Every finding on record at Mercy Health Services, LLC

Emergency Preparedness Survey

EP Training Program CFR(s): 484.102(d)(1) §403.748(d)(1), §416.54(d)(1), §418.113(d)(1), §441.184(d)(1), §460.84(d)(1), §482.15(d)(1), §483.73(d)(1), §483.475(d)(1), §484.102(d)(1), §485.68(d)(1), §485.542(d)(1), §485.625(d)(1), §485.727(d)(1), §485.920(d)(1), §486.360(d)(1), §491.12(d)(1). *[For RNCHIs at §403.748, ASCs at §416.54, Hospitals at §482.15, ICF/IIDs at §483.475, HHAs at §484.102, REHs at §485.542, "Organizations" under §485.727, OPOs at §486.360, RHC/FQHCs at §491.12:] (1) Training program. The [facility] must do all of the following: (i) Initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles. (ii) Provide emergency preparedness training at least every 2 years. (iii) Maintain documentation of all emergency preparedness training. (iv) Demonstrate staff knowledge of emergency procedures. (v) If the emergency preparedness policies and procedures are significantly updated, the [facility] must conduct training on the updated policies and procedures. *[For Hospices at §418.113(d):] (1) Training. The hospice must do all of the following: (i) Initial training in emergency preparedness policies and procedures to all new and existing hospice employees, and individuals providing services under arrangement, consistent with their expected roles. (ii) Demonstrate staff knowledge of emergency procedures. (iii) Provide emergency preparedness training at least every 2 years. (iv) Periodically review and rehearse its emergency preparedness plan with hospice employees (including nonemployee staff), with special emphasis placed on carrying out the procedures necessary to protect patients and others. (v) Maintain documentation of all emergency preparedness training. (vi) If the emergency preparedness policies and procedures are significantly updated, the hospice must conduct training on the updated policies and procedures. *[For PRTFs at §441.184(d):] (1) Training program. The PRTF must do all of the following: (i) Initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles. (ii) After initial training, provide emergency preparedness training every 2 years. (iii) Demonstrate staff knowledge of emergency procedures. (iv) Maintain documentation of all emergency preparedness training. (v) If the emergency preparedness policies and procedures are significantly updated, the PRTF must conduct training on the updated policies and procedures. *[For PACE at §460.84(d):] (1) The PACE organization must do all of the following: (i) Initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing on-site services under arrangement, contractors, participants, and volunteers, consistent with their expected roles. (ii) Provide emergency preparedness training at least every 2 years. (iii) Demonstrate staff knowledge of emergency procedures, including informing participants of what to do, where to go, and whom to contact in case of an emergency. (iv) Maintain documentation of all training. (v) If the emergency preparedness policies and procedures are significantly updated, the PACE must conduct training on the updated policies and procedures. *[For LTC Facilities at §483.73(d):] (1) Training Program. The LTC facility must do all of the following: (i) Initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected role. (ii) Provide emergency preparedness training at least annually. (iii) Maintain documentation of all emergency preparedness training. (iv) Demonstrate staff knowledge of emergency procedures. *[For CORFs at §485.68(d):](1) Training. The CORF must do all of the following: (i) Provide initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles. (ii) Provide emergency preparedness training at least every 2 years. (iii) Maintain documentation of the training. (iv) Demonstrate staff knowledge of emergency procedures. All new personnel must be oriented and assigned specific responsibilities regarding the CORF's emergency plan within 2 weeks of their first workday. The training program must include instruction in the location and use of alarm systems and signals and firefighting equipment. (v) If the emergency preparedness policies and procedures are significantly updated, the CORF must conduct training on the updated policies and procedures. *[For CAHs at §485.625(d):] (1) Training program. The CAH must do all of the following: (i) Initial training in emergency preparedness policies and procedures, including prompt reporting and extinguishing of fires, protection, and where necessary, evacuation of patients, personnel, and guests, fire prevention, and cooperation with firefighting and disaster authorities, to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles. (ii) Provide emergency preparedness training at least every 2 years. (iii) Maintain documentation of the training. (iv) Demonstrate staff knowledge of emergency procedures. (v) If the emergency preparedness policies and procedures are significantly updated, the CAH must conduct training on the updated policies and procedures. *[For CMHCs at §485.920(d):] (1) Training. The CMHC must provide initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles, and maintain documentation of the training. The CMHC must demonstrate staff knowledge of emergency procedures. Thereafter, the CMHC must provide emergency preparedness training at least every 2 years. This STANDARD is not met as evidenced by: Based on record reviews and interviews, the agency failed to ensure direct care staff were trained on their emergency preparedness (EP) plan upon hire, and at least every 2 years thereafter for 4 (S6HHA, S7HHA, S8HHA, and S15RN) of 14 personnel files reviewed. Findings: Review of the agency’s Emergency Operations Plan (EOP) dated 04/08/2025 revealed in part: V. Training A. All new staff will be trained on the EOP in orientation. D. Emergency Preparedness training will be conducted annually. Review of S6HHA’s personnel file revealed a hire date of 02/26/2024. Further review revealed there was no documented evidence EP training was completed upon hire on or after 02/26/2024 or 2025. Review of S7HHA’s personnel file revealed a hire date of 08/17/2021. Further review revealed there was no documented evidence EP training was completed in 2024 or 2025. Review of S8HHA’s personnel file revealed a hire date of 02/19/2026. Further review revealed there was no documented evidence EP training was completed upon hire on or after 02/19/2026. Review of S15RN’s personnel file revealed a hire date of 01/20/2025. Further review revealed there was no documented evidence EP training was completed upon hire on or after 01/20/2025. On 04/20/2026 at 12:55 p.m., an interview was conducted with S2HR. S2HR confirmed there was no documentation available indicating S8HHA had completed EP training upon hire, and there was no documentation EP training had been completed for all other direct care staff mentioned above in 2024 or 2025. On 04/20/2026 at 1:00 p.m., an interview was conducted with S1ADM. S1ADM stated EP training should be completed upon hire and annually. S1ADM confirmed there was no documentation of EP training available for the direct care staff mentioned above for 2024 or 2025.

Recertification Survey Abbreviations: CMS- Centers for Medicare and Medicaid Services DSW- Direct Service Worker EOP- Emergency Operations Plan EP- Emergency Preparedness gms- grams mcg- microgram mg- milligram mg/ml- milligram/milliliter NPP- Non-physician Practitioner OASIS- Outcome and Assessment Information Set OIG- Office of Inspector General POC-Plan of Care PRN- as needed ROC- Resumption of Care SOC- Start of Care

Encoding and transmitting OASIS CFR(s): 484.45(a) Standard: An HHA must encode and electronically transmit each completed OASIS assessment to the CMS system, regarding each beneficiary with respect to which information is required to be transmitted (as determined by the Secretary), within 30 days of completing the assessment of the beneficiary. This STANDARD is not met as evidenced by: Based on record review and interview, the agency failed to encode and electronically transmit each completed OASIS (Outcome and Assessment Information Set) within 30 days of completion date of the assessment. Findings: Review of the agency’s undated policy titled “Encoding and Reporting OASIS Data” revealed, in part: Policy: The agency will electronically report all OASIS data collected in accordance with federal regulations. Special Instructions: 1. Agency will encode and electronically transmit each completed OASIS assessment to the Center for Medicare and Medicaid Services (CMS) system within 30 days of completing the assessment of the client. Review of the agency’s OASIS Agency Final Validation Report dated 01/05/2026 revealed 1 out of 1 record submitted was greater than 30 days after the completion date of 12/05/2025. Review of the agency’s OASIS Agency Final Validation Report dated 01/06/2026 revealed 1 out of 41 records submitted was greater than 30 days after the completion date of 12/05/2025. Review of the agency’s OASIS Agency Final Validation Report dated 01/21/2026 revealed 1 of 1 record submitted was greater than 30 days after the completion date of 12/21/2025. Review of the agency’s OASIS Agency Final Validation Report dated 01/24/2026 revealed 1 of 1 record submitted was greater than 30 days after the completion date of 12/06/2025. Review of the agency’s OASIS Agency Final Validation Report dated 02/14/2026 revealed 1 of 1 record submitted was greater than 30 days after the completion date of 01/13/2026. Review of the agency’s OASIS Agency Final Validation Report dated 03/04/2026 revealed 1 of 8 records submitted was greater than 30 days after the completion date of 01/31/2026. Review of the agency’s OASIS Agency Final Validation Report dated 03/31/2026 revealed 1 of 8 records submitted was greater than 30 days after the completion date of 02/28/2026. On 04/20/2026 at 12:25 p.m., an interview was conducted with S1ADM. S1ADM stated she submitted all OASIS data for the agency. S1ADM confirmed all OASIS should be submitted within 30 days of the completion date and the above-mentioned assessments were late.

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 observations, record reviews, and interviews, the agency failed to maintain an accurate medication profile for 2 (#2 and #5) of 7 sampled patients reviewed who received home visits. This deficient practice had the potential to affect all 228 patients, according to the agency’s current active census reported on 04/13/2026. Findings: Review of the agency’s undated policy titled “Medication Reconciliation” revealed, in part: Policy Agency will reconcile all medications taken by the client prior to admission to home care with those ordered at the time of admission, before and after inpatient facility stays, at 60-day reassessment visits, and at the time of discharge. Special Instructions 1. At the time of admission to the home care agency, the admitting professional will document a complete list of medications taken by the client prior to admission. This will include all over the counter (OTC), prescribed, and as needed (PRN) medications. Patient #2 Review of Patient #2’s Resumption of Care (ROC) orders dated 04/09/2026, for Certification Period 02/27/2026 through 04/27/2026, revealed a Skilled Nursing frequency of two visits every week for one week and one time every week for two weeks effective 04/09/2026; Physical Therapy 2 visits every week for 3 weeks effective 04/14/2026, and Occupational Therapy one visit per week for three weeks effective 04/09/2026. Review of Patient #2’s medication profile provided by the agency on 04/14/2026 revealed the following, in part: Metoprolol Tartrate 25 mg 1 tablet twice daily Combigan Ophthalmic 0.2-0.5% 1 ml both eyes daily Denosumab Subcutaneous 60 mg/ml 1-daily On 04/15/2026 at 3:00 p.m., a home visit observation was conducted with Patient #2, her spouse, sitter, and S14COTA present. Review of the medications on Patient #2's current medication profile list provided by the agency was reviewed with Patient #2’s sitter, who stated she was familiar with all of Patient #2’s medications. Further review revealed the following discrepancies: 1. Metoprolol Succinate 50 mg 1 tablet once daily- this medication was observed in home, sitter verified Patient #2 was currently taking the medication, but medication was not on the agency med profile. 2. Polyethylene Glycol 17 gms by mouth daily- sitter verified Patient #2 was currently taking this medication, but medication was not on the agency med profile. 3. Fluticasone Propionate 50 mcg 1 spray each nostril once daily as needed- sitter verified Patient #2 was currently taking this medication, but medication was not on the agency med profile. 4. Spironolactone 25 mg 1 tablet once daily- sitter verified Patient #2 was currently taking this medication, but medication was not on the agency med profile. 5. Combigan Ophthalmic 0.2-0.5% 1 ml twice daily both eyes-sitter verified Patient #2 was currently taking this medication twice daily, but the agency med profile had patient taking this once daily. 6. Denosumab Subcutaneous 60 mg/ml daily- sitter verified Patient #2 was not currently taking this medication, but medication was on the agency med profile. On 04/15/2026 03:15 p.m., an interview was conducted with Patient #2's Sitter, who stated Patient #2’s daughter managed all the patient’s medications and pre-filled her pill boxes weekly. Sitter stated Patient #2’s Metoprolol medication and dose had changed during her recent hospitalization. The Sitter confirmed Patient #2 was now taking Metoprolol Succinate 50 mg daily, Polyethylene Glycol 17 gms daily, Fluticasone nasal spray one spray each nostril daily as needed, and Spironolactone 25 mg daily. Sitter confirmed Patient #2’s Combigan eye drop was changed to twice daily prior to hospital discharge on 04/08/2026, and she was no longer taking the Denosumab injections. On 04/15/2026 at 3:55 p.m., an interview was conducted with S14COTA. S14COTA stated she asked Patient #2 if medication changes had occurred during their visits, and any medication changes were reported to the nurse. S14COTA stated she had not reviewed or reconciled any of Patient #2’s medication since hospital ROC on 04/09/2026. S14COTA stated all medications used by the patient should be accurately reflected on the agency medication profile. On 04/16/2026 at 2:58 p.m., an interview was conducted with S16RN. S16RN stated he was assigned to Patient #2. S16RN confirmed there was no medication reconciliation completed during Patient #2’s SN visits completed on 04/09/2026 or 04/10/2026. S16RN stated a Discharge Medication list was not provided with Patient #2’s ROC orders prior to visits on 04/09/2026 or on 04/10/2026. S16RN confirmed Patient #2’s med profile did not accurately reflect all current medications taken or not taken. On 04/16/2026 at 12:51 p.m., an interview was conducted with S1ADM. Patient #2’s med profile provided from the agency was compared to the hospital discharge medication list dated 04/08/2026 available in Patient #2’s home. S1ADM confirmed Patient #2’s medication profile from the agency did not accurately reflect all medications Patient #2 was currently taking or no longer taking. Patient #5 Review of Patient #5’s Start of Care (SOC) orders dated 03/30/2026 for Certification Period 03/31/2026 through 05/29/2026, revealed a Skilled Nursing frequency of two visits every week for two weeks and one time every week for seven weeks effective 03/31/2026; Physical Therapy one visit every week for one week, then two visits every week for two weeks, then one visit per week for one week effective 03/31/2026, and Occupational Therapy one visit per week for one week, then two visits per week for two weeks effective 03/31/2026. Review of Patient #5’s medication profile provided by the agency on 04/14/2026 revealed the following, in part: Amiodarone HCL 200 mg 1 tablet by mouth twice a day Furosemide (Lasix) 20 mg 1 tablet daily as needed for shortness of breath (SOB) On 04/15/2026 at 1:00 p.m., a home visit observation was conducted with Patient #5 and S12PTA present. Review of the medications on Patient #5's current medication profile list provided by the agency was reviewed with Patient #5, who stated she managed all of her own medications. Further review revealed the following discrepancies: 1. Amiodarone HCL 200 mg 1 tablet by mouth twice a day; Patient #5 stated she was currently taking 200 mg once daily as of 03/31/2026. 2. Furosemide (Lasix) 20 mg 1 tablet daily as needed for shortness of breath; Patient #5 stated she was taking 20 mg daily as of 03/31/2026. 3. Aldactone 25 mg take 0.5 tablets (12.5 mg) once daily was observed in the home, taken currently by Patient #5 as of 03/31/2026, but medication was not on the agency med profile. 4. Fluticasone-Salmeterol (Advair) 250-50 mcg inhaler- Patient #5 stated she was currently taking this medication twice daily as of 03/31/2026, but medication was not listed on the agency med profile. 5. Tylenol 325 mg take 650 mg every 4 hours as needed for pain; Patient #5 stated she was currently taking this medication as needed as of 03/31/2026, but medication was not listed on the agency med profile. 6. Ezetimibe 10 mg daily; Patient #5 stated she was taking this medication daily as of 03/31/2026, but this medication not listed on the agency med profile. 7. Cyclobenzaprine 10 mg three times daily as needed; Patient #5 stated she was currently taking this medication three times daily as needed as of 03/31/2026, but this medication was not listed on the agency med profile. 8. Sacubitril-Valsartan 24-26 mg two times daily; Patient #5 stated she was currently taking this medication two times daily, but this medication was not listed on the agency med profile. On 04/15/2026 at 1:50 p.m., an interview was conducted with S12PTA. S12PTA confirmed the medication profile in Patient #5’s home did not accurately reflect all medications Patient #5 was currently taking. On 04/17/2026 at 3:25 p.m. a phone interview was conducted with S15RN. S15RN stated she had completed the SOC for Patient #5 on 03/31/2026. S15RN stated Patient #5 managed all of her own medications. Patient #5’s discharge med list dated 03/30/2026 was reviewed. S15RN stated she was unaware of the discharge med list provided to the agency on 03/30/2026, and she had not reconciled Patient #5’s medications according to the hospital discharge list and should have. S15RN confirmed the agency medication profile should have accurately reflected Patient #5’s current medications. On 04/17/2026 at 9:50 a.m., an interview was conducted with S1ADM. The above medication profile discrepancies were discussed. S1ADM stated she expected all nurses to check patient’s medication bottles and compare their home medications against the discharge medication list provided by the referring provider. S1ADM confirmed the information on Patient #5’s referral was incorrect and did not include all of Patient #5’s discharge medication orders. S1ADM confirmed Patient #5’s medication profile from the agency did not accurately reflect all medications Patient #5 was currently taking.

Reviewed, revised by physician every 60 days CFR(s): 484.60(c)(1) The individualized plan of care must be reviewed and revised by the physician or allowed practitioner who is responsible for the home health plan of care and the HHA as frequently as the patient's condition or needs require, but no less frequently than once every 60 days, beginning with the start of care date. This ELEMENT is not met as evidenced by: Based on record reviews and interview, the agency failed to have the Plan of Care (POC) reviewed and revised by the physician every 60 days, beginning with the SOC (Start of Care) date for 1(#6) of 17 sampled patients reviewed. Findings: Review of the agency’s undated policy titled, “Plan of Care” revealed in part: Policy Home care services are furnished under the supervision and direction of the client’s physician/ allowed non-physician practitioner (NPP). The Plan of Care is based on a comprehensive assessment and information provided by the client/family and health team members. The plan will be consistently reviewed to ensure the client needs are met, and will be updated as necessary, but at least every sixty (60) days. Review of Patient #6’s clinical record revealed a SOC date of 12/27/2025. Review of the POC for certification period 12/27/2025 through 02/24/2026 revealed the physician did not review and sign the POC until 03/31/2026. On 04/17/2026 at 11:05 a.m., an interview was conducted with S1ADM. The above POC orders for certification period 12/27/2025 through 02/24/2026 were reviewed. S1ADM confirmed Patient #6’s POC was not reviewed and signed by Patient #6’s physician within the every 60-day timeframe.

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 record reviews and interviews, the agency failed to provide skilled professional services as ordered by the physician in the Plan of Care (POC) for 1 (#2) of 7 sampled patients reviewed with home visits. Findings: Review of the agency’s undated policy titled, “Skilled Professional Services” revealed, in part: Special Instructions 1. Skilled professionals must assume the responsibility for, but not be restricted to the following: c. Providing services that are ordered by the physician/allowed non-physician practitioner (NPP) as indicated in the plan of care. Review of Patient #2’s clinical record revealed she began receiving services from the agency on 02/27/2026, with a primary diagnosis of Laceration without Foreign Body of Other Part of Head, Subsequent Encounter. Review of Patient #2’s POC for Certification Period 02/27/2026 through 04/27/2026 revealed in part: Physical Therapy one time a week for one week, then two times a week for three weeks, effective 03/04/2026. Review of Patient #2’s Episode Manager Visit Calendar for Physical Therapy (PT) visits made during this episode of care revealed, in part: there were two (2) ordered PT visits, per the POC the week of 03/23/2026. Further review revealed only one (1) PT visit was completed on 03/27/2026. There were no other PT visits attempted or documented as refused or missed during the week of 03/23/2026. On 04/14/2026 at 2:20 p.m., an interview was conducted with S18PT. S18PT confirmed she had completed Patient #2’s PT Evaluation on 03/04/2026 and Patient #2’s physician had approved the ordered PT frequency of 1w1, 2w3, per her evaluation. S18PT stated once the PT evaluation was completed, the agency’s scheduler setup the PT visits. S18PT stated she would expect PT services to be provided per the POC orders. Patient #2’s PT schedule for the week of 03/23/2026 was reviewed. S18PT confirmed Patient #2 did not receive PT services per physician’s orders. On 04/14/2026 at 2:48 p.m., an interview was conducted with S17LPN. Patient #2’s PT evaluation dated 03/04/2026 and signed by Patient #2’s physician on 03/16/2026 was reviewed. S17LPN confirmed PT services were not provided to Patient #2, per the physician-ordered frequency the week of 03/23/2026 and should have been. On 04/14/2026 at 2:55 p.m., an interview was conducted with S1ADM. S1ADM reviewed the above PT Episode Visit Calendar for Patient #2, the POC dated 02/27/2026, and the PT evaluation dated 03/04/2026 and signed by the physician on 03/16/2026. S1ADM confirmed there was no missed visit or refusal documentation recorded the week of 03/23/2026, and only one (1) PT visit was completed instead of two (2) PT visits, as per POC orders. S1ADM confirmed all skilled professional services should be provided per physician’s orders and Patient #2’s PT services were not.

Recertification Survey COVID-19 Focused Infection Control Survey with no related deficiencies cited. Abbreviations: c/o complaint of HCl Hydrochloride HHA Home Health Agency mcg microgram(s) MD Medical Doctor meds. medications mg milligram(s) ml milliliter(s) PT Physical Therapist Pt. patient SN Skilled Nurse SQ subcutaneous

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 observations, record reviews, and interviews, the agency failed to ensure the medication profile accurately reflected all medications patients were using, and/or did not reflect medications the patients were no longer using, for 4 of 4 (Patients #4, #5, #6, #7) sampled patients reviewed who received home visits. Findings: Patient #4 Review of the clinical record revealed a start of care date of 06/05/2021. The patient's primary diagnosis was Unspecified Fracture Upper End of Right Humerus. A review of the Home Health Certification and Plan of Care/485 for the Certification Period of 08/04/2021 to 10/02/2021 revealed orders which included SN 1w8. The patient's current medication profile list was provided by S1DON on 09/20/2021. On 09/20/2021 at 2:00 p.m., a home visit was conducted in the home of Patient #4. Review of the medications listed on the patient's current medication profile list provided by the agency was reviewed with a nurse assigned to the patient in the assisted living facility in which the patient resided. The review of the patient's medications revealed the following discrepancies: 1. Norco 5-325 mg one tablet by mouth every 6 hours as needed for pain. This medication was listed as a current medication on the patient's medication list provided by the agency. The assisted living nurse stated this dose had been discontinued on 08/31/2021. She stated the current dose of Norco was 10-325 mg one tablet by mouth every 6 hours, which had a start date of 09/08/2021. 2. Tramadol HCl 50 mg one tablet by mouth every 6 hours as needed for pain. This medication was listed as a current medication on the patient's medication list provided by the agency. The assisted living nurse stated this medication was discontinued on 08/11/2021. 3. Vitamin B12 100 mcg by mouth daily. This medication was listed as a current medication on the patient's medication list provided by the agency. The assisted living nurse stated the patient was no longer taking this medication. 4. Nicotine Transdermal 14 mg/24 hours apply one patch transdermal once daily. This medication was listed as a current medication on the patient's medication list provided by the agency. The assisted living nurse stated this medication was discontinued on 08/19/2021. A review of SN visit documentation revealed SN visits were conducted with Patient #4 on the following dates during the current Certification Period of 08/04/2021 to present: 08/10/2021, 08/14/2021, 08/19/2021, 08/23/2021, 09/09/2021, and 09/16/2021. Patient #5 Review of the clinical record revealed a start of care date of 10/02/2020. A review of the Home Health Certification and Plan of Care/485 for the Certification Period of 07/29/2021 to 09/26/2021 revealed a primary diagnosis of Hypertensive Heart and Chronic Kidney Disease with Heart Failure and orders which included SN 1w8 effective week of 08/01/2021. A current medication profile list was provided by the agency on 09/21/2021. On 09/23/2021 at 11:30 a.m., a home visit was conducted in the home of Patient #5. The patient provided her medications for review. She stated the nurse usually prepared her medications for a week at a time in a medication dispenser box. She verified the medications she provided for review were the only medications she was currently taking. Review of the medications listed on the patient's current medication profile list provided by the agency revealed the following discrepancies when compared with medications in the home: 1. Temazepam 15 mg by mouth daily. This medication was listed as a current medication but was not in the home. 2. Bumex 1 mg by mouth daily as needed for swelling. This medication was listed as a current medication but was not in the home. 3. Amlodipine Besylate 10 mg ½ tablet by mouth daily was listed as a current medication. A bottle of the medication with a prescription fill date of 09/10/2021 was observed in the home; instructions stated 20 mg one tablet by mouth daily. 4. Hydralazine HCl 50 mg by mouth 2 times daily. This medication was listed as a current medication but was not in the home. 5. Protonix 40 mg twice daily by mouth. This medication was listed as a current medication but was not in the home. 6. A bottle of Lexapro 20 mg by mouth daily with a prescription fill date of 08/08/2021 was observed in the home. This medication was not listed as a current medication on the medication profile list provided by the agency. 7. Entresto 24-26 mg ½ tablet by mouth daily was listed as a current medication. A bottle of the medication with a prescription fill date of 09/12/2021 was observed in the home; instructions stated 49-51 mg ½ tablet by mouth daily. A review of SN visit documentation revealed SN visits were conducted with Patient #5 on the following dates during the current Certification Period of 07/29/2021 to present: 08/03/2021, 08/11/2021, 08/20/2021, 08/26/2021, 09/10/2021, and 09/13/2021. Patient #6 Review of the clinical record revealed a start of care date of 09/11/2021. A review of the Home Health Certification and Plan of Care/485 for the Certification Period of 09/11/2021 to 11/09/2021 revealed a primary diagnosis of Parkinson's Disease and orders which included SN 1d1, 2w2, 1w6. A current medication profile list was provided by the agency on 09/21/2021. On 09/22/2021 at 11:30 a.m., a home visit was conducted in the home of Patient #6. The patient's wife was present during the visit. She verified she was familiar with the patient's medications and prepared his medications for the patient. Review of the medications listed on the patient's current medication profile list provided by the agency revealed the following discrepancy when compared with medications in the home: Novolin 70/30 100 units/ml inject 45 units SQ with breakfast and 28 units with dinner. The patient's wife stated the patient takes 24 units in the evening with dinner, not 28 units. She stated the patient has been on 24 units every evening for at least the last 4 months. A review of SN visit documentation revealed SN visits were conducted with Patient #6 on the following dates during the current Certification Period of 09/11/2021 to present: 09/11/2021, 09/13/2021, and 09/20/2021. Patient #7 Review of the clinical record revealed a start of care date of 10/31/2021. A review of the Home Health Certification and Plan of Care/485 for the Certification Period of 08/27/2021 to 10/25/2021 revealed a primary diagnosis of Microscopic Polyangiitis and orders which included SN 1w8 effective week of 08/29/2021. A current medication profile list was provided by the agency on 09/21/2021. On 09/22/2021 at 1:00 p.m., a home visit was conducted in the home of Patient #7 with S2LPN. The patient verified she was familiar with her medications and managed them herself. Review of the medications listed on the patient's current medication profile list provided by the agency revealed the following discrepancies when compared with medications in the home: 1. Butalbital-Aspirin-Caffeine 50-325-40 mg one capsule daily. The patient stated she has this medication in the home but only takes it as needed. She stated she has not had to take the medication in quite a while. 2. Lantus SoloStar Subcutaneous 100 units/ml 100 units as needed. The patient stated she takes 15 units daily and has been on that dose for about a year. 3. Ergocalciferol 1.25 mg one capsule daily. The patient stated she has not taken this medication since October 2020. A review of SN visit documentation revealed SN visits were conducted with Patient #7 on the following dates during the current Certification Period of 08/27/2021 to present: 09/10/2021 and 09/16/2021. An interview with S2LPN was conducted during the home visit. She verified Patient #7's medication list had not been updated to reflect the current medications she was taking. On 09/23/2021 at 2:20 p.m., an interview was conducted with S1DON. She was notified of the medication discrepancies found during the home visits for Patients #4, #5, #6, and #7. She verified the medication profiles were not up to date. S1DON verified nurses should reconcile medications during each SN visit and update the medication profiles accordingly.

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 record reviews and interview, the agency failed to ensure the patient's written Plan of Care was followed as evidenced by the following: 1. SN visits not conducted as ordered for 1 (Patient #5) of 10 (Patients #1 - #10) sampled patient records reviewed that had orders for SN visits; and 2. PT visits not conducted as ordered for 3 (Patient #4, #5, and #6) of 5 (Patients #3, #4, #5, #6, and #10) sampled patient records reviewed that had orders for PT visits out of a total sample of 10 patients. Findings: Patient #4 Review of the clinical record revealed the patient had a Start of Care date of 06/05/2021. The patient's primary diagnosis was Unspecified Fracture Upper End of Right Humerus. A review of the 485/Plan of Care for the cerification period of 08/04/2021 to 10/02/2021 revealed an order for PT evaluation. Review of the therapy notes revealed a PT evaluation was not conducted until 08/14/2021. There was no documentation of a reason for a delay in the evaluation being performed. Patient #5 Review of the clinical record revealed the patient had a Start of Care date of 10/02/2021. The patient's primary diagnosis was Hypertensive Heart and Chronic Kidney Disease with Heart Failure. A review of the 485/Plan of Care for the certification period of 07/29/2021 to 09/26/2021 revealed orders that included the following: SN 1w8 effective week of 08/01/2021. Review of the SN notes for the patient revealed no documentation of a SN visit for the week of 08/30/2021. There was no documentation of the reason for the missed visit. Further review of the clinical record revealed an order dated 08/11/2021 for PT evaluation due to multiple falls, weakness, and poor balance. There was no documentation of a PT evaluation conducted that week. The PT evaluation was not conducted until 08/17/2021. There was no documentation of the reason a PT evaluation was not performed the week of 08/11/2021. Patient #6 Review of the clinical record revealed the patient had a Start of Care date of 09/11/2021. The patient's primary diagnosis was Parkinson's Disease. A review of the 485/Plan of Care revealed orders that included the following: PT 1w1, 2w4 effective 9/11/2021. Review of the PT notes for the patient revealed no documentation of a second PT visit conducted the week of 09/12/2021. There was no documentation of the reason for the missed visit. On 09/23/2021 at 2:15 p.m., an interview was conducted with S1DON. After reviewing the clinical record for Patient #4, S1DON verified the PT evaluation was not conducted in a timely manner and should have been conduted within 24 hours of the order being received. She verified there was no documentation of the reason for the delay in the PT evaluation. After reviewing the clinical record for Patient #5, S1DON verified there was no documentation of a SN visit conducted the week of 08/30/2021 and no documentation of the reason for the missed visit. She further verified the PT evaluation was not conducted in a timely manner and should have been conducted within 24 hours of the order being received. She verified there was no documentation of the reason for the delay in the PT evaluation. After reviewing the clinical record for Patient #6, S1DON verified there was no completed documentation of a second PT visit conducted the week of 09/12/2021. She further verified there was no documentation of a reason for a missed visit.

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 record review and interview, the agency failed to conform with physicians' orders by failing to ensure SN services were provided per physician's orders for 1 (Patient #8) of 10 (Patients #1-10) sampled patients reviewed for SN services. Findings: Patient #1 Review of the clinical record for Patient #1 revealed a start of care date of 09/02/2020. The patient's primary diagnosis was Hypertensive Heart and Chronic Kidney Disease with Heart Failure. A review of the 485/Plan of Care for the certification period from 06/29/2021 to 08/27/2021 revealed Orders and Treatments that included the following: SN 1w9. SN to obtain ankle measurements every visit and report increase in ankle measurement of 1 cm in one day or 2-3 cm in one week. A review of the SN visit notes revealed SN visits were conducted on the following dates for the certification period of 06/29/2021 to 08/27/2021: 06/30/2021, 07/06/2021, 07/11/2021, 07/24/2021, 07/31/2021, 08/07/2021, 08/21/2021, and 08/25/2021. Further review of the SN notes revealed ankle measurements were not documented on the following SN visit dates: 06/30/2021, 07/06/2021, 07/11/2021, and 07/24/2021. On 09/23/2021 at 1:30 p.m., an interview was conducted with S1DON. After reviewing the patient's clinical record, she verified there was no documentation of ankle measurements obtained on every SN visit. She stated she would have expected the nurse to obtain ankle measurements on every SN visit as ordered.

Verbal orders CFR(s): 484.60(b)(3)(4) (3) Verbal orders must be accepted only by personnel authorized to do so by applicable state laws and regulations and by the HHA's internal policies. (4) When services are provided on the basis of a physician or allowed practitioner's verbal orders, a nurse acting in accordance with state licensure requirements, or other qualified practitioner responsible for furnishing or supervising the ordered services, in accordance with state law and the HHA's policies, must document the orders in the patient's clinical record, and sign, date, and time the orders. Verbal orders must be authenticated and dated by the physician or allowed pracitioner in accordance with applicable state laws and regulations, as well as the HHA's internal policies. This ELEMENT is not met as evidenced by: Based on interview and record reviews, the agency failed to ensure the total plan of care was signed and dated by the patient's physician in a timely manner for 8 (Patients #1, #2, #3, #4, #5, #7, #8, #9) of 10 (Patients #1-#10) sampled patient records reviewed. Cross-referenced with State Regulations 9123. Patient Care Standards: C. Plan of Care. The plan of care for each patient must be individualized to address the patient's problems, goals, and required services. 1. The Plan of Care, telephone and/or verbal orders must be signed by the physician within a timely manner, not to exceed 30 days. Findings: Patient #1 Review of the clinical record for Patient #1 revealed a start of care date of 09/02/2020. Review of the plan of care for the certification period 06/29/2021 to 08/27/2021 for the patient revealed a primary diagnosis of Hypertensive Heart & Chronic Kidney Disease with Heart Failure. Further review of the plan of care for the certification period revealed the physician did not sign it until 08/19/2021. Patient #2 Review of the clinical record for Patient #2 revealed a start of care date of 09/23/2020. Review of the plan of care for the certification period 07/20/2021 to 09/17/2021 for the patient revealed a primary diagnosis of Emphysema. Further review of the plan of care for this certification period revealed the physician did not yet sign it. Patient #3 Review of the clinical record for Patient #3 revealed a start of care date of 07/27/2021. Review of the plan of care for the certification period 07/27/2021 to 09/24/2021 for the patient revealed a primary diagnosis of Type 2 Diabetes Mellitus. Further review of the plan of care for this certification period revealed the physician did not yet sign it. Patient #4 Review of the clinical record for Patient #4 revealed a start of care date of 06/05/2021. Review of the plan of care for the certification period 06/05/2021 to 08/03/2021 for the patient revealed a primary diagnosis of Unspecified Fracture Upper End of Right Humerus. Further review of the plan of care for this certification period revealed the physician did not sign it until 08/10/2021. Patient #5 Review of the clinical record for Patient #5 revealed a start of care date of 10/02/2020. Review of the plan of care for the certification period 07/29/2021 to 09/26/2021 for the patient revealed a primary diagnosis of Hypertensive Heart and Chronic Kidney Disease with Heart Failure. Further review of the plan of care for this certification period revealed the physician did not sign it until 09/23/2021. Patient #7 Review of the clinical record for Patient #7 revealed a start of care date of 10/31/2020. Review of the plan of care for the certification period 06/28/2021 to 08/26/2021 for the patient revealed a primary diagnosis of Microscopic Polyangiitis. Further review of the plan of care for this certification period revealed the physician did not sign it until 08/09/2021. Patient #8 Review of the clinical record for Patient #8 revealed a start of care date of 04/08/2021. Review of the plan of care for the certification period 06/07/2021 to 08/05/2021 for the patient revealed a primary diagnosis of Encounter for Change or Removal of Nonsurgical Wound Dressing. Further review of the plan of care for this certification period revealed the physician did not sign it until 09/20/2021. Patient #9 Review of the clinical record for Patient #9 revealed a start of care date of 05/04/2021. Review of the plan of care for the certification period 05/04/2021 to 06/08/2021 for the patient revealed a primary diagnosis of Parkinson's Disease. Further review of the plan of care for this certification period revealed the physician did not sign it until 06/15/2021. On 09/23/2021 at 2:35 p.m., an interview was conducted with S1DON. After reviewing the electronic clinical records for Patients #1, #2, #3, #4, #5, #7, #8, and #9, S1DON verified the physicians' orders were not signed for the patients within the required time frame of 30 days.

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 interview and record reviews, the Home Health Agency failed to ensure a physician was promptly made aware of the status of 1 (Patient #1) of 10 (Patients #1-10) sampled patients reviewed. The agency failed to promptly notify the physician of Patient #1's needs when it was identified that she was experiencing continued high levels of pain. Findings: Review of the clinical record for Patient #1 revealed a Start of Care date of 09/02/2020. The patient had a primary diagnosis of Hypertensive Heart and Chronic Kidney Disease with Heart Failure for the Certification Period from 06/29/2021 to 08/27/2021. Orders and Treatments included the following: SN 1w9. SN Interventions included the following: Skilled staff to assess pain level and effectiveness of pain medications and current pain management therapy every visit. SN Goals included the following: Patient will achieve pain level less than 4 within episode. (Goal Term: long, Target Date: 8/27/21) Review of the SN visit notes for the certification period from 06/29/2021 to 08/27/2021 revealed SN visits were conducted on the following dates: 06/30/2021, 07/06/2021, 07/11/2021 07/24/2021, 07/31/2021, 08/07/2021, 08/21/2021, and 08/ 25/2021. Further review of the SN visit notes revealed the following documentation: 07/31/2021 - SN visit. Patient reported a pain level of 10 - severe in her back/right leg/right arm. Coordination Plan - conferenced with MD regarding pain in back and right foot swelling. Patient requesting pain medication. Comments: Patient states that she's been having some back pain that sometimes rates between nine and ten, patient is requesting some pain medication for her back. There was no documentation of a phone call or communication note sent to the MD by the agency nurse regarding the patient's reported severe level of pain. 08/07/2021 - SN visit. Patient reported a pain level of 10 - severe in her back/right leg/right arm. Coordination Plan - conferenced with MD regarding pain medication. Comments: Patient ask your nurse if we've heard anything back from her doctor regarding giving her some pain medication. Inform patient no we have not but will send another communication out. There was no documentation of a phone call or communication note sent to the MD by the agency nurse regarding the patient's reported severe level of pain. 08/21/2021 - SN visit. Patient reported a pain level of 10 - severe in her back/right leg/right arm. Coordination Plan - conferenced with MD regarding needing pain medication. Comments: Patient ask skilled nurse if we've heard anything back from her doctor regarding giving her some pain medication. Inform patient no we have not but will send another communication out since 8/8/21. There was no documentation of a phone call or communication note sent to the MD by the agency nurse regarding the patient's reported severe level of pain. 08/25/2021 - Recertification reassessment visit. Patient reported a pain level of 6 to her back, right leg. Skilled Intervention: Pt. has been c/o pain to back and right leg. She spoke to SN at MD office yesterday asking for more pain medication. No new meds. noted. There was no documentation of a phone call or communication note sent to the MD by the agency nurse regarding the patient's reported level of pain and request for pain medication. On 09/23/2021 at 1:30 p.m., an interview was conducted with S1DON. After reviewing the clinical record for Patient #1, she verified the patient's continued report of severe pain should have been communicated to the physician by a phone call at least twice a week until an answer was received. She stated any communication with a physician or his/her office staff should be documented on a communication note. She verified there was no documentation of a communication note sent to the patient's physician regarding her continued complaints of severe pain.

Discharge plans communication CFR(s): 484.60(c)(3)(ii) (ii) Any revisions related to plans for the patient's discharge must be communicated to the patient, representative, caregiver, all physicians or allowed practitioner's issuing orders for the HHA plan of care, and the patient's primary care practitioner or other health care professional who will be responsible for providing care and services to the patient after discharge from the HHA (if any). This ELEMENT is not met as evidenced by: Based on record reviews and interview, the agency failed to ensure any revisions to plans for the patient's discharge were communicated to the patient, representative, caregiver, all physicians issuing orders for the HHA plan of care, and the patient's primary care practitioner or other health care professional who will be responsible for providing care and services to the patient after discharge from the HHA (if any). The agency failed to communicate discharge plans to the patient's primary physician for 1 (Patient #8) of 3 (Patients #8, #9, and #10) sampled patients reviewed who were discharged from the agency during the last 6 months. Findings: Patient #8 Review of the clinical record revealed a start of care date of 07/08/2021. Review of the Home Health Certification and Plan of Care for Certification Period form 06/07/2021 - 08/05/2021 revealed a primary diagnosis of Encounter for Change or Removal of Wound Dressing. Orders and Treatments included SN 1w9. Discharge plans included the following: Discharge when medical condition is stable and patient is no longer in need of skilled services. Discharge to care of physician. Review of SN visit notes revealed a SN discharge note dated 08/02/2021. There was no documentation of communication with the primary physician regarding the discharge of the patient from home health services. On 09/23/2021 at 2:30 p.m., an interview was conducted with S1DON. After reviewing the clinical record for Patient #8, she verified there was no documentation that reflected the primary physician was notified of the patient's discharge from home health services. She stated a notification should have been sent out to the physician within 7 days from the discharge date.