Every finding on record at Mountain Home Health Services, LLC

An unannounced, onsite recertification survey was conducted 9/15/25-9/17/25. No deficiencies to the Emergency Preparedness Plan was identified.

An onsite, unannounced recertification survey was conducted 9/15/25-9/17/25. Standard level deficiencies to the Medicare CoP's were identified.

Property and person treated with respect CFR(s): 484.50(c)(1) Have his or her property and person treated with respect; This ELEMENT is not met as evidenced by: Based on agency policy, direct observation, and staff interviews the Registered Nurse failed to provide privacy for the patient during wound care for 1 of 3 patients who received a joint visit [#10]. The findings included: The policy, Patient Bill of Rights and Responsibilities [2/22], was provided by RN # 2 on 9/16/25 at approximately 3:30 pm. The policy stated, " ...Have his/her property and person treated with respect..." Patient # 10 had a Start of Care date of 2/14/25 with an admitting diagnosis of pressure ulcer of left buttock, stage 2 [partial thickness skin injury that involves damage to the top layer of skin]. Review of the Plan of Care for the certification period 8/13/25-10/11/25 included orders for SN [skilled nursing] 1 time a week for 1 week, 2 times a week for 8 weeks and “Skilled nurse to perform pressure ulcer care to buttocks weekly. Cleanse with wound cleanser and pat dry ...cover with duoderm.” On 9/16/25 at approximately 9:30 am a joint visit was made with RN # 3 to observe wound care. Patient # 10 lived in an apartment complex. Upon arrival at the patient’s home and throughout the visit the front door remained open. Several people were noted to be passing by the front door. As the patient prepared to receive wound care, she stood up at a small table in the living area and RN # 3 started to assist the patient to remove her outside garment. The front door remained open. The surveyor stopped the visit and closed the front door. After the front door was closed the RN continued with wound care. During an interview with the agency director and RN # 2 on 9/16/25 at approximately 3 pm they confirmed the front door should have been closed prior to beginning the wound care.

Plan of care must include the following CFR(s): 484.60(a)(2)(i-xvi) The individualized plan of care must include the following: (i) All pertinent diagnoses; (ii) The patient's mental, psychosocial, and cognitive status; (iii) The types of services, supplies, and equipment required; (iv) The frequency and duration of visits to be made; (v) Prognosis; (vi) Rehabilitation potential; (vii) Functional limitations; (viii) Activities permitted; (ix) Nutritional requirements; (x) All medications and treatments; (xi) Safety measures to protect against injury; (xii) A description of the patient's risk for emergency department visits and hospital re-admission, and all necessary interventions to address the underlying risk factors. (xiii) Patient and caregiver education and training to facilitate timely discharge; (xiv) Patient-specific interventions and education; measurable outcomes and goals identified by the HHA and the patient; (xv) Information related to any advanced directives; and (xvi) Any additional items the HHA or physician or allowed practitioner may choose to include. This ELEMENT is not met as evidenced by: Base on agency policy, direct observation, clinical review, and interviews with staff and patients/caregivers, the Plan of Care [POC] failed to include all the current/correct medications the patient was taking for 4 of 5 patients who received a home visits [#6,7,8, and 10]. The findings included: The policy, Medication Reconciliation [2/2021] was provided by the agency administrator on 9/17/25 at approximately 9:30 am. The policy stated, "...Medications ordered while the patient is receiving care will be compared to the medication list/profile. The medication list/profile will be updated with each new or changed medication. The patient's medication list in the home will also be updated..." 1. Patient # 6 had a Start of Care date of 8/19/22 with admitting diagnoses of burn of second degree of left foot and pressure ulcer of left buttock, stage 3 [full thickness skin loss that extends into the subcutaneous tissue, but does not involve muscle, tendon or bone]. Review of the Plan of Care [POC] for the certification period 8/3/25-10/1/25 included orders for SN [skilled nursing] 2 times a week for 8 weeks and “Skilled nurse to review medication profile and reconcile medications as needed...” On 9/15/25 at approximately 11:30 am a joint visit was made with RN # 1 to observe wound care. During the visit a medication review was completed using a medication profile provided by the agency. The following discrepancy was noted: The medication profile listed Minocycline [antibiotic] 100 mg. Take 1 tablet twice daily. During an interview with the patient, he reported the physician had discontinued the medication “earlier in the month.” During an interview on 9/16/25 at approximately 3 pm with the agency director and RN # 2 both confirmed the POC did not include all current/correct medications the patient was taking. 2. Patient # 7 had a Start of Care date of 8/25/25 with an admitting diagnosis of type 2 diabetes mellitus with other circulatory complications. Review of the Plan of Care [POC] for the certification period 8/25/25-10/23/25 included orders for PT [Physical therapy] 1 time a week for 1 week then 2 times a week for 8 weeks and “Clinician to perform drug regimen review/assessment...” On 9/16/25 at approximately 10 am a joint visit was made with PT # 9. During the visit a medication review was conducted using a medication profile provided by the agency. The following discrepancies were noted: Famotidine [reflux] 40 mg daily was on the medication profile. During an interview with the patient he reported, “If it’s not on my list of medications in my wallet, I don’t take it.” [Review of the medication list provided by the patient did not include Famotidine]. During an interview on 9/16/25 at approximately 3 pm with the agency director and RN # 2 both confirmed the POC did not include all current/correct medications the patient was taking. 3. Patient # 8 had a Start of Care date of 5/5/25 with an admitting diagnosis of chronic venous hypotension [increase in pressure in the veins of the lower body] with ulcer of bilateral lower extremity. Review of the Plan of Care [POC] for the certification period 9/2/25-10/31/25 included orders for PT [physical therapy] 2 times a week for 9 weeks. On 9/16/25 at approximately 12 noon a joint visit was made with PTA # 6. During the visit a medication review was conducted using a medication profile provided by the agency. The following discrepancies were noted: The medication profile listed Hydralazine [blood pressure] 25 mg three times a day. During an interview with the patient, he reported the medication [Hydralazine] was not reordered when he was discharged from the hospital. During an interview with the administrator and RN # 2 on 9/16/25 at approximately 3 pm, they confirmed the POC did not include all/correct medications the patient was taking. 4. Patient # 10 had a Start of Care date of 2/14/25 with an admitting diagnosis of pressure ulcer of left buttock, stage 2 [partial thickness skin injury that involves damage to the top layer of skin]. Review of the Plan of Care for the certification period 8/13/25-10/11/25 included orders for SN [skilled nursing] 1 time a week for 1 week, 2 times a week for 8 weeks and “Skilled Nurse to review medication profile and reconcile medications as needed...” On 9/16/25 at approximately 9:30 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 discrepancies were noted: The medication profile listed Lasix [fluid medication] 40 mg daily. During an interview with the patient she stated, “The doctor stopped that and put me back on Bumex [fluid medication].” Review of the medication profiled revealed the patient started on Bumex 1 mg daily on 7/22/25. The medication profile listed Oxybutynin [bladder spasms] 5 mg daily. During the interview with the patient, the patient stated, “I don’t take that anymore.” Novolog [diabetes] insulin was not on the medication profile. The patient presented a bottle of Novolog and reported she takes 40 units with meals. Tylenol [over the counter pain relief] was not on the medication profile. The patient stated, “I take 500 mg. I take 2 in the morning and 2 at bedtime.” During an interview on 9/16/25 at approximately 3 pm with the agency director and RN # 2 both confirmed the POC did not include all current/correct 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 follow the physician's order on the Plan of Care [POC] related to reporting vital signs outside of the given parameters for 3 of 19 records reviewed [#10, 2, 13, and 16]; and failed to follow the physician's order for foley catheter size for 1 of 2 charts reviewed with a foley catheter [#16]. The findings included: The policy, Coordination of Patient Care [4/2024], was provided by the agency director on 9/17/25 at approximately 9:30 am. The policy stated, "...The agency must assure communication with all physicians/practitioners involved in the plan of care..." 1. Patient # 10 had a Start of Care date of 2/14/25 with an admitting diagnosis of pressure ulcer of left buttock, stage 2 [partial thickness skin injury that involves damage to the top layer of skin]. Review of the Plan of Care [POC] for the certification period 8/13/25-10/11/25 included orders for SN [skilled nursing] 1 time a week for 1 week, 2 times a week for 8 weeks and “Vitals Physician Alert Range...Pain greater than 7...” Review of the clinical record revealed LPN # 5 conducted routine visits on 8/18/25, 9/1/25, 9/4/25, 9/8/25, and 9/11/25. LPN # 5 documented a pain level of 8. There is no evidence the physician was notified of the patient’s pain level being outside the given parameters. During an interview with the agency director and RN # 2 on 9/17/25 at approximately 9:30 am, it was confirmed the LPN failed to notify the physician of the pain level in accordance with the POC. 2. Patient # 2 had a Start of Care date of 3/18/25 with an admitting diagnosis of chronic hepatic failure without coma. Review of the Plan of Care [POC] for the certification period 3/18/25-5/16/25 included orders for 1 time a week for 4 weeks and “Vitals Physician Alert Range...fasting blood sugar less than 65 or greater than 225...random blood sugar less than 65 or greater than 300...” Review of the clinical record revealed RN # 3 conducted a routine visit on 4/22/25 and documented a blood sugar of 381. There was no evidence the RN notified the physician of the blood sugar being outside the given parameter. During an interview with the administrator on 9/17/25 at approximately 11 am, the administrator confirmed the physician was not notified of the blood sugar in accordance with the POC. 3. Patient # 13 had a Start of Care date of 5/1/525 with an admitting diagnosis of hemiplegia and hemiparesis [paralyzed and weakness on one side of the body] following cerebral infarction [stroke]. Review of the Plan of Care [POC] for the certification period 5/1/25-6/29/25 revealed orders for ST [speech therapy] 1 time a week for 1 week; home health aide 1 time a week for 8 weeks and “Vitals Physician Alert Range...blood pressure systolic [bottom number] less than 104 or greater than 190...diastolic [top number] less than 50 or greater than 100...” Review of the clinical record revealed ST # 7 conducted an evaluation visit on 5/15/25 and documented a blood pressure reading of 150/107. Further review of the clinical record revealed the home health aide documented a blood pressure reading of 148/102 on 6/17/25. There was no evidence the physician was notified of either blood pressure reading. During an interview with the agency administrator on 9/17/25 at approximately 11 am, it was confirmed the physician was not notified of the blood pressure readings in accordance with the POC. 4. Patient # 16 had a Start of Care date of 5/31/24 with an admitting diagnosis of encounter for fitting and adjustment of urinary device. Review of the Plan of Care [POC] for the certification period 7/25/25-9/22/25 revealed orders for SN [skilled nursing] 1 time a month for 2 months and “Skilled nurse for insertion of foley catheter size 16 french, 10 cc balloon...Change monthly [due on or around the 23rd of the month] ...Review of the clinical record revealed RN # 4 changed the foley catheter on 8/25/25 and placed the old foley catheter with an 18 french catheter with a 10 cc balloon. During an interview with the administrator on 9/17/25 at approximately 11 am, the administrator confirmed the RN failed to follow the physician’s order related to the size of the foley catheter.

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 agency policy, direct observation, and staff interviews the Registered Nurse failed to practice proper hand hygiene/correct bag technique for 1 of 3 patients who received a joint visit to observe wound care [# 6 ]. The findings included: The policy, Hand Hygiene Policy and Compliance Program [7/2021], was received by RN # 2 on 9/15/25 at approximately 3:24 pm. The policy stated, "Hand hygiene will be done by all employees to reduce the transfer of microbes to patients...The agency will follow the Centers for Disease Control and Preventions [CDC] guidelines for hand hygiene...After removing gloves...Moving from contaminated patient body site to clean site during patient care, After contact with inanimate objects or medical equipment close to the patient...Use of gloves...Change or remove gloves if moving from contaminated to clean patient site or the environment..." The policy, Home Care Bag Technique [4/2024], was received by RN # 2 on 9/15/25 at approximately 3:24 pm. The policy stated, "...The home care bag is placed on a clean, dry surface and a barrier placed between the bag and the surface... Patient # 6 had a Start of Care date of 8/19/22 with an admitting diagnosis of burn of second degree of left foot and pressure ulcer of left buttock, stage 3 [full thickness skin loss that extends into the subcutaneous tissue, but does not involve muscle, tendon or bone]. Review of the Plan of Care [POC] for the certification period 8/3/25-10/1/25 included orders for SN [skilled nursing] 2 times a week for 8 weeks and “SN to perform and teach pt/cg to perform following wound care...to left medial gluteal fold cleanse wound and peri wound with normal saline and pat dry...apply thin layer of triad to periwound area. Apply lightly moistened collagen to wound bed, cover with mepilex border...” On 9/15/25 at approximately 11:30 am a joint visit was made with RN # 1 to observe wound care. Upon arrival, the RN placed her nursing bag and documentation device on the floor of the patient’s bedroom without placing a barrier under the items. The RN then removed a barrier from bag and placed nursing bag on the barrier on the floor. The RN proceeded to perform wound care to the gluteal fold. The RN sanitized her hands and donned gloves and proceeded to clean the wound with wound cleanser. She then reached back into the patient’s box of clean supplies and removed 4x4’s from a large pack with the soiled gloves on. She continued with wound care. After completing the wound care to the gluteal fold, the RN proceeded to reach back into the box of supplies to remove items for the patient’s foot while still wearing the soiled gloves. During an interview on 9/16/25 at approximately 3 pm with the agency director and RN # 2 both confirmed the RN failed to follow proper glove/hand hygiene while doing the dressing change and failed to use proper bag technique during the visit.

Preparing clinical notes CFR(s): 484.75(b)(6) Preparing clinical notes; This ELEMENT is not met as evidenced by: Based on agency policy, clinical record review and staff interviews the Registered Nurse failed to document a wound assessment with each nursing visit when wound care was preformed for 5 of 6 patients with a wound [#6, 8, 10, 11, and 12]; and the Registered Nurse copied and pasted nursing notes for 1 of 19 charts reviewed [#9]. The findings included: The policy, Wound Care [no date], was provided by the RN # 3 on 9/16/25 at approximately 3:35 pm. The policy stated, "...The nurse should assess the wound for symptoms of inflammation or infection on each visit.... 1. Patient # 6 had a Start of Care date of 8/19/22 with an admitting diagnosis of burn of second degree of left foot and pressure ulcer of left buttock, stage 3 [full thickness skin loss that extends into the subcutaneous tissue, but does not involve muscle, tendon or bone]. Review of the Plan of Care [POC] for the certification period 8/3/25-10/1/25 included orders for SN [skilled nursing] 2 times a week for 8 weeks and “SN to perform and teach pt/cg to perform following wound care...to left medial gluteal fold cleanse wound and peri wound with normal saline and pat dry...apply thin layer of triad to periwound area. Apply lightly moistened collagen to wound bed, cover with mepilex border...” Review of the clinical record revealed the patient received 15 SN visits from 8/4/25-9/15/25. Further review of the clinical record revealed no documented wound assessment for 6 of the 15 SN visits. During an interview with the agency administrator on 9/17/25 at approximately 11 am, the administrator stated, “They should document a wound assessment with every visit that wound care is completed.” 2. Patient # 8 had a Start of Care date of 5/5/25 with an admitting diagnosis of chronic venous hypotension [ increase in pressure in the veins of the lower body] with ulcer of bilateral lower extremity. Review of the Plan of Care [POC] for the certification period 9/2/25-10/31/25 included orders for SN [skilled nursing] 3 time a week for 9 weeks and “Wound care to left proximal lateral lower leg...cleanse wound and periwound with normal saline or wound cleanser...apply prisma collagen in wound bed...apply gauze...apply tubigrip ...cleanse wound to left upper leg with saline or wound cleanser...apply prisma collagen in wound bed... apply tubigrip...lower right extremity...cleanse wound...apply thin layer of triad...apply prisma collagen...apply tubigrip...” Review of the clinical record revealed the patient received 4 SN visits from 9/2/25-9/12/25. Further review revealed no documented wound assessment for 2 of the 4 SN visits. During an interview with the agency administrator on 9/17/25 at approximately 11 am, the administrator stated, “They should document a wound assessment with every visit that wound care is completed.” 3. Patient # 10 had a Start of Care date of 2/14/25 with an admitting diagnosis of pressure ulcer of left buttock, stage 2 [partial thickness skin injury that involves damage to the top layer of skin]. Review of the Plan of Care for the certification period 8/13/25-10/11/25 included orders for SN [skilled nursing] 1 time a week for 1 week, 2 times a week for 8 weeks and “Skilled nurse to perform pressure ulcer care to buttocks weekly. Cleanse with wound cleanser and pat dry ...cover with duoderm.” Review of the clinical record revealed the patient received 14 SN visits from 8/4/25-9/10/25. Review of the SN documentation revealed no documented wound assessments for 8 of the 14 visits. During an interview with the agency administrator on 9/17/25 at approximately 11 am, the administrator stated, “They should document a wound assessment with every visit that wound care is completed.” 4. Patient # 11 had a Start of Care date of 8/29/25 with an admitting diagnosis of encounter for surgical aftercare following surgery on the digestive system. Review of the Plan of Care for the certification period 8/29/25-10/27/25 revealed orders for SN [skilled nursing] 1 time a week for 6 weeks and “Skilled nurse to perform/teach wound care to incision/suture site located mid abdomen and left knee...” Review of the clinical record revealed no wound assessments with the visit on 9/4/25. During an interview with the agency administrator on 9/17/25 at approximately 11 am, the administrator stated, “They should document a wound assessment with every visit that wound care is completed.” 5. Patient # 12 had a Start of Care date of 8/16/25 with an admitting diagnosis of open bite, right lower leg. Review of the Plan of Care for the certification period 8/16/25-10/14/25 included orders for SN [skilled nursing] 1time a week for 1 week, 2 times a week for 7 weeks, 1 time a week for 1 week and “Skilled nurse to perform/teach wound care to right posterior leg as follow: ...cleanse with wound cleanser or normal saline...apply triad paste...apply iodosorb...cover with aquacel ag...” Review of the clinical record revealed the patient received 7 SN visits from 8/16/25 – 9/12/25. Further review of the clinical record revealed no documented wound assessments for 5 of the 7 visits. During an interview with the agency administrator on 9/17/25 at approximately 11 am, the administrator stated, “They should document a wound assessment with every visit that wound care is completed.” 6. Patient # 9 had a Start of Care date of 8/26/25 with an admitting diagnosis of displaced tri-malleolar [ankle area] fracture of right lower leg. Review of the Plan of Care for the certification period 8/26-25-10/24/25 included orders for SN [skilled nursing] beginning 9/7/25 1 time a week for 1 week, 2 times a week for 2 weeks, 1 time a week for 1 week. Review of the clinical record revealed RN # 1 completed the SOC assessment on 8/26/25. Further review of the clinical record revealed RN # 10 conducted routine visits on 8/29/25 and 9/2/25. Review of the documentation for 8/29/25 and 9/2/25 revealed the same visit notes as RN # 1 had documented at the time of admission. During an interview with the administrator on 9/17/25 at approximately 10 am, the administrator stated, “She copied and pasted the admission note to her visit notes on 8/29/25 and 9/2/25.

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 clinical record review and staff interviews the agency failed to provide aide supervisory visits at least every 14 days for 2 of 3 patients who received aide services [#13 and 17]. The findings included: 1. Patient # 13 had a Start of Care date of 5/1/525 with an admitting diagnosis of hemiplegia and hemiparesis [paralyzed and weakness on one side of the body] following cerebral infarction [stroke]. Review of the Plan of Care [POC] for the certification period 5/1/25-6/29/25 revealed orders for SN [skilled nursing] 1 time a week for 4 weeks; home health aide 1 time a week for 8 weeks; PT [physical therapy] 1 time a week for 8 weeks. Review of the clinical record revealed the patient received weekly home health aide visits beginning 5/6/25. Further review of the clinical record revealed no home health aide supervisory visit was conducted until 6/17/25. During an interview with the administrator on 6/17/25, the administrator stated, “Clinicians are supposed to do aide supervisory visits each visit to prevent missing one. They know they must be done within 14 days.” 2. Patient # 17 had a Start of Care date of 11/23/22 with an admitting diagnosis of encounter for fitting and adjustment of urinary device. Review of the Plan of Care for the certification period 7/10/25-9/7/25 revealed orders for SN [skilled nursing] 1 time a week for 8 weeks starting 7/13/25 and home health aide 1 time a week for 8 weeks beginning 7/13/25. Further review of the clinical record revealed the patient received weekly aide visits. No aide supervisory visits were completed until 8/4/25. There was a second aide supervisory visit conducted 8/18/25. There was no evidence of another aide supervisory visit from 8/18/25-9/5/25. During an interview with the administrator on 6/17/25, the administrator stated, “Clinicians are supposed to do aide supervisory visits each visit to prevent missing one. They know they must be done within 14 days.”

An onsite recertification survey was conducted 9/26/2022 to 9/29/2022. No deficiencies to the Emergency Preparedness Plan was identified.

An onsite recertification survey was conducted 9/26/2022 to 9/29/2022. Standard level deficiencies to the Medicare CoP's were identified.

Patient's needs CFR(s): 484.55(c)(4) The patient's medical, nursing, rehabilitative, social, and discharge planning needs; This ELEMENT is not met as evidenced by: Based on policy, clinical record review and staff interviews, the agency failed to clarify medication doses for 1 of 1 patients [#6] that had routine medications with a varying dose. The findings included: The policy/procedure “Medication Reconciliation” with an effective date of 9/15/2020, provided by Agency administrator on 9/28/2022 at 12:35pm, stated, “the agency will reconcile patient’s medications at time of admission and on an ongoing basis… at time of admission, the admitting registered nurse, PT [physical therapist] … will create and document a complete list of medications that patient is taking at home, including dose, strength, route, and frequency… Any concerns or discrepancies will be reconciled by a RN with the patient’s physician… Discrepancies include…contraindications and/or unclear information.” Patient #6 had a Start of Care [SOC] of 8/9/2022 which included diagnoses of Hypo-osmolality [levels or electrolytes, proteins, and nutrients in the blood are below normal]; Hyponatremia [ low sodium]; Cirrhosis of the liver [chronic liver damage]; Hypokalemia [ low potassium]. A review of the Plan of Care (POC) with a certification period of 8/9/2022 to 10/7/2022 had orders for (physical therapy) PT 2 times per week for 4 weeks; Skilled nursing [SN] 1 time per week for 5 weeks, 2 times per week for 4 weeks. The hospital discharge summary from 8/6/2022 provided by Agency administrator on 9/28/2022 at 11:52 am, included the following medications for patient #6: · Potassium Chloride 20 mEq [milliequivalent] oral tablet, extended release, 1 tablet daily. o Electrolyte supplement: helps your cells, kidneys, heart, muscles, and nerves work properly. · Spironolactone 100 mg [milligram] oral tablet, 1 tablet daily. o Treats high blood pressure and heart failure. A review of the POC showed the PT #8 documented the following medications as: · Potassium Chloride 20 mEq oral tablet, extended release 1-2 tablets daily · Spironolactone 100 mg oral tablet ½ - 1 tablet daily There were no parameters of when to take each dose. An evaluation by SN#7 on 8/10/2022 revealed documentation that stated, “all medications reviewed, and profile updated.” There was no evidence of parameters listed. PT #8 reported in an interview on 9/28/2022 at 2:29 pm that the discharge medication list is reviewed with the medications the patient had in the home. A communication note to the physician would be sent if differences were found. According to PT #8 there were no differences. An interview with the Director of Regional Operations revealed on 9/28/2022 at 10:24 am, no parameters were documented for Potassium Chloride or Spironolactone.

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 clinical record review and staff interviews the Plan of Care [POC] failed to include all required components for 2 of 24 patients [#15 and 24]. The findings included: 1. Patient #15 was admitted on 6/29/22 with a diagnosis of neuromuscular dysfunction of the bladder (a condition where the nerves and the muscles of the bladder do not communicate). The Plan of Care (POC) for 8/28/22-10/26/22 included orders for skilled nursing visits weekly for 4 visits, then one visit the week of 10/23/22. The POC included the patient was on a regular diet. The visit note on 8/31/22 did not include a nutrition assessment. The visit notes on 9/6/22, 9/14/22, and 9/19/22 stated, “use thickened liquids due to swallowing issues…” An interview on 9/29/22 at 11:00 a.m. with the agency director confirmed thickened liquids was not included on the POC. 2. Patient #19 was admitted on 4/29/22 with diagnoses of alcoholic cirrhosis of the liver with ascites (abnormal build-up of fluid in the abdomen, pleural effusion (fluid in the space surrounding the lung), and a closed chest drainage system (used to drain fluid from the lining of the lung). The Plan of Care (POC) for 4/29/22-6/27/22 included orders for skilled nursing twice weekly for three weeks, then weekly for five weeks. The POC also included orders for “…l instruct cg [caregiver] on proper method to use PleurX drain [brand of closed chest drainage system] using sterile technique…” There was no order for the frequency for the nurse/caregiver to drain, nor was there an order for any type of dressing to be applied over the site. The initial assessment on 4/29/22 stated, “HW [homework] drain daily…” An interview with agency director on 9/29/22 at 12:00 p.m. confirmed the order was incomplete.

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, clinical record review and staff interviews the agency failed to use the correct volume of saline flush after a blood draw for 1 of 1 patients [#8] with a PICC [Peripherally inserted central catheter]. The findings included: The policy/procedure “Plan of Care” with effective date of 9/15/2022 stated, “care and services provided will be provided according to physician orders… drug, services and treatments are administered as ordered by physician.” Patient #8 had a Start of Care 9/2/2022 that included diagnoses of Pyothorax without a fistula [the presence of inflammatory fluid or pus within the chest cavity without an abnormal connection between an artery and vein in the lungs]; Enterococcus [bacteria]. A review of the Plan of care for the certification period 9/2/2022 to 10/31/2022 included orders for skilled nurse [SN] 1 time per week for 10 weeks with 2 PRN [as needed]. Other orders included, “Lab draw…flush PICC line with 10 milliliters [ml] of sterile saline… visualize blood return and draw 10ml for waste… flush PICC line with 20 ml of sterile saline…” Documentation from SN #11 visit on 9/6/2022; and SN #12 visit on 9/19/2022 showed 10 ml of sterile saline had been used to flush after lab draws instead of 20ml as per physician’s order. An interview with Director of Regional Operations on 9/29/2022 at 3:47pm verified the nurses had documented the incorrect amount of saline flush.

Promptly alert relevant physician of changes CFR(s): 484.60(c)(1) The HHA must promptly alert the relevant physician(s) or allowed practitioner(s) to any changes in the patient's condition or needs that suggest that outcomes are not being achieved and/or that the plan of care should be altered. This ELEMENT is not met as evidenced by: Based on policy/procedure, clinical record review and staff interviews there was no evidence the agency notified the physician of an oxygen saturation out of parameters for 1 of 1[#10] on oxygen; of a change in patients condition for 1 of 1 [#6] that were jaundice; and failed to notify the physician of a full urinary system assessment for 1 of 1 patient with noted blood in the adult brief [#22] The findings included: 3. Patient #22 was admitted on 2/21/22 with diagnoses of type 2 diabetes mellitus with diabetic chronic kidney disease and congestive heart failure (heart disease that affects the pumping action of the heart). The Plan of Care (POC) for 2/21/22-4/21/22 included orders for skilled nursing twice weekly for two weeks, then once weekly for two weeks. The visit note on 3/4/22 stated, “Hematuria noted this visit, PCP [primary care provider] notified regarding this also. Patient just finished up cephalexin for a UTI [urinary tract infection]…” The Care Coordination Orders that was sent to the physician stated, “Patient also noted to have blood in her diaper during SN visit, daughter reports this has happened in the past, just wanted you to be aware…” There was no evidence the nurse communicated with the physician the source of the blood (bowels or bladder). Nor, was there evidence the physician was provided with a full urinary system assessment. An interview with the agency director on 9/29/22 at 12:41 p.m. confirmed the physician was not informed of the source of blood or provided any further urinary assessment. A policy/procedure of “coordination of care, effective 9/15/2022” that was provided on 9/28/2022 at 1:00 pm by the Director of Regional Operations, stated the agency must: assure communication with all physicians involved in the plan of care… provide the physician with patient information on an ongoing basis regarding… current condition and changes in condition. 1-Patient #10 had a Start of Care 8/22/2022 which included diagnoses of atrial fibrillation [abnormal heartbeat]; Chronic obstructive pulmonary disease with acute lower lung infection [lung disease]. A review of the Plan of care for the certification 8/22/2022 to 10/20/2022 had orders for SN [skilled nurse] 1 time per week for 6 weeks with 2 PRN [as needed] visits for respiratory. Included were orders for the clinician [SN] “to assess oxygen saturation [level of oxygen saturated blood] on room air every visit and to report to the physician oxygen saturation less than 91%.” SN #9 visited on 8/30/2022 and documented in a clinical note “… Pt educated to wear O2 [oxygen] at home due to low O2 saturation on room air [RA]. 85 on RA and 93 at 2L [liter]…” An interview with the Director of Regional Operations on 9/29/2022 at 4:15 pm verified there was no documentation that SN #9 had communicated with the physician. 2- Patient #6 had a Start of Care [SOC] of 8/9/2022 which included diagnoses of Hypo-osmolality [levels or electrolytes, proteins, and nutrients in the blood are below normal]; Hyponatremia [ low sodium]; Cirrhosis of the liver [chronic liver damage]; Hypokalemia [ low potassium]. A review of the Plan of Care with a certification period of 8/9/2022 to 10/7/2022 had orders for PT 2 times per week for 4 weeks; Skilled nursing [SN] 1 time per week for 5 weeks, 2 times per week for 4 weeks; Aide 1 time per week for 7 weeks. Documentation by PT #8 on the initial assessment 8/9/2022 reported patient #6 skin color was pale and had “yellowing of whites of eyes.” On 8/10/2022 documentation by SN #7 did not report patient skin color. LPN #6 on 8/19/2022 and 8/26/2022 reported skin color within normal limits. On 8/24/2022 the aide reported notification was sent to SN #7 of “patients skin and eyes very yellow.” SN #7 made a visit on 8/29/2022 and reported patient #6 as jaundice with 2 + [severity of swelling] edema. The physician was notified by SN #7 of edema to lower extremities but not of the patient being jaundice. An interview with SN #7 on 9/28/2022 at 12:44pm verified the physician was not notified of patient #6 jaundice.

Responsibilities of skilled professionals CFR(s): 484.75(b) Standard: Responsibilities of skilled professionals. Skilled professionals must assume responsibility for, but not be restricted to, the following: This STANDARD is not met as evidenced by: Based on clinical record, and staff, the agency failed to conduct wound assessments for 3 of 10 patients with wounds (#13, 16, 21 and #8); and to accurately assess vision for 1 of 24 patients (#24); failed to obtain PICC line [ Peripheral inserted central catheter] and arm circumference measurements for 1 of 1 patient [#8] with a PICC line. Findings included: 5. Patient #8 had a Start of Care 9/2/2022 that included diagnoses of Pyothorax without a fistula [the presence of inflammatory fluid or pus within the chest cavity without an abnormal connection between an artery and vein in the lungs]; Enterococcus [bacteria] and adjustment and management of a vascular access device. A review of the Plan of care for the certification period 9/2/2022 to 10/31/2022 included orders for skilled nurse [SN] 1 time per week for 10 weeks with 2 PRN [as needed]. Other orders included, “SN to perform/ instruct patient/caregiver … to administer [intravenous medication] via [PICC] … to flush peripheral IV [intravenous] … before and after IV antibiotic administration… to perform weekly dressing change to left upper extremity midline catheter and to change statlock device [a stabilization device], biopatch [ a protective foam disc applied to the insertion site to prevent infection] and endcaps weekly. Patient #8 received IV antibiotics every 24 hours for 14 days. Documentation by SN #11 visit on 9/6/2022 stated, “PICC dressing changed, no s/s [signs/symptoms] of infection noted. PICC flushed… labs obtained… end cap changed, and line flushed…” LPN #2 on 9/12/2022 documented, “the PICC line dressing was changed… labs obtained via venipuncture due to no blood return via PICC.” SN #12 on 9/19/2022 documented, “PICC line dressing changed… labs obtained… end cap changed, and line flushed…” SN #13 documented on 9/26/2022, “PICC line dressing changed, no s/s of infection noted. … end cap changed, and protection cap applied.” Clinical records reviewed for SN visits on 9/2/2022, 9/6/2022, 9/12/2022 and 9/19/2022 showed no evidence of arm circumference and external catheter measurements. An interview with the Director of Regional Operations on 9/29/2022 at 3:44pm verified there was no documented PICC line measurements. 1. Patient #13 was admitted on 5/13/22 with a diagnosis of stage 3 pressure ulcer left foot (full thickness wound that may extend into the subcutaneous tissue layer). The Plan of Care for 9/10/22-11/8/22 included orders for skilled nursing weekly for nine weeks for wound care to the left heel and the sacrum (triangular bone at the base of the spine). The visit note for 9/13/22 stated, “Patient continues to need assistance from SN to preform [sic] wound care due to being unable to preform [sic] herself from limited ROM [range of motion] and not having anyone in the home to assist…Patient instructed on pressure ulcer to sacrum.” There was no wound measurement for the left heel wound, and there was no assessment documented for the sacral wound. The visit note for 9/21/22 stated, “Patient cannot preform [sic] wound care on her own…Patient instructed on pressure ulcer to sacrum.” There was no wound measurement for the left heel, and there was no assessment documented for the sacral wound. An interview with the agency director on 9/29/22 at 10:48 a.m. confirmed there were no wounds measurements documented for the heel and no assessment for the sacrum. 2. Patient #16 was admitted on 8/19/22 with a diagnosis of Spastic diplegic cerebral palsy (a form of cerebral palsy that is a chronic neuromuscular condition of low muscle tone and increased rigidity of muscles). The Plan of Care (POC) included orders for one time for one week, then twice weekly for four weeks. The initial assessment was completed by the physical therapist on 8/19/22. The assessment identified a stage 1 pressure injury (a non-blanchable red area on intact skin that is caused by pressure). There was no further assessment or documentation regarding the stage 1. An interview with the agency director on 9/29/22 at 11:15 a.m. confirmed there was no further documentation regarding a wound or a treatment. 3. Patient #21 was admitted on 1/20/22 with diagnoses of a non-pressure chronic ulcer to the left lower leg with fat layer exposed, stage 1 pressure ulcer to the sacrum, hemiplegia (paralysis on one side of the body) and hemiparesis (weakness on one side of the body following cerebral infarctions (strokes), and a history of neoplasm of the bronchus and lung. The Plan of Care for 1/20/22-3/20/22 included orders for skilled nursing two time per week for one week, three times per week for two weeks, then twice weekly for six weeks. The wound care orders to the left lower leg were “Cleanse with wound cleanser. Apply Polymem AG. Cover with foam bordered dressing. USING CLEAN/ASEPTIC TECHNIQUE. CHANGE DRESSING 3 times weekly AND PRN.” Wound care order for the sacrum (triangular bone at the base of the spine) was “CLEANSE WITH WOUND CLEANSER. APPLY TRIPLE CREAM. USING CLEAN/ASEPTIC TECHNIQUE. CHANGE DRESSING 3 TIMES WEEKLY AND PRN.” A visit note on 2/21/22 stated, “He has developed a new stage 2 [a superficial open area cause by pressure] on his sacrum. Wound care per POC. There was no assessment of the new wound on the patient’s sacrum. There was no further documentation regarding a new wound. An interview with the agency director on 9/29/22 at 12:29 p.m. confirmed there was no assessment or further documentation of a new wound on the sacrum. 4. Patient #24 was admitted on 3/8/22 with a diagnosis of a urinary tract infection. The Plan of Care (POC) for 3/8/22-5/6/22 included orders for skilled nursing one time for one week; physical therapy twice weekly for three weeks; and occupational therapy (OT) twice weekly for one week, then one time for one week. The initial assessment conducted by the RN stated, “Normal vision…” The physical therapy assessment on 3/8/22 revealed poor vision. The OT evaluation on 3/8/22 stated, “Patient is blind as he has been throughout adulthood.” An interview with the agency director on 9/29/22 at 3:00 p.m. confirmed the poor vision was not identified in the initial nursing assessment

Provide services in the plan of care CFR(s): 484.75(b)(3) Providing services that are ordered by the physician or allowed practitioner as indicated in the plan of care; This ELEMENT is not met as evidenced by: Based on policy review, clinical record review, and staff interview, the agency failed to follow the Plan of Care for obtaining weight for 2 of 2 patients with weights ordered (#13 and #8); to obtain ankle circumference on 1 of 1 with ankle circumference ordered (#22); and to obtain a urinalysis on 1 of 1 patients with an urinalysis ordered (#24). Findings included: 4.Patient #8 had a Start of Care 9/2/2022 that included diagnoses of Pyothorax without a fistula [the presence of inflammatory fluid or pus within the chest cavity without an abnormal connection between an artery and vein in the lungs]; Enterococcus [bacteria]. A review of the Plan of care for the certification period 9/2/2022 to 10/31/2022 included orders for skilled nurse [SN] 1 time per week for 10 weeks with 2 PRN [as needed]. The POC for 9/2/2022 to 10/31/2022 had orders for SN to instruct patient/primary caregiver to record weight daily and to report weight gain… Documentation from SN# 11 on 9/6/2022 and LPN #2 on 9/12/2022 showed no evidence of patient #8 weight. An interview with Director of Regional Operations on 9/29/2022 at 3:49pm verified the nurses did not document patient #8 weight. A policy, Plan of Care (effective 9/15/20), was provided by the Director of Regional Operations on 9/29/22 at 2:00 p.m. The policy stated, “Skilled nursing and other home health services will be in accordance with a Plan of Care based on the patient’s diagnosis and assessment of immediate and long range [sic] needs and resources…Care and services provided will be provided according to physician orders.” 1. Patient #13 was admitted on 5/13/22 with a diagnosis of stage 3 pressure ulcer (full thickness wound that may extend into the subcutaneous tissue layer) left foot and congestive heart failure (CHF—a progressive heart disease that affects pumping action of the heart muscles). The Plan of Care (POC) for 9/10/22-11/8/22 included orders for skilled nursing weekly for nine weeks. The POC also included an order for the nurse to instruct the patient/caregiver on CHF disease process, to record daily weights and to report weight gain of 2 lbs [pounds] in one day or 5 lbs in one week. There was no evidence of weights on 9/13/22 or 9/21/22. An interview with the agency director on 9/29/22 at 10:48 a.m. confirmed there were no weights documented. 2. Patient #22 was admitted on 2/21/22 with diagnoses of type 2 diabetes mellitus with diabetic chronic kidney disease and congestive heart failure. The Plan of Care (POC) for 2/21/22-4/21/22 included orders for skilled nursing twice weekly for two weeks, then once weekly for two weeks. The POC also included orders for the nurse “to measure bilateral ankle circumference every visit, notify PCP if greater than 2cm increase.” The initial assessment conducted on 2/21/22 did not have baseline ankle circumference measurements. There was no evidence of ankle circumference measurements for 2 of 5 skilled nursing visits. An interview with the agency director on 9/29/22 at 12:42 p.m. confirmed there were no measurement for the two visits. 3. Patient #24 was admitted on 3/8/22 with a diagnosis of a urinary tract infection. The Plan of Care (POC) for 3/8/22-5/6/22 included orders for skilled nursing one time for one week. No further nursing frequency orders were written. The POC also included skilled nursing interventions which included obtaining a urine specimen for urinalysis the week of 3/14/22. The initial assessment on 3/8/22 stated, “Primary Reason for Home Health Recent UTI.” The urinary assessment revealed urgency/frequency, cloudy urine, and an odor to the urine. There was no evidence of any further nursing visits. An interview with the agency director on 9/29/22 at 3:00 p.m. confirmed there were no further nursing visits

Preparing clinical notes CFR(s): 484.75(b)(6) Preparing clinical notes; This ELEMENT is not met as evidenced by: Based on policy review, clinical record review, and staff interviews, the nurse failed to complete timely documentation for 1 of 24 patients reviewed (#13). Findings included: A policy, Timely Submission of Patient Documentation (effective 9/15/20), was provided by the agency director on 9/26/22 at 4:30 p.m. The policy stated, “Itineraries, with all visit reports attached, must be submitted the next scheduled work day, not exceeding three (3) business days…Timeframe for Office Intervention…Any note [greater than] 5 days…” Patient #13 was admitted on 5/13/22 with a diagnosis of stage 3 pressure ulcer (full thickness wound that may extend into the subcutaneous tissue layer) left foot. The Plan of Care for 9/10/22-11/8/22 included orders for skilled nursing weekly for nine weeks for wound care. The visit notes for 9/13/22 and 9/21/22 were not completed as of 9/26/22 at 4:20 p.m. An interview with the Director of Regional Operations on 9/26/22 at 4:20 p.m. confirmed the documentation was incomplete. As of 9/29/22 the 9/13/22 visit note remained incomplete. An interview with the agency director on 9/29/22 at 10:35 a.m. revealed the nurse visit note had been returned to the nurse for corrections after the quality assurance review.

Discharge and transfer summaries CFR(s): 484.110(a)(6)(i-iii) (i) A completed discharge summary that is sent to the primary care practitioner or other health care professional who will be responsible for providing care and services to the patient after discharge from the HHA (if any) within 5 business days of the patient's discharge; or (ii) A completed transfer summary that is sent within 2 business days of a planned transfer, if the patient's care will be immediately continued in a health care facility; or (iii) A completed transfer summary that is sent within 2 business days of becoming aware of an unplanned transfer, if the patient is still receiving care in a health care facility at the time when the HHA becomes aware of the transfer. This ELEMENT is not met as evidenced by: Based on policy review, clinical record review, and staff interview, the agency failed to send a transfer summary within 2 business days from becoming aware of the transfer for 1 of 3 patients that had a transfer to another healthcare setting (#13); and to send a discharge summary within 5 business days of discharge for 5 of 7 patients discharged from the agency (#19, 20, 21, 23, and 24). Findings included: A policy, Discharge Summary (effective 9/15/20), was provided by the Director of Regional Operations on 9/29/22at 2:00 p.m. The policy stated, “A Discharge Summary will be sent within 5 business days of patient discharge to the primary care practitioner or other health care professional who will be responsible for providing care and services to the patient.” 1. Patient #13 was admitted on 9/7/22 with a diagnosis of diverticulosis (pockets form in the walls of the digestive tract) of the large intestine without perforation (a small hole) or abscess (collection of pus) without bleeding. The Plan of Care for 9/7/22-11/5/22 included orders for skilled nursing one time per week for one week and physical therapy twice weekly for four weeks. A Discharge/Transfer Summary was completed on 9/19/22 with a transfer date of 9/19/22. In an interview with the agency director on 9/29/22 at 11:30 a.m. it was revealed the transfer summary was sent to the receiving provider on 9/27/22. 2. Patient #19 was admitted on 4/29/22 with diagnoses of alcoholic cirrhosis of the liver with ascites (abnormal build-up of fluid in the abdomen, pleural effusion (fluid in the space surrounding the lung), and a PleurX drain (used to drain fluid from the lining of the lung). The Plan of Care (POC) for 4/29/22-6/27/22 included orders for skilled nursing twice weekly for three weeks, then weekly for five weeks, physical therapy one time for one week, then twice weekly for four weeks. Documentation on 6/10/22 revealed the patient would transfer to hospice services. A Discharge/Transfer Summary was completed on 6/14/22. In an interview with the agency director on 9/29/22 at 12:11 p.m. it was revealed the discharge summary was sent to the receiving provider on 7/11/22. 3. Patient #20 was admitted on 4/11/22 with a diagnosis of emphysema (a lung disease). The Plan of Care (POC) for 6/10/22-8/8/22 included orders for skilled nursing weekly for four weeks and physical therapy twice weekly for four weeks. The patient was discharged to hospice services. A Discharge/Transfer Summary was completed on 6/29/22 with a discharge date of 6/21/22. An interview with the agency director on 9/29/22 at 12:07 p.m. revealed there was no evidence the discharge summary was sent to the receiving provider. 4. Patient #21 was admitted on 1/20/22 with a diagnosis of a non-pressure chronic left leg ulcer. The Plan of Care (POC) included orders for skilled nursing twice weekly for one week, three times per week for two weeks, then twice weekly for six weeks; hospice aide services weekly for six weeks; and physical therapy one time for one week. The patient was discharged to Hospice services. The Discharge Summary was completed on 3/12/22 with a discharge charge date of the same. An interview with the agency director on 9/29/22 at 12:32 p.m. revealed the discharge summary was sent to the receiving provider on 4/14/22. 5. Patient #23 was admitted on 12/14/21 with a diagnosis of urinary tract infection. The Plan of Care for 2/12/22-4/12/22 included skilled nursing weekly for four weeks. The discharge assessment was conducted on 4/5/22. An interview with the Director of Regional Operations on 9/29/22 at 1:13 p.m. revealed the discharge summary was sent to the receiving provider on 4/28/22. 6. Patient #24 was admitted on 3/8/22 with a diagnosis of a urinary tract infection. The Plan of Care (POC) for 3/8/22-5/6/22 included orders for skilled nursing one time for one week; physical therapy twice weekly for three weeks; and occupational therapy twice weekly for one week, then one time for one week. The discharge assessment was conducted on 3/23/22. An interview with the agency director on 9/29/22 at 3:00 p.m. revealed the discharge summary was sent to the receiving provider on 4/14/22.