Every finding on record at Missouri Home Care of Rolla Inc

The Emergency Preparedness regulations were reviewed as part of the Medicare recertification survey completed on 06/17/2026. 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 06/17/2026. The provider had a total of 585 current patients in the two branches and the parent provider. A patient from each branch was sampled, for a total sample of six full records.

5 calendar days after start of care CFR(s): 484.55(b)(1) The comprehensive assessment must be completed in a timely manner, consistent with the patient's immediate needs, but no later than 5 calendar days after the start of care. This ELEMENT is not met as evidenced by: Based on policy review, record review, and interview, the home health provider failed to ensure that staff completed the initial comprehensive assessment within the required time frame for all disciplines ordered at the start of care in one of five full records reviewed (Record/Patient #1). This deficient practice has the potential to affect all the patients served by the provider. Findings included: Review of the provider’s policy titled, “Patient Assessments,” revised 01/2026, showed that the initial comprehensive assessment must be completed no later than five calendar days after the start of care. RECORD/PATIENT #1: Review of the clinical record showed the patient was admitted to home health services on 05/26/2026 with a primary diagnosis of aftercare following joint replacement surgery. The patient lived at home alone. Review of the patient information report showed a coordination note dated 05/21/2026 that showed verbal orders for a start of care on 05/26/2026 for physical therapy (PT) and occupational therapy (OT) to evaluate and treat. Review of a coordination note dated 06/15/2026 showed on 06/02/2026 the OT stated that: - The patient was not available for a visit on 06/03/2026 (eight days after admission) and that was the only day the OT was available to be in the area that the patient lived in; and - Per request of the patient, the OT evaluation visit was rescheduled to the following week on 06/08/2026 and then rescheduled per patient request to 06/09/2026. Review of the OT evaluation note dated 06/09/2026 showed that the assessment visit was conducted 14 days after the patient was admitted. During an interview on 06/17/2026 at 2:40 PM, the home health administrator stated that the OT evaluation should have been completed within the five-day window or on the physician ordered date, and there were no orders in the record for the delay in the OT evaluation.

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, observation, and interview, the home health provider failed to ensure an accurate medication list was maintained for the patient in one of three home visits conducted (Record/Patient #3). This deficient practice has the potential to affect all the patients served by the provider. Findings included: Review of the provider’s policy titled, “Medication Review and Documentation,” revised 03/2026, showed that during each visit the provider would review all medications the patient was taking for any medication changes, patient adherence to medication orders, and patient knowledge of medications. RECORD/PATIENT #3: Review of the clinical record showed the patient was admitted to home health services on 01/06/2026 with a primary diagnosis of type 2 (two) diabetes mellitus with foot ulcer (a chronic disease that affects how the body uses sugar for energy). The patient lived at home alone. Observation and interview on 06/17/2026 at 9:45 AM, showed the RN reviewed all of the patient’s medications and stated that the medications in the home and the provider’s medication profile (PMP) did not match. The following discrepancies were identified: - The PMP showed acetaminophen 325 milligrams (mg) two tablets every six hours as needed for pain. The patient had 500 mg and stated he/she took two tablets twice daily; - The PMP showed allopurinol (lowers uric acid levels) 100 mg daily. The patient had 300 mg tablets one daily; - The PMP showed amiodarone (heart rhythm) 200 mg daily. The patient had 100 mg tablets one daily; - The PMP showed desvenlafaxine succinate (treat depression) ER (extended release) 50 mg daily. The patient had 50 mg and 25 mg tablets and stated that he/she took 75 mg daily; - The PMP showed digoxin (treat heart failure) 0.125 mg every Monday, Wednesday, and Friday. The patient stated that he/she took this every day; - The PMP showed Eliquis (thins the blood) 5 mg twice daily. The patient was out of this medication and stated that he/she took it once daily when he/she had the medication; - The PMP showed fish oil 1000 mg daily. The patient had 2400 mg daily; - The PMP showed furosemide (water pill) 40 mg twice daily. The patient stated that he/she took one daily; - The PMP showed gabapentin (for nerve pain) 100 mg two at bedtime. The patient had 300 mg and took this three times daily; - The PMP showed Klor-Con (water pill) 20 milliequivalents (meq) twice daily. The patient stated that he/she was not taking this medication; - The PMP showed metoprolol (blood pressure) 50 mg daily. The patient had 25 mg daily; - The PMP showed omeprazole (reduce stomach acid) 20 mg daily. The patient stated that he/she was not taking this medication; - The patient had hydroxyzine 25 mg ½ tablet every eight hours as needed for anxiety, glipizide (lower blood sugar) 5 mg daily, and spironolactone (water pill) 50 mg daily in the home and these medications were not on the PMP. During an interview on 06/17/2026 at 2:50 PM, the home health administrator stated that the medication list in the computer should have matched what the patient was taking. If the medications did not match, the physician should have been notified for clarification.

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, observation, and interview, the provider failed to ensure that each patient's written individualized plan of care (POC) included patient-specific interventions and education, all safety measures regarding high-risk medications, the physical therapy (PT) frequency and duration of visits to be made, and measurable outcomes and goals as identified in the comprehensive assessment, in one of five full records reviewed (Record/Patient: #5). This deficient practice had the potential to affect all the patients served by the provider. Findings included: Review of the provider’s policy titled, “Care Planning,” dated 03/2026, showed in part that each patient had to receive an individualized written POC, including updates based on patient findings. The POC had to specify care and services to meet patient-specific needs and include responsible disciplines, measurable outcomes, and patient/caregiver education. RECORD/PATIENT #5: Review of the clinical record showed the patient was admitted to home health services on 03/10/2026 with a primary diagnosis of right total knee replacement. The patient resided in his/her own home with the assistance of his/her family. Review of the initial comprehensive assessment, dated 03/10/2026, showed in part that: - The patient reported pain managed with ice, medications, positioning, and rest/sleep; and - The patient had a closed surgical incision with a non-removable dressing. Review of the home health certification and plan of care, with certification dates of 03/10/2026 to 05/08/2026, showed in part that the POC failed to contain: - Orders for the patient to use ice to manage his/her pain; and - Orders for incisional care and/or a removal plan for the non-removable dressing. During an interview on 06/17/2026 at 11:40 AM, the administrator stated that: - They would expect orders for ice therapy, incisional care, and care of the non-removable dressing to be included on the POC; and - They were unable to locate the orders on the patient's 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 home health provider failed to ensure that drugs, services, and treatments were administered only as ordered by a physician in one of five records reviewed (Record/Patient #3). This deficient practice has the potential to affect all the patients served by the provider. Findings included: Review of the provider’s policy titled, “Physician/Allowed Practitioner Orders,” dated 01/2026, showed that all services, treatments, and medications had to be ordered by a physician or allowed practitioner and had to be detailed to include disciplines, visit frequency and duration, and skilled services to be provided. RECORD/PATIENT #3: Review of the clinical record showed the patient was admitted to home health services on 01/06/2026 with a primary diagnosis of type 2 (two) diabetes mellitus with foot ulcer (a chronic disease that affects how the body uses sugar for energy). The patient lived at home alone. Review of the skilled nurse visit report notes dated 05/11/2026 and 05/14/2026 showed that the nurse documented he/she applied triamcinolone cream (topical steroid) to the patient's bilateral lower extremities for treatment of itchy, dry skin. The clinical record failed to include an order. During an interview on 06/17/2026 at 2:55 PM, the home health administrator stated that he/she was unable to find an order for the treatment of itchy, dry skin, but the patient had an order for the use of triamcinolone cream to a rash (no location listed on the order).

Infection Prevention CFR(s): 484.70(a) Standard: Infection Prevention. The HHA must follow accepted standards of practice, including the use of standard precautions, to prevent the transmission of infections and communicable diseases. This STANDARD is not met as evidenced by: Based on nationally recognized standards, procedure review, record review, observation, and interview, the home health provider failed to ensure that staff followed infection control procedures in two of three home visits conducted (Records/Patients #1 and #2). This deficient practice has the potential to affect all the patients served by the provider. Findings included: Review of the Centers for Disease Control (CDC) document titled, "Clinical Safety: Hand Hygiene for Healthcare Workers," dated 02/27/2024, showed in part that clinicians must clean their hands: - Immediately before touching a patient; - Before moving from work on a soiled body site to a clean body site on the same patient; - After contact with blood, body fluids, or contaminated surfaces; and - Immediately after glove removal. Review of the provider's procedure titled, "Standard Precautions," revised 09/2025, showed that staff perform hand hygiene before and after patient contact, after contact with potentially infectious material, and before performing aseptic tasks; and use alcohol-based hand rubs or soap and water per CDC guidelines. Review of the provider's procedure titled, "Bag Technique, Home Care," revised May 19, 2025, showed that the staff would leave disposable, single patient-use items in the home for continued use or have dedicated equipment according to the provider's guidelines. RECORD/PATIENT #1: Review of the clinical record showed the patient was admitted to home health services on 05/26/2026 with a primary diagnosis of aftercare following joint replacement surgery. The patient lived at home alone. Observation and interview on 06/16/2026 at 10:45 AM, showed the Physical therapist (PT) placed a cloth gait belt on the patient and conducted therapeutic exercises. The PT removed the gait belt from the patient, failed to clean the gait belt, and placed it in his/her supply bag where he/she had just placed his/her clean vital sign equipment. The PT stated that he/she preferred vinyl gait belts, and that he/she cleaned the gait belt weekly in his/her washing machine. During an interview on 06/16/2026 at 1:00 PM, the home health clinical manager for branch office A stated that their practice was for each patient to have their own gait belt. During an interview on 06/17/2026 at 2:50 PM, the home health administrator stated that all equipment was to be cleaned before going in or out of the patient’s home. RECORD/PATIENT #1: Review of the clinical record showed the patient was admitted to home health services on 05/26/2026 with a primary diagnosis of aftercare following joint replacement surgery. The patient lived at home alone. Observation and interview on 06/16/2026 at 10:45 AM, showed the physical therapist (PT) placed a cloth gait belt on the patient and conducted therapeutic exercises. The PT removed the gait belt from the patient, failed to clean the gait belt, and placed it in his/her supply bag where he/she had just placed his/her clean vital sign equipment. The PT stated that he/she preferred vinyl gait belts, and that he/she cleaned the gait belt weekly in his/her washing machine. During an interview on 06/16/2026 at 1:00 PM, the home health clinical manager for branch office A stated that their practice was for each patient to have their own gait belt. During an interview on 06/17/2026 at 2:50 PM, the home health administrator stated that all equipment was to be cleaned before going in or out of the patient’s home. RECORD/PATIENT #2: Review of the clinical record showed the patient was admitted to home health services on 05/28/2025 with a primary diagnosis of a pressure injury to the left and right buttocks (a skin injury caused by unrelieved pressure). The patient resided in a private residence with his/her family member. Observation on 06/17/2026 at 9:45 AM showed registered nurse (RN) A: Performed hand hygiene (PHH) and put on gloves; - Removed the soiled dressings from the right and left buttock; - Performed hand hygiene and put on gloves; - Cleansed the wound on the right buttock; - Failed to remove the soiled gloves, perform hand hygiene, and put on clean gloves; - Cleansed the wound on the left buttock; - Failed to remove the soiled gloves, perform hand hygiene, and put on clean gloves; and - Applied a clean dressing to the right and left buttock; - RN A then removed his/her soiled gloves, performed hand hygiene, and put on clean gloves; - Removed the soiled dressing from the patient’s sacrum (tail bone); - Failed to remove his/her soiled gloves and perform hand hygiene; and - Reached into the clean supply area to retrieve a clean dressing, opened the dressing, and applied it to the patient’s sacrum. During an interview on 06/17/2026 at 11:00 AM, RN B stated that, upon reflection, he/she had failed to perform hand hygiene and put on clean gloves when he/she cleaned the right and left buttock wounds.

Provide services in the plan of care CFR(s): 484.75(b)(3) Providing services that are ordered by the physician or allowed practitioner as indicated in the plan of care; This ELEMENT is not met as evidenced by: Based on record review and interview, the home health provider failed to ensure clinicians provided services that were ordered by the physician in one of five records reviewed (Record/Patient #2). This deficient practice has the potential to affect all the patients served by the provider. Findings included: RECORD/PATIENT #2: Review of the clinical record showed the patient was admitted to home health services on 05/28/2025. He/she had a primary diagnosis of a pressure injury to the left and right buttocks (a skin injury caused by unrelieved pressure). The patient had secondary diagnoses of heart failure (a decreased ability of the heart to pump blood) and malnutrition. The patient resided in a private residence with his/her family member. Review of the home health certification and plan of care, with certification dates of 05/23/2026 to 07/21/2026, showed that the nurse was to assess/instruct on daily weight and keeping a log, notify the physician of a weight gain of two to three pounds in 24 hours or five pounds in a week, and, if the patient was unable to weigh, obtain lower extremity circumference at each visit and notify the physician of an increase of 2 centimeters or greater. Review of the skilled nursing visit notes dated 05/29/2026, 06/03/2026, 06/05/2026, 06/08/2026, 06/10/2026, and 06/12/2026, showed the notes failed to contain documentation of the patient’s weight. During an interview on 06/17/2026 at 12:00 PM, the administrator stated that: - They would expect the skilled nurse to document the patient’s weight at each visit; and - They were unable to locate documentation of the patient’s weight in the visit documentation dated 05/29/2026, 06/03/2026, 06/05/2026, 06/08/2026, 06/10/2026, and 06/12/2026.

In accordance with current clinical practice CFR(s): 484.105(f)(2) All HHA services must be provided in accordance with current clinical practice guidelines and accepted professional standards of practice. This ELEMENT is not met as evidenced by: Based on review of Missouri statutes, employee file review, and interview, the home health provider failed to ensure that Alzheimer’s (a disease marked by progressive loss of mental capacity) and dementia (a decline in mental capacity) training was provided to non-direct care employees at orientation and annually. This deficient practice had the potential to affect all the patients served by the provider. Findings included: Review of 19 CSR 30-26.010 (1) (B) showed the following requirement: "Licensed home health agencies shall provide dementia-specific training about Alzheimer's disease and related dementias to their employees and those persons working as independent contractors who provide direct care to or may have daily contact with residents, patients, clients or consumers with Alzheimer's disease or related dementias. 1.The training for persons providing direct care shall address the following areas, at a minimum: (A) An overview of Alzheimer's disease and related dementias; (B) Communicating with persons with dementia; (C) Behavior management; (D) Promoting independence in activities of daily living; and (E) Understanding and dealing with family issues. 2.Employees or independent contractors who did not provide direct care for, but may have daily contact with, persons with Alzheimer's disease or related dementias shall receive dementia-specific training that included, at a minimum: (A) An overview of Alzheimer's disease and related dementias; and (B) Communicating with persons with dementia. 3.Dementia-specific training about Alzheimer's disease and related dementias shall be incorporated into orientation for new employees with direct patient contact and independent contractors with direct patient contact. The training shall be presented by an instructor who was qualified by education, experience, and knowledge in the current standards of practice regarding individuals with Alzheimer's disease and other related dementias. The training shall be provided annually and updated as needed." Review of non-direct care employee files #1, #2, and #3 showed that the files failed to contain documentation of initial and annual Alzheimer’s and dementia training. During an interview on 06/17/2026 at 9:00 AM, the home health administrator stated that: - Alzheimer’s and dementia training had not been assigned to non-direct care staff members in the past; and - They had already changed the initial and annual training calendar to include Alzheimer’s and dementia training for non-direct care staff.

Authentication CFR(s): 484.110(b) Standard: Authentication. All entries must be legible, clear, complete, and appropriately authenticated, dated, and timed. Authentication must include a signature and a title (occupation), or a secured computer entry by a unique identifier, of a primary author who has reviewed and approved the entry. This STANDARD is not met as evidenced by: Based on policy review, record review, observation, and interview, the home health provider failed to ensure that staff provided clear and accurate documentation in one of five full records reviewed (Record/Patient #3). This deficient practice has the potential to affect all the patients served by the provider. Findings included: Review of the provider’s policy titled, “Medical Record Documentation,” revised 03/2026, showed that the patient’s medical record was a legal document and all entries would be accurate, complete, legible, and support coordination of care, coverage, coding, and payment. RECORD/PATIENT #3: Review of the clinical record showed the patient was admitted to home health services on 01/06/2026 with a primary diagnosis of type 2 (two) diabetes mellitus with foot ulcer (a chronic disease that affects how the body uses sugar for energy). The patient lived at home alone. Review of the clinical record showed: - The plan of care (POC) dated 05/26/2026 included an order for the skilled nurse (SN) to perform/teach diabetic ulcer care to the right foot; - The SN visit notes dated 05/04/2026 through 06/08/2026 contained an anatomical view wound assessment tool that showed the location of the diabetic ulcer was the proximal dorsum right (top of right foot) and included an anatomical figure with an “x” that marked a location on the top of the right foot; - The SN visit notes dated 05/11/2026 through 05/18/2026 and 06/01/2026 through 06/08/2026 included a nursing assessment/plan note that stated the patient’s wound was located on the left plantar foot (bottom/sole of the left foot); and - An interim order dated 06/04/2026 for wound care to the left plantar foot. Observation and interview on 06/17/2026 at 9:45 AM, showed the patient had a wound to the sole of his/her left foot and the SN provided care per the physician order. The SN stated that they had been treating this wound for a while. During an interview on 06/17/2026 at 2:50 PM, the home health administrator stated that the wound is labeled incorrectly and they would fix the record to reflect the correct location.

The Emergency Preparedness regulations were reviewed as part of the Medicare recertification survey completed on 08/28/2023. 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 standard survey for Medicare recertification for the home health provider was completed on 08/28/2023. The provider had 639 current patients.

HHA administrator contact information CFR(s): 484.50(a)(1)(ii) (ii) Contact information for the HHA administrator, including the administrator's name, business address, and business phone number in order to receive complaints. This ELEMENT is not met as evidenced by: Based on review of the admission booklet, home visit observation, and interview, the home health provider failed to provide their patients with the contact information for the administrator including the administrator's name, in two of three home visit observations (Records/Patients #4 and #6). This deficient practice has the potential to affect the rights of all the provider's patients. Findings included: Review of the admission booklets provided to the patient during the admission process showed the admission booklets for the provider’s branches failed to contain the administrator’s name and contact information. RECORD/PATIENT #4: Observation on 08/23/2023 at 1:00 PM, during the patient’s home visit showed the admission booklet in the patient’s home failed to contain the administrator’s name and contact information to lodge complaints. During an interview on 08/23/2023 at 1:00 PM, OT1 reviewed the admission booklet in the patient's home, and stated that he/she was unable to find the administrator’s name and contact information to lodge complaints. RECORD/PATIENT #6: Observation on 08/24/2023 at 3:00 PM, during the patient's home visit showed the admission booklet in the patient's home failed to contain the administrator’s name (instead the name of the agency branch director was listed), and failed to contain the verbiage, “to receive complaints.”

State toll free HH telephone hotline CFR(s): 484.50(c)(9) Be advised of the state toll free home health telephone hot line, its contact information, its hours of operation, and that its purpose is to receive complaints or questions about local HHAs. This ELEMENT is not met as evidenced by: Based on review of the admission booklet in the patient's home during the home visit observations, the provider failed to advise patients of the state toll-free hotline hours of operation in two of three home visit observations (Records/Patients #4 and #5). This deficient practice has the potential to affect the rights of all the provider's patients. Findings included: RECORD/PATIENT #4: Observation on 08/23/2023 at 1:00 PM, during the patient’s home visit, showed the admission booklet in the patient’s home failed to contain the correct hours of operation for the state toll-free hotline. RECORD/PATIENT #5: Observation on 08/24/2023 at 2:30 PM, during the patient’s home visit, showed the admission booklet failed to contain the hours of operation for the state toll-free hotline.

Contact info Federal/State-funded entities CFR(s): 484.50(c)(10)(i,ii,iii,iv,v) Be advised of the names, addresses, and telephone numbers of the following Federally-funded and state-funded entities that serve the area where the patient resides: (i) Agency on Aging (ii) Center for Independent Living (iii) Protection and Advocacy Agency, (iv) Aging and Disability Resource Center; and (v) Quality Improvement Organization. This ELEMENT is not met as evidenced by: Based on review of the admission booklets, home visit observation, and interview, the home health provider failed to advise patients of the names, addresses, and telephone numbers of the Aging and Disability Resource Center and Quality Improvement Organization in one of three applicable records (Record/Patient #4). This deficient practice has the potential to affect the rights of all the provider's patients. Findings included: Review of the admission booklets provided to the provider’s patients during the admission process showed the admission booklets for the provider’s branches failed to contain the names, addresses, and telephone numbers for the Aging and Disability Resource Center, and the Quality Improvement Organization. RECORD/PATIENT #4: Observation on 08/23/2023 at 1:00 PM, during the patient’s home visit, showed the admission booklet in the patient’s home contained two different pages with information for the Quality Improvement Organization, and each page contained different addresses and phone numbers. During an interview on 08/28/2023 at 3:00 PM, the administrator stated that the admission booklet: - Contained conflicting information for the Quality Improvement Organization, and - Failed to contain the address and phone number for the Aging and Disability Resource Center.

Investigate complaints made by patient CFR(s): 484.50(e)(1)(i) (i) Investigate complaints made by a patient, the patient's representative (if any), and the patient's caregivers and family, including, but not limited to, the following topics: This ELEMENT is not met as evidenced by: Based on policy review, complaint log review, and record review, the provider failed to investigate complaints made by a patient, the patient's representative, or the patient's caregivers in one of six records reviewed (Record/Patient #2). This deficient practice has the potential to affect complaint reporting for all the provider's patients. Findings included: Review of the home health provider’s policy titled, “Complaint Management,” dated 04/2022 showed that: - All complaints made by patients, family, or the patient’s responsible party either verbally or in writing will be reviewed, evaluated, and forwarded to the appropriate manager for resolution. Actions and resolution will be documented on the Complaint log; - All complaints will be logged with ongoing documentation until resolved; and - Patient complaints/concerns related to third party payers coverage will be addressed in the same manner as other complaints. RECORD/PATIENT #2: Review of the clinical record showed the patient was admitted to home health services on 03/02/2023, with a primary diagnosis of pulmonary embolism (a life threatening condition in which a blood clot that develops in a blood vessel in the body (often in the leg) which then travels to a lung artery where it suddenly blocks blood flow); - The patient resided in their own home with the assistance of family/friends; - The Veteran’s Administration was the primary pay source for the episodes of care; - The provider received an order from the primary care practitioner to discharge the patient from all home health services on 07/26/2023, and transfer care to home based primary care through the Veteran’s Administration; and - Per OT (Occupational Therapy) visit note dated 07/28/2023, "Patient/caregiver angry regarding unplanned OT DC (discharge) secondary to physician request secondary to recent falls and medical decline.” Review of the provider’s complaint logs for 07/2023 to 08/2023 showed the logs failed to contain documentation of the caregiver’s complaint regarding the discharge of the patient.

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 and clinical record review, the provider failed to ensure the plan of care include the types of services, supplies, and equipment required; all medications and treatments; safety measures to protect against injury; and patient specific interventions and measurable outcomes/goals in three of six records reviewed (Records/Patients #3, #4, and #5). This deficient practice has the potential to affect the care planning for all of the provider's patients. Findings included: Review of the provider policy titled, “Care Planning,” dated 09/2022 showed that the plan of care must include: - Types of services, supplies, and equipment required; - All medications and treatments; - Safety measures to protect against injury; and - Patient specific interventions and measurable outcomes/goals. RECORD/PATIENT #3: Review of the clinical record showed the patient was admitted to home health services on 02/08/2023 with a primary diagnosis of non-pressure, chronic ulcer (wound) of the right ankle with necrosis (death) of muscle. The patient had secondary diagnoses of diabetes (a chronic, metabolic disease characterized by elevated levels of blood glucose (or blood sugar), which leads over time to serious damage to the heart, blood vessels, eyes, kidneys and nerves), a history of recurrent pneumonia (an infection that affects one or both lungs), and falling. Review of the comprehensive reassessment dated 06/05/2023 showed that the patient: had diabetes and checked their own blood glucose (sugar) with a meter independently and was, “fairly confident,” in managing their diabetes. Review of the plan of care with start date of 06/08/2023 showed that the document failed to contain interventions for the frequency of blood sugar monitoring, and identification of who was responsible for monitoring the patient’s blood sugars. RECORD/PATIENT #4: Review of the clinical record showed the patient was admitted to home health services on 08/15/2023 with diagnoses that included primary generalized (osteo) arthritis and long-term use of anticoagulants (medication used to thin the blood and prevent clots). The patient resided in their own home with the assistance of family/friends. Review of the comprehensive assessment dated 08/15/2023 showed that the patient was taking an anticoagulant. Review of the plan of care with start date of 08/15/2023 showed that the document failed to contain safety measures to protect against injury for a patient on anticoagulant therapy. RECORD/PATIENT #5: Review of the clinical record showed the patient was admitted to home health services on 07/28/2023 with a primary diagnosis of bilateral osteoarthritis (arthritis) of the knee, chronic pain, heart failure (a decrease in the ability of the heart to pump blood, resulting in an accumulation of fluid in the lungs and other areas of the body), and atrial fibrillation (an irregular and often very rapid heart rhythm). The patient resided in their own home with the assistance of family/friends. Review of the comprehensive assessment dated 07/28/2023 showed that the patient: - Wore braces on the right and left knees; - Was taking an anticoagulant medication; - Had a history of congestive heart failure, and - Had urinary incontinence. Review of the plan of care with start date of 07/28/2023 showed that the document failed to contain: - Safety measures to protect against injury for a patient on anticoagulant therapy; and - Patient specific interventions for the frequency and use of the braces to the right and left knees.

Integrate all services CFR(s): 484.60(d)(3) Integrate services, whether services are provided directly or under arrangement, to assure the identification of patient needs and factors that could affect patient safety and treatment effectiveness and the coordination of care provided by all disciplines. This ELEMENT is not met as evidenced by: Based on provider policy, clinical record review, and interview, the provider failed to ensure the clinicians integrate services to assure the identification of patient needs and factors that could affect patient safety and treatment effectiveness and the coordination of care provided by all disciplines in one of six records reviewed (Record/Patient #2). This deficient practice has the potential to affect the coordination of all the provider's care. Findings included: Review of the policy titled, "Coordination of Care - Case Conferences," dated 07/2022 showed that: - Communication with other team members may be face-to-face, via phone, other telecommunication technology and/or secure email including but not limited to: * contact between clinical associates involved in the patient’s care; * All contact with the patient’s physician/allowed practitioner; * Review of clinical care and supportive documentation to ensure medical necessity; * Effectiveness of treatment plan; * Progress toward goals; * Changes in the patient’s condition resulting in a need to revise/update plan of care; * Safety concerns impacting patient well-being and plan of care; * Review of the plan of care to support recertification or discharge; and - All communication will be documented in the patient’s medical record. RECORD/PATIENT #2: Review of the clinical record showed the patient was admitted to home health services on 03/02/2023 with a primary diagnosis of pulmonary embolism (a life threatening condition in which a blood clot that develops in a blood vessel in the body (often in the leg) which then travels to a lung artery where it suddenly blocks blood flow), and secondary diagnoses of spinal stenosis (a condition in which the space around the spinal cord become narrow, irritating the spinal cord and/or the nerves that branch off it causing symptoms like back or neck pain and tingling in the arms or legs), and rheumatic disorder of mitral, aortic, and tricuspid valves (a condition in which the heart valves become inflamed and scarred over time resulting in narrowing or leaking of the heart valves making it hard for the heart to function normally). The patient resided in their own home with the assistance of family/friends. Review of the plan of care with certification dates of 06/30/2023 to 08/28/2023 contained the intervention to report weight gain of two to three pounds per day or five pounds in a week. Review of the clinical documentation showed that: - On 07/20/2023, the PTA (physical therapy assistant) documented that he/she was unable to provide therapy services due to the patient having nausea and increased pain in his/her back, the PTA failed to document that he/she notified the PT (physical therapist) and/or physician; - On 07/21/2023 the COTA (certified occupational therapy assistant), noted a four-pound weight gain from the last weight documented on 07/20/2023, and the COTA failed to document physician or Occupational Therapist (OT) notification of the abnormal finding; and - On 07/28/2023 a missed visit notification note showed a missed visit documentation for PTA visit 07/26/2023. The reason for the missed visit was for caregiver request due to multiple recent falls. The note failed to contain documentation of physician and/or PT notification for the missed visit. During an interview on 08/23/2023 at 4:05 PM, the administrator stated that all disciplines would be expected to report weight gain to the supervising discipline, the nurse at the office, and the physician in patients who had heart failure.

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 provider policy, record review, and interview the provider failed to ensure clinicians provided services that are ordered by the physician or allowed practitioner as indicated in the plan of care in one of six records reviewed (Record/Patient #2). This deficient practice has the potential to affect the provision of services for all of the provider's patients. Findings included: Review of the provider's policy titled, "Care planning," dated 09/2022 showed that Professional disciplines - Registered Nurse (RN), Physical Therapist (PT), Speech-Language Pathologist (SLP), Occupational Therapist (OT), Medical Social Worker (MSW) - must assume responsibility for but not be restricted to providing services ordered by the physician/allowed practitioner as indicated in the POC/Interim (plan of care) orders. RECORD/PATIENT #2: Review of the clinical record showed the patient was admitted to home health services on 03/02/2023 with a primary diagnosis of pulmonary embolism (a life threatening condition in which a blood clot that develops in a blood vessel in the body (often in the leg) which then travels to a lung artery where it suddenly blocks blood flow), and secondary diagnoses of spinal stenosis (a condition in which the space around the spinal cord become narrow, irritating the spinal cord and/or the nerves that branch off it causing symptoms like back or neck pain and tingling in the arms or legs), and rheumatic disorder of mitral, aortic, and tricuspid valves (a condition in which the heart valves become inflamed and scarred over time resulting in narrowing or leaking of the heart valves making it hard for the heart to function normally). The patient resided in their own home with the assistance of family/friends. Review of the comprehensive reassessment dated 06/26/2023 showed that the patient did not test his/her blood sugars because a monitor was not available. Review of the plan of care with certification dates of 06/30/2023 to 08/28/2023 contained interventions and goals: - Skilled nurse to assess/evaluate co-morbid conditions including HTN (hypertension), CHF (congestive heart failure), DM (diabetes mellitus) and other conditions that present themselves during the course of this episode to identify changes and intervene to minimize complications; - Skilled nurse to teach related to diabetes management including disease process, nutrition, medications, activities, and personal/environmental factors. Biometrics out of parameters and significant changes in status will be reported to the physician; - Skilled nurse to perform blood glucose analysis every visit if patient/caregiver unable/unwilling; - Patient/caregiver verbalizes/demonstrates diabetes management as evidenced by decreased symptoms, blood glucose within parameters, and no unplanned hospitalizations; and - Patient tolerates blood glucose testing without complications as evidenced by improved blood glucose levels and no unplanned hospitalizations. Review of the clinical visits/assessments showed: - Certified Occupational Therapy Assistant (COTA) visits dated 07/03/2023, 07/05/2023, 07/18/2023, and 07/21/2023 contained assessment documentation that, "Patient does not have an endocrine condition"; and - Nursing visits dated 07/13/2023 and 07/20/2023 failed to contain documentation of an endocrine system assessment including (but not limited to) the client’s blood sugar readings. The administrator received a written summary of the record findings on 08/28/2023 at 12:16 PM. During an interview on 08/28/2023 at 4:50 PM, the administrator stated that they had no additional information to provide, and would expect the information to be in the clinical record.

Responsible for all day-to-day operations CFR(s): 484.105(b)(1)(ii) (ii) Be responsible for all day-to-day operations of the HHA; This ELEMENT is not met as evidenced by: Based on admission booklet review, provider policy review, complaint log review, and interview, the provider failed to ensure the administrator was responsible for all day-to-day operations of the provider. This deficient practice has the potential to affect the administration of all the provider's patients. Findings included: Review of the admission booklets provided to the provider’s patients during the admission process showed the admission booklets for the provider’s branches failed to contain the administrator’s name and contact information. Review of the provider’s policy titled, “Administration,” dated 04/2022 showed that the administrator responsibilities include, but are not limited to, organization and direction of the HHA office ongoing day-to-day operations. Review of the provider’s policy titled, “Complaint Management,” dated 04/2022 showed that: - The administrator will be responsible for documentation of investigation and resolution of the complaint on the agency’s Complaint log; and - The administrator is accountable for receiving and resolving patient grievances. Review of the agency complaint logs for 2023 showed the investigation and resolution of three complaints. The complaint documentation failed to demonstrate the administrator’s involvement in the investigation or resolution of the complaints. During an interview on 08/22/2023 at 2:00 PM, the administrator stated that he/she was unable to print/provide reports for one of the agency branches, as he/she did not have access to the specific branch’s electronic medical record. During an interview on 08/23/2023 at 10:10 AM, the branch manager (BM1) stated that: - The current administrator was “just placed” in his/her role and had not visited his/her branch since taking over the role; - He/she considered day-to-day functions to be the running of daily reports for productivity, high hospitalization risk, low utilization payment adjustments, patient transfers, infections, complaints, falls, and performing daily meetings with office staff; and - A summary of the reports are sent to the administrator daily via email.

The Emergency Preparedness regulations were reviewed as part of the Medicare certification survey completed on 01/14/2021. During this survey it was determined Kindred At Home is in compliance with the requirements of 42 CFR 484.102 Condition of Participation: Emergency Preparedness for Home health Agencies.

A partial extended survey for Medicare certification was completed on 01/14/2021 for Kindred At Home with standard level deficiencies cited. The agency had 765 current patients. The parent census at Rolla was 261, the Farmington branch census was 304, and the West Plains branch census was 200. A COVID-19 Focused Infection Control survey was completed in conjunction with the survey and no deficiencies were identified related to the Focused Infection Control survey.

Health, psychosocial, functional, cognition CFR(s): 484.55(c)(1) The patient's current health, psychosocial, functional, and cognitive status; This ELEMENT is not met as evidenced by: Based on policy review, clinical record review, and interview, the agency failed to ensure the skilled clinician's assessments of patients accurately reflected the patient's current health, status for one (Record/Patient #3) of seven records reviewed. This deficient practice has the potential to affect the accuracy of the skilled assessments of all patients served by the agency. Findings included: Review of the agency policy dated 09/28/18 and titled, "Assessment," showed the following: - Each patient's physical, nutritional, and psychosocial status will be assessed (including vital signs); - The assessment is the basis for planning patient care and is the baseline against which progress toward stated goals/outcomes is measured; - All patients will be assessed for the presence of pain management needs and will be reassessed based on their continued needs; - The registered nurse (RN) is responsible for verification of data collected and reported by the licensed practical nurse (LPN); and - All patients must have a comprehensive reassessment performed in the last five days of the 60-day episode, if the plan is to recertify the patient for an additional 60-day episode. RECORD/PATIENT #3: Review of the clinical record showed that the patient was admitted to home health services on 07/14/2020 with a primary diagnosis of diabetes (a disorder characterized by a high blood sugar level over a prolonged period of time resulting in complications including lower extremity wounds and nerve damage), and secondary diagnoses of diabetic ulcer of left heel/mid-foot with necrosis (death) of the muscle, diabetic neuropathy (damage to the nerves associated with diabetes), and hypertension (elevated blood pressure). Review of the plan of care (POC) dated 11/11/2020 showed: - Client to monitor blood sugars three times per day and self-administer 10 units of Novolin regular insulin (medication used to treat diabetes) if blood sugar reading greater than 150; - Tramadol (an opioid pain medication) 50 milligram (mg) tablets, take one tablet every six hours as needed for pain; - The nurse will observe/assess for pain, effectiveness of pain management regimen, identify changes in pain, intervene to minimize complications; and - significant changes in status will be reported to the physician. Review of LPN visits dated 12/14/2020, 12/16/2020, 12/21/2020, 12/28/2020, and 12/30/2020, showed: - The patient reported pain. The patient rated the pain a 3 (on a 0-10 high scale) at the time of the visit, 2 at the best, and 5 at the worst. The pain was located in the left and right upper extremities. Medications, positioning, and rest/sleep relieved the pain; - The patient reported that he/she took pain medication the morning of the visit; and - The patient checks his/her blood sugars three times per day. During an interview 01/14/21 at 12:16 PM, the patient stated that he/she always has pain, it is never less than a two. The patient states that there has never been a nursing visit in the past month that he/she has been pain free. Review of recertification comprehensive assessment visit dated 01/06/21 showed the RN; - Documented the following pain and diabetic assessments: * The pain reading in the vital signs section of the visit note was a 3. The patient did not report pain. There were no objective pain symptoms, and no additional details necessary to describe the patient's pain; and * The patient is taking insulin, checks his/her blood sugars daily, and had a range of blood sugar readings from 100-200. - Failed to document: * Verification of the pain assessment findings of the LPN including level of pain, character of pain, location of pain, occurrence of pain, and frequency of opioid medication used to reduce pain; and * Verification of the diabetic assessment findings of the LPN including frequency of blood sugar monitoring three times per day as directed on the POC. The findings were presented to the administrator on 01/13/21 at 2:23 PM, no further documentation was provided. During an interview 01/14/21 at 12:16 PM, the patient stated that he/she always has pain, it is never less than a two. The pain assessment performed by the nurse on 01/13/21 was reviewed with the client. The client stated his/her pain has been at that level for at least six months. The patient states that there has never been a nursing visit in the past month that he/she has been pain free.

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 perform a review of all medications the patient is currently using in order to identify any potential adverse effects, drug reactions, including ineffective drug therapy, significant side effects, significant drug interactions, duplicate drug therapy, and noncompliance with drug therapy in one (Record/Patient #3) of seven records reviewed. This deficient practice as the potential to affect the medication management of all patients served by the agency. Findings included: Review of the agency policy dated 09/28/18 and titled, "Assessment," showed that: - The assessment is the basis for planning patient care and is the baseline against which progress toward stated goals/outcomes is measures; - At the time of the initial assessment and each subsequent assessment, prescription, over-the-counter drugs, and herbals the patient is taking will be evaluated; - A review will include viewing the bottles and labels of the drugs the patient has in the home, asking about over-the-counter medications the patient is taking, asking the patient about when and how the patient is taking the medications, and asking the patient about potential side effects of the drugs; and - Medications will be entered in the clinical record and will be updated as the agency becomes aware of changes in the prescribed medications. RECORD/PATIENT #3: Review of the clinical record showed that the patient was admitted to home health services on 07/14/2020 with a primary diagnosis of diabetes (a disorder characterized by a high blood sugar level over a prolonged period of time resulting in complications including lower extremity wounds and nerve damage), and secondary diagnoses of diabetic ulcer of left heel/mid-foot with necrosis (death) of the muscle, diabetic neuropathy (damage to the nerves associated with diabetes), and hypertension (elevated blood pressure). During a home visit observation on 01/13/21 at 10:00 AM, the patient stated that: - He/she checks his/her blood sugar three times per day, and self-injects a dose of Novolin R (NR) insulin (used to treat diabetes) 40 units three times per day if his/her blood sugar reading is greater than 120; - When the blood sugar is greater than 150, he/she adds an additional 10 units of NR to the baseline dose of 40 units, for a total of 50 units; - When the blood sugar is greater than 200, he/she adds an additional 20 units of NR to the baseline dose of 40 units, for a total of 60 units; - He/she has been taking the NR in this manner for many months; - For over four months he/she has been taking docusate sodium 250 mg (a stool softener used to treat constipation); and - A review of the label on the NR bottle showed that the patient was to self-inject insulin two times per day, not to exceed 60 units twice a day. Review of the agency medication list dated 01/13/21 showed: - Novolin regular insulin, check blood sugars three times per day, give 10 units if blood sugar greater than 150; and - Failed to include orders for docusate sodium. Review of the comprehensive recertification nursing visit performed 01/06/21, showed that: - The patient/caregiver were compliant with all medication administration; - There were no changes in medications; and - There were no medication discrepancies noted. The findings were presented to the administrator on 01/13/21 at 2:23 PM, no further documentation provided.

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 may choose to include. This ELEMENT is not met as evidenced by: Based on policy review, and record review, the agency failed to develop an individualized plan of care that included all of the patient-specific interventions in two (Records/Patients #3 and #5) of seven records reviewed. This deficient practice has the potential to affect the plans of care for all patients served by the agency. Findings included: Review of the agency policy dated 05/13/2020 and titled, "Care Planning," showed that the individualized plan of care must include all medications and treatments and patient-specific interventions identified by the agency and the patient. RECORD/PATIENT #3: Review of the clinical record showed that the patient was admitted to home health services on 07/14/2020 with a primary diagnosis of diabetes (a disorder characterized by a high blood sugar level over a prolonged period of time resulting in complications including lower extremity wounds and nerve damage), and secondary diagnoses of diabetic ulcer of left heel/mid-foot with necrosis (death) of the muscle, diabetic neuropathy (damage to the nerves associated with diabetes), and hypertension (elevated blood pressure). The plan of care dated 07/14/2020 failed to contain parameters identifying when the physician should be notified of high or low blood sugar readings. The findings were presented to the administrator on 01/13/21 at 2:23 PM, no further documentation was provided. RECORD/PATIENT #5: Review of the clinical record showed that the patient was admitted to home health services on 11/04/2020 with a primary diagnosis of pressure ulcer of the right heel, and secondary diagnoses of diabetes (a disorder characterized by a high blood sugar level over a prolonged period of time resulting in complications including lower extremity wounds and nerve damage) and diabetic neuropathy (damage to the nerves associated with diabetes). The plan of care dated 11/04/2020 failed to contain orders to assess and evaluate the diagnosis of diabetes. The findings were presented to the administrator on 01/14/21 at 1:09 PM, no further documentation was provided.

Only as ordered by a physician CFR(s): 484.60(b)(1) Drugs, services, and treatments are administered only as ordered by a physician. This ELEMENT is not met as evidenced by: Based on policy review, and record review, the agency failed to provide/administer drugs, services, and treatments only as ordered by a physician in one (Record/Patient #5) of seven records reviewed. This deficient practice has the potential to affect the administration of drugs, services, and treatments for all patients served by the agency. Findings included: Review of the agency policy dated 09/28/18 and titled, "Physician's Orders," showed that: - Patients will be accepted for home health services only when a plan of care (POC) has been established by the attending physician in consultation with the location staff; and - Physician orders are required for all services through the agency except for homemaker services which do not require medical supervision. RECORD/PATIENT #5: Review of the clinical record showed that the patient was admitted to home health services on 11/04/2020 with a primary diagnosis of pressure ulcer of the right heel, and secondary diagnoses of diabetes (a disorder characterized by a high blood sugar level over a prolonged period of time resulting in complications including lower extremity wounds and nerve damage) and diabetic neuropathy (damage to the nerves associated with diabetes). Review of the start of care visit dated 11/04/2020 showed that the nurse performed the care to the right heel wound by using a dry dressing secured with tape. Review of the POC dated 11/04/2020 showed that: - The POC failed to contain an order to perform care to right heel by applying a dry dressing secured with tape; and - The nurse was to prefill a medication planner weekly. Review of nursing visits performed on 11/04/2020, 11/07/2020, 11/09/2020, 11/11/2020, 11/13/2020, 11/16/2020, 11/21/2020, 11/24/2020, and 11/30/2020 failed to contain documentation that the medication planner was prefilled. Review of the resumption of care (ROC) orders dated 12/10/2020 showed that: - The nurse was to perform care to the right heel by cleansing with wound cleanser, applying alginate (a dressing used to absorb wound drainage), and covering with foam adhesive dressing two to three times per week; and - The medication profile included in the ROC contained orders for the use of Santyl ointment (an ointment used to remove dead tissue from wounds) every two to three days. Review of the ROC nursing visit performed on 12/10/2020 failed to contain documentation of the application of Santyl to the right heel wound. Review of the ROC orders dated 12/23/2020 failed to contain orders for the provision of care to the right heel wound. Review of the nursing visits performed 12/23/2020 and 12/31/2020 contained documentation of the provision of care to the wound on the right heel. The findings were presented to the administrator on 01/14/21 at 1:09 PM, no further was documentation provided.

Infection Prevention CFR(s): 484.70(a) Standard: Infection Prevention. The HHA must follow accepted standards of practice, including the use of standard precautions, to prevent the transmission of infections and communicable diseases. This STANDARD is not met as evidenced by: Based on policy review, home visit observation, and interview the agency failed to follow accepted standards of practice, including the use of standard precautions, to prevent the transmission of infections and communicable diseases in one (Record/Patient #3) of three home visit observations. This deficient practice has the potential to affect the infection control for all patients served by the agency. Findings included: Review of the Centers for Disease Control (CDC) publication dated 01/08/21 and titled, "Hand Hygiene in Healthcare Settings," showed the following clinical indications for hand hygiene: - Immediately before touching a patient; - Before performing an aseptic task (i.e., placing an indwelling device) or handling invasive medical devices; - Before moving from work on a soiled body site to a clean body site on the same patient; - After contact with blood, body fluids, or contaminated surfaces; and - Immediately after glove removal. Review of agency policy dated 08/19/19 and titled, "Engineering and Work Practice Controls," showed that hands will be washed with soap or approved sanitizer before donning gloves, after removing gloves, and prior to direct contact with patients or procedure. Hands and other skin surfaces will be washed immediately and thoroughly if contaminated with blood or other body fluids. Review of agency policy dated April 2018 and titled, "Bag Technique and Equipment Cleaning," showed: - The clean side of the home health bag included wound care supplies; - As you use your items from the clean side during the visit, move them to the dirty side of your barrier. if you need to re-enter your bag, clean your hands with a waterless alcohol-based hand washing product unless hands are visibly soiled. If visibly soiled, use soap and water to wash before re-entering the bag; and - When you complete the visit, clean all the equipment using the equipment wipes on your barrier. As you clean them, place the items back on the clean side of your barrier to dry for the two minutes that the manufacturer requires. RECORD/PATIENT #3: Review of the clinical record showed that the patient was admitted to home health services on 07/14/2020 with a primary diagnosis of diabetes (a disorder characterized by a high blood sugar level over a prolonged period of time resulting in complications including lower extremity wounds and nerve damage), and secondary diagnoses of diabetic ulcer of left heel/mid-foot with necrosis (death) of the muscle, diabetic neuropathy (damage to the nerves associated with diabetes), and hypertension (elevated blood pressure). During a home visit observation, performed on 01/13/2021 beginning at 10:00 AM, the licensed practical nurse (LPN): - Held the wound cleanser spray bottle while wearing gloves soiled during the wound cleansing procedure; - Failed to remove soiled gloves, and perform hand hygiene, after removing the patient's soiled dressing and cleaning the wound; - Applied the clean dressing while wearing soiled gloves; and - Failed to cleanse the outside of the wound cleanser spray bottle before placing it back into the clean supply box. During an interview on 01/13/21 at 11:00 AM the LPN stated that he/she was not aware of any breaks in infection control or bag technique during the observation visit. The findings were presented to the administrator on 01/13/21 at 2:23 PM, no further documentation was provided.

Services provided by HH aide CFR(s): 484.80(g)(2) A home health aide provides services that are: (i) Ordered by the physician; (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, and record review, the agency failed to assure that the home health aide (HHA) provided services that were included in the plan of care for one (Record/Patient #4) of three records reviewed. This deficient practice has the potential to affect all of the patients served by the agency. Findings included: Review of the agency policy dated 03/19/2020 and titled, "Coordination of Care - Case Communication," showed: - Communication with other team members may be face-to-face, via telephone, electronically and may include (but is not limited to): * Contact between team members involved in the care of the patient; * Communication of changes in the planned care; and - All communication will be documented in each patient's clinical record. Review of the agency policy dated 03/11/2020 and titled, "Patient Care Supervision," showed: - The registered nurse or other appropriate skilled professional will assign the home health aides. The RN or therapist responsible for supervising the aide will complete a written instruction plan for the aide. RECORD/PATIENT #4: Review of the clinical record showed the patient was admitted to home health services on 11/19/2020 with primary diagnosis of Parkinson's (chronic disorder of the nervous system characterized by tremors (shaking), and or body stiffness) disease, and secondary diagnoses of hypertension (high blood pressure), anxiety, legal blindness. Review of the HHA assignment sheet dated 11/19/2020 and titled, "Aide Care Plan Report," showed the HHA was to perform the service "Bathing-Bed Bath" every visit. Review of HHA visits dated 12/14/2020, 12/23/2020, 12/31/2020, 01/04/2021, and 01/07/2021 showed: - A visit narrative that stated that the HHA assisted the patient with a shower. Patient tolerated shower well; and - Failed to contain documentation that the HHA notified the supervising nurse that a shower was given instead of a bed-bath. The findings were presented to the administrator on 01/13/21 at 10:10 PM, no further documentation was provided.