Every finding on record at Mooresville Home Care Services, LLC

An onsite recertification survey was conducted 10/14/24-10/16/24. No deficiencies to the Emergency Preparedness Plan was identified.

An onsite, non-announced recertification survey was conducted 10/14/24-10/16/24. Standard level deficiencies to the Medicare CoP were identified.

Plan of care must include the following CFR(s): 484.60(a)(2)(i-xvi) The individualized plan of care must include the following: (i) All pertinent diagnoses; (ii) The patient's mental, psychosocial, and cognitive status; (iii) The types of services, supplies, and equipment required; (iv) The frequency and duration of visits to be made; (v) Prognosis; (vi) Rehabilitation potential; (vii) Functional limitations; (viii) Activities permitted; (ix) Nutritional requirements; (x) All medications and treatments; (xi) Safety measures to protect against injury; (xii) A description of the patient's risk for emergency department visits and hospital re-admission, and all necessary interventions to address the underlying risk factors. (xiii) Patient and caregiver education and training to facilitate timely discharge; (xiv) Patient-specific interventions and education; measurable outcomes and goals identified by the HHA and the patient; (xv) Information related to any advanced directives; and (xvi) Any additional items the HHA or physician or allowed practitioner may choose to include. This ELEMENT is not met as evidenced by: Based on agency policy, home visits, clinical record review, and staff interviews, the Plan of Care [POC] failed to include all medications the patient was using for 2 of 4 home visits [# 8 and 9]. The findings included: The policy, Plan of Care [POC] [9/1/24], was provided by the agency administrator on 10/16/24 at approximately 8:30 am. The policy stated, “...The POC includes...medications and treatments...all patient care orders...” 1. Patient # 8 had a Start of Care date of 9/16/24 with admitting diagnoses of secondary and unspecified malignant neoplasm of nodes of multiple regions, secondary malignant neoplasm of right lung, and acute diastolic [congestive] heart failure [heart doesn’t pump effectively]. The patient was hospitalized from 10/4/24-10/7/24. Review of the resumption of care [comprehensive assessment completed after in patient stay] POC included orders for PT [physical therapy] 1 time a week for 1 week, 2 times a week for 1, 1 time a week for 3 weeks. A joint visit was conducted with PT # 4 on 10/15/24 at 11:30 am. During the visit, a medication review was conducted using a medication profile provided by the agency. The following discrepancy was noted: The medication profile listed Omeprazole [reflux] 2o mg daily. During an interview with the caregiver, the caregiver reported the patient no longer takes the medication and “has not taking it since coming home from the hospital”. During an interview with employee # 1 on 10/16/24 at approximately 11 am, employee # 1 confirmed the POC did not include all medications the patient was taking. 2. Patient # 9 had a Start of Care date of 9/5/24 with an admitting diagnosis of encounter for surgical aftercare following surgery on the digestive system. Review of the Plan of Care [POC] for the certification period 9/5/24-11/3/24 included orders for SN [skilled nursing] 1 time a week for 1 week, 2 times a week for 1 week, 1 time a week for 3 weeks, 1 time every 2 weeks for 4 weeks. On 1016/24 at approximately 9 am a joint visit was made with RN # 3. During the visit a medication review was conducted using a medication profile provided by the agency. The following medications were not included on the patient’s POC: Imodium [antidiarrheal] 2 mg. Take 1 tablet every 6 hours for diarrhea for up to 10 days. The bottle of medication included a start date of 3/6/23. During an interview with the patient, the patient reported she continues to use the Imodium as needed for diarrhea. Aleve PM [sleep aid]. Take 2 tablets as needed at bedtime for sleep. During an interview with the patient, the patient advised she has been taking the Aleve PM as needed to help with sleep and pain. During an interview with employee # 1 on 10/16/24 at approximately 11 am, employee # 1 confirmed the POC did not include all medications the patient was taking.

Only as ordered by a physician CFR(s): 484.60(b)(1) Drugs, services, and treatments are administered only as ordered by a physician or allowed practitioner. This ELEMENT is not met as evidenced by: Based on agency policy, clinical record review, and staff interviews the agency failed to change the infusion cap for 1 of 1 patient with a vascular assess device [medical device that provides access to a patient’s blood stream for administration of medications or obtain blood for lab work] [#5] in accordance with the physician's order; and failed to flush a vascular access device with the correct amount of normal saline after obtaining a blood specimen in accordance with the physician's order for 1 of 1 patient with a vascular access device [#5]; and failed to obtain the patient's weight each visit in accordance with the physician's order for 1 of 4 patients who received a home visit [#8]; and failed to obtain oxygen saturations in accordance with the physician's order for 1 of 4 patients who received a home visit [#8]. The findings included: The policy, Physician Orders [10/1/23], was provided by the agency administrator on 10/16/24 at 8:30 am. The policy stated, “...No medications, treatments, diagnostic studies...will be administered without the order of a qualified physician or authorized practitioner...” 1A. Patient # 5 had a Start of Care [SOC] date of 9/18/24 with admitting diagnoses of infection/inflammation reaction due to internal right knee prosthesis and encounter for adjustment and management of VAD [vascular access device [ medical device that provides access to a patient’s blood stream for administration of medications or obtain blood for lab work]. Review of the Plan of Care [POC] for the certification period 9/18/24-11/16/24 included orders for SN [skilled nursing] 2 times a week for 1 week, 1 time a week for 5 weeks, 2 times a week for 1 week and “Skilled nurse to perform site care for infusion access device...once a week and prn [as needed]…injection cap change once a week and with each lab draw...” Review of the clinical record revealed RN # 6 conducted a routine visit on 9/20/24. The clinical record revealed the RN did complete site care for the infusion access device. The RN failed to change the injection cap in accordance with the POC. During an interview with employee # 1 on 10/16/24 at approximately 11 am, employee # 1 confirmed the injection cap was not changed in accordance with the physician’s order. 1B. Patient # 5 had a Start of Care [SOC] date of 9/18/24 with admitting diagnoses of infection/inflammation reaction due to internal right knee prosthesis and encounter for adjustment and management of VAD [vascular access device [ medical device that provides access to a patient’s blood stream for administration of medications or obtain blood for lab work]. Review of the Plan of Care [POC] for the certification period 9/18/24-11/16/24 included orders for SN [skilled nursing] 2 times a week for 1 week, 1 time a week for 5 weeks, 2 times a week for 1 week and “Skilled nurse to perform lab draw...in 2-3 days from SOC and every week...Skilled nurse to flush with 10 ml of normal saline prior to specimen draw...flush with 20 ml of normal saline...after specimen draw...” Further review of the clinical record revealed LPN # 5 conducted a routine visit on 9/23/24 to obtain labs via the vascular access device. Review of the documentation by the LPN revealed she flushed the access device with 10 ml of saline after obtaining the specimen instead of 20 ml of saline. During an interview with employee # 1 on 10/16/24, employee # 1 confirmed the LPN failed to flush the device in accordance with the physician’s order. 2A. Patient # 8 had a Start of Care date of 9/16/24 with admitting diagnoses of secondary and unspecified malignant neoplasm of nodes of multiple regions, secondary malignant neoplasm of right lung, and acute diastolic [congestive] heart failure [heart doesn’t pump effectively]. Review of the Plan of Care [POC] for the certification period 9/16/24-11/14/24 included the orders for SN [skilled nursing] 1 time a week for 3 weeks, 1 time a week every 2 weeks for 6 weeks and “Skilled nurse to obtain weight every visit and notify RN/Physician of weight gain or loss of 3 pounds within 1 day or 5 pounds within 1 week”. Review of the clinical record revealed RN # 3 conducted SN visits on 9/24/24 and 10/3/24. The clinical record revealed no evidence of a weight was obtained. During an interview with employee # 1 on 10/16/24 at approximately 11 am, employee # 1 confirmed the weight was not obtained in accordance with the physician's order. 2B. Patient # 8 had a Start of Care date of 9/16/24 with admitting diagnoses of secondary and unspecified malignant neoplasm of nodes of multiple regions, secondary malignant neoplasm of right lung, and acute diastolic [congestive] heart failure [heart doesn’t pump effectively]. Review of the Plan of Care [POC] for the certification period 9/16/24-11/14/24 included the orders for SN [skilled nursing] 1 time a week for 3 weeks, 1 time a week every 2 weeks for 6 weeks. A supplemental order was written on 9/25 24 for SN to “check 02 sat [saturation] next visit while at rest, while exercising and with oxygen in use, while exercising with oxygen not in use...Fax results...” Review of the clinical record revealed LPN # 5 completed a routine visit on 10/1/24 [this was the first SN visit after the order was obtained]. The clinical record does not include any documentation related to the 02 sat related to the supplemental order. During an interview with employee # 1 on 10/16/24 at 11 am, employee # 1 confirmed the 02 saturation was not obtained in accordance with the physician’s order.

Onsite supervisory visit every 14 days CFR(s): 484.80(h)(1)(i) (1)(i) If home health aide services are provided to a patient who is receiving skilled nursing, physical or occupational therapy, or speech language pathology services— (A) A registered nurse or other appropriate skilled professional who is familiar with the patient, the patient's plan of care, and the written patient care instructions described in paragraph (g) of this section, must complete a supervisory assessment of the aide services being provided no less frequently than every 14 days; and (B) The home health aide does not need to be present during the supervisory assessment described in paragraph (h)(1)(i)(A) of this section. This ELEMENT is not met as evidenced by: Based on policy review, client record review, and staff interviews, the agency failed to provide home health aide supervision for 1 of 1 home health aide records reviewed [#7]. Findings included: Review of policy “Home Health Aide Supervision” revised 6/1/24 was received from the agency director on 10/16/24 at 8:35 AM. The policy stated,” …at least every 14 days with or without aide present with an onsite visit with aide at least annually…” Patient #7 had a SOC (start of care) of 7/12/24 and included diagnoses of pressure ulcer of sacral region; stage 2; major depressive disorder, anxiety disorder, hypokalemia (low potassium), and hypertension. Home health aide orders were for 1 time a week for 9 weeks. Review of home health aide visits for 9/13/24, 9/20/24, 9/27/24, and 10/2/24 revealed no aide supervision visits were made until 10/9/24.

An unannounced onsite recertification survey was conducted 4/26/22-4/27/22. No deficiencies to the Emergency Preparedness Plan was identified.

An unannounced onsite recertification survey was conducted 4/26/22-4/27/22. Standard level deficiencies to the Medicare CoP were identified.

Plan of care must include the following CFR(s): 484.60(a)(2)(i-xvi) The individualized plan of care must include the following: (i) All pertinent diagnoses; (ii) The patient's mental, psychosocial, and cognitive status; (iii) The types of services, supplies, and equipment required; (iv) The frequency and duration of visits to be made; (v) Prognosis; (vi) Rehabilitation potential; (vii) Functional limitations; (viii) Activities permitted; (ix) Nutritional requirements; (x) All medications and treatments; (xi) Safety measures to protect against injury; (xii) A description of the patient's risk for emergency department visits and hospital re-admission, and all necessary interventions to address the underlying risk factors. (xiii) Patient and caregiver education and training to facilitate timely discharge; (xiv) Patient-specific interventions and education; measurable outcomes and goals identified by the HHA and the patient; (xv) Information related to any advanced directives; and (xvi) Any additional items the HHA or physician or allowed practitioner may choose to include. This ELEMENT is not met as evidenced by: Based on agency policy, clinical record review and staff interviews the Plan of Care [POC] failed to include all the current/correct medications the patient was using for 1 of 13 records reviewed [#1]; failed to include all pertinent diagnoses on for 2 of 13 records reviewed [#2, 8] The findings included: The policy, Plan of Care [POC] [revised date 12/1/21], was provided by the agency director on 4/27/22 at 9 am. The policy stated, “…A POC is developed for all patients and updated no less than every 60 days…The POC includes: …f. Medications and treatments…h. Pertinent diagnosis [es]…” 1A. Patient # 1 had a Start of Care [SOC] date of 8/4/21 and admitting diagnoses of Parkinson’s Disease, Hypertension and Type 2 Diabetes Mellitus. A review of the Plan of Care [POC] for the certification period 8/4/21 to 10/2/21 revealed orders for SN [skilled nursing] 1 time a week for 3 weeks and “Skilled nurse to monitor pain and instruct/reinforce patient regarding pharmacologic and non-pharmacologic and other pain control measures…” A review of the clinical record revealed LPN # 6 made a routine visit on 8/12/21. A review of the visit note report for the 8/12/21 visit revealed the following documentation, “…Medications reviewed with no changes or concerns…Patient with complaints of constipation and painful legs at night. States she took Tylenol with no relief…” Further review of the clinical record revealed no order on the POC for Tylenol. LPN # 6 was not available for interview. An interview was conducted with the agency director on 4/27/22 at approximately 9:45 am. During the interview the director confirmed the POC did not include all the medications the patient was taking. 1B. Patient # 1 had a Start of Care [SOC] date of 8/4/21 and admitting diagnoses of Parkinson’s Disease, Hypertension and Type 2 Diabetes Mellitus. A review of the Plan of Care [POC] for the certification period 8/4/21 to 10/2/21 revealed orders for OT [occupational therapy] 1 time a week for 1 week, 1 time every 2 weeks for 4 weeks. A review of the clinical record revealed OT # 11 completed a routine visit on 8/20/21. A review of the visit note report for 8/20/21 revealed the following documentation by OT # 11,”…Has not taken any medications yet today…Patient questioned OT about a packet of pills as she was not taking them for not knowing what they were. OT determined these were her thyroid pills and instructed her these are to be taken first each morning at least 2H [2 hours] before any other medications or food…” A review of the Plan of Care revealed no order for “thyroid pills”. An interview was conducted with the agency director on 4/27/22 at approximately 1 pm. During the interview the director stated, “The OT worked really hard to get those medications straight. She said the medication was lying on the counter and she instructed the patient on how to take the medications without updating the POC. 2A. Patient # 2 had a Start of Care [SOC] date of 2/9/21 and an admitting diagnosis of Alzheimer’s Disease. A review of the Plan of Care [POC] for the certification period 2/9/21 to 4/9/21 revealed orders for PT [physical therapy] 2 times a week for 2 weeks, 1 time a week for 4 weeks. A review of the clinical record revealed PT # 8 completed the SOC visit. Further review of the clinical record revealed the POC included the following medication, “Humalog U-100 Insulin 100 unit/ml 3 times per day take 15-24 units per sliding scale”. The medication profile did not include the sliding scale reading to determine the number of units of insulin. PT # 8 was not available for interview. An interview was conducted with the agency director on 4/27/22 at approximately 11:45 am. During the interview the agency director confirmed the POC did not include the complete instructions for the insulin. counter and she instructed the patient on how to take the medications without updating the POC. 2B. Patient # 2 had a Start of Care [SOC] date of 2/9/21 and an admitting diagnosis of Alzheimer’s Disease. A review of the Plan of Care [POC] for the certification period 2/9/21 to 4/9/21 revealed orders for PT [physical therapy] 2 times a week for 2 weeks, 1 time a week for 4 weeks. A review of the Start of Care Clinical Summary completed by PT # 8 on 3/4/21. A review of the clinical summary revealed the following information, “…PMH [past medical history] includes DM [diabetes mellitus] Type 2…” Further review of the POC revealed the 2 of the medications the patient was prescribed was Lantus Insulin and Humalog insulin. Type 2 Diabetes Mellitus was not included on the POC under the diagnoses section. PT # 8 was not available for interview. An interview was conducted with the agency director on 4/17/22 at approximately 1:45 pm. During the interview the director reported, “That was before my time here as director. I am really not sure what the process was then.” The agency director confirmed Type 2 Diabetes should have been included on the POC as a pertinent diagnosis. 3. Patient # 8 had a Start of Care [SOC] date of 4/7/22 and the admitting diagnoses on the Plan of Care for the certification period 4/7/22 to 6/5/22 was Unspecified Open Wound, Left Hip. A review of the SOC Clinical Summary completed on 4/7/22 by RN # 12 revealed the following documentation, “…Patient’s primary focus of care is pressure injuries, indwelling catheter. The patient also has the following co-morbidities that are new or have been exacerbated…paraplegic, fall risk, HTN [hypertension]…” An interview was conducted with the agency director on 4/27/22 at approximately 11:35 am. During the interview the agency director stated, “Our policy says we have 30 days to lock the Oasis [Outcome and Assessment Information Set]. I guess I thought that would mean we had 30 days to update the POC.”

Conformance with physician orders CFR(s): 484.60(b) Standard: Conformance with physician or allowed practitioner orders. This STANDARD is not met as evidenced by: Based on agency policy, clinical record review and staff interviews the agency failed to obtain an order to flush a “clogged” G tube [gastrostomy] for 1 of 1 record with a G tube [#3]; failed to report pain levels outside the given parameters for 3 of 13 records reviewed [#3, 4, 9]; failed to change an indwelling catheter in accordance with the Plan of Care [POC] for 1 of 2 records with an indwelling catheter [#3]; failed to follow physician’s orders related to wound care for 3 of 8 records with a wound [#5, 6, 12 ]. The findings included: The policy, Physician’s Orders [revised date 11/1/21] was provided by the agency director on 4/27/22 at 9 am. The policy stated, “…Services/treatments are provided based on the most current plan of care…” 1A. Patient # 3 had a Start of Care [SOC] date of 3/19/21 and admitting diagnoses of Aftercare Following Surgery for Neoplasm, Malignant Neoplasm of Lower Third of Esophagus and Type 2 Diabetes Mellitus without Complications. A review of the Plan of Care [POC] for the certification period 3/19/21 to 5/17/21 revealed orders for SN [skilled nursing] 1 time a week for 1 week, 2 times a week for 1 week, 1 time a week for 7 weeks and ,”Skilled nurse for instructions/reinforcement of administration of G [gastrostomy] tube feedings Jevity 1.5 @ 40 ml per hour continuous via feeding pump…” A review of the clinical record revealed RN # 4 made a PRN [as needed] visit on 3/26/21. The following information was documented in the visit note report by RN # 4, “Patient seen after call because G Tube was clogged. Warm water used and tube is flushing without difficulty. Educated caregiver to use warmer water or cola product to try and unclog…” A review of the clinical record revealed no order to use a cola product in case of clogged G tube. RN # 4 was unavailable for interview. An interview was conducted with the agency director on 4/27/22 at approximately 9:45 am. During the interview the director stated, “We no longer educate caregivers or patients to use any type of soda to unclog a G tube. There is no order to unclog the G tube with soda and the nurse should not have told the caregiver to use cola products if the tube became clogged again.” 1B. Patient # 3 had a Start of Care [SOC] date of 3/19/21 and admitting diagnoses of Aftercare Following Surgery for Neoplasm, Malignant Neoplasm of Lower Third of Esophagus and Type 2 Diabetes Mellitus without Complications. A review of the Plan of Care [POC] for the certification period 3/19/21 to 5/17/21 revealed orders for SN [skilled nursing] 1 time a week for 1 week, 2 times a week for 1 week, 1 time a week for 7 weeks; OT [occupational therapy] effective the week of 3/21/21 - 2 times a week for 1 week, 1 time every 2 weeks for 2 weeks, 1 time a week for 1 week and “When vital signs are obtained licensed professional to report vital signs fall outside the following established parameters…pain greater than 6…” A review of the clinical record revealed RN # 2 documented a pain level of 7 at the time of admission [3/19/21], OT # 3 documented a pain level of 7 on 4/5/21, OT # 5 documented a pain level of 8 on 4/24/21. Further review of the clinical record revealed no evidence the physician was notified of the pain levels in accordance with the POC. An interview was conducted with the agency director on 4/27/22 at approximately 9:45 am. During the interview the director confirmed the physician was not notified of the pain levels. 1C. Patient # 3 had a Start of Care [SOC] date of 3/19/21 and admitting diagnoses of Aftercare Following Surgery for Neoplasm, Malignant Neoplasm of Lower Third of Esophagus and Type 2 Diabetes Mellitus without Complications. A review of the Plan of Care [POC] for the certification period 3/19/21 to 5/17/21 revealed orders for SN [skilled nursing] 1 time a week for 1 week, 2 times a week for 1 week, 1 time a week for 7 weeks and “Skilled nurse for insertion of 16 fr [French] 10 cc balloon indwelling/catheter using aseptic technique; change every 30 days and PRN [as needed] dislodgement or blockage…” A review of the documentation by RN # 2 at the time of admission revealed the indwelling catheter was last changed on 3/17/21. There was no evidence the indwelling catheter was changed again in 30 days in accordance with the POC. RN # 2 was unavailable for an interview. The agency director was interviewed on 4/27/22 at approximately 9:45 am. During the interview the director confirmed the indwelling catheter was not changed in accordance with the POC. 2. Patient # 4 had a Start of Care [SOC] date of 3/8/22 and admitting diagnoses of Type 2 Diabetes Mellitus without complications and Essential Hypertension. A review of the Plan of Care [POC] for the certification period 3/8/22 to 5/6/22 revealed orders for SN [skilled nursing] 1 time a week for 1 week, 2 times a week for 1 week, 1 time a week for 3 weeks, 1 time every 2 weeks for 2 weeks, 2 times a week for 1 week, 1 time a week for 1 week and “When vital signs are obtained licensed professional to report vital signs falling outside the following established parameters…pain greater than 7…” A review of the clinical record revealed LPN # 7 made a routine visit on 3/17/22 and documented the following information, “…Patient states that pain level at a ‘10’ but patient talking, singing and laughing to SN…”Further review of the clinical record revealed no evidence the LPN notified the physician of the pain level being outside the given parameter. An interview was conducted with the agency director on 4/27/22 at approximately 9:40 am. During the interview the director stated, “ I see no documentation where the physician was notified. 3. Patient # 9 had a Start of Care [SOC] date of 3/6/22 and admitting diagnoses of Type 2 Diabetes Mellitus with foot ulcer, Non-pressure chronic ulcer other part left foot and Type 2 Diabetes Mellitus with Diabetic Polyneuropathy. A review of the Plan of Care [POC] for the certification period 3/6/22 to 5/4/22 revealed orders for SN [skilled nursing] 3 times a week for 1 week, 2 times a week for 7 weeks, 1 time a week for 1 week and “When vital signs are obtained licensed professional to report vital signs falling outside the following established parameters…pain greater than 7…” A review of the clinical record revealed LPN # 10 made a routine visit on 3/9/22. The visit note revealed the following information, “…Patient reports chronic bilateral leg pain-pain disrupting sleep, 9/10 pain every night round 2 am. Patient takes oxycodone every 6 hours and patient states it does not help pain at night…” There was no evidence the LPN contacted the physician of the pain level being outside the given parameter. An interview was conducted with the agency director on 4/27/22 at approximately 1 pm. During the interview the director stated, “I guess she just forgot to chart it.“ 4. Patient # 5 had a Start of Care [SOC] date of 3/14/22 and admitting diagnoses of Encounter for change or removal of Surgical Wound” of Left Foot and Type 2 Diabetes Mellitus without complications. A review of the Plan of Care [POC] for the certification period 3/14/22 to 5/12/22 revealed orders for SN [skilled nursing] 2 times a week for 8 weeks, 1 time a week for 1 week and “Skilled nurse to cleanse wound to left foot with wound cleanser, prepare periwound area with vac drape…Apply negative pressure at 125 MM/HG continuous…Dressing to be changed 3 times weekly, 2 times by HH [home health and 1 time by wound center]…” A supplemental order was written on 4/5/22 by _____ [wound care physician]. The order stated, “…Home health to change [wound vac] on Tuesday and Saturday this week 4/7/22 and 4/9/22”. Further review of the clinical record revealed the wound vac was changed on 4/4/22 and 4/8/22. An interview was conducted with the agency director on 4/27/22 at approximately 11:20 am. During the interview the director confirmed the wound vac was not changed in accordance with the physician’s orders. “I guess it was caused by an issue related to the fax machine” . 5. Patient # 6 had a Start of Care [SOC] date of 3/24/22 and an admitting diagnosis of Encounter for Surgical Aftercare Following Surgery on the Digestive System. A review of the Plan of Care [POC] for the certification period 3/24/22 to 5/22/22 revealed orders for SN [skilled nursing] 1 time a week for 8 weeks, 3 times a week for 1 week. Further review of the POC revealed the following order,”…Skilled nurse to perform/instruct/reinforce patient/caregiver procedure of wound care to midline abdomen 2x [2 times] daily. Cleanse with normal sailine [sic] and gauze. Cover with dry gauze dressing and secure with tape using clean technique. Instruct patient/caregiver signs/symptoms of wound infection and proper disposal of dressings. Caregiver to perform dressing change in absence of nurse…” A review of the clinical record revealed RN # 1 made visits on 3/25/22, 4/1/22, 4/8/22, 4/12/22 and 4/22/22. A review of the visit note report documentation revealed the following documentation by RN # 1: 3/25/22-“…Nurse oversaw pt [patient] husband perform wound care of a dry dressing change as ordered from the surgeon…” 4/1/22-“…Pt [patient] wanted nurse to watch sister do the wound care. Nurse supervised but the sister did great…” 4/8/22-“…Patient still refusing to allow nurse to perform wound care on patient. Nurse watched husband do it and consoled patient…” 4/22/22-“…Nurse oversaw wound care for patient…” An interview was conducted with the agency director on 4/27/22 at approximately 9:30 am. During the interview the director confirmed RN # 1 did not do the dressing changes in accordance with the POC. 6. Patient # 12 had a Start of Care [SOC] date of 3/2/22 and an admitting diagnosis of Diverticulosis of Large Intestines with Perforation and abscess without bleeding. A review of the Plan of Care [POC] for the certification period 3/2/22 to 4/30/22 revealed orders for SN [Skilled nursing] 1 time a week for 9 weeks and “ …Skilled nurse to perform/instruct/reinforce patient/caregiver procedure of wound care to abodomen [sic] daily, cleanse with wound cleanser, apply nickel thick layer of Santyle [sic] to slough, cover with moist gauze, cover with dry gauze and abd pad, secure with tape. CG [caregiver to perform in abscnece [sic] of SN…” A review of the clinical record revealed nursing visits were made on 3/3/22, 3/8/22, 3/15/22, 3/23/22, 3/29/22, 4/5/22, 4/15/22 and 4/21/22. A review of SN visit notes revealed the nurse did not do the dressing changes in accordance with the POC. The nurse’s notes indicate the caregiver completed the wound care during each of the visits. An interview was conducted with the agency director on 4/27/22 at approximately 11:15 am. During the interview the director confirmed the dressing changes were not completed by the nursing staff in accordance with the POC.

Communication with physicians CFR(s): 484.75(b)(7) Communication with all physicians involved in the plan of care and other health care practitioners (as appropriate) related to the current plan of care; This ELEMENT is not met as evidenced by: Based on agency policy, clinical record review and staff interviews the agency failed to communicate with the physician new skin breakdown was identified for 1 of 8 records with a wound [#2]; a report of possible drug diversion for 1 of 13 records [#3]; the patient was not taking pain medication in accordance with the Plan of Care [POC] for 1 of 13 records reviewed [#4]; and failed to notify the physician when the caregiver was not performing wound care in accordance with the POC for 1 of 8 records[#9] with a wound. The findings included: The policy, Coordination of Care, From Admit Through Discharge [revised date of 4/1/21], was provided by the agency director on 4/27/22 at 9 am. The policy stated, “…Coordination of care with physician: At admission, throughout care, and at discharge, coordination of services is promoted through routine communication with the patient’s physician: a. When changes occur in the patient’s condition or response to treatment b. When changes occur in caregiver support or the environment that affect patient treatment…e. When there is a need to change the patient’s plan of care…" 1. Patient # 2 had a Start of Care [SOC] date of 2/9/21 and an admitting diagnosis of Alzheimer’s Disease. A review of the Plan of Care [POC] for the certification period 2/9/21 to 4/9/21 revealed orders for PT [physical therapy] 2 times a week for 2 weeks, 1 time a week for 4 weeks. A review of the clinical record revealed PTA # 9 made a routine visit on 3/2/21. A review of the visit note report revealed the following documentation by PTA # 9, “Dtr [daughter] reports newly developed pressure sore R [right] posterior thigh, Paal8ative [sic] care nsg [nursing] coming OYT [sic] to assess today…” There was no evidence the PTA notified the physician of the daughter’s report of new skin breakdown. PTA # 9 was not available for interview. An interview was conducted with the agency director on 4/27/22 at approximately 12 noon. During the interview the director confirmed the PTA failed to notify the PT or the Physician of the reports of new skin breakdown. The director stated, “I assume it was because the patient was going to be assessed by palliative care that day or the next day.” 2. Patient # 3 had a Start of Care [SOC] date of 3/19/21 and admitting diagnoses of Aftercare Following Surgery for Neoplasm, Malignant Neoplasm of Lower Third of Esophagus and Type 2 Diabetes Mellitus without Complications. A review of the Plan of Care [POC] for the certification period 3/19/21 to 5/17/21 revealed orders for SN [skilled nursing] 1 time a week for 1 week, 2 times a week for 1 week, 1 time a week for 7 weeks. A review of the clinical record revealed RN # 2 conducted he SOC visit on 3/19/21. A review of the documentation for that visit revealed the following information, “…Patient lives with her son, and her daughter was also present during the visit. However, the son is the primary caregiver and she lives in the son’s home. After my visit, the daughter called me to let me know that the son is taking the patient’s narcotics as he has a history of narcotic abuse…” Further review of the clinical record revealed no evidence the RN notified the physician of this conversation. RN # 2 is no longer employed by the agency. An interview was conducted with the agency director on 4/27/22 at approximately 9:45 am. During the interview the director confirmed there was no evidence in the clinical record the physician was notified. 3. Patient # 4 had a Start of Care [SOC] date of 3/8/22 and admitting diagnoses of Type 2 Diabetes Mellitus without complications and Essential Hypertension. A review of the Plan of Care [POC] for the certification period 3/8/22 to 5/6/22 revealed orders for SN [skilled nursing] 1 time a week for 1 week, 2 times a week for 1 week, 1 time a week for 3 weeks, 1 time every 2 weeks for 2 weeks, 2 times a week for 1 week, 1 time a week for 1 week. A review of the clinical record revealed LPN # 7 made a routine visit on 3/17/22 and documented the following information, “…Patient states that pain level at a “10” but patient talking, singing and laughing to SN. Patient stated, “I take [sic] 2 pain pills this morning and two Tylenol” Patient stated I will run out of pain pills before the end of the month. SN educated that patient was not following orders for pain medications. Patient medication orders calls for 1 tablet [oxycodone] twice a day. Patient states, “I always take 2”. Further review of the clinical record revealed no evidence the LPN notified the physician the patient was not taking the pain medication in accordance with the POC. An interview was conducted with the agency director on 4/27/22 at approximately 9:40 am. During the interview the director stated the LPN # 7 stated, “The nurse told me she just forgot to chart it” . 4. Patient # 9 had a Start of Care [SOC] date of 3/6/22 and admitting diagnoses of Type 2 Diabetes Mellitus with foot ulcer, Non-pressure chronic ulcer other part left foot and Type 2 Diabetes Mellitus with Diabetic Polyneuropathy. A review of the Plan of Care [POC] for the certification period 3/6/22 to 5/4/22 revealed orders for SN [skilled nursing] 3 times a week for 1 week, 2 times a week for 7 weeks, 1 time a week for 1 week and “Skilled nurse to perform/instruct/patient/caregiver procedure of wound care to diabetic ulcer left medial heel 2 times week and PRN [as needed] for dressing soilage or dislodgement. Cleanse with wound cleanser. Apply santyl to wound bed. Cover with foam border dressing. Wrap with rolled gsuze [sic] and secure with tape…” LPN # 7 made a routine visit on 3/11/22 and documented the following information, “ …During dressing change pt [patient] daughter stated, “ I am not doing it that way” SN questioned “How are you doing the dressing?” Daughter stated “I am using just this and pointed to the gauze” she then stated I put the santyl on it then gauze and wrap with rolled gauze then wrap with ace wrap. SN stated that was not the way the orders were written...SN educated on correct amount of santyl to be applied and the correct way to dress wound…” Further review of the clinical record revealed no evidence LPN # 7 notified the physician the caregiver was not completing the wound care in accordance with the POC. An interview was conducted with the agency director on 4/27/22 at approximately 12:15 pm. During the interview the director stated “ I guess she failed to chart that she contacted the MD."