Every finding on record at Mercy Hospital Jefferson

The Emergency Preparedness regulations were reviewed as part of the Medicare recertification survey completed on 11/06/2024. During the survey it was determined the home health provider is in compliance with the requirements of 42 CFR 484.102 Condition of Participation: Emergency Preparedness for Home Health Providers.

A partial extended survey for Medicare recertification for the home health provider was completed on 11/06/2024. The provider had 226 current patients.

Patient's needs CFR(s): 484.55(c)(4) The patient's medical, nursing, rehabilitative, social, and discharge planning needs; This ELEMENT is not met as evidenced by: Based on policy review, record review, home visit observation, and interview, the home health provider failed to ensure the comprehensive assessment accurately reflected the patient’s medical and nursing needs in two of five records reviewed (Records/Patients #1 and #3). This deficient practice has the potential to affect all patients served by the provider. Findings included: Review of the document titled, “Comprehensive Assessment and Reassessment Policy,” dated 10/14/2024, showed in part, the comprehensive assessment included the patient’s: - Current health, psychosocial, functional, and cognitive status; and - Medical, nursing, rehabilitative, social and discharge planning needs. RECORD/PATIENT #1: Review of the clinical record showed the patient was admitted to home health services on 10/26/2024 with a primary diagnosis of pleural effusion (a condition where fluid builds up in the thin cavity between the lungs and the chest wall). The patient had secondary diagnoses of follicle center lymphoma (a form of skin cancer), hypertensive kidney disease (kidney disease resulting from chronically elevated blood pressure), moderate protein-calorie malnutrition (the patient does not eat enough proteins and calories to meet nutritional needs). The patient was temporarily staying at their adult child’s home. Review of the document titled, “SN-OASIS Start of Care,” (Skilled nurse - Outcome, Outcome and Assessment Information Set) dated 10/26/2024 showed in part, the patient had: - No pressure injuries (skin injury caused by unrelieved pressure); - Scattered bruising to right breast and chest from placement of an infusion port; - Surgical wounds on the right lower flank and right neck; and - A Braden Scale rating (a tool used to determine a patient’s risk for the development of pressure injury) of 18 (a mild risk for pressure injury). Observation on 11/04/2024 at 12:30 PM, during the patient’s home visit, the patient and caregiver stated that: - They had wounds on both elbows that developed while the patient was in the hospital, and were present at the time of admission to the provider’s service; - They had not notified the nurses of the wounds until this date; - The wound on the right elbow had healed, and - They were using mupirocin (antibiotic) ointment and band-aids to treat the wound on the left elbow. Review of the record failed to show the patient's elbow wounds were identified until 11/04/2024 (Nine days after admitted to service). During an interview on 11/06/2024 at 10:55 AM, the home health/hospice lead registered nurse stated that they would: - Expect all wounds to be assessed and documented on the initial, comprehensive assessment; and - They were unable to locate an assessment of the wounds on the patient’s elbows prior to the nursing visit dated 11/04/2024. RECORD/PATIENT #3: Review of the record showed the patient was admitted to home health services on 10/18/2024 with a primary diagnosis of aftercare following joint replacement surgery, right knee. The patient had a significant secondary diagnosis of pulmonary embolism (a blockage in an artery in the lungs that's usually caused by a blood clot traveling from a vein in the leg or pelvis). The patient resided in their own home with their spouse. Review of the document titled, “SN-OASIS Start of Care,” dated 10/18/2024, showed in part, the patient had: - A surgical wound with a non-removeable dressing; - A skilled assessment note stating, “Patient educated to change dressing if he/she does shower;” - A wound management note stating that, “The dressing is dry and intact, patient will change dressing after they shower, written wound care instructions left in the home;” and - A comprehensive assessment completion date of 10/21/2024. Review of the document titled, “PT – Initial Discipline Visit (Physical Therapy),” dated 10/21/2024, showed in part, the patient’s wound had no odor, no signs or symptoms of infection. The SN (Skilled nurse) was to manage. See SN note for full wound assessment. The comprehensive assessment including the SN visit on 10/18/2024 and the PT visit on 10/21/2024 failed to contain a description of the type of wound dressing used for the patient’s incision. During an interview on 11/06/2024 at 11:20 AM, the governing body appointee A stated that: - They were unable to locate documentation identifying the type of dressing used for the patient; - They would expect the comprehensive assessment to include the type of dressing utilized for wound care.

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, record review, and interview, the home health provider failed to ensure the plan of care (POC) included patient specific interventions and individualized goals in three of five records reviewed (Records/Patients #1, #2, and #3). This deficient practice has the potential to affect all patients served by the provider. Findings included: Review of the document titled, “Plan of Care Policy,” dated 09/07/2024, showed in part, that: - A patient specific POC shall be developed and implemented by each professional discipline providing services; - The care plan shall be based on a systematic process of a comprehensive assessment, problem and needs identification, and physician orders; and - Each individualized POC will include [but not limited to] the following: * Nutritional requirements; * Patient specific interventions and education; and * Measurable outcomes and goals. RECORD/PATIENT #1: Review of the clinical record showed the patient was admitted to home health services on 10/26/2024 with a primary diagnosis of pleural effusion (a condition where fluid builds up in the thin cavity between the lungs and the chest wall). The patient had secondary diagnoses of follicle center lymphoma (a form of skin cancer), hypertensive kidney disease (kidney disease resulting from chronically elevated blood pressure), moderate protein-calorie malnutrition (the patient does not eat enough proteins and calories to meet nutritional needs). The patient was temporarily staying at their adult child’s home. Review of the document titled, “SN-OASIS Start of Care,” (Skilled nurse - Outcome, Outcome and Assessment Information Set) dated 10/26/2024, showed in part, the patient had: - A sodium restricted, no added salt diet; - Ate three meals and one supplement per day; - Received education to eat proteins first during meals; and - Pain in the right flank that affected the patient’s sleep, appetite, mood, and physical activity. Review of the document titled, “Plans of Care,” finalized on 11/04/2024, showed in part, that: - The POC included the following interventions and goals: * A goal that the patient’s nutritional/caloric requirements were met; * Nutritional orders for a low sodium diet, and interventions for the staff to provide teaching on a regular diet; and * An intervention to utilize a pain management scale appropriate for age and condition; - The POC failed to include: * An individualized nutritional goal describing the evidence that the patient’s nutritional/caloric goals were met; * Interventions related to protein calorie malnutrition including the quantity of protein supplements the patient should consume each day, and the need to eat protein first during meals; and * Identification of the pain management scale utilized for the patient and the location of the patient’s pain. During an interview on 11/06/2024 at 10:55 AM, the governing body appointee A stated that they would expect the POC to contain accurate and individualized goals and interventions. RECORD/PATIENT #2: Review of the record showed the patient was admitted to services on 09/11/2024 with a primary diagnosis of conversion disorder with motor symptom or deficit (psychiatric condition that causes physical symptoms related to motor or sensory function that have no known medical explanation). The patient resided in their parent’s home. The parent was the primary care provider for the patient. Review of the document titled, “SN-OASIS Start of Care,” dated 09/11/2024, showed in part, the patient had: - No current treatments for an infection, antibiotics, or used an incentive spirometer; - An emergency plan to move to their relative’s house with their parent; and - Pain in their bilateral lower extremities. Review of the document titled, “Home Health Plan of Care,” dated 09/11/2024, showed in part, that: -The POC included the following interventions and goals: * The patient was to use an incentive spirometer and antibiotics; * An emergency plan to move to a hotel with the patient’s spouse; * Instruct the patient to use ice and/or heat to the painful area for 10 to 20 minutes two to three times a day as needed to relieve pain; and -The POC failed to include: *An individualized intervention for the incentive spirometer and antibiotics when the assessment showed the patient was not using either; *An individualized emergency plan when the patient was living with their parent; *An individualized intervention for when to use ice and when to use heat and where to use the ice and/or heat application. During an interview on 11/03/2024 at 11:01 AM, the governing body appointee A stated that they would expect the POC to be individualized and accurate. RECORD/PATIENT #3: Review of the record showed the patient was admitted to home health services on 10/18/2024 with a primary diagnosis of aftercare following joint replacement surgery, right knee. The patient had a significant secondary diagnosis of pulmonary embolism (a blockage in an artery in the lungs that's usually caused by a blood clot traveling from a vein in the leg or pelvis). The patient resided in their own home with their spouse. Review of the document titled, “SN-OASIS Start of Care,” dated 10/18/2024, showed in part, the patient: - Had a surgical wound to the right knee; - A moderate nutritional risk; - Was using ice to reduce swelling, and the nurse provided education on the use of an ice machine; - Was to use thromboembolic deterrent hose (TED) hose on bilateral legs (specially designed stockings that help prevent blood clots and swelling in the legs); and - Had right knee pain rated a “7” (seven) on a 0 (zero) to10 high scale. Review of the document titled, “Home Health Plan of Care,” finalized on 10/23/2024, showed in part: - The POC included the following interventions and goals: * A goal of wounds improving or healed, as evidenced by wound measurements and/or characteristics; * A goal stating that the patient will report that pain has been reduced or controlled through verbal or nonverbal means that measures to promote comfort are effective; * An intervention for pain stating that the staff would use a pain scale appropriate for the patient’s age and cognition; and - The POC failed to include: * Wound care interventions identifying the type of dressing used; * An individualized plan for pain management that included identification of the type of pain scale the patient utilized; and * Interventions for the use of TED hose and an ice machine. During an interview on 11/06/2024 at 11:20 AM, the governing body appointee A stated that they would expect: - The POC to contain specific, and individualized interventions and goals; and - They were unable to locate interventions for the use of an ice machine and TED hose on the POC.

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 policy review, record review, and interview the home health provider failed to update the plan of care (POC) to reflect changes in wound care needs in two of five full records reviewed (Records/Patients #3 and #5). This deficient practice has the potential to affect all patients served by the provider. Findings included: Review of the provider’s policy titled, “Plan of Care and Orders Change Policy,” dated 11/04/2024, showed in part: - The plan shall be reviewed by the attending physician in consultation with the provider’s professional co-workers at such intervals as the patient’s condition requires but no less frequently than once every 60 days; and - The relevant physician shall be notified/alerted of any changes in the patient’s condition which may indicate needed changes to the POC. RECORD/PATEINT #3: Review of the record showed the patient was admitted to home health services on 10/18/2024 with a primary diagnosis of aftercare following joint replacement surgery, right knee. The patient had a significant secondary diagnosis of pulmonary embolism (a blockage in an artery in the lungs that's usually caused by a blood clot traveling from a vein in the leg or pelvis). The patient resided in their own home with their spouse. Review of document titled, “SN Discipline Discharge (Skilled nurse),” dated 10/30/2024, showed that: - The surgical incision on the patient’s right knee was left open to air with steri-strips (lightweight strips of adhesive used to pull skin together) in place; and - The clinical record failed to contain an update to the POC with orders to discontinue the dressing to the patient’s right knee. During an interview on 11/06/2024 at 11:20 AM, the governing body appointee A stated that they: - Would expect the POC to be updated to include a physician’s order to leave the patient’s right knee incision open to air; and - They were unable to locate a physician’s order to leave the patient’s right knee incision open to air. RECORD/PATIENT #5: Review of the clinical record showed the patient was admitted to home health services on 08/16/2024 with the primary diagnosis of type two diabetes mellitus (a group of diseases that result in too much sugar in the blood) with foot ulcer. Additional diagnoses included non-pressure chronic ulcer of other part of left foot, and hypertensive heart disease with heart failure (a decrease in the ability of the heart to pump blood). The patient lived in his/her own home and had around the clock assistance available. Review of the initial assessment, dated 08/16/2024, showed the patient had a left toe ulceration with a “dry, yellow” wound base and a “pin-point black area to center”. The wound had a scant amount of drainage and measured 0.4 centimeters (cm) long, 0.4 cm wide and 0.01 cm deep. Review of the POC, dated 08/16/2024, showed the following orders: - Skilled nurse (SN) visits for wound care twice weekly for eight weeks; - Left foot second toe and peri wound area, cleanse with wound cleanser or Vashe wash (a wound cleansing solution that contains hypochlorous acid), pat dry; - MediHoney gel wound filler (a medical grade honey used for wound healing); - Apply alginate (a soft, fibrous, absorbent dressing); - Cover with a two-by-two gauze and secure with Hypafix (brand) tape; - Treatment to be done every other day and as needed for one month; and - Patient or caregiver may do the wound care and dressing change in nurse absence. Review of the SN notes showed, in part: - Wound care was documented on 08/20/2024, 8/22/2024, and 08/26/2024; - On 08/29/2024, the SN documented “There are no open areas on either foot at this time”; - On 09/03/2024, the SN documented “No wound assessment. Left foot wound closed up”; - On 09/05/2024, the SN documented “No skin breakdown observed at this time” and resolved the wound care intervention (10 days and four SN visits after the wound was documented as healed); and - The record failed to show the physician was notified that the wound had healed. During an interview on 11/05/2024, at 1:34 P.M., governing body appointee A stated that he/she would expect the nurse who first discovered the wound was healed to resolve the problem and then coordinate with the case manager to resolve the problem from the POC and notify the physician.

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 policy review, record review, home visit observation, and interview, the home health provider failed to ensure that staff were providing services that are ordered by the physician as indicated in the plan of care (POC) in two of five records reviewed (Records/Patients #1 and #4). This deficient practice has the potential to affect all patients served by the provider. RECORD/PATIENT #4: Review of the plan of care (POC), dated 10/07/2024, showed an order for the skilled nurse (SN) to obtain vital signs every visit and notify the physician for temperature greater than 100.5 degrees, blood pressure greater that 180/90 or less than 90/50, pulse less than 56 or greater than 100, respirations less than 12 or greater than 24, and pulse oximetry less than 90%. Review of the SN notes showed, in part: - On 10/21/2024, the patient’s blood pressure was 162/92 (SN was to notify the physician if diastolic blood pressure was greater than 90) and the nurse failed to recheck the blood pressure or notify the physician that blood pressure was outside of the ordered parameters; and - On 10/28/2024, the patient’s blood pressure was 152/92 (SN was to notify the physician if diastolic blood pressure was greater than 90) and the nurse failed to recheck the blood pressure or notify the physician that blood pressure was outside of the ordered parameters. During an interview on 11/05/2024 at 2:30 P.M., governing body appointee A stated that he/she would expect the clinician to recheck the patient’s vital signs and, if still outside of the parameters, to report it to the physician. If it was a consistent discrepancy in the vital sign, he/she would expect the clinician to call the physician and get the parameters changed to be individualized for that patient. Findings included: RECORD/PATIENT #1: Review of the clinical record showed the patient was admitted to home health services on 10/26/2024 with a primary diagnosis of pleural effusion (a condition where fluid builds up in the thin cavity between the lungs and the chest wall). The patient had secondary diagnoses of follicle center lymphoma (a form of skin cancer), hypertensive kidney disease (kidney disease resulting from chronically elevated blood pressure), moderate protein-calorie malnutrition (the patient does not eat enough proteins and calories to meet nutritional needs). The patient was temporarily staying at their adult child’s home. Review of the document titled, “Plans of Care,” finalized on 11/04/2024 showed in part, to include an assessment of the patient’s reproductive system each visit. Review of the nursing visits dated 10/26/2024, 10/28/2024, 10/30/2024, and 11/01/2024, showed the documentation failed to contain an assessment of the patient’s reproductive system. Observation on 11/04/2024 at 12:30 PM, during the patient’s home visit, the clinician failed to assess and document the patient’s reproductive history. During an interview on 11/06/2024 at 10:55 AM, the governing body appointee A stated that they would expect the clinicians to provide assessments and interventions according to the physician orders on the POC.

The Emergency Preparedness regulations were reviewed as part of the Medicare certification survey completed on 02/10/2022. During the survey it was determined Mercy Home Health is in compliance with the requirements of 42 CFR 484.102 Condition of Participation: Emergency Preparedness for Home Health Agencies.

An extended survey for Medicare certification for Mercy Home Health agency was completed on 02/07/2022. The agency had 133 current patients. One condition-level deficiency was identified at an immediate jeopardy (IJ) level as follows: - §484.60 Condition of Participation: Care Planning, Coordination of Services, and Quality Care. An immediate jeopardy level for actual harm to one patient (Record/Patient #3) and potential for future harm to other patients was identified during the survey. The findings were confirmed as immediate jeopardy by the Centers for Medicare and Medicaid Services (CMS). On 02/04/2022 at 3:15 PM, the administrator was informed verbally and in writing via the IJ Template, of the finding(s) identified at an immediate jeopardy level. A formal written removal plan was submitted by the agency prior to the survey exit. This removal plan was reviewed by CMS and it was determined at the time of the survey exit on 02/10/2022, that a satisfactory removal plan had been initiated related to the immediate jeopardy findings. The condition level deficiencies identified above remain as cited. A home health agency that is found out of compliance with any Condition of Participation evaluated as part of a standard survey may not train or competency evaluate their home health aides for a period of two (2) years following the date of this survey. A deficiency has been cited at §484.80(f)(3) – see Tag G788. A Covid-19 Focused Infection Control survey was also completed on 02/10/2022. One standard level deficiency was identified.

RN performs assessment CFR(s): 484.55(a)(1) A registered nurse must conduct an initial assessment visit to determine the immediate care and support needs of the patient; and, for Medicare patients, to determine eligibility for the Medicare home health benefit, including homebound status. The initial assessment visit must be held either within 48 hours of referral, or within 48 hours of the patient's return home, or on the physician or allowed practitioner - ordered start of care date. This ELEMENT is not met as evidenced by: Based on policy review, record review, and interview, the agency failed to ensure the registered nurse (RN) conducted an initial assessment within 48 hours of the referral, or within 48 hours of the patient's return home for one (Record/Patient #3) of five full records reviewed. This deficient practice has the potential to affect all patients served by the agency. Findings included: Review of the agency's policy titled, "Comprehensive Assessment and Reassessment Policy," dated 04/09/2019, showed the RN must conduct an initial assessment visit to determine immediate care and support needs of the patient. For Medicare patients, to determine eligibility for the Medicare home health benefit, including homebound status within 48 hours of referral, within 48 hours of a patient's return home from an inpatient stay or on the physician's ordered start of care date. RECORD/PATIENT #3: Review of the referral information, showed in part: - Referral received on 12/30/2021; - Hospital discharge date 12/31/2021; - (MO104) referral date 01/03/2022, (a portion of a federally mandated assessment that indicates the date that the written or verbal referral for initiation or resumption of care was received by the agency); - Disciplines: Skilled nursing (SN) and physical therapy (PT); and - Cleanse right lower leg ulcer with wound cleanser, pat dry, apply Santyl (a topical treatment that removes dead tissue from wounds) from edge to edge, cover with alginate (an antimicrobial dressing that keeps the wound moist and protects from contamination) fit to size and bordered foam. Change dressing daily and as needed. Review of the record showed the nursing start of care comprehensive assessment was dated 01/04/2022 (four days after discharge from the hospital). Review of the record showed no contact with the patient or physician regarding the delay in the start of care. During an interview on 02/03/2022 beginning at 4:15 PM, the findings were reviewed with the administrator, clinical manager, clinical supervisor, and quality coordinator. The clinical supervisor stated that they try to see the patients within 48 hours of the referral. The staff should contact the patient and physician if not seeing within that time frame. Review of emailed information from the agency sent to the surveyor on 02/04/2022, showed the patient was discharged from the hospital on 12/31/2022, "but our office was closed due to the holiday". A referral was received from the physician on 01/03/2022.

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, record review, home visit observation, and interview, the agency failed to ensure a complete/accurate medication review and/or update of the patient's medications was completed in, but not limited to, three (Records/Patients #1, #4 and #5) of five full records reviewed. This deficient practice has the potential to affect all patients served by the agency. RECORD/PATIENT #4: Review of the clinical record showed the patient was admitted to the agency with diagnoses of quadriplegia (paralysis of all four limbs), traumatic subarachnoid hemorrhage (bleeding in the space surrounding the brain) with loss of consciousness, and a motor vehicle collision on 12/09/2021. Review of physical therapy (PT) notes dated, 12/13/2021 through 12/27/2021, showed “nursing reviewer to do full medication review and education in office.” The agency failed to document a medication review by nursing. Review of the comprehensive assessment, dated 12/09/2021, showed no presence of a gastric feeding tube (G tube) (a tube surgically inserted into the stomach through the abdominal wall used to deliver food, water and medications). The comprehensive assessment also showed the patient had no oral problems and ate a regular diet with his/her food cut up into small pieces. Review of the medication profile, dated/reviewed on 09/24/2021, showed: - Guaifenesin (Robitussin) 100 milligrams (mg) / 5 milliliters (mL) solution. Take 10 mL (200mg) by G tube route every 4 hours; - Famotidine (Pepcid) 20 mg tablet. Take 20 mg by G tube route two times daily; - Acetaminophen (Tylenol) 325 mg/10.15 mL oral solution. Take 20.3 mL (650 mg) by G tube route every four hours as needed for fever greater than 100.4 degrees; - The remaining medication routes are directed to take by mouth; and - The agency failed to ensure the patient’s medication orders reflect that the patient is taking his/her medications orally. Review of the medication profile also showed the patient takes omeprazole oral 1 tablet by mouth daily after breakfast. The agency failed to include a dosage for the medication on the plan of care. RECORD/PATIENT #5: Review of the clinical record showed the patient was admitted with diagnoses of sepsis (a life-threatening response of the body to an infection) , pneumonia (an infection that inflames air sacs in the lungs), chronic obstructive pulmonary disease (COPD) (a group of lung diseases that block airflow and make it difficult to breathe), hypertensive chronic kidney disease (elevated blood pressure caused by kidney disease), clostridium difficile colitis (C. Diff) (an infection and inflammation of the intestines caused by a bacteria) and a history of lung cancer. Review of the hospital discharge summary, dated/printed 10/29/2021, showed the patient was to start taking: - Naloxone 4 mg (milligrams) spray. Administer one spray in one nostril one time. May repeat in alternating nostrils every two to three minutes until responsive or EMS (emergency medical services) arrives; - Tramadol 50 mg tablet by mouth every six hours as needed (PRN) for pain; and - Vancomycin 250 mg capsule by mouth four times daily for fourteen days. Review of the plan of care (POC), dated 11/01/2021, showed the agency failed to include the naloxone, tramadol or vancomycin on the patient’s POC or medication profile. The agency failed to document any communication with the physician regarding why the medications were omitted from the POC. Review of the physical therapy notes showed: - A visit note, dated 11/04/2021, showed the “patient using Tylenol and rest prn to manage pain;” and - The agency failed to include Tylenol on the POC or medication profile. During an interview on 02/03/2022 beginning at 4:15 PM, findings were reviewed with the administrator, clinical manager, quality coordinator, and the clinical supervisor. The administrator stated that he/she would expect medication routes and dosages to be reviewed on admission. The clinical supervisor stated that he/she would expect the medications on the plan of care and medication profile to match what the patient is actually taking. Findings included: Review of the agency policy titled, "Medication Reconciliation Medication Regime Review Policy," dated 06/08/2021, showed in part: - The medication regime review will occur as part of a comprehensive assessment; - The review will include a thorough review of all medications, including all prescribed and over the counter, herbal and topical preparations the patient is using at the time of the assessment; - On admission, a patient's medications will be reconciled with a list obtained from the referral source, patient's current medications as currently listed in the patient's electronic EPIC (an electronic health record for hospitals and large practices) record, any physician orders for medication, and a complete bottle to bottle review; - Discrepancies to the medications will be addressed with the physician involved in the patient's care. - The electronic clinical record is updated to identify all medications the patient is taking, including the frequency of administration, route and date ordered; - Documentation is entered within the electronic medical record (EMR); - For therapy only cases: * The medication regime will be reviewed by the supervisory nurse, quality nurse or designee; * Any clinically significant or assessed problems are brought to the attention of the supervisory nurse, quality nurse or designee; and * The physician is notified promptly. RECORD/PATIENT #1: Review of the hospital discharge summary dated 01/11/2022 showed: - Start taking these medications: *Aspirin 81 milligrams (mg) two times a day for eight days; *Hydrocodone-acetaminophen (pain medication) 5-325 mg one tablet every four hours as needed for pain; *Ondansetron four mg one tablet under the tongue every six hours as needed for nausea/emesis; - Change how you take these medications: *Lactobacillus (probiotic) 10 billion cell one capsule daily; - Continue taking these medications: *Trospium (used to treat overactive bladder) 20 mg one tablet daily; *Famotidine (Pepcid, acid reducer) 40 mg at bedtime; - Stop taking: *Pantoprazole (Protonix, acid reducer) 40 mg; and *Potassium chloride 10 milliequivalent (meq). Observation and interview on 02/01/2022 beginning at 9:20 AM, during the patient’s home visit, showed the following discrepancies with the discharge medication list, current medication profile and plan of care (POC): - The medication profile and POC showed an order for lactobacillus 10 billion cell one capsule daily. The patient took probiotic gummies four billion cell twice daily; - The POC showed an order for aspirin 81 mg one tablet two times a day for eight days. The medication profile did not include this medication. The patient stated that he/she currently took aspirin 81 mg daily. He/she started this while in the rehabilitation facility. There was no physician order or clarification the patient was to continue this past eight days; - The medication profile and POC showed no orders for trospium. The patient stated that he/she has taken this since 12/07/2021; - He/she currently takes pantoprazole 40 mg daily. This was not included on the medication profile and POC; - He/she currently takes famotidine 40 mg at bedtime. This was not included on the medication profile and POC; - He/she has taken potassium 10 meq daily since coming home from the rehabilitation facility. This was not included on the medication profile and POC; - The medication profile and POC showed an order for hydrocodone-acetaminophen 5-325 mg one tablet every four hours as needed for pain. The patient stated that he/she has not taken this since coming home; and - The medication profile and POC showed an order for ondansetron four mg one tablet under the tongue every six hours as needed for nausea/emesis. The patient stated that he/she never took this medication Review of the nursing start of care assessment dated 01/12/2022 showed no clarification of the above medication orders with the physician. During an interview on 02/01/2022 at 11:28 AM the findings were reviewed with the administration, clinical manager, clinical supervisor and quality coordinator. The clinical supervisor stated that when staff reconciled medications they compare the discharge medication list with all the medications the patient took. If they were any discrepancies, staff should notify the physician. If a new or changed medication was found in the home, the medication profile should be updated in the computer system while they were in the home.

Discharge Planning CFR(s): 484.58(a) Standard: Discharge planning. An HHA must develop and implement an effective discharge planning process. For patients who are transferred to another HHA or who are discharged to a SNF, IRF or LTCH, the HHA must assist patients and their caregivers in selecting a post-acute care provider by using and sharing data that includes, but is not limited to HHA, SNF, IRF, or LTCH data on quality measures and data on resource use measures. The HHA must ensure that the post-acute care data on quality measures and data on resource use measures is relevant and applicable to the patient's goals of care and treatment preferences. This STANDARD is not met as evidenced by: Based on policy review, record review, and interview, the agency failed to develop and implement an effective discharge planning process in one (Record/Patient #5) of one full discharge record reviewed. This deficient practice has the potential to affect all patients served by the agency. Findings included: Review of the agency’s policy titled, “Discharged Criteria Policy,” dated 06/24/2020, showed: - Discharge criteria are standards that facilitate the appropriate planning for resource utilization, effective service evaluation/termination, or ongoing care continuation/coordination with other providers or health care settings; - The agency discharges patients on the basis of a reasonable expectation that the patient’s medical, nursing and social needs have been met by the agency; - Additional planning with the patient shall occur throughout the course of care; - The planning will include documentation of specific plans and the expected time frame for discharge; - Patients will receive proper and reasonable notices for discharge and termination purposes; and - Reasonable notice is considered two to five days. RECORD/PATIENT #5: Review of skilled nursing notes dated, 11/04/2021 through 12/23/2021, showed the patient had the following continued skilled home health needs: - Oxygen therapy education and safety; - Medication management; - Pain management; - Home and safety fall precautions; and - Monitoring for signs of infection. Review of a skilled nursing note, dated 12/23/2021, showed the following plan: - The patient will be discharged once goals are met; and - The clinician to see the patient the following week. Review of physical therapy (PT) notes showed the following: - A visit note, dated 12/20/2021, that showed: * The therapist will contact the patient on Monday, 12/28/2021, about resuming therapy sessions; * The patient requested holding therapy until 12/28/2021, due to chemotherapy treatments for the next three days; * The physical therapist documented the patient had continued home health needs to improve functional mobility and stability for reintegration into the community; * A plan to see the patient the next week to continue treatment; - A missed visit note, dated 12/22/2021, that showed the patient refused the physical therapy visit because he/she was too fatigued from chemotherapy and the plan is to resume visits next week; and - A missed visit note, dated 12/27/2021, that showed the therapist called to schedule a visit and the patient cancelled stating that he/she was still a little ill from the chemotherapy. The note showed the patient agreed to a visit the following Wednesday (01/05/2022). Review of the physical therapy non-visit discharge summary, dated 12/27/2021, showed the patient discharged from home physical therapy per his/her request and that his/her goals were met. Review of the nursing discharge summary, dated 12/27/2021, showed the patient’s condition improved and he/she met goals. The patient was discharged from home health services. The agency failed to document any nursing discharge planning for the patient prior to the discharge date of 12/27/2021. During an interview on 02/03/2022 beginning at 4:15 PM, findings were reviewed with the administrator, clinical manager, quality coordinator, and the clinical supervisor. The clinical manager stated that they believed the agency had a note that showed the patient was discharged per his/her request. No further documentation was produced that showed nursing did discharge planning or that the patient was discharged from nursing per the patient’s request.

Care planning, coordination, quality of care CFR(s): 484.60 Condition of participation: Care planning, coordination of services, and quality of care. Patients are accepted for treatment on the reasonable expectation that an HHA can meet the patient's medical, nursing, rehabilitative, and social needs in his or her place of residence. Each patient must receive an individualized written plan of care, including any revisions or additions. The individualized plan of care must specify the care and services necessary to meet the patient-specific needs as identified in the comprehensive assessment, including identification of the responsible discipline(s), and the measurable outcomes that the HHA anticipates will occur as a result of implementing and coordinating the plan of care. The individualized plan of care must also specify the patient and caregiver education and training. Services must be furnished in accordance with accepted standards of practice. This CONDITION is not met as evidenced by: Based on policy review, record review and interview the agency failed to: - Develop a complete plan of care (G574); - Ensure treatments were provided only as ordered by the physician (G580); - Ensure coordination of care delivery (G608); - Promptly alert the physician to changes in the patient’s condition or needs that suggest that outcomes are not being achieved and/or the plan of care (POC) should be altered (G590); and - Provide pertinent written instructions related to the patient's care and treatments (G620). The cumulative affect of these deficient practices has the potential to affect all patients served by the agency.

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, record review, and interview, the agency failed to develop a complete plan of care (POC) for three (Records/Patients #3, #4, and #5) of five full records reviewed. This deficient practice has the potential to affect all patients served by the agency, RECORD/PATIENT #4: Review of the clinical record showed the patient was admitted to the agency with diagnoses of quadriplegia (paralysis of all four limbs), traumatic subarachnoid hemorrhage (bleeding in the space surrounding the brain) with loss of consciousness, and a motor vehicle collision on 12/09/2021. Review of the plan of care (POC), dated 12/09/2021, showed the patient needed the following durable medical equipment (DME): - A tilt in space wheelchair; and - A sliding extended bath bench. Review of the occupational therapy notes, dated 12/22/2021 through 01/18/2022, showed the patient also used the following DME: - A mechanical (Hoyer) lift; - A sit-to-stand lift; - A manual wheelchair; - A standard walker; - A bedside commode; - A ROHO cushion (a pressure relieving wheelchair cushion); and - Rails on his/her bed. The agency failed to include the additional DME on the plan of care. RECORD/PATIENT #5: Review of the clinical record showed the patient was admitted with diagnoses of sepsis (a life-threatening response of the body to an infection) , pneumonia (an infection that inflames air sacs in the lungs), chronic obstructive pulmonary disease (COPD) (a group of lung diseases that block airflow and make it difficult to breathe), hypertensive chronic kidney disease (elevated blood pressure caused by kidney disease), clostridium difficile colitis (C. Diff) (an infection and inflammation of the intestines caused by a bacteria) and a history of lung cancer. Review of the skilled nursing notes, dated 11/02/2021 through 12/23/2021, showed: - The patient used a wheeled walker (DME); - The patient takes vancomycin (an antibiotic) 250 mg by mouth four times a day for fourteen days; - The patient is on contact precautions (measures used to prevent transmission of infectious agents) for clostridium difficile colitis (C. Diff) (inflammation and infection of the intestines caused by a bacteria); and - The patient has chronic edema (swelling) to the lower legs and needs to elevate his/her legs to reduce the swelling. Review of the plan of care, dated 11/01/2021, showed: - The patient’s need for DME was marked as N/A (not applicable); and - A goal that stated the patient/caregiver will demonstrate knowledge of the ordered wound care. The agency failed to include the wheeled walker, vancomycin, contact C. Diff precautions, and interventions to address lower leg edema on the plan of care. The agency failed to individualize the plan of care by including an intervention for education on wound care when the patient did not have an order for wound care. During an interview on 02/03/2022 beginning at 4:15 PM, findings were reviewed with the administrator, clinical manager, quality coordinator, and the clinical supervisor. The clinical supervisor stated that he/she would expect any DME the patients are using, the vancomycin and the C. Diff precautions to be added to the plan of care. The quality coordinator stated that he/she would expect interventions for the edema to be on the plan of care. The administrator stated that he/she would expect an assessment of the edema to be done followed by physician notification and the doctor ordered interventions placed in the care plan. Findings included: Review of the agency policy titled, "Plan of Care," dated 04/09/2019, showed in part a patient specific POC shall be developed and implemented by each professional discipline providing services; - A patient-specific measurable outcome, goal-oriented and discipline specific POC will be established by a registered nurse (RN) regarding nursing services; - Each individualized POC will include patient specific interventions and education, measurable outcomes and goals identified by the agency and the patient, types of services, supplies and equipment required; and - Each individualized plan of care will include patient-specific interventions and education. RECORD/PATIENT #3: Review of the nursing start of care assessment dated 01/04/22 showed the patient reported pain in the left leg (ulcer was on the right leg) at a level of eight on a scale of zero to 10 (pain is assessed on a scale of zero to 10 with zero meaning no pain and 10 meaning the worst pain) that was aching and stabbing, frequently occurred, duration two to three hours, worsened with movement, relieved with tramadol (pain medication) and rest. No documentation of how much, how often the patient took his/her pain medication The highest pain level in the last 24 hours was eight and the lowest pain level was eight. Associated symptoms showed nausea. The patient's pain goal was one out of 10. Review of the POC dated 01/04/2022 showed the clinician plans to provide care that included pain management. The RN failed to include specific interventions and goals related to pain management. During an interview on 02/03/2022 beginning at 4:15 PM the findings were reviewed with the administrator, clinical manager, clinical supervisor, and quality coordinator. The clinical supervisor stated that there should be specific interventions for pain management on the nursing 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 policy review, record review, and interview, the agency failed to ensure treatments were administered only as ordered by the physician in one (Record/Patient #3) of five full records reviewed, This deficient practice has the potential to affect all patients served by the agency, Findings included: Review of the agency's policy titled, "Plan of Care and Orders Change Policy," dated 10/13/2021, showed drugs, services, and treatments are administered only as ordered by a physician. RECORD/PATIENT #3: Review of the plan of care (POC) dated 01/04/2022, showed an order for daily wound care to the right lower extremity to be performed by the skilled nurse (SN), patient or caregiver. The wound care consisted of removing the old dressing, cleanse the right lower leg ulcer with wound cleanser, pat dry, Apply Santyl (a topical treatment that removes dead tissue from wounds) nickel thickness from edge to edge, cover with alginate (antimicrobial dressing that keeps the wound moist and protects from contamination) fit to size and bordered foam. Change dressing daily and as needed. Review of a physician order dated 01/13/2022, showed an order to cleanse with wound cleanser, cleanse the peri-ulcer area with wound cleanser, use collagen (promotes healing by keeping the wound moist,/timalol (an eye drop that can be used to help wounds heal) drops as the primary dressing, use alginate bordered foam and xeroform (non-adherent) gauze as the secondary dressing. Review of the SN note dated 01/27/2022, showed the wound was cleansed with normal saline (a solution containing salt, the order showed to cleanse with wound cleanser) and under the wound care section, the order showed to cleanse with wound cleanser. Review of the record showed no physician order to cleanse with normal saline. During an interview on 02/03/2022 beginning at 2:55 PM, the patient stated that they had been using normal saline instead of wound cleanser because the wound cleanser burned too much. During an interview on 02/09/2022 at 3:22 PM,, the clinical manager stated that they did not find an order for the normal saline. He/she would expect the nurse to notify the physician to get an order for normal saline.

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, record review, and interview, the agency failed to alert the physician to changes in the patient’s condition or needs that suggest that outcomes are not being achieved and/or the plan of care (POC) should be altered in three (Records/Patients #3, #4 and #5) of five full records reviewed. This deficient practice has the potential to affect all patients served by the agency. RECORD/PATIENT #4: Review of the clinical record showed the patient was admitted to the agency with diagnoses of quadriplegia (paralysis of all four limbs), traumatic subarachnoid hemorrhage (bleeding in the space surrounding the brain) with loss of consciousness, and a motor vehicle collision on 12/09/2021. Review of the comprehensive assessment, dated 12/09/2021, showed: - The patient was confined to a wheelchair; - The patient’s Braden assessment (a tool for predicting pressure sore risk) showed the following: * His/her activity is chair fast (unable to leave ones chair); * His/her mobility (the ability to move freely) is very limited; * The patient’s risk for friction/shear (the force of rubbing two surfaces against one another) is a potential problem; - The patient has bladder incontinence (lack of control over urination); and - The patient’s caregiver was trained on assisting patient with sliding board transfers. Review of the physical therapy notes showed the following: - A visit note, dated 12/13/2021, showed the patient’s transfer training involved “scooting in wheelchair;” and - Visit notes, dated 01/13/2022 through 01/18/2022, showed the patient uses a sliding board for transfers. Review of the occupational therapy notes showed the following: - A home visit note, dated 12/22/2021, showed education and return demonstration techniques to move the patient up in bed. The caregiver stands at the head of bed, pulling on the draw sheet while patient pushes off of the bed with his/her feet; - A home visit note, dated 01/07/2022, showed the patient used a sliding bath bench; - A home visit note, dated 01/26/2022, showed the patient moved himself/herself up in bed using the bridge technique; - A home visit note, dated 1/18/2022, showed the patient complained of soreness in hips and tailbone after sitting in his/her reclining wheelchair; and - A home visit note, dated 01/26/2022, showed the patient has two small reddened areas on his/her sacrum/pelvis. The agency failed to notify the physician of the reddened areas on sacrum. Review of the plan of care, dated 12/09/2021, showed the following orders: - Physical therapy visits one visit a week for one week, three visits a week for four weeks, and two visits a week for four weeks; and - Obtain vital signs every visit, notify the physician of a pulse rate less than 56 beats per minute (bpm) or greater than 100 bpm. Review of the clinical record showed the following: - A physical therapy (PT) missed visit note, dated 12/23/2021; - A PT note, dated 12/20/2021, that showed the patient’s pulse rate is 102 bpm; - A PT note, dated 01/13/2022, that showed the patient’s pulse rate is 120 bpm; - An occupational therapy visit note, dated 12/20/2021, that showed the patient’s pulse is 102 bpm; - The agency failed to notify the physician of the missed therapy visit; and - The agency failed to notify the physician that the patient’s pulse rate was outside of the ordered parameters. RECORD/PATIENT #5: Review of the clinical record showed the patient was admitted with diagnoses of sepsis (a life-threatening response of the body to an infection) , pneumonia (an infection that inflames air sacs in the lungs), chronic obstructive pulmonary disease (COPD) (a group of lung diseases that block airflow and make it difficult to breathe), hypertensive chronic kidney disease (elevated blood pressure caused by kidney disease), clostridium difficile colitis (C. Diff) (an infection and inflammation of the intestines caused by a bacteria) and a history of lung cancer. Review of a physical therapy note, dated 12/08/2021, showed the patient reported a skin tear on the right arm. The note stated that a Band-Aid was in place over the skin tear. The agency failed to notify the physician of the patient’s skin tear. During an interview on 02/03/2022 beginning at 4:15 PM, findings were reviewed with the administrator, clinical manager, quality coordinator, and the clinical supervisor. The clinical manager stated that the clinicians have been instructed to notify their supervisor (if applicable) and the clinical manager to address any worsening patient issues including potential skin issues. The clinical supervisor stated that he/she would expect nursing to perform an assessment, followed by physician notification, receipt of treatment orders, and documentation of the entire process in the clinical record. The clinical supervisor stated that he/she would expect the physician to be notified of any missed visits. The clinical supervisor stated that if the patient’s vital signs were outside of the ordered parameters, he/she would expect the clinician to reassess after a rest period and, if the vital signs are still outside of the ordered parameters, notify the physician. Findings included: Review of the agency policy titled, "Plan of Care," dated 04/09/2019, showed in part the agency must promptly alert the relevant physician to any changes in the patient's condition or needs that suggest the outcomes are not being achieved and/or that the POC should be altered. Review of the agency policy titled, “Pain Management,” dated 09/02/2020, showed in part: - Upon admission each patient will be assessed and evaluated regarding pain; - Upon admission patients will receive instructions regarding patient rights and responsibilities regarding pain control and assessment, instruct patient to honestly communicate pain and suffering status to physician and other healthcare personnel and that pain management is an important part of their care, complete ongoing pain assessments throughout care, implement, assess and document the physician ordered pain management plan and also the effectiveness of pain treatment regularly and inform the physician if a change is indicated. RECORD/PATIENT #3: Review of the hospital discharge summary dated 12/31/2021, showed in part diagnoses that included ulcer of the right lower extremity with muscle involvement without evidence of necrosis (dead tissue). The patient's MRI (magnetic resonance imaging, a scan that produces detailed images of inside the body) did not show evidence of osteomyelitis (infection of the bone). The patient was seen by wound care and started Santyl. Review of the nursing start of care assessment dated 01/04/2022 (four days after discharge from the hospital) from 9:40 AM to 10:50 AM showed the patient reported pain in the left leg (ulcer was on the right leg) at a level of eight on a scale of zero to 10 (pain is assessed on a scale of zero to 10 with zero meaning no pain and 10 meaning the worst pain) that was aching and stabbing, frequently occurred, duration two to three hours, worsened with movement, relieved with tramadol (pain medication) and rest. No documentation of how much, how often the patient took his/her pain medication. The highest pain level in the last 24 hours was eight and the lowest pain level was eight. Associated symptoms showed nausea. The patient's pain goal was one out of 10. No documentation the nurse notified the physician of the patient's pain level of eight for 24 hours; Review of the POC dated 01/04/2022 showed: - Diagnoses that included non-pressure chronic ulcer of other part of the right lower leg with muscle involvement without evidence of necrosis, cellulitis (infection) of the right lower limb, and methicillin susceptible staphylococcus aureus infection (MRSA, an antibiotic resistant infection); - SN visits two times a week; - The clinician plans to provide care that included pain management (no specific nursing interventions or goals related to pain management); and - Pain medication orders included tramadol 50 milligrams (mg) one or two tablets every six hours as needed for pain, not to exceed six pills in 24 hours, fioricet (a pain medication used for headaches) and gabapentin (used for nerve pain) 300 mg one capsule three times daily. Review of the physical therapy POC dated 01/05/2022 showed pain assessment and management as needed per assessment. Evaluate the effectiveness of the current pain treatment regimen and notify the physician for the need for changes. Instruct the patient/caregiver on the use of ice to the area of chief complaint (unsure if this referred to the wound on the right lower leg) for ten minutes as many times as needed to relieve pain. Goals included that the pain/discomfort would be reduced to the patient's acceptable level and verbalize understanding of the pain management plan. Review of information emailed from the agency on 02/04/2022 showed a telemedicine (virtual) audio visit dated 01/04/2022 and signed by the physician at 11:54 AM showed the patient reported he/she was referred to the wound care by orthopedics. Home health was out earlier and it looked a bit better. It has been quite painful. He/she has not had any bleeding since home and has had yellow, clear drainage. The patient had headaches and took ibuprofen. Medication list at the end of the visit on 01/04/2022 showed an order with a start date of 01/03/2022 for tramadol 50 mg one or two tablets every six hours as needed for pain not to exceed six pills in a 24 hour interval. Hospital discharge summary and medications were reviewed. Communication with home health - no. Review of the physical therapist (PT) initial visit dated 01/05/2022 showed the patient had pain in the right leg at a level of six out of 10 that was aching, constant, worsened with touch, relieved with medication/positioning. The highest pain level in the past 24 hours was eight out 10 and lowest was six out of 10. The patient's pain goal was zero out of 10. The progression of pain was improving, and associated symptoms was guarding. The pain affected sleep and physical activity. No documentation the PT notified the physician of the pain levels. Review of an SN note dated 01/06/2022 showed the patient had pain in the right leg at a level of six out 10 that was stabbing, frequent, duration two to three hours, worsened with movement and relieved with rest/tramadol. The highest level of pain and lowest level of pain in the past 24 hours was six out of 10. The patient's pain goal was one out of 10. The patient complained of pain in the right lower leg due to the wound at a level of six out of 10. No documentation the nurse notified the physician of the pain levels. Review of a physical therapy assistant (PTA) note dated 01/07/2022 showed the patient had pain in the right leg at a level of six out of 10 that was sharp, constant, worsened with movement and weight bearing and relieved with rest/elevation. Highest pain level in the past 24 hours was nine out of 10 and lowest level was six out of 10. The patient's pain goal was zero out of 10. Progression of pain was unchanged. Current pain treatments included tramadol, gabapentin, fiorcet, elevation and rest. The patient complained of pain in the ulcer site on the right lower leg that was worse with movement and weight bearing. No documentation the PTA notified the physician of the pain levels. Review of an SN note dated 01/10/2022 showed the patient had pain in the right leg at a level of seven out of 10 that was aching and stabbing, frequent, duration two to three hours, worsened with movement and relieved with rest/tramadol. The highest level of pain and lowest level of pain in the past 24 hours was seven out of 10. The patient's pain goal was one out of 10. No documentation the nurse notified the physician of the pain levels. Review of a social work note dated 01/10/2022 showed patient reported to be in pain and had no appetite. He/she reported almost going to the emergency room last night because of feeling so bad. The nurse just left and took care of him/her. So, the nurse was notified. Review of a PT note dated 01/13/2022 showed the patient had pain in the right leg at a level of four out of 10 that was aching, frequent, duration varies, worsened with standing and walking, and relieved with medication and positioning. The highest pain level in the past 24 hours was eight and lowest was zero. The pain goal was zero out of 10. Progression of pain gradually improving, associated symptoms was guarding. Current pain treatments were medication and positioning. Under the section for physical discomfort showed pain assessment and management as needed per assessment. He/she went to the wound clinic and had a debridement (removal of dead tissue) performed. No documentation the PT notified the physician of the pain levels. Review of the SN notes showed: - On 01/14/2022 the patient had pain in the right leg at a level of seven out of 10 that was sharp, intermittent, long duration, exacerbating factors - wound (unclear what this meant), relieved with rest. The highest pain level in the past 24 hours was seven out of 10 and lowest pain level in the past 24 hours was two. The pain affected physical activity. The patient's pain goal was zero out of 10. Progression of pain was unchanged. The patient had a debridement yesterday (01/13/2022). No documentation the nurse notified the physician of the pain levels; and - On 01/17/2022 the patient had pain in the right leg at a level of four out of 10 that was throbbing, intermittent, long duration, worsened with activity, and relieved with medications/rest. The highest pain level in the past 24 hours was six out of 10 and lowest pain level in the past 24 hours was four. The patient's pain goal was zero out of 10. The progression of pain remained unchanged. The pain affected physical activity. No documentation the nurse notified the physician of the pain levels. Review of the PTA visit notes showed: - On 01/17/2022 showed the patient had pain in the right foot at a level of four out of 10 that was sharp, tight, frequency was with activity, duration not addressed, worsened with standing and pressure, and relieved with elevation. The highest and lowest pain level in the past 24 hours was four out of 10. Progression of pain was waxing and waning. Current pain treatments was tramadol and most recent dose was one hour prior to treatment. No documentation the PTA notified the physician of the pain levels; and - On 01/19/2022 the patient had pain in the right foot at a level of three out of 10 that was sharp, pulling, constant, worsened with movement and walking and relieved with rest, elevation and medication. The highest and lowest pain level in the past 24 hours was three out of 10. The progression of pain was gradually improving. Current pain treatments included tramadol and fioricet. Most recent dose was yesterday. The patient also used rest and elevation to manage pain. The patient complained of pain in the right foot around the wound. No documentation the PTA notified the physician regarding the patient's pain level and pain around the wound. Review of the SN notes showed: - On 01/20/2022 the nurse documented a missed visit note. The nurse documented he/she made a well call. He/she reviewed the wound care orders as the patient would change his/her dressing today. No documentation of the patient's pain levels or condition of the wound. The patient has an appointment with the wound clinic on Monday (01/24/2022) so the nurse would see the patient on Thursday, 01/27/2022. No documentation of why the visit was missed or that he/she notified the physician of the missed visit and plan to only visit the patient once that week; and - On 01/24/2022 the nurse documented a missed visit note. The nurse documented the patient has a wound clinic appointment today. The nurse will see the patient on 01/27/2022 as scheduled. No documentation the nurse notified the physician of the plan to only visit the patient one time that week. Review of a PTA note on 01/25/2022 showed the patient had pain in the right foot at a level of nine out of 10 that was burning, sharp, constant, worsened with weight bearing and movement, relieved with pain medications. The highest pain level in the past 24 hours was 10 out of 10 and lowest was nine out of 10. The patient's pain goal was zero out of 10. The progression of pain was rapidly worsening. The patient was taking tramadol. The patient reported increased pain in the right foot from infection in his/her wound. The patient was sent by the wound care physician to the emergency room on 01/24/2022 for pain and infection in the right foot. The medications were yet to be picked up. The patient was instructed to avoid weight bearing as much as possible on the right leg and to keep the right leg elevated. The PTA left a message for the social worker to see if a walker could be brought to the patient. The patient has been prescribed two antibiotics and has a new prescription for tramadol and cortisol cream for topical application. A family member was picking them up today. A case communication note dated 01/25/2022 was sent to the PT, social worker, and nurse regarding the emergency room visit on 01/24/2022 for pain and infection in the right foot. No documentation the PTA notified the physician of the pain levels. Review of a PT note on 01/27/2022 the patient had pain in the right ankle at a level of seven out of 10 that was aching and burning, constant, no worsening factors and relieved with medication and positioning. The highest pain level in the past 24 hours was nine out of ten and lowest was four out of 10. The patient's pain goal was zero out of 10. Progression of pain was unchanged. Current pain treatments were medication and positioning. No documentation the PT notified the physician of the pain levels. Review of a SN note dated 01/27/2022 showed the patient had pain in the right leg at a level of six out of ten, that was burning, intermittent, sh (unclear what this meant), exacerbating factors - wound (unclear what this meant), relieved with medications. The highest pain level in the past 24 hours was six out of 10 and lowest was five out of 10. The patient's pain goal was zero out of 10. Progression of pain was unchanged. No documentation the nurse notified the physician of the pain levels. Review of a PTA note dated 01/31/2022 showed the patient had pain in the right foot at a level of five out of ten that was throbbing, burning, constant, duration chronic, worsened with walking and touch, and relieved with medications, rest and elevation. The highest pain level in the past 24 hours was nine out of 10 and lowest was five out of 10. The progression of pain was unchanged. The patient was taking ibuprofen with the most recent dose approximately one hour prior to treatment. The patient stated that he/she was taking approximately 1200 mg every six hours. Nursing was informed. The patient stated that the infection persists and the signs and symptoms have not lessened with antibiotics. No documentation the PTA notified the physician of the pain levels or that the signs and symptoms had not lessened with antibiotics. Review of a social work note dated 01/31/2022 from 2:35 PM to 3:08 PM showed the patient reported the pain he/she is experiencing is bad. He/she is taking six 200 mg of ibuprofen to relieve the pain. The patient had tramadol prescribed cut he/she can't tell it is working at all. The patient has been worrying a lot about the pain, and that the infection will move to other parts of his/her body. He/she doesn't think the antibiotic is working at all and his/her concerns have been voiced to the nurse (unclear whether it was the patient or social worker that discussed the concerns with the nurse). Review of a SN visit note dated 01/31/2022 from 3:05 PM to 3:45 PM, the patient had pain in the right foot at a level of eight out of 10 that was sharp, constant, duration long, exacerbating factors - wound (unclear what this meant), and relieved with medications/rest. The highest pain level in the past 24 hours was 10 out of 10 and lowest level was four out of 10. The patient's pain goal was zero out of 10. The progression of pain remained unchanged. The pain affected physical activity. The patient reported he/she had been taking six 200 mg of ibuprofen (anti-inflammatory) every eight hours. The nurse educated the patient on safe dosage amounts and recommended to scale back to nor more than six tablets/day. Under the section for skilled assessment of the wound, the nurse documented the wound was CD/I (clean, dry and intact) and had a pink, warm area surrounding the wound. Under the section for skilled assessment risk for infection the nurse documented the wound bed was clean (no further wound assessment) and the surrounding wound was red and warm. No documentation the nurse notified the physician of the patient's pain or the pink/redness and warmth surrounding the wound. During an interview on 02/03/2022 at 11:06 AM, the social worker stated that the patient had a leg that was infected and couldn't stand for long periods of time. He/she had taken food, a shower chair and a four legged walker to the patient. The patient told him/her he/she was taking six ibuprofen at a time for pain. He/she talked to the PTA who had contacted the nurse and physician about it. The PTA had told the physician how much ibuprofen the patient was taking and the pain was not controlled with the tramadol. During an interview on 02/03/2022 at 12:15 PM, registered nurse (RN) B stated that the patient has been battling this wound since Thanksgiving. When the patient went to the emergency room they started him/her on two antibiotics. He/she did not think they discontinued the tramadol but the patient was not taking the tramadol because it did not help. The PTA had notified the physician on 01/31/2022 because the tramadol was not helping. The PT sent him/her a message that they called the physician about the patient taking more than the recommended dose of ibuprofen. There was a case communication from the PTA that the physician had responded to their previous case communication on 01/31/2022 and that the patient was not to exceed 800 mg of ibuprofen three times a day for a maximum dose of 2400 mg/day. No one had notified the physician about the pain before 01/31/2022. The RN had not called the physician about the pain. Initially the pain was mostly with dressing changes and the wound looked better. The redness and warmth around the wound was not new for the patient. He/she calls the patient about 30 minutes before the dressing change so he/she could take the ibuprofen which seemed to help the pain. During an interview on 02/03/2022 at 1:10 PM with the physician's patient care representative (PCR) showed that the physician wanted the surveyor to know the patient had been on tramadol for pain. He/she did not recall having a communication with him/her about high levels of pain. The PCR did not see any communication from home health about the patient's pain until 01/31/2022. On 01/31/2022 the PT notified them about the patient taking ibuprofen. The physician said for the patient not to exceed 800 mg at a time and not to exceed 2400 mg per day. There was an order in the system from the emergency room on 01/24/2022 for tramadol 50 mg one tablet every six hours. The patient had called the office on 01/31/2022 about his/her shingles not improving and talked to the nurse practitioner. There were no orders. The NP told the patient he/she needed to be seen. During an interview on 02/03/2022 at 2:55 PM the patient stated that his/her right leg still hurt and swelled. He/she has an appointment with the wound clinic on Monday and thinks they will have to put him/her back on the antibiotics because he/she could not put any weight on his/her leg. He/she finishes one of his/her current antibiotics tonight and one tomorrow. The nurses do ask him/her about his/her pain. When asked what the nurses say about his/her pain, the patient stated that they did not say much of anything about it. His/her leg has been red since coming home from the hospital. Before he/she went to the emergency room on 01/24/2022 it started getting warm. They took an X-ray and did blood work. The bone was not infected and the bloodwork was okay. They started him/her on two antibiotics The wound still hurt as much as ever. Sometimes it may feel a little better, but it still felt like a "torch" in his/her wound and leg. He/she was taking tramadol but it didn't work and he/she started taking ibuprofen. He/she thought the other day the PT called the doctor about his/her pain but did not know of any time before that that anyone had called the doctor about his/her pain. When asked if he/she would have liked for someone to have talked to the doctor about his/her pain, the patient stated, "oh yes". He/she was taking three ibuprofen about every eight hours. He/she stated that he/she waited as long as he/she could before taking it. During an interview on 02/03/2022 beginning at 4:15 PM the findings were reviewed with the administrator, clinical manager, clinical supervisor, and quality coordinator. He/she would expect the physician to be notified of the patient's pain levels. On 01/20/2022 there should have been documentation of why the visit was missed and that the physician was notified. He/she stated that the physician was not included in the notification of the missed visit. On 01/31/2022 they would expect the physician to be notified of any signs and symptoms of infection.

Coordinate care delivery CFR(s): 484.60(d)(4) Coordinate care delivery to meet the patient's needs, and involve the patient, representative (if any), and caregiver(s), as appropriate, in the coordination of care activities. This ELEMENT is not met as evidenced by: Based on policy review, record review, and interview, the agency failed to ensure coordination of care delivery in three (Records/Patients #3, #4 and #5) of five full records reviewed. This deficient practice has the potential to affect all patients served by the agency. RECORD/PATIENT #4: Review of the clinical record showed the patient was admitted to the agency with diagnoses of quadriplegia (paralysis of all four limbs), traumatic subarachnoid hemorrhage (bleeding in the space surrounding the brain) with loss of consciousness, and a motor vehicle collision on 12/09/2021. Review of the occupational therapy notes showed: - A home visit note, dated 1/18/2022, showed the patient complained of soreness in his/her hips and tailbone after sitting in his/her reclining wheelchair; and - A home visit note, dated 01/26/2022, showed the patient had two small reddened areas on his/her sacrum/pelvis; - The occupational therapy assistant performing the visits failed to notify the supervising occupational therapist or the clinical manager that the patient had potential pressure injuries to his/her sacrum; and - The agency failed to integrate nursing services when the potential pressure injury was identified. RECORD/PATIENT #5: Review of a physical therapy note, dated 12/08/2021 showed; - The patient reports a skin tear on the right arm; -The physical therapy assistant (PTA) documented that a Band-Aid was in place over the skin tear; and The physical therapy assistant performing the visit failed to notify the supervising physical therapist or the clinical manager that the patient had a skin tear. During an interview on 02/03/2022 beginning at 4:15 PM, findings were reviewed with the administrator, clinical manager, quality coordinator, and the clinical supervisor. The clinical manager stated that the clinicians have been instructed to notify their supervisor and the clinical manager to assess worsening patient issues including potential skin issues. He/she stated that the treating clinician should have reported the patient’s skin issues. Findings included: Review of the agency policy titled, "Coordination of Patient Services," dated 07/22/2021, showed in part: - All personnel furnishing services will ensure coordination of patient services through documentation, communication and reporting mechanisms. These mechanisms will be the electronic medical record, clinical notes, summary notes, and care conference minutes. The clinical manager will provide oversight of all patient care services and personnel including coordinating patient care and coordinating referrals; - Care coordination occurring through face-to-face conversations, telephone, and on-site visits will be noted in the contact tab; - The agency will coordinate care delivery to meet the patient's needs. - The agency will assure communication with all relevant physicians involved in the plan of care; - The agency will integrate services to assure: * The identification of patient needs; * Factors that could affect patient safety; * Treatment effectiveness; and * The coordination of care provided by all disciplines. RECORD/PATIENT #3: Review of the nursing start of care assessment dated 01/04/2022 showed the patient reported pain in the left leg (ulcer was on the right leg) at a level of eight on a scale of zero to 10 (pain is assessed on a scale of zero to 10 with zero meaning no pain and 10 meaning the worst pain) that was aching and stabbing, frequently occurred, duration was two to three hours, worsened with movement, relieved with tramadol (pain medication) and rest. The highest pain level in the last 24 hours was eight and the lowest pain level was eight. Associated symptoms showed nausea. The patient's pain goal was one out of 10. No documentation the nurse notified the physician of the pain level of eight for 24 hours. Review of the POC dated 01/04/2022 showed the clinician plans to provide care that included pain management (no specific nursing interventions or goals related to pain management). Review of the physical therapy POC dated 01/05/2022 showed pain assessment and management as needed per assessment. Evaluate the effectiveness of the current pain treatment regimen and notify the physician for the need for changes. Goals included that the pain/discomfort would be reduced to the patient's acceptable level and verbalize understanding of the pain management plan. Review of the PT initial visit dated 01/05/2022 showed the patient had pain in the right leg at a level of six out of 10 that was aching, constant, worsened with touch, relieved with medication/positioning. The highest pain level in the past 24 hours was eight out 10 and lowest was six out of 10. The patient's pain goal was zero out of 10. The progression of pain was improving, and associated symptoms was guarding. No documentation the PT discussed the pain levels with the nurse or physician. Review of an SN note dated 01/06/2022 showed the patient had pain in the right leg at a level of six out of 10 that was stabbing, frequent, duration two to three hours, worsened with movement and relieved with rest/tramadol. The highest level of pain and lowest level of pain in the past 24 hours was six out of 10. The patient's pain goal was one out of 10. The patient complained of pain in the right lower leg due to the wound at a level of six out of 10. No documentation the nurse notified the physician of the pain levels. Review of a physical therapy assistant (PTA) note dated 01/07/2022 showed the patient had pain in the right leg at a level of six out of 10 that was sharp, constant, worsened with movement and weight bearing and relieved with rest/elevation. Highest pain level in the past 24 hours was nine out of 10 and lowest level was six out of 10. The patient's pain goal was zero out of 10. Progression of pain was unchanged. Current pain treatments included tramadol, gabapentin (nerve pain medication) fiorcet (a pain medication used to treat headaches), elevation and rest. The patient complained of pain in the ulcer site on the right lower leg that was worse with movement and weight bearing. No documentation the PTA discussed the pain levels with the supervising PT, nurse or physician. Review of an SN note dated 01/10/2022 showed the patient had pain in the right leg at a level of seven out of 10 that was aching and stabbing, frequent, duration two to three hours, worsened with movement and relieved with rest/tramadol. The highest level of pain and lowest level of pain in the past 24 hours was seven out of 10. The patient's pain goal was one out of 10. No documentation the nurse notified the physician of the pain levels. Review of a social work note dated 01/10/2022 showed patient reported to be in pain and had no appetite. He/she reported almost going to the emergency room last night because of feeling so bad. The nurse just left and took care of him/her. So, the nurse was notified. No documentation the social worker discussed the patient's condition with the nurse. Review of a PT note dated 01/13/2022 showed the patient had pain in the right leg at a level of four out of 10 that was aching, frequent, duration varies, worsened with standing and walking, and relieved with medication and positioning. The highest pain level in the past 24 hours was eight and lowest was zero. The pain goal was zero out of 10. Progression of pain gradually improving, associated symptoms was guarding. Current pain treatments were medication and positioning. The patient reported feeling well except for head and back still itching from shingles. He/she went to the wound clinic and had a debridement (removal of dead tissue) performed. No documentation the PT notified the nurse or physician of the pain levels. Review of the SN notes showed: - On 01/14/2022 the patient had pain in the right leg at a level of seven out of 10 that was sharp, intermittent, long duration, exacerbating factors - wound (unclear what this meant), relieved with rest. The highest pain level in the past 24 hours was seven out of 10 and lowest pain level in the past 24 hours was two. The patient's pain goal was zero out of 10. Progression of pain was unchanged. The patient had a debridement yesterday (01/13/2022). No documentation the nurse notified the physician of the pain levels; and - On 01/17/2022 the patient had pain in the right leg at a level of four out of 10 that was throbbing, intermittent, long duration, worsened with activity, and relieved with medications/rest. The highest pain level in the past 24 hours was six out of 10 and lowest pain level in the past 24 hours was four. The patient's pain goal was zero out of 10. The progression of pain remained unchanged. No documentation the nurse notified the physician of the pain levels. Review of the PTA visit notes showed: - On 01/17/2022 the patient had pain in the right foot at a level of four out of 10 that was sharp, tight, frequency was with activity, duration not addressed, worsened with standing and pressure, and relieved with elevation. The highest and lowest pain level in the past 24 hours was four out of 10. Progression of pain was waxing and waning. Current pain treatments was tramadol and most recent dose was one hour prior to treatment. No documentation the PTA notified the supervising PT, physician or nurse of the pain levels; and - On 01/19/2022 the patient had pain in the right foot at a level of three out of 10 that was sharp, pulling, constant, worsened with movement and walking and relieved with rest, elevation and medication. The highest and lowest pain level in the past 24 hours was three out of 10. The progression of pain was gradually improving. Current pain treatments included tramadol and fioricet. Most recent dose was yesterday. The patient also used rest and elevation to manage pain. The patient complained of pain in the right foot around the wound. The patient reported a fall with no injury on 01/17/2022. The PTA sent a communication to the physician, supervising therapist and case manager by case communication regarding the fall. No documentation the PTA discussed the pain levels and pain around the wound with the supervising PT, nurse or physician. Review of the SN notes showed: - On 01/20/2022 the nurse documented a missed visit note. The nurse documented he/she made a well call. He/she reviewed the wound care orders as the patient would change his/her dressing today. No documentation of the patient's pain levels or condition of the wound. The patient has an appointment with the wound clinic on Monday (01/24/2022) so the nurse would see the patient on Thursday, 01/27/2022. No documentation of why the visit was missed or that he/she notified the physician of the missed visit; and - On 01/24/2022 the nurse documented a missed visit note. The nurse documented the patient has a wound clinic appointment today. The nurse will see the patient on 01/27/2022 (three days later) as scheduled. No documentation the nurse notified the physician of the plan to only see the patient once this week. Review of a PTA note dated 01/25/2022 showed the patient had pain in the right foot at a level of nine out of 10 that was burning, sharp, constant, worsened with weight bearing and movement, relieved with pain medications. The highest pain level in the past 24 hours was 10 out of 10 and lowest was nine out of 10. The patient's pain goal was zero out of 10. The progression of pain was rapidly worsening. The patient was taking tramadol. The patient reported increased pain in the right foot from infection in his/her wound. The patient was sent by the wound care physician to the emergency room on 01/24/2022 for pain and infection in the right foot. The medications were yet to be picked up. The patient was instructed to avoid weight bearing as much as possible on the right leg and to keep the right leg elevated. The PTA left a message for the social worker to see if a walker could be brought to the patient. The patient has been prescribed two antibiotics and has a new prescription for tramadol and cortisol cream for topical application. A family member was picking them up today. The PTA sent a case communication note dated 01/25/2022 to the supervising PT, social worker, and nurse regarding the emergency room visit on 01/24/2022 for pain and infection in the right foot. No documentation the PTA reported the pain levels to the supervising PT, nurse or physician. Review of a PT note on 01/27/2022 the patient had pain in the right ankle at a level of seven out of 10 that was aching and burning, constant, no worsening factors and relieved with medication and positioning. The highest pain level in the past 24 hours was nine out of ten and lowest was four out of 10. The patient's pain goal was zero out of 10. Progression of pain was unchanged. Current pain treatments were medication and positioning. No documentation the PT reported the pain levels to the nurse or physician. Review of a SN note dated 01/27/2022 showed the patient had pain in the right leg at a level of six out of ten, that was burning, intermittent, sh (unclear what this meant), exacerbating factors - wound (unclear what this meant), relieved with medications. The highest pain level in the past 24 hours was six out of 10 and lowest was five out of 10. The patient's pain goal was zero out of 10. Progression of pain was unchanged. No documentation the nurse notified the physician of the pain levels. Review of a PTA note on 01/31/2022 showed the patient had pain in the right foot at a level of five out of ten that was throbbing, burning, constant, duration chronic, worsened with walking and touch, and relieved with medications, rest and elevation. The highest pain level in the past 24 hours was nine out of 10 and lowest was five out of 10. The progression of pain was unchanged. The patient was taking ibuprofen with the most recent dose approximately one hour prior to treatment. The patient stated that he/she was taking approximately 1200 mg every six hours. Nursing was informed. The patient stated that the infection persists and the signs and symptoms have not lessened with antibiotics. No documentation the PTA discussed the pain levels with the physician or nurse or that the patient stated his/her symptoms had not lessened with the antibiotics. Review of a social work note dated 01/31/2022 from 2:35 PM to 3:08 PM showed the patient reported the pain he/she is experiencing is bad. He/she is taking six 200 mg of ibuprofen to relieve the pain. The patient had tramadol prescribed cut he/she can't tell it is working at all. The patient has been worrying a lot about the pain, and that the infection will move to other parts of his/her body. He/she doesn't think the antibiotic is working at all and his/her concerns have been voiced to the nurse (unsure whether it was the patient or social worker that discussed the concerns with the nurse). Review of a SN visit note on 01/31/2022 from 3:05 PM to 3:45 PM, the patient had pain in the right foot at a level of eight out of 10 that was sharp, constant, duration long, exacerbating factors - wound (unclear what this meant), and relieved with medications/rest. The highest pain level in the past 24 hours was 10 out of 10 and lowest level was four out of 10. The patient's pain goal was zero out of 10. The progression of pain remained unchanged. The patient reported he/she had been taking six 200 mg of ibuprofen (anti-inflammatory) every eight hours. The nurse educated the patient on safe dosage amounts and recommended to scale back to nor more than six tablets/day. Under the section for skilled assessment of the wound, the nurse documented the wound was CD/I (clean, dry and intact) and had a pink, warm area surrounding the wound. Under the section for skilled assessment risk for infection the nurse documented the wound bed was clean (no further wound assessment) and the surrounding wound was red and warm. No documentation the nurse notified the physician of the pain levels or the pink/redness and warmth surrounding the wound. During an interview on 02/03/2022 at 11:06 AM, the social worker stated that the patient had a leg that was infected and couldn't stand for long periods of time. He/she had taken food, a shower chair and a four legged walker to the patient. The patient told him/her that he/she was taking six ibuprofen at a time for pain. He/she talked to the PTA who had contacted the nurse and physician about it. The PTA had told the physician how much ibuprofen the patient was taking and the pain was not controlled with the tramadol. During an interview on 02/03/2022 at 12:15 PM, registered nurse (RN) B stated that the patient has been battling this wound since Thanksgiving. When the patient went to the emergency room on 01/24/2022 they started him/her on two antibiotics. He/she did not think they discontinued the tramadol but the patient was not taking the tramadol because it did not help. The PTA had notified the physician on 01/31/2022 because the tramadol was not helping. The PT sent him/her a message that they called the physician about the patient taking more than the recommended dose of ibuprofen. There was a case communication from the PTA that the physician had responded to their previous case communication on 01/31/2022 and that the patient was not to exceed 800 mg of ibuprofen three times a day for a maximum dose of 2400 mg/day. No one had notified the physician about the pain before 01/31/2022. The RN had not called the physician about the pain. Initially the pain was mostly with dressing changes and the wound looked better. The redness and warmth around the wound was not new for the patient (no prior documentation of this except on 01/27/2022 that the peri-wound was pink). He/she calls the patient about 30 minutes before the dressing change so he/she could take the ibuprofen which seemed to help the pain. During an interview on 02/03/3022 at 1:10 PM with the physician's patient care representative (PCR) showed that the physician wanted the surveyor to know the patient had been on tramadol for pain. He/she did not recall having a communication with him/her about high levels of pain. The PCR did not see any communication from home health about the patient's pain until 01/31/2022. He/she would have hoped they would have contacted them if the patient had high levels of pain. On 01/31/2022 the PT notified them about the patient taking ibuprofen. The physician said for the patient not to exceed 800 mg at a time and not to exceed 2400 mg per day. There was an order in the system from the emergency room on 01/24/2022 for tramadol 50 mg one tablet every six hours. The patient had called the office on 01/31/2022 about his/her shingles not improving and talked to the nurse practitioner (NP). There were no orders. The NP told the patient he/she needed to be seen. During an interview on 02/03/2022 beginning at 4:15 PM, findings were reviewed with the administrator, clinical manager, quality coordinator, and the clinical supervisor. The clinical manager stated that the clinicians have been told to notify the clinical manager if there are worsening patient issues. The clinical supervisor stated that he/she would expect an assessment, notification of the physician to inform and obtain orders, if needed followed by documentation in the medical record of any changes in the patient's condition.

Other pertinent instructions CFR(s): 484.60(e)(4) Any other pertinent instruction related to the patient's care and treatments that the HHA will provide, specific to the patient's care needs. This ELEMENT is not met as evidenced by: Based on policy review, record review, home visit observation, and interview, the agency failed to provide the patient and caregiver with a copy of pertinent written instructions outlining treatments to be administered by agency personnel and personnel acting on behalf of the agency related to the patient's care and treatments. This deficient practice has the potential to affect all patients served by the agency. Findings included: Review of the agency's policy titled, "Coordination of Patient Services," dated 07/22/2021, showed the agency will provide the patient and caregiver with a copy of written instructions outlining any treatment to be administered by agency personnel and personnel acting on behalf of the agency and any other pertinent instructions related to the patient's care and treatments that the agency will provide, specific to the patient's care needs. Review of the agency's policy titled, "Patient Education Policy," dated 06/24/2020, showed verbal and/or written instruction will be provided regarding any procedures and treatments to be performed. RECORD/PATIENT #1: Review of the home health referral showed: - Discharged from the rehabilitation facility on 01/11/2022; - Disciplines ordered included skilled nursing (SN); - Intravenous (IV) medications provided per (named infusion therapy service company); and - Specific orders showed to evaluate and treat, (named infusion therapy service company) to arrange IV medications, and home health for labs and PICC (peripherally inserted central catheter) line dressing changes. Review of the plan of care (POC) dated 01/12/2022, showed an order for Rocephin (antibiotic) 2000 milligrams (mg) for home infusion (started 01/11/2022). Inject one dose by IV injection every 24 hours for 19 days. Observation and interview on 02/01/2022 beginning at 9:20 AM, during the patient's home visit, showed the patient's home folder failed to include written instructions regarding IV medication infusion and PICC line care. The patient stated that he/she did not think they left him/her any instructions about the IV infusions. If they did, it would be in the folder. During an interview on 02/01/2022 beginning at 11:28 AM, the clinical manager stated that he/she would expect the instructions to be left in the patient's home packet.

Infection Prevention CFR(s): 484.70(a) Standard: Infection Prevention. The HHA must follow accepted standards of practice, including the use of standard precautions, to prevent the transmission of infections and communicable diseases. This STANDARD is not met as evidenced by: Based on policy review, observation, and interview, the agency failed to incorporate Centers for Disease Prevention and Control (CDC) Guidance for COVID-19 by ensuring policies and procedures were followed for screening persons entering the agency and the agency failed to follow accepted standards of practice to prevent the transmission of infections and communicable diseases in one (Patient/Record #2) of two home visits. This deficient practice has the potential to affect all patients served by the agency. Findings included: Review of the agency’s undated policy, titled “Mercy Hospital Jefferson Home Health and Hospice COVID-19 Plan,” showed walk-in delivery people, visitors, and other non-employees are asked screening questions at the point of entry per Mercy Wide Guidelines. On 01/31/2022, the survey team rang the doorbell for entry and entered the agency with appropriate face masks in place. The surveyors introduced themselves to the staff at the reception desk and were escorted to a conference room to work for the duration of the survey. The survey team re-entered the agency on 02/01/2022. The agency failed to ask the surveyors any COVID-19 screening questions on either day. An observation of a delivery to the agency, on 02/01/2022 at 10:40 AM, showed the delivery personnel rang the doorbell for entry, entered the agency with a delivery of boxes that he/she wheeled past the staff at the reception desk. The agency failed to ask the delivery person any COVID-19 screening questions. During an interview with the administrator, clinical manager and quality coordinator on 02/01/2022, the administrator stated that the receptionist has the screening questions in a plastic sleeve at his/her desk. The clinical manager stated that he/she would expect the staff to ask all non-employees who enter the agency the COVID-19 screening questions. RECORD/PATIENT #2: Review of the agency’s policy, titled “Hand Hygiene Policy,” dated 06/08/2021 showed: - Hand hygiene is performed: * After touching a patient; * After removing gloves; * When moving from one task to another; and - To avoid cross contamination of surfaces, co-workers should: * Perform hand hygiene; * Don gloves; * Remove gloves; * Perform hand hygiene; and * Don new pair of gloves before starting a new task. Observation on 02/01/2022 at 9:15 AM, during the patient's home visit, showed registered nurse (RN) A: - Wore gloves to assess the patient’s blood pressure, temperature, pulse and respiratory rate; - Laid the soiled blood pressure cuff and thermometer on a barrier that had been placed on the patient’s kitchen table; - Cleaned the blood pressure cuff and thermometer and placed them back into his/her bag; and - Failed to remove his/her soiled gloves, sanitize hands and don clean gloves prior to cleaning the equipment and placing it back into his/her bag. During an interview conducted during the home visit on 02/01/2022 at 10:05 AM, RN A stated that he/she could see how the vital signs equipment would get cross-contaminated by failing to change the gloves and cleanse his/her hands prior to cleaning the equipment. He/she stated that he/she was very nervous and just didn’t think about it. During an interview with the administrator, clinical manager and quality coordinator on 02/01/2022 at 11:30 AM, both the administrator and the clinical manager stated that they would expect the nurse to have changed his/her gloves and sanitize his/her hands after direct patient contact prior to cleaning the equipment.

Interdisciplinary assessment of the patient CFR(s): 484.75(b)(1) Ongoing interdisciplinary assessment of the patient; This ELEMENT is not met as evidenced by: Based on policy review, record review and interview, the agency failed to ensure staff provided ongoing assessments for three (Records/Patients #1, #3, and #5) of five full records reviewed. This deficient practice has the potential to affect all patients served by the agency. RECORD/PATIENT #5: Review of the comprehensive assessment completed by the physical therapist, dated 11/01/2021, showed a wound assessment of a red, soft lesion, approximately 1 centimeter (cm) in diameter, on the lower medial aspect (middle) of the left leg. Review of the plan of care, dated 11/01/2021, showed a wound assessment of a lesion on the lower medial aspect of the left leg that is red and soft and approximately 1 cm in diameter. Review of the skilled nurse visit notes, dated 11/02/2021 through 12/23/2021, showed the agency failed to document an assessment of the red soft leg lesion identified in the plan of care. Review of the physical therapy visit note, dated 12/08/2021, showed the patient reported a skin tear on his/her right arm with a Band-Aid in place. The therapy assistant performing the visit failed to document any further information regarding the skin tear. Review of the skilled nurse notes dated, 12/08/2021 through 12/23/2021, showed the agency failed to perform an assessment of the skin tear reported by the patient during the 12/08/2021 home visit. During an interview on 02/03/2022 beginning at 4:15 PM, findings were reviewed with the administrator, clinical manager, quality coordinator, and the clinical supervisor. The clinical manager stated that the clinicians have been instructed to notify their supervisor and the clinical manager to assess worsening patient issues including potential skin issues. He/she stated that the treating clinician should have reported the patient’s skin issues. The clinical supervisor stated that he/she would expect the nurses to perform an assessment, with subsequent notification of the physician, of any skin tears reported by the patient. Findings included: Review of the agency policy titled, “Pain Management,” dated 09/02/2020, showed in part: - Upon admission each patient will be assessed and evaluated regarding pain; - If the patient has a diagnosis which would lead you to believe they may have pain, currently on a pain medication regime or have had a recent history of pain, the clinician will then complete an in-depth pain assessment that includes pain intensity (use a pain intensity rating scale appropriate for the patient population), location of pain, quality, patterns of radiation, if any, character (elicit and record the patient’s own words whenever possible), alleviating and aggravating factors, present pain management regimen and effectiveness, pain management (including medication history), effects of pain (impact on daily life, functional ability, sleep, appetite, etc.), the patient’s pain goal, exam/observation of the pain site and document findings; and - Upon admission patients will receive instructions regarding patient rights and responsibilities regarding pain control and assessment, instruct patient to honestly communicate pain and suffering status to physician and other healthcare personnel and that pain management is an important part of their care, complete ongoing pain assessments throughout care, implement, assess and document the physician ordered pain management plan and also the effectiveness of pain treatment regularly. Review of the agency policy titled, "Infection Prevention Policy," dated 06/08/2021, showed in part: - General wound and skin care guidelines that should be completed for all patients with potential and/or actual skin impairment in skin integrity included to measure wounds weekly, preferably at the beginning of each week; - Cleanse wounds prior to assessing; - Document dressing application and wound status with weekly wound measurements and re-evaluate dressing and skin integrity as needed; and - Provide physician with wound status and if wound fails to progress consult with the physician for new or changed treatment regime. Review of the agency’s policy, titled “Comprehensive Assessment and Reassessment Policy,” dated 04/09/2019, showed: - The registered nurse must conduct an initial assessment visit to determine the immediate care and support needs of the patient; - The assessment must contain the patient’s current health status including a wound assessment as applicable; and - The assessment must contain the patient’s medical and nursing needs. RECORD/PATIENT #1: Review of the plan of care (POC) dated 01/12/2022 showed for the skilled nurse to assess the PICC (peripherally inserted central catheter. IV access that can be used for long periods of time) line infusion site each visit. Observe and evaluate the device and surrounding tissue, integrity of the device/cover dressing, security of the connections. Review of the initial nursing visit dated 01/12/2022 showed no documented assessment of the PICC line insertion site. During an interview on 02/03/2022 beginning at 4:14 PM with the administrator, clinical manager, clinical supervisor and quality coordinator, the clinical supervisor stated that he/she would expect the nurse to document an assessment of the insertion site on the initial visit. RECORD/PATIENT #3: Review of the referral information showed in part to cleanse the right lower leg ulcer with wound cleanser, pat dry, apply Santyl (a topical treatment that removes dead tissue from wounds) nickel thickness from edge to edge, cover with alginate (an antimicrobial dressing that keeps the wound moist and protects from contamination) fit to size and bordered foam. Change dressing daily and as needed. Review of the nursing start of care assessment dated 01/04/2022 showed: - The patient reported pain in the left leg (ulcer was on the right leg) at a level of eight on a scale of zero to 10 (pain is assessed on a scale of zero to 10 with zero meaning no pain and 10 meaning the worst pain) that was aching and stabbing, frequently occurred, duration was two to three hours, worsened with movement, relieved with tramadol (pain medication) and rest. The assessment failed to address how much or how often the patient took his/her pain medication; and - Interventions included to assess and document the wound location, size of visible granulation (new connective tissue that forms during wound healing) tissue or epithelialization (new healing surface on an open wound), necrotic tissue, signs and symptoms of infection. Assess and document exudate (drainage), volume, color, consistency and odor. The wound assessment showed the dressing appearance was moist drainage, oval shaped, wound base beefy red, peri-wound (surrounding) area intact and moderate serosanguinous (thin, watery pink colored) drainage. The nurse failed to document whether odor was present. Review of the POC dated 01/04/2022 showed: - The clinician plans to provide care that included wound care, dressing change education and pain management (no specific nursing interventions or goals related to pain management); and - Skilled assessment of the wound each visit. Assess and document wound location, size of visible granulation tissue or epithelialization, necrotic tissue, signs and symptoms of infection. Assess and document exudate volume, color, consistency and odor. Review of the physical therapy (PT) POC dated 01/05/2022 showed interventions that included pain assessment and management as needed per assessment. Evaluate the effectiveness of the current pain treatment regimen and notify the physician for the need for changes. Goals included that the pain/discomfort would be reduced to the patient's acceptable level and verbalize understanding of the pain management plan. Review of the PT initial visit dated 01/05/2022 showed the patient had pain in the right leg at a level of six out of 10 that was aching, constant, worsened with touch, relieved with medication/positioning. The highest pain level in the past 24 hours was eight out 10 and lowest was six out of 10. The assessment failed to address how much or how often the patient took pain medication. Review of an SN note dated 01/06/2022 showed the patient had pain in the right leg at a level of six out 10 that was stabbing, frequent, duration two to three hours, worsened with movement and relieved with rest/tramadol. The highest level of pain and lowest level of pain in the past 24 hours was six out of 10. The assessment failed to address how much and how often the patient took his/her pain medication. The nurse provided wound care and changed the patient's dressing. The wound on the right leg measured 2.5 x 2.0 centimeters (cm). No further documented assessment of the wound. Review of a physical therapy assistant (PTA) note dated 01/07/2022 showed the patient had pain in the right leg at a level of six out of 10 that was sharp, constant, worsened with movement and weight bearing and relieved with rest/elevation. Highest pain level in the past 24 hours was nine out of 10 and lowest level was six out of 10. The assessment failed to address how much and how often the patient was taking pain medication. Review of a PT note dated 01/10/2022 the patient had no current pain and no pain in the last 24 hours. Current pain treatments included medication, ice and positioning. The assessment failed to include how much and how often the patient used pain medication. Review of a SN note dated 01/10/2022 showed the patient had pain in the right leg at a level of seven out of 10 that was aching and stabbing, frequent, duration two to three hours, worsened with movement and relieved with rest/tramadol. The assessment failed to address how much and how often the patient took his/her pain medication. The wound on the right leg measured 2.5 x 2.5 cm. Pictures of the wound were added. No signs and symptoms of infection. No documentation of the wound tissue, surrounding skin, drainage or odor. Review of a PT note dated 01/13/2022 showed the patient had pain in the right leg at a level of four that was aching, frequent, duration varies, worsened with standing and walking, and relieved with medication and positioning. The assessment failed to address how much and how often the patient took pain medication. Review of the SN notes showed: - On 01/14/2022 the patient had pain in the right leg at a level of seven out of 10 that was sharp, intermittent, long duration, exacerbating factors - wound (unclear what this meant), relieved with rest. The assessment failed to address whether the patient was using his/her pain medication and its effectiveness. The wound on the right leg had pink/white granulation tissue. The wound assessment failed to include surrounding skin, amount of drainage and whether odor was present; and - On 01/17/2022 the patient had pain in the right leg at a level of four out of 10 that was throbbing, intermittent, long duration, worsened with activity, and relieved with medications/rest. The assessment failed to address how much and how often the patient took his/her pain medication. Under the section for skilled assessment of the wound, the nurse documented to see wound assessment and no signs and symptoms of infection. No further documentation of a wound assessment was found. Review of the PTA visit notes showed: - On 01/17/2022 the patient had pain in the right foot at a level of four out of 10 that was sharp, tight, frequency was with activity, duration not addressed, worsened with standing and pressure, and relieved with elevation. Current pain treatments was tramadol and most recent dose was one hour prior to treatment. The pain assessment failed to address how much and how often the patient took the pain medication; and - On 01/19/2022 the patient had pain in the right foot at a level of three out of 10 that was sharp, pulling, constant, worsened with movement and walking and relieved with rest, elevation and medication. Current pain treatments included tramadol and fioricet. Most recent dose was yesterday. The patient also used rest and elevation to manage pain. The patient complained of pain in the right foot around the wound. The assessment failed to address which pain medication and how much pain medication the patient took. Review of a PTA note dated 01/25/2022 showed the patient had pain in the right foot at a level of nine out of 10 that was burning, sharp, constant, worsened with weight bearing and movement, relieved with pain medications. The highest pain level in the past 24 hours was 10 out of 10 and lowest was nine out of 10. The assessment failed to address how much or how often the patient took pain medication. Review of a PT note dated 01/27/2022 the patient had pain in the right ankle at a level of seven out of 10 that was aching and burning, constant, no worsening factors and relieved with medication and positioning. The highest pain level in the past 24 hours was nine out of ten and lowest was four out of 10. The assessment failed to address how much and how often the patient took pain medication. Review of a SN note dated 01/27/2022 showed the patient had pain in the right leg at a level of six out of ten, that was burning, intermittent, sh (unclear what this meant), exacerbating factors - wound (unclear what this meant), relieved with medications. The highest pain level in the past 24 hours was six out of 10 and lowest was five out of 10. The assessment failed to address how much and how often the patient took pain medication. The wound assessment showed the dressing had moist drainage, the wound base showed pink, slough (dead tissue), white tissue, measured 2.5 x 2.5 x 0.2 cm, small amount of serosanguineous drainage. The assessment failed to include whether odor was present. Review of a SN visit note dated 01/31/2022 from 3:05 PM to 3:45 PM, showed under the section for skilled assessment of the wound, the nurse documented the wound was CD/I (clean, dry and intact) and had a pink, warm area surrounding the wound. Under the section for skilled assessment risk for infection the nurse documented the wound bed was clean and the surrounding wound was red and warm. No further documented wound assessment. During an interview on 02/03/2022 beginning at 4:15 PM the findings were reviewed with the administrator, clinical manager, clinical supervisor, and quality coordinator. The clinical supervisor stated that the staff should address all aspects of the pain assessment in their system. They should address how much and how often the patient was using their pain medication. The wound assessments should include location, type of wound, description of the wound, surrounding skin, drainage, odor. Wounds should be measured at the start of care and weekly. He/she would expect a full assessment of the wound to be documented when they did the wound care. They had been stressing to have the nurses do a written assessment along with the pictures taken.

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 policy review, record review and interview the agency failed to provide services ordered by the physician as indicated in the plan of care in, but not limited to, two (Records/Patients #2 and #5) of five full records reviewed. This deficient practice has the potential to affect all of the patients served by the agency. Findings included: Review of the agency’s policy, titled “Plan of Care and Orders Change Policy,” dated 10/13/2021, showed: - The physician’s orders on the plan of care shall relate to the diagnosis and must be considered reasonable and necessary treatment for that diagnosis; - The agency co-workers will provide care/services consistent with the plan of care; and - Drugs, services, and treatments are administered only as ordered by a physician. RECORD/PATIENT #2: Review of the clinical record showed the patient was admitted to the agency on 01/06/2022 with diagnoses of a type 2 diabetic foot ulcer (wound) on the left 5th metatarsal (the bones that connect the bones near the ankle to the bones of the toes), osteomyelitis (a bone infection) of the diabetic left foot ulcer, diabetic chronic kidney disease (damage to the blood vessels of the kidneys caused by poorly controlled diabetes), and a history of a right leg amputation (removal of a limb) below the knee. Review of the plan of care, dated 01/06/2022, showed the following: - The nurse was to assess and document the wound’s location, size of visible granulation tissue or epithelialization, necrotic tissue, signs and symptoms of infection, wound exudate (drainage) volume, color, consistency, and odor on each visit; - The patient was to perform a fasting blood sugar and record it daily in his/her log; and - The nurse was to review the log every visit and notify the physician of blood sugars less than 70 mg/dL (milligrams per deciliter) or greater than 300 mg/dL. Review of the skilled nursing notes showed the following: - During a visit, dated 01/10/2022, the nurse failed to document an assessment of the wound drainage, including color, consistency and the wound odor and the nurse failed to document a review of the patient’s blood sugar log; - During a visit, dated 01/14/2022, the nurse failed to document an assessment of the wound drainage, including color, consistency and the wound odor and the nurse failed to document a review of the patient’s blood sugar log; - During a visit, dated 01/18/2022, the nurse failed to document an assessment of the wound’s odor and the nurse failed to document a review of the patient’s blood sugar log; - During a visit, dated 01/21/2022, the nurse failed to document a review of the patient’s blood sugar log; - During a visit, dated 01/25/2022, the nurse failed to document an assessment of the wound’s odor; and - During a visit, dated 01/28/2022, the nurse failed to document an assessment of the wound’s odor and the nurse failed to document a review of the patient’s blood sugar log. RECORD/PATIENT #5: Review of the clinical record showed the patient was admitted with diagnoses of sepsis (a life-threatening response of the body to an infection) , pneumonia (an infection that inflames air sacs in the lungs), chronic obstructive pulmonary disease (COPD) (a group of lung diseases that block airflow and make it difficult to breathe), hypertensive chronic kidney disease (elevated blood pressure caused by kidney disease), clostridium difficile colitis (C. Diff) (an infection and inflammation of the intestines caused by a bacteria) and a history of lung cancer. Review of the plan of care, dated 11/01/2021, showed the physical therapist was to perform a general systems assessment to include vital signs and to obtain vital signs at every visit. Review of the physical therapy note, dated 12/6/2021, showed the physical therapist failed to obtain vital signs. During an interview on 02/03/2022 beginning at 4:15 PM, findings were reviewed with the administrator, clinical manager, quality coordinator, and the clinical supervisor. The clinical supervisor stated that he/she would expect the wound drainage and odor to be documented at every visit since that is how the intervention is written in the plan of care. The clinical supervisor stated that he/she would expect the clinician to document the review of the patient’s blood sugar log at every visit since that is how the intervention is written in the plan of care. The clinical supervisor stated that he/she would expect the physical therapist to obtain vital signs at every visit since that is how the intervention is written in the plan of care.

Patient and caregiver education CFR(s): 484.75(b)(5) Patient and caregiver education; This ELEMENT is not met as evidenced by: Based on policy review, record review, and interview, the agency failed to ensure the skilled professional staff assumed responsibility for patient and caregiver education in three (Records/Patients #1, #3, and #4) of five full records reviewed. This deficient practice has the potential to affect all patients served by the agency. RECORD/PATIENT #4: Review of the clinical record showed the patient was admitted to the agency with diagnoses of quadriplegia (paralysis of all four limbs), traumatic subarachnoid hemorrhage (bleeding in the space surrounding the brain) with loss of consciousness, and a motor vehicle collision on 12/09/2021. Review of the plan of care, dated 12/09/2021, showed the following: - The physical therapy plan was to instruct the patient/caregiver on pressure ulcer prevention education, including: * Proper hydration and nutrition; * Keeping skin clean and dry; * Proper positioning; and - The occupational therapy plan showed the patient/caregiver will demonstrate good knowledge of pressure ulcer prevention education by the end of the treatment episode. Review of the physical therapy notes, dated 12/13/2021 through 01/26/2022, showed the agency failed to provide any education on pressure ulcer prevention. Review of the occupational therapy notes showed: - A visit note, dated 01/26/2022, showed the patient had two small reddened areas on his/her sacrum; and - Visit notes, dated 12/10/2021 through 01/26/2022, showed the agency failed to provide any education on pressure ulcer prevention. During an interview on 02/03/2022 beginning at 4:15 PM, findings were reviewed with the administrator, clinical manager, quality coordinator, and the clinical supervisor. The quality coordinator stated that he/she would expect pressure ulcer prevention teaching to be documented in the clinical record. Findings included: Review of the agency policy titled, "Patient Education Policy," dated 06/24/2020, showed in part: - Patients and, as appropriate, their families are educated to improve individual outcomes; - Patient is assessed initially on admission to determine their educational needs, abilities and readiness for learning; - Patient's knowledge, performance of skills and behavior are assessed on an on-going basis with re-education provided as necessary; - Initial and on-going assessments will document patient education as appropriate to the patient's conditions and assessed needs. This included the safe and effective use of medications, special directions for preparation, self-administration and use of the medication in the home, appropriate administration techniques; and - Education performed will be documented including subject matter taught, the individuals taught, barriers to learning and response to teaching. Review of the agency policy, titled “Plan of Care Policy,” dated 04/09/2019, showed actions taken, education and services provided are documented within the visit note and shall be consistent with the care plan. RECORD/PATIENT #1: Review of the referral showed: - Discharged from the rehabilitation facility on 01/11/2022; - Disciplines ordered included skilled nursing (SN); - Intravenous (IV) medications provided per Optioncare (infusion therapy services); and - Specific orders showed to evaluate and treat, Optioncare to arrange intravenous (IV) medications, and home health for labs and PICC (peripherally inserted central catheter) line dressing changes. Review of the plan of care (POC) dated 01/12/2022 showed: - An order for Rocephin (antibiotic) 2000 mg for home infusion (started 01/11/2022). Inject one dose by IV injection every 24 hours for 19 days; and - Skilled nursing assessment and implementation of infusion therapy. Teaching of patient/caregiver role in infusion therapy; - Instruct patient in infusion administration purpose, dosages, preparation, scheduling, side effects, storage, food/drug interactions and potential complications. Review of the start of care nursing assessment dated 01/12/2022 failed to show the nurse educated the patient/caregiver regarding the IV medication administration with return demonstration to ascertain the patient and/or caregiver's ability to do so. Per interview conducted during observation on 02/01/2022 beginning at 9:20 AM the patient stated that his/her family member has done the IV infusion since he/she came home. The family member learned how to do the infusion before he/she left the rehabilitation facility. During an interview on 02/08/2022 at 9:45 AM, the clinical supervisor stated that he/she did not see documentation of the infusion education on the initial visit. He/she would expect the nurse to provide education on the PICC line and infusion on the initial visit, document the education provided, and the patient/caregiver's ability to perform the care. RECORD/PATIENT #3: Review of the referral information showed in part: - Hospital discharge date 12/31/2021; and - Cleanse right lower leg ulcer with wound cleanser, pat dry, apply Santyl (a topical treatment that removes dead tissue from wounds) nickel thickness from edge to edge, cover with alginate (an antimicrobial dressing that keeps the wound moist and protects from contamination) fit to size and bordered foam. Change dressing daily and as needed. Review of the nursing start of care assessment dated 01/04/2022 (four days after discharge from the hospital) showed wound care education was provided but failed to show a return demonstration to ascertain the patient's ability to perform the wound care. Review of the POC dated 01/04/2022 showed: - The clinician plans to provide care that included wound care and dressing change education; and - Cleanse right lower leg ulcer with wound cleanser, pat dry, apply Santyl (a topical treatment that removes dead tissue from wounds) nickel thickness from edge to edge, cover with alginate (an antimicrobial dressing that keeps the wound moist and protects from contamination) fit to size and bordered foam. Change dressing daily and as needed. Review of the physical therapy POC dated 01/05/2022 showed to Instruct the patient/caregiver on the use of ice to the area of chief complaint (unclear if this referred to the wound on the right lower leg) for ten minutes as many times as needed to relieve pain. Review of the physical therapist (PT)/Physical therapy assistant (PTA) notes from 01/05/2022 through 01/31/2022 failed to show documentation that the patient was educated regarding the use of ice for pain. Review of a physician order dated 01/13/2022 showed an order to cleanse with wound cleanser, cleanse the peri-ulcer area with wound cleanser, use collagen (promotes healing by keeping the wound moist,/timalol (an eye drop that can be used to help wounds heal) drops as the primary dressing, use alginate bordered foam and xeroform (non-adherent) gauze as the secondary dressing. Review of the SN notes dated 01/14/2022 showed the new order for wound care and that wound care education was provided but failed to show a return demonstration to ascertain the patient's ability to perform the wound care. During an interview on 02/03/2022 at 2:55 PM when asked if he/she used ice on the area, the patient stated that he/she thought someone told him/her not to. During an interview on 02/03/2022 beginning at 4:15 PM the findings were reviewed with the administrator, clinical manager, clinical supervisor, and quality coordinator. The clinical supervisor stated that he/she would expect the nurse to educate the patient on wound care and document the education and the patient's ability to do the wound care. They had been stressing for the clinicians to have the patients do a return demonstration to assess their ability to perform the care.

Org. had partial/extended survey CFR(s): 484.80(f)(3) Was subjected to an extended (or partially extended) survey as a result of having been found to have furnished substandard care (or for other reasons as determined by CMS or the state); or This ELEMENT is not met as evidenced by: Based on the results of this extended level survey, resulting in noncompliance with one Condition of Participation: 484.60-Care planning, Coordination of Services and Quality of Care the agency may not train or competency evaluate their home health aides for a period of two (2) years following the date of this survey. The restriction ends 02/10/2024.

Home health aide assignments and duties CFR(s): 484.80(g)(1) Standard: Home health aide assignments and duties. Home health aides are assigned to a specific patient by a registered nurse or other appropriate skilled professional, with written patient care instructions for a home health aide prepared by that registered nurse or other appropriate skilled professional (that is, physical therapist, speech-language pathologist, or occupational therapist). This STANDARD is not met as evidenced by: Based on policy review, record review, and interview, the agency failed to ensure the registered nurse (RN) developed a complete aide plan of care (POC) for one (Record/Patient #1) of one record reviewed that received aide services. This deficient practice has the potential to affect all patients that receive aide services. Findings included: Review of the agency's policy titled, "Home Health Aide Services," dated 09/01/2020, showed in part: - Specific personal care services to be provided by the home health aide must be determined by a registered professional nurse (RN); - The RN assesses and evaluates the patient/caregiver needs for home health aide services; - A physician must order services; and - The nurse completes the home health aide care plan in its entirety. RECORD/PATIENT #1: Review of the plan of care (POC) dated 01/12/2022 showed: - The patient received intravenous (IV) medication through a PICC (peripherally inserted central catheter) and wound care that included to keep the left knee covered with an island dressing (provides a protection for surgical incisions) and - The home health aide POC failed to include instructions regarding care of the PICC line site and knee dressing during showers. During an interview on 02/03/2022 beginning at 4:15 PM the findings were reviewed with the administrator, clinical manager, clinical supervisor and quality coordinator. The clinical supervisor stated that the aide care plan should include that the PICC line site and knee dressing needed to be covered.

Services provided by HH aide CFR(s): 484.80(g)(2) A home health aide provides services that are: (i) Ordered by the physician or allowed practitioner; (ii) Included in the plan of care; (iii) Permitted to be performed under state law; and (iv) Consistent with the home health aide training. This ELEMENT is not met as evidenced by: Based on policy review, record review and interview, the registered nurse (RN) failed to provide an individualized, patient specific home health aide plan of care, therefore the home health aide was unable to specifically follow the plan of care in one (Record/Patient #1) of one record reviewed that received aide services. This deficient practice has the potential to affect all patients that receive home health aide services. Findings included: Review of the agency policy titled, "Home Health Aide Services," dated 09/01/2020, showed: - Specific personal care services to be provided by the home health aide must be determined by a registered professional nurse (RN); - The RN assesses and evaluates the patient/caregiver needs for home health aide services; - A physician must order services; and - The nurse completes the home health aide care plan in its entirety. RECORD/PATIENT #1: Review of the plan of care (POC) dated 01/12/2022 showed: - The patient received intravenous (IV) medication through a PICC (peripherally inserted central catheter) and wound care that included to keep the left knee covered with an island dressing (provides a protection for surgical incisions) and - The home health aide POC failed to include instructions regarding care of the PICC line site and knee dressing during showers. Review of the home health aide visits showed: - On 01/13/2022 no documentation of care of the PICC line site and left knee dressing; and - From 01/17/2022 through 01/31/2022 showed the aide wrapped the PICC line site and left knee with plastic wrap during showers. Review of a home health aide supervisory note dated 01/24/2022 showed the RN documented he/she reviewed the POC, and the aide provided care as assigned. Review of the record showed no update of the aide POC to include instructions for covering the PICC line site and knee dressing during showers. During an interview on 02/03/2022 beginning at 4:15 PM the findings were reviewed with the administrator, clinical manager, clinical supervisor and quality coordinator. The clinical supervisor stated that the aide care plan should include that the PICC line site and knee dressing needed to be covered.