive chronic kidney disease with chronic kidney failure, and type 2 diabetes. The Plan of Care for 4/16/23-6/14/23 was not completed until 5/8/23. 6. Patient #18 was admitted on 4/3/23 with diagnoses of chronic pulmonary edema (excessive liquid accumulation in the tissue and air spaces of the lungs) and hypertensive chronic kidney disease. The Plan of Care for 4/3/23-6/1/23 was not completed until 5/8/23.

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, home visit observation, clinical record review, the Plan of Care did not include current medications for 5 of 18 patients (#5,1, 2, 3, 13). Findings included: 2. Patient # 1 had a Start of Care date of 4/20/23 with an admitting diagnosis of aftercare following surgery for neoplasm. Review of the Plan of Care [POC] for the certification period 4/20/23 to 6/18/23 included orders for SN [skilled nursing] 1 time a week for 1 week, 2 times per week for 4 weeks, then 1 time per week for 4 weeks. On 5/9/23 at approximately 10 am, a joint visit was made with LPN # 3. During the visit a medication review was conducted using a medication profile provided by the agency. The following discrepancies were noted: The medication profile listed Potassium Chloride ER [extended relief] [supplement] 10 mEq 1 tablet daily. During an interview with the caregiver, the caregiver stated, “He don’t [sic] take the potassium every day. He will eat a banana when he thinks his potassium is low.” During an interview with the director on 5/9/23 at approximately 10:30 am, the director confirmed the POC did not include the correct medication/dosage the patient was taking. 3. Patient # 2 had a Start of Care [SOC] date of 4/10/23 with an admitting diagnosis of neoplasm of the bladder. Review of the Plan of Care for the certification period 4/10/23 to 6/8/23. Review of the Plan of Care for the certification period 4/10/3 to 6/8/23 included orders for SN [skilled nursing] 1 time a week for 9 weeks. On 5/9/23 at approximately 1 pm, a joint visit was conducted with RN # 5. A medication review was conducted during the visit using a medication profile provided by the agency. The following discrepancies were noted: The medication listed Cosopt Ophthalmic [eye drops] 22.3-6.9 mg per ml. Place 1 drop into right eye 2 times per day; Xalatan Ophthalmic [eye drops] 0.005%. Place 1 drop into right eye at bedtime; Oxybutynin Chloride [bladder spasms] 5 mg. Take 1 by mouth daily for 30 days. During an interview with the caregiver during the visit, the caregiver reported the patient no longer used eyedrops or the Oxybutynin. “He hasn’t been on those medications for a while now.” 4. Patient # 3 had a Start of Care [SOC] date of 4/3/23 and an admitting diagnosis of longstanding persistent atrial fibrillation [irregular heartbeat]. Review of the ROC [resumption of care-comprehensive assessment completed after inpatient stay] Plan of Care [POC] dated 4/21/23 included orders for PT [physical therapy] 1 time a week for 1 week, 2 times a week for 2 weeks, 1 time a week for 4 weeks. On 5/9/23 at approximately 11 am, a joint home visit was made with PT # 6. During the visit, a medication review was conducted using a medication profile provided by the agency. The following discrepancies were noted: The medication profile list Potassium Chloride [supplement] 10 mEq 1 tablet each day. The patient was taking Potassium Chloride 20 mEq daily with a start date of 4/14/23. The medication profile did not include Docusate Sodium [stool softener] 100 mg 2 caps daily or Ferrous Sulfate [iron supplement] 325 mg daily. During an interview with PT # 6 on 5/9/23 at approximately 11:20 am, the PT stated, “the daughter manages the medications, she goes by the list the VA [veterans administration] gave her.” 5. Patient # 13 had a Start of Care date of 8/24/21. Review of the Plan of Care [POC] for the certification period 2/20/22 to 4/20/22 revealed diagnoses of laceration without foreign body of right hand, laceration without foreign body, right lower leg, type 2 diabetes mellitus with foot ulcer, non-pressure chronic ulcer, right foot and non-pressure chronic ulcer of left heel and midfoot. Orders on the POC included SN [skilled nursing] 1 time a week for 9 weeks, 5 PRN [as needed] for wound issues. Further review of the POC included Insulin Lispro [diabetes] Subcutaneous [under the skin] 100 units per milliliter. Take 2-12 units 3 times a day for diabetes. The POC did not include the sliding scale for the amount of insulin the patient should take. During an interview with the agency administrator on 5/10/23 at approximately 3:20 pm, administrator confirmed the POC should have included the sliding scale reading. A policy, “Medication Management” (revised 8/2021), was provided by the agency direction on 5/8/23 at 3:30 p.m. The policy stated, “The list of current medications is incorporated into the plan of care.” 1. Patient #5 was admitted on 4/16/23 with diagnoses of right femur (thigh bone) fracture, essential hypertension, type 2 diabetes, and schizophrenia. The Plan of Care (POC) was not completed until 5/8/23. On 5/9/23, a POC was provided for dates of 4/16/23-6/14/23. There were orders for physical therapy three times per week for two weeks; occupational therapy weekly for five weeks; and speech therapy weekly for six weeks. Skilled nursing visits were ordered effective 4/27/23 weekly for four weeks. A home visit was made to the patient’s home with the speech therapist on 5/9/23 at 10:30 a.m. The patient had Systane eye drops, Voltaren gel 1%, Glucose tablets 4 grams in the home that he said he was currently using. The medications were not listed on the current POC.

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 follow the physician’s orders for 3 of 8 patients receiving wound care [#7, 12, 15]. The findings included: 1. Patient # 7 had a Start of Care date of 4/14/23. Review of the ROC [resumption of care-comprehensive assessment completed after inpatient stay] Plan of Care [POC] dated 4/30/23 to 6/12/23 included diagnoses of non-pressure chronic ulcer other part right low leg w fat layer exposed and laceration without foreign body, right lower leg. The POC also included orders for SN [skilled nursing] 2 times a week for 5 weeks, 2 PRN [as needed] for wound decline and “SN to provide wound care to right lower leg trauma wound by cleaning with saline, apply medihoney gel to wound bed, cover with abd pad, secure with rolled gauze/coban from base of toes to bend of knee, pad bend of knee and ankle to abd pad. Change 2 times weekly and PRN soiling and dislodgement…” Review of the Skilled Nursing Visit note dated 5/1/23 and completed by RN # 1 revealed the RN cleaned the wound with saline and applied anasept [antimicrobial skin and wound cleanser to wound bed, then covered with saline moistened gauze, Vaseline gauze and abd pad. During an interview with RN # 1 on 5/10/23 at approximately 11:30 am, during the interview the RN she confirmed she did not apply the dressing to the wound as ordered on the ROC POC. 2. Patient # 12 had a Start of Care date of 2/14/23 and admitting diagnosis of pressure ulcer of left buttock, stage 2 [Partial thickness loss of dermis presenting as a shallow open ulcer with a red or pink wound bed. May also present as an intact or open/ruptured blister]. Review of the Plan of Care [POC] for the certification period 4/15/23 to 6/13/23 included orders for SN [skilled nursing] 2 times a week for 4 weeks, 1 time a week for 5 weeks, 2 PRN [as needed] for medical/wound decline and “SN to cleanse stage 2 pressure ulcer to left buttock with 0.9 % sodium chloride. Paint wound with betadine. Apply optifoam AG and cover with adhesive foam twice weekly…” Review of the clinical record revealed a routine visit was conducted on 4/18/23. The Skilled Nurse Visit Note indicated the betadine was not applied to the wound as indicated by the POC . 3. Patient # 15 had a Start of Care [SOC] date of 1/28/22 with an admitting diagnosis of acute and chronic respiratory failure with hypoxia [low oxygen levels in the blood]. Review of the Plan of Care for the certification period 1/28/22 to 3/28/22 included orders for SN [skilled nursing] 1 time a week for 1 week, 2 times a week for 3 weeks, 2 PRN [as needed] for wound problems. A supplemental order was written on 2/22/22 for wound care to the right calf – apply xeroform and apply secondary dressing. Review of the clinical record revealed LPN # 15 conducted a routine visit on 2/22/22 and documented the following treatment to the right calf “applied nonstick abd and kerlix”. There was no evidence the LPN applied the physician ordered dressing. During an interview with LPN # 15 on 5/10/23 at approximately 1:35 pm, the LPN stated, “I applied whatever I documented.”

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 policy review, clinical record review, and staff interview, there was no evidence staff notified the physician of changes in behaviors/conditions/living situations/medications for 8 of 18 patients (#5, 9, 16, 10, 7, 11, 13, and 15). Findings included: 5. Patient # 7 had a Start of Care date of 4/14/23 and admitting diagnoses of cellulitis [bacterial skin infection] of right lower limb, laceration without foreign body, right lower leg, type 2 diabetes mellitus with diabetic chronic kidney disease. Review of the Plan of Care for the certification period from 4/14/23 to 6/12/23 included order for SN [skilled nursing] to evaluate. RN # 1 completed the SN evaluation on 4/19/23. RN # 1 documented the following information, “Patient reports continued burning when urination despite administration of ABX [antibiotic] during recent hospitalization. The patient was not discharged with any further medications for UTI [urinary tract infection]. Patient has upcoming clinic appt [appointment] with PCP [primary care provider]. Encouraged patient to report symptoms during visit…Instructed patient to continue to drink water and cranberry juice. Daughter is given AZO [over the counter medication used for urinary tract pain].” The patient was admitted to ______ [name of hospital] on 4/20/23 with a diagnosis of urinary tract infection. There was no evidence the RN notified the physician of the patient’s complaints of dysuria at the time of the nursing evaluation. During an interview with RN # 1 on 5/10/23 at approximately 1:45 pm the RN confirmed she did not inform the physician of the patient’s complaints. 6. Patient # 7 had a Start of Care date of 4/14/23 and admitting diagnoses of cellulitis [bacterial skin infection] of right lower limb, laceration without foreign body, right lower leg, type 2 diabetes mellitus with diabetic chronic kidney disease. Review of the clinical record revealed the patient had an inpatient stay from 4/20/23-4/27/23. Review of the ROC [resumption of care-comprehensive assessment completed after inpatient stay] Plan of Care [POC] dated 4/30/23 to 6/12/23 included diagnoses of non-pressure chronic ulcer other part right low leg w fat layer exposed and laceration without foreign body, right lower leg. The POC also included orders for SN [skilled nursing] 2 times a week for 5 weeks, 2 PRN [as needed] for wound decline. Review of the Skilled Nursing Note dated 5/7/23 revealed RN # 1 documented a blood sugar of 507. On 5/9/23, the RN documented a blood sugar of 379. There was no evidence the RN contacted the physician related to the blood sugar readings. During an interview with the RN on 5/10/23 at approximately 11:30 am, the RN stated, “I didn’t call the physician, the family always notified the physician of these types of things.” 7. Patient # 11 had a Start of Care [SOC] date of 4/4/23 and an admitting diagnosis of type 2 diabetes mellitus with diabetic poly neuropathy [complication of diabetes resulting in damage to nerve fibers]. Review of the Plan of Care for the certification period 4/4/23-6/2/23 included order for SN [skilled nursing] 1 time a week for 4 weeks, 1 time a week every other week for 5 weeks and “Notify physician of… Pulse greater than (>) 110 or less than () 160 or less than ()100 or less than ( Review of the clinical record revealed RN # 8 conducted a routine visit on 4/12/23 and documented a pulse of 58. There was no evidence the nurse contacted the physician of the pulse being outside the given parameter. An interview was conducted with RN # 8 on 5/10/23 at approximately 2:35 pm, during the interview the nurse stated, “If I called the physician, I would have documented it.” RN # 8 conducted a routine visit on 4/28/23 and documented a blood pressure reading of 164/64. There was no evidence the physician was notified of the reading. During the interview with the RN on 5/10/23 at 2:35 pm, the RN stated, “I guess not [when asked if the physician was notified of the BP].” 8. Patient # 13 had a Start of Care date of 8/24/21. Review of the Plan of Care [POC] for the certification period 2/20/22 to 4/20/22 revealed diagnoses of laceration without foreign body of right hand, laceration without foreign body, right lower leg, type 2 diabetes mellitus with foot ulcer, non-pressure chronic ulcer, right foot and non-pressure chronic ulcer of left heel and midfoot. Review of the ROC [resumption of care-comprehensive assessment after inpatient stay] Plan of Care [POC] dated 3/27/22 included orders for SN [skilled nursing] 2 times a week for 3 weeks and 2 PRN [as needed for wound care] and “…SN to instruct pt [patient] on wound care as follows: R [right]plantar ft [foot]: cleanse with ns [normal saline], apply betadine, secure with kerlix and tape daily…SN to instruct pt on wound care as follows: digits on R ft: cleanse with ns, apply betadine, secure with kerlix and tape daily…To R plantar foot and R ankle wound; Cleanse with NS and gauze, apply Santyl to wound bed, abd pad, kerlix, tape. to be performed daily. To L dry gangrene toe wounds, L heel wound; Cleanse with NS and gauze, apply betadine, gauze between toes, abd pad, kerlix tape, to be performed daily…” Review of the clinical record revealed RN # 26 conducted a routine visit on 4/5/22 and documented the following information, “patient refused all wound assessments and wound care today. Dressing changed by spouse this morning…” Further review of the clinical record revealed no evidence the physician was notified that the patient refused wound care. RN # 26 was not available for interview. During an interview with the agency administrator on 5/10/23 at approximately 3:40 pm, the administrator confirmed there was no evidence the physician was notified. 9. Patient # 15 had a Start of Care date of 1/28/22 with an admitting diagnosis of acute and chronic respiratory failure with hypoxia [low oxygen levels in the blood]. Review of the Plan of Care for the certification period 1/28/22 to 3/28/22 included orders for SN [skilled nursing] 1 time a week for 1 week, 2 times a week for 3 weeks, 2 PRN [as needed] for wound problems. Review of the clinical record revealed RN # 1 documented the following information during a routine visit on 3/14/22, “Patient lying in bed resting upon SN [skilled nurse] arrival. CG [caregiver] at bedside. CG voiced concern over the large amount of bruising noted to patient's bodydue [sic] to bedbound status. Patient does have extraordinary amount of new and old bruising noted over entire body. The CG expressedconcern [sic] that the patient was being abused by the other CG. She stated that the other CG is rough with the patient, and she stated that shehad [sic] voiced her concerns to the family with no results. She also stated that when she questioned the patient about possible abuse thepatient [sic] voiced agreement… Spoke with patients [sic]son who is POA [power of attorney] about SN concerns of possibleabuse [sic] and of the documentation taken, he verbalized understanding and he stated he would speak with CG in question…” Further review of the clinical record revealed no evidence the nurse contacted the physician regarding the concern for abuse. During an interview with RN # 1 on 5/10/23 at approximately 12:30 pm, the RN confirmed she did not notify the physician. “I spoke with our clinical manager, and she told me to take pictures and talk to the son.” 10. Patient # 15 had a Start of Care [SOC] date of 1/28/22 with an admitting diagnosis of acute and chronic respiratory failure with hypoxia [low oxygen levels in the blood]. Review of the Plan of Care for the certification period 1/28/22 to 3/28/22 included orders for SN [skilled nursing] 1 time a week for 1 week, 2 times a week for 3 weeks, 2 PRN [as needed] for wound problems. Review of the clinical record revealed LPN # 15 conducted a routine visit on 2/16/22 and documented the presence of unstageable [an ulcer that has full thickness tissue loss but is either covered by extensive necrotic tissue or by an eschar] pressure ulcers on bilateral heels. LPN # 15 documented the following information…” Patient has new areas to bilateral heels. CG reports thesewere [sic] observed yesterday by MD [physician] who did not give orders for skilled care to HH [home health] …” The clinical record revealed no evidence the LPN followed up with the physician to ensure the physician was aware of the unstageable pressure ulcers. During an interview with LPN # 15 on at approximately 1:35 pm, the LPN stated, “the doctor made a home visit, and the caregiver told me he saw the new areas.” A policy, “Coordination of Services” (revised 12/2021), was provided by the agency administrator on 5/9/23 at 8:30 a.m. The policy stated, “___ Home Health Agency staff promptly contacts the physician…When there are changes in the patient’s condition…When the patient requests changes or voices concerns…When changes occur in caregiver support or the environment…When ____ Home Health Agency can no longer adequately meet the patient’s medical, nursing, and/or social needs in patient’s place of residence.” A policy, “Care Plan Implementation” (reviewed 12/2022), was provided by the agency administrator on 5/9/23 at 8:30 a.m. The policy stated, “The HHA [home health agency] will notify the physician promptly to any changes in the patient condition or needs that suggest outcomes are not being achieved and/or that the plan of care should be altered." 1. Patient #5 was admitted on 4/16/23 with diagnoses of right femur (thigh bone) fracture, essential hypertension, type 2 diabetes, and schizophrenia. The Plan of Care (POC) was not completed until 5/8/23. On 5/9/23, a POC was provided for dates of 4/16/23-6/14/23. There were orders for physical therapy three times per week for two weeks; occupational therapy weekly for five weeks; and speech therapy weekly for six weeks. PT #22 visit note on 4/24/23 stated, “Session was extremely limited this date, as pt [patient] experiencing substance intoxication from Marijuana usage. Pt was extremely unsteady in [sic] his feel, presenting with poor judgment and safety awareness and saturated in urine.” On 4/25/23, ST #18 conducted a visit. The visit note stated, “…strong odor of marijuana upon arrival; observed a plastic container of it on his kitchen table.” On 5/4/23, PT #22 visit note stated, “Pt intoxicated from Marijuana…Pt very [unsteady] due to being intoxicated…Session limited due to pt intoxication…” There was no evidence the physician was notified of the marijuana use. An interview with PT #22 on 5/10/23 at 2:38 p.m. revealed the patient began smoking marijuana after his family stopped staying at the patient’s home. The PT stated that they “thought” they told the physician. 2. Patient #9 was admitted on 3/21/23 with a diagnosis of hemiplegia (paralysis on one side of body) following a cerebral infarction (stroke). The Plan of Care for 3/21/23-5/19/23 included orders for physical therapy and occupational therapy. Skilled nursing completed an assessment on 4/9/23. On 5/2/23, RN #___ witnessed a young female enter the patient’s room and ask for money. She became agitated and yelled and cursed at the patient. The patient gave the young female $10 and she yelled and screamed at the patient again telling him “she was gonna [sic] starve cause she needed gas money. She finally grabbed the little bit of money he had and stormed out of the room. The pt started crying stating he didn’t know why she was like [sic]. Emotional support was given and or was informed if nurse would leave if she came back during visit and that he should contact the police as her behavior was not acceptable. He just said she has anger issues but would be fine.” There was no evidence the physician was notified of the event. An interview was conducted with RN #7 on 5/10/23 at 1:16 p.m. The RN stated, “I reported to ____ [clinical manager] and she just said to document it.” The interview confirmed the physician was not notified. 3A. Patient #16 was admitted on 6/18/22 with diagnoses of stage 2 pressures (an open area or blister caused by pressure) ulcers to abdominal pannus (dense layer of fatty tissue within the lower abdominal region), type 2 diabetes, morbid (severe) obesity, and dependence on supplemental oxygen. The Plan of Care (POC) for 6/18/22-8/16/22 included orders for skilled nursing weekly for one week, then twice weekly for seven weeks. The visit notes for 6/21/22 stated, “Nurse notes patients bed sheets are extremely filthy with crumbs of Cheetos and all other kinds of food and dead skin on them. Patients [sic] hygiene is poor and patient states that he just does not feel like bathing and patient is laying in the bed completely naked. Nurse can see dried stole [sic] on the inside of the patients [sic] thighs. On 6/23/22, the visit note stated, “Nurse notes patients bed sheets are still visibly filthy and patient still has Brown residue in between the folds of his legs.” There was no evidence the physician was notified of the concerns related to the patient’s hygiene. An interview with the clinical manager on 5/10/23 at 3:30 p.m. confirmed there was no evidence the physician was notified. 3B. Patient #16 was admitted on 6/18/22 with diagnoses of stage 2 pressures (an open area or blister caused by pressure) ulcers to abdominal pannus (dense layer of fatty tissue within the lower abdominal region), type 2 diabetes, morbid (severe) obesity, and dependence on supplemental oxygen. The Plan of Care (POC) for 6/18/22-8/16/22 included orders for skilled nursing weekly for one week, then twice weekly for seven weeks. The POC included orders for oxygen 2 liters per minute. The initial assessment conducted on 6/18/22 revealed the patient was on oxygen 2 liters per minute. The visit notes on 6/21/22, 6/23/22, 7/6/22, 7/8/22, 7/11/22, 7/15/22, 7/19/22, and 7/28/22, stated that the patient was on oxygen 3 liters per minute. An interview with the agency administrator on 5/10/23 at 3:28 p.m. confirmed the order was for 2 liters per minute, and there was no evidence the physician was notified of oxygen used at 3 liters per minute. 3C. Patient #16 was admitted on 6/18/22 with diagnoses of stage 2 pressures (an open area or blister caused by pressure) ulcers to abdominal pannus (dense layer of fatty tissue within the lower abdominal region), type 2 diabetes, morbid (severe) obesity, and dependence on supplemental oxygen. The Plan of Care (POC) for 6/18/22-8/16/22 included orders for skilled nursing weekly for one week, then twice weekly for seven weeks. The POC included orders for wound to abdominal pannus stage 2 pressure ulcers: clean with wound cleanser, apply mepilex, change twice weekly and as needed. There were no other wound care orders. On 6/23/23, the visit note stated, “Wife stated she…changed the bandage on his foot using hydrocortisone cream…Wife said she also uses a silver Silvadene cream on patients [sic] heel as well sometimes [sic].” On 5/10/23 at 3:28 p.m., the clinical manager confirmed that there were orders for hydrocortisone or Silvadene, and there was evidence the physician was notified that the caregiver was using those medications. 3D. Patient #16 was admitted on 6/18/22 with diagnoses of stage 2 pressures (an open area or blister caused by pressure) ulcers to abdominal pannus (dense layer of fatty tissue within the lower abdominal region), type 2 diabetes, morbid (severe) obesity, and dependence on supplemental oxygen. The Plan of Care (POC) for 6/18/22-8/16/22 included orders for skilled nursing weekly for one week, then twice weekly for seven weeks. The POC included orders for wound to abdominal pannus stage 2 pressure ulcers: clean with wound cleanser, apply mepilex, change twice weekly and as needed. The visit notes on 7/1/23, stated, “Patient’s wife states that she has started putting raw honey on the wound on the left side of his stomach…Patient’s wife states that she got this idea from the internet after doing some research on what would be the best option to heal the wound.” On 5/10/23 at 3:28 p.m., the clinical manager confirmed there was evidence the physician was notified that the caregiver was using honey until 7/6/23. 4. Patient #10 was admitted on 8/19/23 with diagnoses of infection/inflammation due to an internal right hip prosthesis, type 2 diabetes, and chronic kidney disease. The Plan of Care (POC) for 4/16/23-6/14/23 included orders for skilled nursing visits three times per week for eight weeks, then twice for one week. The visit notes on 4/17/23 stated that pain was managed by “hydrocodeine [sic].” The visit notes on 4/24/23 stated that pain was managed by “hydrocodone.” Hydrocodone was not included in the POC. An interview with RN # 13 on 5/10/23 at 2:20 p.m. revealed the hydrocodone was discontinued in November 2022. There was no notification to the physician that the patient took it in April 2023.

Revised plan of care CFR(s): 484.60(c)(2) A revised plan of care must reflect current information from the patient's updated comprehensive assessment, and contain information concerning the patient's progress toward the measurable outcomes and goals identified by the HHA and patient in the plan of care. This ELEMENT is not met as evidenced by: Based on policy review, clinical record review, and staff interviews, the agency failed to update the Plan of Care for 1 of 13 active patients (#10). Findings included: A policy, “Care Plan Implementation” (reviewed 12/2022), was provided by the agency administrator on 5/9/23 at 8:30 a.m. The policy stated, “A written plan of care is developed in consultation with the patient, physician and agency staff…Each patient will receive an individualized plan of care including any revision or additions.” Patient #10 was admitted on 8/19/23 with diagnoses of infection/inflammation due to an internal right hip prosthesis, type 2 diabetes, and chronic kidney disease. The Plan of Care (POC) for 4/16/23-6/14/23 included orders for skilled nursing visits three times per week for eight weeks, then twice for one week. A nurse’s note on 5/3/23 stated, “Both feet and ankles have less edema set [sic] started on Lasix [fluid pill]. An interview with the agency administrator on 5/10/23 at 2:58 p.m. confirmed the Lasix was not added to the POC.

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, home visit observation, record review, and staff interviews, the agency failed to comply with hand hygiene standards for 1 of 6 home visit observations (#6). Findings included: A policy, “Bag Technique” (revised 12/2022), was provided by the agency administrator on 5/9/23 at 4:30 p.m. The policy stated, “Hands are cleansed prior to returning clean equipment and supplies to bag.” Patient #6 was admitted on 7/25/22 with diagnoses of pressure ulcer right buttock stage 3 (a wound caused by pressure that involves full-thickness skin loss and extends into the fatty tissue), pressure ulcer left buttock unstageable (a wound caused by pressure, but depth obscured) and paraplegia (paralysis of the lower body). The Plan of Care (POC) for 3/22/23-5/20/23 included nursing visits weekly for nine weeks. A home visit was conducted with RN #7 on 5/9/23 at approximately 9:00 a.m. During the visit, the RN obtained vital signs, cleaned equipment, and placed equipment back into clinical back without performing hand hygiene between cleaning dirty equipment and entering the bag. An interview RN #7 was conducted on 5/10/23 at 1:10 p.m. The RN said that the cleansing wipe used to clean the equipment also cleaned her hands prior to entering clinical bag. Clinical Manager #25 also observed the visit. The Clinical Manager confirmed the RN returned the equipment to the bag without performing hand hygiene.

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 policy review, clinical record review, and staff interview, the skilled nurse failed to assess areas of potential concern on a patient’s feet for 1 of 1 patient in which the physical therapist requested nursing to assess feet (#5); failed to obtain wound measurements for 1 of 8 patients with a wound (#15). Findings included: The policy, Wound Care Standards [review 8/2022] was provided by the agency administrator on 5/9/23 at 4:30 pm. The policy stated, “…After the initial assessment, skin integrity will be assessed at every visit. Any patient with an open area will have sites measured and documented weekly…” The policy, Wound Care Standards [review 8/2022] was provided by the agency administrator on 5/9/23 at 4:30 pm. The policy stated, “…After the initial assessment, skin integrity will be assessed at every visit. Any patient with an open area will have sites measured and documented weekly…” 1. Patient #5 was admitted on 4/16/23 with diagnoses of right femur (thigh bone) fracture, essential hypertension, type 2 diabetes, and schizophrenia. The Plan of Care (POC) was not completed until 5/8/23. On 5/9/23, a POC was provided for dates of 4/16/23-6/14/23. There were orders for physical therapy three times per week for two weeks; occupational therapy weekly for five weeks; and speech therapy weekly for six weeks. The initial assessment was conducted on 4/16/23 by the physical therapist (PT). The PT visit note for 4/19/23 revealed the patient had “small black places” on multiple toes. The PT was not clear of origin and requested an order from the physician for a nursing evaluation. An order for a nursing evaluation was received on 4/25/23, and the evaluation was conducted on 4/27/23. There was no assessment of the feet documented in the nursing evaluation. An interview with RN #7 on 5/10/23 at 1:20 p.m. The RN stated, “I don’t remember looking at his feet.” An interview with the agency administrator on 5/10/23 at 3:00 p.m. confirmed the nurse should have assessed the patient’s feet. 2. Patient # 15 had a Start of Care [SOC] date of 1/28/22 with an admitting diagnosis of acute and chronic respiratory failure with hypoxia [low oxygen levels in the blood]. Review of the Plan of Care for the certification period 1/28/22 to 3/28/22 included orders for SN [skilled nursing] 1 time a week for 1 week, 2 times a week for 3 weeks, 2 PRN [as needed] for wound problems. Supplemental orders were written on 3/27/22 for SN [skilled nursing] 2 times a week for 3 weeks and 2 PRN [as needed for wound care]. Review of the clinical record revealed on 2/16/22 LPN # 15 identified 2 unstageable [an ulcer that has full thickness tissue loss but is either covered by extensive necrotic tissue or by an eschar - a dry, dark scab] pressure ulcers on bilateral heels. Further review of the clinical record revealed no wound measurements from 2/16/22 to the week of 3/27/22 [discharge]. During an interview with the agency administrator on 5/10/23 at approximately 3:05 pm, during the interview the administrator confirmed the wounds were not measured.

Preparing clinical notes CFR(s): 484.75(b)(6) Preparing clinical notes; This ELEMENT is not met as evidenced by: Based on agency policy review, clinical record review and staff interviews, the skilled nurse failed to assess a wound for 1 of 8 patients with a wound [#15]. The findings included: The policy, Wound Care Standards [review 8/2022] was provided by the agency administrator on 5/9/23 at 4:30 pm. The policy stated, “…After the initial assessment, skin integrity will be assessed at every visit. Any patient with an open area will have sites measured and documented weekly…” Patient # 15 had a Start of Care [SOC] date of 1/28/22 with an admitting diagnosis of acute and chronic respiratory failure with hypoxia [low oxygen levels in the blood]. Review of the Plan of Care for the certification period 1/28/22 to 3/28/22 included orders for SN [skilled nursing] 1 time a week for 1 week, 2 times a week for 3 weeks, 2 PRN [as needed] for wound problems. Supplemental orders were written on 3/27/22 for SN [skilled nursing] 2 times a week for 3 weeks and 2 PRN [as needed for wound care]. Review of the clinical record revealed the LPN # 15 identified 2 unstageable [ an ulcer that has full thickness tissue loss but is either covered by extensive necrotic tissue or by an eschar] pressure ulcers on bilateral heels. Review of the clinical record revealed RN # 1 conducted routine visits on 3/4/22 and 3/14/22. There was no evidence the RN assessed the bilateral heels. During an interview with RN # 2 on 5/10/23 at approximately 11:30 am, the RN stated, “I am sure I assessed the heels, I guess I forgot to document it.”

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 document follow-up for 1 of 1 patients (#16). Findings included: Patient #16 was admitted on 6/18/22 with diagnoses of stage 2 pressures (an open area or blister caused by pressure) ulcers to abdominal pannus (dense layer of fatty tissue within the lower abdominal region), type 2 diabetes, morbid (severe) obesity, and dependence on supplemental oxygen. The Plan of Care (POC) for 6/18/22-8/16/22 included orders for skilled nursing weekly for one week, then twice weekly for seven weeks. The visit notes for 6/21/22 stated, “Nurse notes patients bed sheets are extremely filthy with crumbs of Cheetos and all other kinds of food and dead skin on them. Patients [sic] hygiene is poor and patient states that he just does not feel like bathing and patient is laying in the bed completely naked. Nurse can see dried stole [sic] on the inside of the patients thighs. On 6/23/22, the visit note stated, “Nurse notes patients bed sheets are still visibly filthy and patient still has Brown residue in between the folds of his legs.” On 7/6/23, the visit note stated, “…nurse notes patient hygiene is very poor and he is soiled from sweat in between all folds of his skin. Patients [sic] wife is still refusing help of a home health aide for a bath…” On 7/28/23, the visit note stated, “Nurse notes patients [sic] sheets are extremely filthy. Wife has to put trash can behind the bed and rake out all the crumbs and dry skin off of patient’s bed whenever we get him to sit up to provide wound care. Nurse notes there were pills that patient had dropped unknowingly in his bed. Nurse expresses that she is concerned for patient and his wife’s well being in this condition…Home health nurse tries to call VA nurse to express concern and see what our options are or the possibility of Adult Protection Services paying a visit…” An interview on 5/10/23 at ___ p.m. with RN #7 confirmed the physician office returned the call and stated, “They were handling.” There was no evidence in the clinical record that the VA stated that they would follow-up.

An unannounced onsite complaint investigation was conducted 10/11/21-10/12/21. The allegation was unsubstantiated. The survey did result in standard level deficiencies to the Medicare CoP.

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 related to wound care for 1 of 3 charts [#1]; failed to follow the plan of care related to lab work for 1 of 1 charts [#1]. The findings included: 1A. Patient # 1 had a Start of Care [SOC] date of 2/22/21 and admitting diagnoses of Encounter for Orthopedic aftercare following surgical amputation and Type 2 Diabetes Mellitus with other specified complications, Other acute Osteomyelitis [infection of the bone] left ankle and foot. A review of the Plan of Care [POC] for the certification period 2/22/21 to 4/22/21 revealed an order for SN [skilled nursing] 1 time a week for 6 weeks; 2 PRN [ as needed] for PICC [peripherally inserted central catheter] complications. A supplemental order was written on 3/9/21. The order stated, "...Wound orders for 4th digit on L [left] ft [foot]: cleansed [sic] soap/water, apply xeroform and dry dressing. amputation of 5th digit on L ft: cleansed with vashe, apply dakin's soaked 1/4" packing strips to wound beds, cover with dry dressing. Change daily and prn for soiling. SN to change weekly..." A review of the clinical record revealed the following information, on 3/15/21 RN # 4 made a routine visit. A review of the clinical record revealed no assessment of the wound and no evidence the treatment to the wound was completed. On 3/23/21 RN # 1 made a routine visit and documented the following information, “Pt [patient] declined wound care today-spouse changed dressing this morning before leaving for a dr [doctor] appt [appointment]. Dressing cdi [clean, dry, intact] …”. On 4/6/21 RN # 1 made a routine visit and documented the following information, “… Pt declined wound care today - spouse changed dressing this morning. Dressing cdi…” On 4/13/21, RN # 1 made a visit to discharge the patient and documented the following information, “…declined wound care today. spouse already changed dressing…” An interview was conducted with RN # 1 on 10/21/21. During the interview the RN stated, “the patient only let me look at the wound a couple of times. I did not call the doctor each time she refused to let me change the dressing…” An interview was conducted with the agency director on 10/12/21. The agency director confirmed the POC was no followed. 2B. Patient # 1 had a Start of Care [SOC] date of 2/22/21 and admitting diagnoses of Encounter for Orthopedic aftercare following surgical amputation and Type 2 Diabetes Mellitus with other specified complications, Other acute Osteomyelitis [infection of the bone] left ankle and foot. A review of the Plan of Care [POC] for the certification period 2/22/21 to 4/22/21 revealed an order for SN [skilled nursing] 1 time a week for 6 weeks; 2 PRN [ as needed] for PICC [peripherally inserted central catheter] complications. A supplemental order was written on 2/18/21 for lab work. The order was for the SN to obtain a CBC [complete blood count] w/diff, BMP [basic metabolic panel] and ESR [erythrocyte sedimentation rate] each Monday. A review of the clinical record revealed the lab work was obtained on 3/2/21 [Tuesday], 3/23/21 [Tuesday], 3/30/21 [Tuesday] and 4/6/21 [Tuesday]. Further review of the clinical record revealed no evidence a new order was written to obtain lab work on Tuesday. An interview was conducted with the agency director on 10/12/21. During the interview the agency director confirmed the POC was not followed related to the day of the week the labs were obtained.

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 agency failed to document PICC [peripherally inserted central catheter]line measurements for 1 of 2 charts with a PICC line [#1]; failed to document wound measurements for 1 of 3 charts with a wound [#1]; failed to transcribe discharge orders correctly on the resumption of care orders for 1 of 3 charts [#2]. The findings included: The policy, Central Venous Catheters and Midline Catheters [revised date of 9/2021], was provided by the agency director on 10/12/21. The policy stated, “…Weekly the PICC line care should include measurement and observation of the site. The clinician will measure the amount of catheter visible outside of the arm…Weekly the clinician should measure the arm circumference of the affect arm…” The policy, Wound Care Standards [revised date 8/2021], was provided by the agency director on 10/12/21. 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…” 1A. Patient # 1 had a Start of Care [SOC] date of 2/22/21 and admitting diagnoses of Encounter for Orthopedic aftercare following surgical amputation and Type 2 Diabetes Mellitus with other specified complications, Other acute Osteomyelitis [infection of the bone] left ankle and foot. A review of the Plan of Care [POC] for the certification period 2/22/21 to 4/22/21 revealed an order for SN [skilled nursing] 1 time a week for 6 weeks; 2 PRN [ as needed] for PICC [peripherally inserted central catheter] complications. A review of the clinical record revealed Patient # 1 received nursing visits on 2/22/21, 3/2/21, 3/8/21, 3/12/21, 3/15/21, 3/23/21, 3/30/21, 4/6/21 and 4/13/21 [discharge visit and PICC line was discontinued]. Further review of the clinical record revealed no PICC line measurements during the nursing visits. On 10/12/21 a telephone interview was conducted with RN # 1. During the interview the RN reported, “I only document if the PICC line is not the same length as the previous visit.” An interview was conducted with RN # 2 on 10/12/21 at approximately 11 am. During the interview RN # 2 confirmed the PICC line was no measured in accordance with the agency policy. 1B. Patient # 1 had a Start of Care [SOC] date of 2/22/21 and admitting diagnoses of Encounter for Orthopedic aftercare following surgical amputation and Type 2 Diabetes Mellitus with other specified complications, Other acute Osteomyelitis [infection of the bone] left ankle and foot. A review of the Plan of Care [POC] for the certification period 2/22/21 to 4/22/21 revealed an order for SN [skilled nursing] 1 time a week for 6 weeks; 2 PRN [ as needed] for PICC [peripherally inserted central catheter] complications. A review of the clinical record revealed Patient # 1 was admitted with a surgical wound to left foot. Further review of the clinical record revealed no wound measurements/assessment to the surgical wound until 3/12/21. There was a wound measurement documented on 3/12/21. The next wound measurement was not obtained until 3/30/21. An interview was conducted with RN # 2 on 10/12/21. During the interview the RN confirmed the wound should have been measured/assessed weekly. 2. Patient # 2 had a Start of Care [SOC] date of 8/24/21 and an admitting diagnosis of Type 2 diabetes mellitus with foot ulcer. A review of the Plan of Care for the certification period 8/24/21 to 10/22/21 revealed orders for SN [skilled nursing] Effective 8/24/2021 2 times a week for 9 weeks and 2 PRN [as needed] for wound related problems. A review of the clinical record revealed Patient # 2 had an inpatient stay from 8/26/21 to 9/1/21. A review of the ROC [resumption of care] orders revealed the following SN orders-1 time a week for 1 week; 2 times a week for 1 week; 3 times a week for 6 weeks; 5 PRN for wound changes. A review of the hospital discharge orders dated 9/1/21 revealed the following order, “Right Great toe: Continue to paint with betadine daily and cover with dry dressing. Bilateral heels: Mepilex foam boarder to bilateral heels. Change every Monday, Friday and PRN. Right first metatarsal head, posterior: Aquacel to wound bed, followed by dry dressing. Change every Monday, Wednesday and Friday. Right medial thigh vein harvest site (area of dehishence [sic]): Normal saline packing gauze. Change daily. Right groin: Twice daily wet-to-dry dressing changes. May transition back to wound vac on Friday, 9/3/2021…” A review of the ROC orders dated 9/3/21 and signed by RN # 4 did not include the discharge orders from the hospital. The wound care on the ROC orders were the following, “…SN to change negative pressure wound therapy dressing…2 times per week and as needed…clean wound with saline, pack with saline soaked strip, cover with abd pad and secure with tape…” An interview was conducted with RN # 3 on 10/12/21. RN # 3 confirmed the wound care orders on the ROC were not the orders the physician had ordered. Patient # 2 was hospitalized from 9/8/21 until 9/15/21 with the ROC being done on 9/16/21. A review of the wound care discharge orders included the following order, “Wound VAC dressing changes 3 x weekly . Further review of the agency ROC order revealed the following order “…SN to change negative pressure wound therapy dressing…2 times per week and as needed…clean wound with saline, pack with saline soaked strip, cover with abd pad and secure with tape. The correct wound care order from the hospital was not transcribed correctly to the agency ROC orders. The patient was hospitalized from 9/24/21 until 9/27/21. The ROC was completed on 9/29/21. A review of the discharge orders for wound care included the following order, “ …continue wound vac, change MWF [Monday, Wednesday, Friday]…” A review of the agency ROC order revealed the following order, "SN to change negative pressure wound therapy dressing 2 times per week and as needed..." An interview was conducted with the agency director on 10/12/21. During the interview the director confirmed the clinical record did not contain the correct wound care orders.