Every finding on record at Mother's Care Home Health Services, Inc

This Statement of Deficiencies was generated as a result of an Emergency Preparedness survey conducted in your agency from June 5, 2024, through June 7, 2024, in accordance with 42 Code of Federal Regulations (CFR) and the State Operations Manual (SOM), Appendix Z- Emergency Preparedness for All Provider and Certified Supplier Types. The findings and conclusions of any investigation by the Division of Public and Behavioral Health shall not be construed as prohibiting any criminal or civil investigations, actions or other claims for relief that may be available to any party under applicable federal, state, or local laws. The following regulatory deficiencies were identified.

Develop EP Plan, Review and Update Annually CFR(s): 484.102(a) §403.748(a), §416.54(a), §418.113(a), §441.184(a), §460.84(a), §482.15(a), §483.73(a), §483.475(a), §484.102(a), §485.68(a), §485.542(a), §485.625(a), §485.727(a), §485.920(a), §486.360(a), §491.12(a), §494.62(a). The [facility] must comply with all applicable Federal, State and local emergency preparedness requirements. The [facility] must develop establish and maintain a comprehensive emergency preparedness program that meets the requirements of this section. The emergency preparedness program must include, but not be limited to, the following elements: (a) Emergency Plan. The [facility] must develop and maintain an emergency preparedness plan that must be [reviewed], and updated at least every 2 years. The plan must do all of the following: * [For hospitals at §482.15 and CAHs at §485.625(a):] Emergency Plan. The [hospital or CAH] must comply with all applicable Federal, State, and local emergency preparedness requirements. The [hospital or CAH] must develop and maintain a comprehensive emergency preparedness program that meets the requirements of this section, utilizing an all-hazards approach. * [For LTC Facilities at §483.73(a):] Emergency Plan. The LTC facility must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least annually. * [For ESRD Facilities at §494.62(a):] Emergency Plan. The ESRD facility must develop and maintain an emergency preparedness plan that must be [evaluated], and updated at least every 2 years. . This STANDARD is not met as evidenced by: Based on interview and document review, the agency failed to provide documented evidence the agency’s emergency preparedness (EP) plan had been reviewed and updated at least every two years. The deficient practice had the potential to affect the agency’s ability to respond effectively and address the safety needs of the patients, and staff members in the event of an emergency. Findings include: A review of the agency’s EP Plan revealed the EP Plan was reviewed and approved on 01/25/2021. There was no documented evidence the EP Plan had been reviewed and updated two years thereafter or in 2023. On 06/07/2024 at 11:53 AM, the Administrator and the Human Resource (HR) Manager confirmed the findings and acknowledged the EP Plan should have been reviewed and updated every two years. The agency’s policy titled “Emergency Operations Plan and Policies” dated February 2022, documented the agency had developed and maintained an emergency preparedness plan and policies which were reviewed and updated at least every two years.

Plan Based on All Hazards Risk Assessment CFR(s): 484.102(a)(1)-(2) §403.748(a)(1)-(2), §416.54(a)(1)-(2), §418.113(a)(1)-(2), §441.184(a)(1)-(2), §460.84(a)(1)-(2), §482.15(a)(1)-(2), §483.73(a)(1)-(2), §483.475(a)(1)-(2), §484.102(a)(1)-(2), §485.68(a)(1)-(2), §485.542(a)(1)-(2), §485.625(a)(1)-(2), §485.727(a)(1)-(2), §485.920(a)(1)-(2), §486.360(a)(1)-(2), §491.12(a)(1)-(2), §494.62(a)(1)-(2) [(a) Emergency Plan. The [facility] must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least every 2 years. The plan must do the following:] (1) Be based on and include a documented, facility-based and community-based risk assessment, utilizing an all-hazards approach.* (2) Include strategies for addressing emergency events identified by the risk assessment. * [For Hospices at §418.113(a):] Emergency Plan. The Hospice must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least every 2 years. The plan must do the following: (1) Be based on and include a documented, facility-based and community-based risk assessment, utilizing an all-hazards approach. (2) Include strategies for addressing emergency events identified by the risk assessment, including the management of the consequences of power failures, natural disasters, and other emergencies that would affect the hospice's ability to provide care. *[For LTC facilities at §483.73(a):] Emergency Plan. The LTC facility must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least annually. The plan must do the following: (1) Be based on and include a documented, facility-based and community-based risk assessment, utilizing an all-hazards approach, including missing residents. (2) Include strategies for addressing emergency events identified by the risk assessment. *[For ICF/IIDs at §483.475(a):] Emergency Plan. The ICF/IID must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least every 2 years. The plan must do the following: (1) Be based on and include a documented, facility-based and community-based risk assessment, utilizing an all-hazards approach, including missing clients. (2) Include strategies for addressing emergency events identified by the risk assessment. This STANDARD is not met as evidenced by: Based on interview and document review, the agency failed to provide documented evidence the agency’s emergency preparedness (EP) plan included a facility-based and community-based risk assessment utilizing an all-hazard approach. The deficient practice had the potential to affect the agency’s ability to respond effectively and address the safety needs of the patients, and staff members in the event of an emergency. Findings include: A review of the agency’s EP Plan revealed the following forms incorporated in the EP Plan were not completed: - Hazard Vulnerability Analysis (HVA): Agency (Facility-Based) - Biennial Evaluation of Hazard Vulnerability Analysis (HVA): Agency (Facility-Based) - Hazard Vulnerability Analysis (HVA): Community-Based - Biennial Evaluation of Hazard Vulnerability Analysis (HVA): Community-Based On 06/07/2024 at 12:00 PM, the Administrator and the Human Resource (HR) Manager confirmed the findings and acknowledged the above-mentioned forms should have been completed. The agency’s policy titled “Agency Facility-Based and Community-Based Risk Assessment Policy” dated February 2022, documented the agency would perform a facility-based and community-based risk assessment utilizing an all-hazard approach in order to develop an emergency plan. Hazard Vulnerability Analysis (HVA) would be conducted and evaluated biennially. The HVA would include both facility-based and community-based risk assessments.

Names and Contact Information CFR(s): 484.102(c)(1) §403.748(c)(1), §416.54(c)(1), §418.113(c)(1), §441.184(c)(1), §460.84(c)(1), §482.15(c)(1), §483.73(c)(1), §483.475(c)(1), §484.102(c)(1), §485.68(c)(1), §485.542(c)(1), §485.625(c)(1), §485.727(c)(1), §485.920(c)(1), §486.360(c)(1), §491.12(c)(1), §494.62(c)(1). [(c) The [facility must develop and maintain an emergency preparedness communication plan that complies with Federal, State and local laws and must be reviewed and updated at least every 2 years [annually for LTC facilities]. The communication plan must include all of the following:] (1) Names and contact information for the following: (i) Staff. (ii) Entities providing services under arrangement. (iii) Patients' physicians (iv) Other [facilities]. (v) Volunteers. *[For Hospitals at §482.15(c) and CAHs at §485.625(c)] The communication plan must include all of the following: (1) Names and contact information for the following: (i) Staff. (ii) Entities providing services under arrangement. (iii) Patients' physicians (iv) Other [hospitals and CAHs]. (v) Volunteers. *[For RNHCIs at §403.748(c):] The communication plan must include all of the following: (1) Names and contact information for the following: (i) Staff. (ii) Entities providing services under arrangement. (iii) Next of kin, guardian, or custodian. (iv) Other RNHCIs. (v) Volunteers. *[For ASCs at §416.45(c):] The communication plan must include all of the following: (1) Names and contact information for the following: (i) Staff. (ii) Entities providing services under arrangement. (iii) Patients' physicians. (iv) Volunteers. *[For Hospices at §418.113(c):] The communication plan must include all of the following: (1) Names and contact information for the following: (i) Hospice employees. (ii) Entities providing services under arrangement. (iii) Patients' physicians. (iv) Other hospices. *[For HHAs at §484.102(c):] The communication plan must include all of the following: (1) Names and contact information for the following: (i) Staff. (ii) Entities providing services under arrangement. (iii) Patients' physicians. (iv) Volunteers. *[For OPOs at §486.360(c):] The communication plan must include all of the following: (2) Names and contact information for the following: (i) Staff. (ii) Entities providing services under arrangement. (iii) Volunteers. (iv) Other OPOs. (v) Transplant and donor hospitals in the OPO's Donation Service Area (DSA). This STANDARD is not met as evidenced by: Based on interview and document review, the agency failed to provide documented evidence the communication plan of the agency’s emergency preparedness (EP) plan contained the contact information for the staff, entities providing services under arrangement, and other sources of assistance. The deficient practice had the potential to affect the agency’s ability to respond effectively and address the safety needs of the patients, and staff members in the event of an emergency. Findings include: A review of the agency’s EP Plan revealed the following forms incorporated in the EP Plan were not completed: - Communication Plan: Staff Contact Information - Communication Plan: Contracted Services Contact Information - Communication Plan: Other Sources of Assistance Contact Information (including the federal, state, tribal, regional, and local emergency preparedness staff, and other sources of emergency preparedness assistance) On 06/07/2024 at 12:10 PM, the Administrator and the Human Resource (HR) Manager confirmed the findings and acknowledged the above-mentioned forms should have been completed. The agency’s policy titled “Communication Plan and Policy for Emergency Operations Plan (EOP)” dated February 2022, documented the communication plan included the following: - Names and contact information for the staff, entities providing services under arrangement or contract, patients’ physicians/practitioners, and volunteers (if applicable). - Contact information for the federal, state, tribal, regional, or local emergency preparedness staff and other sources of assistance.

EP Training Program CFR(s): 484.102(d)(1) §403.748(d)(1), §416.54(d)(1), §418.113(d)(1), §441.184(d)(1), §460.84(d)(1), §482.15(d)(1), §483.73(d)(1), §483.475(d)(1), §484.102(d)(1), §485.68(d)(1), §485.542(d)(1), §485.625(d)(1), §485.727(d)(1), §485.920(d)(1), §486.360(d)(1), §491.12(d)(1). *[For RNCHIs at §403.748, ASCs at §416.54, Hospitals at §482.15, ICF/IIDs at §483.475, HHAs at §484.102, REHs at §485.542, "Organizations" under §485.727, OPOs at §486.360, RHC/FQHCs at §491.12:] (1) Training program. The [facility] must do all of the following: (i) Initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles. (ii) Provide emergency preparedness training at least every 2 years. (iii) Maintain documentation of all emergency preparedness training. (iv) Demonstrate staff knowledge of emergency procedures. (v) If the emergency preparedness policies and procedures are significantly updated, the [facility] must conduct training on the updated policies and procedures. *[For Hospices at §418.113(d):] (1) Training. The hospice must do all of the following: (i) Initial training in emergency preparedness policies and procedures to all new and existing hospice employees, and individuals providing services under arrangement, consistent with their expected roles. (ii) Demonstrate staff knowledge of emergency procedures. (iii) Provide emergency preparedness training at least every 2 years. (iv) Periodically review and rehearse its emergency preparedness plan with hospice employees (including nonemployee staff), with special emphasis placed on carrying out the procedures necessary to protect patients and others. (v) Maintain documentation of all emergency preparedness training. (vi) If the emergency preparedness policies and procedures are significantly updated, the hospice must conduct training on the updated policies and procedures. *[For PRTFs at §441.184(d):] (1) Training program. The PRTF must do all of the following: (i) Initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles. (ii) After initial training, provide emergency preparedness training every 2 years. (iii) Demonstrate staff knowledge of emergency procedures. (iv) Maintain documentation of all emergency preparedness training. (v) If the emergency preparedness policies and procedures are significantly updated, the PRTF must conduct training on the updated policies and procedures. *[For PACE at §460.84(d):] (1) The PACE organization must do all of the following: (i) Initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing on-site services under arrangement, contractors, participants, and volunteers, consistent with their expected roles. (ii) Provide emergency preparedness training at least every 2 years. (iii) Demonstrate staff knowledge of emergency procedures, including informing participants of what to do, where to go, and whom to contact in case of an emergency. (iv) Maintain documentation of all training. (v) If the emergency preparedness policies and procedures are significantly updated, the PACE must conduct training on the updated policies and procedures. *[For LTC Facilities at §483.73(d):] (1) Training Program. The LTC facility must do all of the following: (i) Initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected role. (ii) Provide emergency preparedness training at least annually. (iii) Maintain documentation of all emergency preparedness training. (iv) Demonstrate staff knowledge of emergency procedures. *[For CORFs at §485.68(d):](1) Training. The CORF must do all of the following: (i) Provide initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles. (ii) Provide emergency preparedness training at least every 2 years. (iii) Maintain documentation of the training. (iv) Demonstrate staff knowledge of emergency procedures. All new personnel must be oriented and assigned specific responsibilities regarding the CORF's emergency plan within 2 weeks of their first workday. The training program must include instruction in the location and use of alarm systems and signals and firefighting equipment. (v) If the emergency preparedness policies and procedures are significantly updated, the CORF must conduct training on the updated policies and procedures. *[For CAHs at §485.625(d):] (1) Training program. The CAH must do all of the following: (i) Initial training in emergency preparedness policies and procedures, including prompt reporting and extinguishing of fires, protection, and where necessary, evacuation of patients, personnel, and guests, fire prevention, and cooperation with firefighting and disaster authorities, to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles. (ii) Provide emergency preparedness training at least every 2 years. (iii) Maintain documentation of the training. (iv) Demonstrate staff knowledge of emergency procedures. (v) If the emergency preparedness policies and procedures are significantly updated, the CAH must conduct training on the updated policies and procedures. *[For CMHCs at §485.920(d):] (1) Training. The CMHC must provide initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles, and maintain documentation of the training. The CMHC must demonstrate staff knowledge of emergency procedures. Thereafter, the CMHC must provide emergency preparedness training at least every 2 years. This STANDARD is not met as evidenced by: Based on interview, personnel record review and document review, the agency failed to provide documented evidence employees had signed and completed training on the agency’s emergency preparedness (EP) plan for 10 of 10 employee files reviewed (Employee 1 to 10). The deficient practice had the potential to affect the employees’ ability to assist the agency in continuing to provide patient care and address safety needs of the patients, and staff members in the event of an emergency. Findings include: A review of ten employee files and the agency’s EP program revealed there was no documented evidence EP training was provided to the ten employees. On 06/07/2024 at 12:08 PM, the Human Resource (HR) Manager confirmed the findings and acknowledged initial EP training, and on-going training at least every two years should have been provided to all staff members. The HR Manager indicated the Employee Training: Emergency Operations Plan (EOP) form incorporated in the agency’s EP Plan should have been utilized. The agency’s policy titled “Emergency Operations Plan (EOP) Training Program” dated February 2022, documented the agency would provide initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement and volunteers (if applicable) consistent with their expected roles. The agency would provide emergency preparedness training at least every two years. Training should be modified, incorporating any lessons learned from the most recent exercises, real-life emergencies which occurred in the last two years and during review of the emergency operations plan every two years. The agency would maintain documentation of the training.

This Statement of Deficiencies was generated as a result of a Medicare Recertification Survey and a complaint investigation conducted in your agency from June 5, 2024, through June 7, 2024, in accordance with 42 Code of Federal Regulations (CFR) Part 484 - Home Health Services. The census on the first day of the survey was 41 patients. Seven clinical records were reviewed. Three home visits were conducted. There was one complaint investigated. Complaint #104557 was substantiated. (See Tag’s G454, G580, and G592) The findings and conclusions of any investigation by the Division of Public and Behavioral Health shall not be construed as prohibiting any criminal or civil investigation, actions or other claims for relief that may be available to any party under applicable federal, state, or local laws. The following regulatory deficiencies were identified:

Encoding and transmitting OASIS CFR(s): 484.45(a) Standard: An HHA must encode and electronically transmit each completed OASIS assessment to the CMS system, regarding each beneficiary with respect to which information is required to be transmitted (as determined by the Secretary), within 30 days of completing the assessment of the beneficiary. This STANDARD is not met as evidenced by: Based on interview and document review, the agency failed to electronically transmit each completed Outcome and Assessment Information Set (OASIS) assessment within 30 days of completing the assessment of the beneficiary for 4 of 11 quarters since the last recertification survey in April 2021. Findings include: According to the state's OASIS Education Coordinator the agency was late in transmitting OASIS data for 4 of 11 quarters since the last recertification survey in April 2021. The assessments submitted late for the four quarters varied from a low of 18.06% to a high of 20.5% of all quarterly submissions. On 06/06/2024 in the morning, the Administrator confirmed the findings.

HHA can no longer meet the patient's needs CFR(s): 484.50(d)(1) The transfer or discharge is necessary for the patient's welfare because the HHA and the physician or allowed practitioner, who is responsible for the home health plan of care agree that the HHA can no longer meet the patient's needs, based on the patient's acuity. The HHA must arrange a safe and appropriate transfer to other care entities when the needs of the patient exceed the HHA's capabilities; This ELEMENT is not met as evidenced by: Based on record review and interview, the agency failed to ensure it facilitated a transfer or appropriate follow-up for speech therapy that could meet a patient's needs for 1 of 7 sampled patients (Patient 7). The deficient practice had the potential of preventing the patient from achieving their speech therapy goals. Findings include: Patient 7 (P7) P7 was admitted on 02/19/2023, with diffuse traumatic brain injury. On 04/19/2023, the agency recertified the patient from 04/20/2023 through 06/18/2023. On 04/20/2023, the plan of care revealed a physician order for a speech therapy evaluation. On 04/25/2023 and 04/28/2023, the speech therapist conducted and documented skilled visits. On 04/28/2023, the speech therapist documented the patient's discharge from services due to speech therapy being unavailable for five weeks. It was hoped the patient would transition to a veteran's facility for outpatient speech therapy. On 06/06/2023 at 3:15 PM, the speech therapist indicated being out for surgery for five weeks at the time with no available replacement therapist. The clinical record lacked documented evidence the patient was transitioned to an outpatient speech therapy or attempted to transfer services to another agency. The clinical record lacked documented evidence the agency monitored the patient's progress with outpatient speech therapy. The clinical record lacked documented evidence the patient received any speech therapy until December 2023. On 06/06/2023 in the afternoon, the Director of Nursing indicated the third-party provider did not have another available speech therapist. Complaint #104557

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 observation, interview, record review and document review, the agency failed to ensure the comprehensive assessment included an accurate patient medication record for 1 of 7 sampled patients (Patient 1). The deficient practice had the potential for failing to provide an effective medication management for the patient. Findings include: Patient 1 (P1) P1 was admitted on 04/15/2024, with diagnoses including aftercare following joint replacement surgery and hypertensive heart disease without heart failure. The physician’s order dated 04/15/2024, included the following: - Carvedilol 12.5 milligram (mg) one tablet by mouth twice per day - Docusate Sodium 100 mg two capsules by mouth daily - Sennosides 8.6 mg two tablets by mouth twice per day The above-mentioned medications were included in the Home Health Certification and Plan of Care for P1’s current certification period from 04/15/2024 to 06/13/2024. On 06/05/2024 at 1:00 PM, the Quality Assurance (QA) Coordinator confirmed the medications listed in P1’s Home Health Certification and Plan of Care were the current medications the patient was receiving and included in P1’s comprehensive assessment. On 06/05/2024 at 2:32 PM, during a home visit with P1, a reconciliation of the patient’s home medications with the medications listed in P1’s Home Health Certification and Plan of Care was conducted with the patient’s caregiver. The three medications mentioned above could not be located in the patient’s home. P1’s caregiver indicated the patient had been receiving Carvedilol 3.125 mg by mouth twice per day and not Carvedilol 12.5 mg. The caregiver confirmed P1 had stopped taking Docusate Sodium and Sennosides two weeks ago. The caregiver revealed the patient was receiving therapy services and the last skilled nursing visit was on 05/03/2024. On 06/06/2024 at 11:39 AM, the Director of Nursing (DON) explained the nurses were expected to reconcile the patient’s medications on every skilled nursing visit. The DON indicated the Clinical Manager should have called P1’s caregiver to reconcile the patient’s medications when skilled nursing visits were discontinued. The agency’s policy titled “Medication Reconciliation” dated February 2021, documented the agency would reconcile patient’s medications at the time of admission and on an ongoing basis. Medications ordered while the patient was receiving care would be compared to the medication list/profile. The medication list/profile would be updated with each new or changed medication. The patient’s medication list in the home would also be updated.

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 interview, record review and document review, the agency failed to ensure physician’s orders were obtained and followed for skilled visits for 2 of 7 sampled patients (Patient 1 and 7); and weight assessment was performed in accordance with the physician order for 1 of 7 sampled patients (Patient 4). The deficient practice had the potential for patients’ adverse events or decline for not receiving the care and services as ordered. Findings include: Patient 7 (P7) P7 was admitted on 02/19/2023, with diffuse traumatic brain injury. On 03/16/2023, the resumption of care plan revealed a speech therapy evaluation. On 03/23/2023, a physician ordered speech therapy once weekly for 2 weeks, one visit the third week and then twice weekly for 3 more weeks. On 06/06/2024, the clinical record revealed the following visit frequency for the respective weeks: Visits dated 03/23/2023 and 03/25/2023. A missed visit dated 03/29/2023. Visits dated 04/04/2023 and 04/05/2023. Visits dated 04/11/2023 and 04/13/2023. Except for the missed visit on 03/29/2023, the visit frequency ordered was not followed. The clinical record lacked documented evidence a physician decreased, discontinued, increased, or otherwise modified the ordered skilled speech therapy visits. The clinical record lacked documented evidence of the reason the speech therapy evaluation was not conducted within 72 hours after the resumption of care dated 03/16/2023. On 04/04/2023, the speech therapist documented a communication note that skilled visits would be conducted twice weekly. On 06/06/2024, the clinical record lacked documented evidence the speech therapist conducted skilled visits for the week of 04/16-22/2023. On 04/19/2023, the agency recertified the patient from 04/20/2023 through 06/18/2023. On 04/20/2023, the plan of care revealed a physician ordered a speech therapy evaluation. On 04/25/2023 and 04/28/2023, the speech therapist conducted and documented skilled visits. The clinical record lacked documented evidence of skilled visit frequency. On 06/06/2023 at 3:15 PM, the speech therapist indicated it was a difficult case. The speech therapist would visit according to physician orders, but the patient would not always cooperate due to current status and/or fatigue. On 06/06/2023 in the afternoon, the Director of Nursing indicated a therapy evaluation expectation was 72 hours after ordered. The written agreement for therapy services revealed the third-party provider would place contractual staff with the agency within 72 hours of request. Complaint #104557 The agency’s policy titled “Plan of Care – CMS #485” and “Physician/Practitioners Orders” dated February 2023, documented care and services would be provided according to physician/practitioner’s orders. Patient 1 (P1) P1 was admitted on 04/15/2024, with diagnoses including aftercare following joint replacement surgery and hypertensive heart disease without heart failure. The physician order dated 04/15/2024, documented skilled nursing (SN) visit every three days until 04/22/2024, or twice weekly for two weeks then reassess until 04/22/2024. Review of P1’s medical record revealed the following SN visits were performed: - Week 1 (04/15/2024 to 04/20/2024): SN visits done on 04/15/2024 and 04/18/2024. - Week 2 (04/21/2024 to 04/27/2024): SN visits done on 04/21/2024 and 04/25/2024. - Week 3 (04/28/2024 to 05/04/2024): SN visit done on 05/03/2024. P1’s medical record lacked documented evidence a reassessment was completed per the physician’s order and a physician’s order was obtained for the SN visits conducted on 04/25/2024 and 05/03/2024. On 06/06/2024 at 11:25 AM, the Director of Nursing (DON) confirmed the findings and explained the reassessment mentioned in the physician’s order should have been completed by 04/22/2024 to determine if further SN visits were needed. The DON revealed P1 was seen for wound treatment and other SN interventions. The Quality Assurance (QA) Coordinator, who was present during the interview, indicated the nurse who performed the SN visit on 04/21/2024 should have reassessed if P1 needed further SN visits, coordinated with the Clinical Manager, and obtained a physician’s order for additional SN visits. The QA Coordinator acknowledged the reassessment was not completed per the physician’s order and a physician’s order was not obtained for the SN visits conducted on 04/25/2024 and 05/03/2024. Patient 4 (P4) P4 was admitted on 05/25/2024, with diagnoses including malignant neoplasm of rectum and ileostomy care. The physician order dated 05/27/2024, documented SN to assess weight every week and report to the physician for any variation of more than five pounds per week. P4’s medical record revealed SN visits were performed on 05/26/2024, 05/30/2024, 06/02/2024, and 06/06/2024. P4’s medical record lacked documented evidence the patient’s weight was assessed weekly in accordance with the physician order. On 06/06/2024 at 2:25 PM, the DON confirmed the findings and indicated the nurses should have obtained P4’s weight weekly per the physician order and documented the patient’s weight in the Skilled Nursing Visit Note. The DON explained any variation of more than five pounds per week should have been reported to the physician.

Revised plan of care CFR(s): 484.60(c)(2) A revised plan of care must reflect current information from the patient's updated comprehensive assessment, and contain information concerning the patient's progress toward the measurable outcomes and goals identified by the HHA and patient in the plan of care. This ELEMENT is not met as evidenced by: Based on record review and interview, the agency failed to develop an accurate resumption of the plan of care for 1 of 7 sampled patients (Patient 7). Findings include: Patient 7 (P7) P7 was admitted on 2/19/2023with traumatic brain injury. On 04/19/2023, the agency recertified the patient from 04/20/2023 through 06/18/2023. On 05/03/2023, the patient returned from a brief hospitalization, and the agency resumed care. On 05/03/2023, the resumption of the plan of care included speech therapy evaluation and treatment. The clinical record lacked documented evidence of a physician order for the speech therapy evaluation. On 06/07/2024 in the afternoon, the Director of Nursing indicated there was no speech therapy order and provided a copy of the resume care order without speech therapy included. Complaint #104557

Patient medication schedule/instructions CFR(s): 484.60(e)(2) Patient medication schedule/instructions, including: medication name, dosage and frequency and which medications will be administered by HHA personnel and personnel acting on behalf of the HHA. This ELEMENT is not met as evidenced by: Based on observation, interview, record review and document review, the agency failed to ensure an updated and accurate medication profile was provided to the patient and caregiver for 1 of 7 sampled patients (Patient 1). The deficient practice had the potential for medication administration errors and failing to provide an effective medication management for the patient. Findings include: Patient 1 (P1) P1 was admitted on 04/15/2024, with diagnoses including aftercare following joint replacement surgery and hypertensive heart disease without heart failure. On 06/05/2024 at 2:32 PM, during a home visit with P1, a reconciliation of the patient’s home medications with the medications listed in P1’s Home Health Certification and Plan of Care was conducted with the patient’s caregiver. There were discrepancies identified during the medication reconciliation. The following medications were included in P1’s Home Health Certification and Plan of Care or list of active medications but could not be located in the patient’s home: - Carvedilol 12.5 milligram (mg) one tablet by mouth twice per day - Docusate Sodium 100 mg two capsules by mouth daily - Sennosides 8.6 mg two tablets by mouth twice per day P1’s caregiver indicated the patient had been receiving Carvedilol 3.125 mg by mouth twice per day and not Carvedilol 12.5 mg. The caregiver confirmed P1 had stopped taking Docusate Sodium and Sennosides two weeks ago. A review of P1’s home health folder maintained in the patient’s home revealed there was no medication profile included in the folder which should have contained the list of P1’s active medications, medication schedule/instructions, dosage, and frequency. On 06/05/2024 at 2:40 PM, the Occupational Therapist (OT), who was present during the home visit, confirmed the findings and acknowledged P1’s home health folder should have contained a medication profile. P1’s caregiver was present during the OT interview and explained preparing their own list of patient’s medications. P1’s caregiver confirmed an updated and accurate medication profile had not been provided to the patient and the caregiver. On 06/06/2024 at 11:31 AM, the Director of Nursing (DON) explained the nurses were expected to provide a copy of the patient’s medication profile to the patient or caregiver. The medication profile should have been updated every skilled nursing visit and included in the home health folder maintained in the patient’s home. The agency’s policy titled “Medication Reconciliation” dated February 2021, documented the agency would provide the patient and/or caregiver with written patient medication schedule/instructions, including medication name, dose, strength, route, and frequency as well as which medications would be administered by agency staff and staff acting on behalf of the agency. The medication list/profile would be updated with each new or changed medication. The patient’s medication list in the home would also be updated.

Required items in clinical record CFR(s): 484.110(a)(1) The patient's current comprehensive assessment, including all of the assessments from the most recent home health admission, clinical notes, plans of care, and physician or allowed practitioner orders; This ELEMENT is not met as evidenced by: Based on record review and interview, the agency failed to ensure ordered skilled nursing visits were documented as conducted for 1 of 7 sampled patients (Patient 6). Findings include: Patient 6 (P6) P6 was admitted on 02/03/2024, with Parkinson's disease and hypertension. On 03/29/2024, the agency recertified the patient for 60 days from 04/03/2024 forward. The plan of care revealed a physician ordered weekly skilled nursing visits. On 04/03/2024 at 2:00 PM, a registered nurse conducted a skilled nursing visit based on a signed and dated route sheet. The clinical record lacked documented evidence the registered nurse documented the skilled visit. On 06/07/2024 at 1:35 PM, the Director of Nursing confirmed the finding and verbalized the registered nurse would be in-serviced.

Social Worker CFR(s): 484.115(m) Standard: Social worker. A person who has a master's or doctoral degree from a school of social work accredited by the Council on Social Work Education, and has 1 year of social work experience in a health care setting. This STANDARD is not met as evidenced by: Based on interview, personnel record review and document review, the agency failed to ensure the Social Worker (Employee 9) hired to provide the medical social services obtained a master’s or doctoral degree in social work. The deficient practice had the potential for the patients not receiving the required social services per the physician’s orders from a qualified staff. Findings include: Employee 9 was hired on 03/20/2015 as a Medical Social Worker. The Job Description of an MSW documented the following: - Qualifications: A person who had a master’s degree from a school of social work accredited by the Council on Social Work Education and had one year experience in a health care setting; or had a baccalaureate degree in social work, psychology, sociology, or other field related to social work, and had at least one year experience in a health care setting (functioned as an assistant). - Supervised by the Director of Clinical Services/Nursing Supervisor. If Social Work Assistant, supervised by the Social Worker. - Employee 9 signed the Medical Social Worker Job Description on 03/14/2015. Employee 9’s personnel record lacked documented evidence of a master’s degree or doctoral degree in social work. The agency’s list of active employees did not include any other Social Worker aside from Employee 9. On 06/07/2024 at 10:00 AM, the Human Resource (HR) Manager confirmed the findings and revealed Employee 9 functioned as a medical social worker and not a social work assistant. The HR Manager confirmed the job description of medical social worker required a master’s degree from a school of social work accredited by the Council on Social Work Education.

A Medicare Recertification Survey including a review of the Emergency Preparedness Program was conducted by Healthcare Management Solutions, LLC on behalf of the Nevada Department of Health and Human Services. The survey conducted from 03/31/2021 through 04/02/2021 resulted in a finding of no deficiencies respective to the Emergency Preparedness Program Condition of Participation under 42 CFR 484.22. Survey Census: 123 Sample Size :7

A Medicare Recertification Survey was conducted by Healthcare Management Solutions, LLC on behalf of the Nevada Department of Health and Human Services. The survey conducted from 03/31/2021 through 04/02/2021 resulted in a finding of substantial compliance respective to the applicable Condition of Participation (CoP) under 42 CFR 484, Subparts A through C with the following standard-level deficiency listed below. Current Census: 123 Sample Size:7

Protection of records CFR(s): 484.110(d) Standard: Protection of records. The clinical record, its contents, and the information contained therein must be safeguarded against loss or unauthorized use. The HHA must be in compliance with the rules regarding protected health information set out at 45 CFR parts 160 and 164. This STANDARD is not met as evidenced by: Based on observation, record review and interview, the home health agency (HHA) failed to monitor, manage, and maintain the equipment used to access the web-based medical record system. This had the potential to result in unauthorized access to patient information for all patients receiving care from the HHA. Findings include: During an interview on 03/31/2021 at 2:30 PM, the Administrator stated the HHA used a web-based electronic medical record (EMR) system for patient documentation. The Administrator revealed the staff used their personal desktop computers in their homes, laptops, cell phones or any other device capable of accessing the internet. The HHA did not provide the electronic devices for staff who work out in the field to complete patient documentation in the EMR. The survey team was given log-in information and a password to access the agency patient records. During review of patient information in the EMR it was observed that the patient assessment, plan of care, visit notes, and patient personal information including address, date of birth, social security number, and insurance information, could be saved to the computer desktop which enabled the information to be accessed without logging into the web based EMR system. During a home visit observation on 04/01/2021 from 11:00 AM until 11:40 AM the surveyor observed Licensed Practical Nurse (LPN)2 performing wound care on Patient (P)3. After removing the wound dressing from the patient's foot, LPN2 took a picture of the wound with a cell phone. LPN2 identified the photo was taken with a personal cell phone, and the photograph of the wound would be uploaded to the EMR after returning home. Review of a policy titled, "Information Confidentiality, Security and Data Integrity," dated March 2018 revealed "The Agency will monitor staff compliance with confidentiality, privacy and security." During an interview on 04/02/2021 at 10:15 AM, the Administrator confirmed the HHA was not able to access the personal electronic equipment that staff used to document in the EMR system. The Administrator acknowledged the HHA would not know if a staff person saved patient information to a personal computer or if a staff persons personal computer or cell phone was lost or stolen.