Every finding on record at Msa Home Health and Hospice of Nc, Inc.

An unannounced on-site recertification survey was conducted on 04/28/2025-04/30/2025. No deficiencies for Emergency Preparedness were identified.

An unannounced on-site recertification survey was conducted on 04/28/2025-04/30/2025. Standard level deficiencies to the Medicare Conditions of Participations were identified.

Plan of care must include the following CFR(s): 484.60(a)(2)(i-xvi) The individualized plan of care must include the following: (i) All pertinent diagnoses; (ii) The patient's mental, psychosocial, and cognitive status; (iii) The types of services, supplies, and equipment required; (iv) The frequency and duration of visits to be made; (v) Prognosis; (vi) Rehabilitation potential; (vii) Functional limitations; (viii) Activities permitted; (ix) Nutritional requirements; (x) All medications and treatments; (xi) Safety measures to protect against injury; (xii) A description of the patient's risk for emergency department visits and hospital re-admission, and all necessary interventions to address the underlying risk factors. (xiii) Patient and caregiver education and training to facilitate timely discharge; (xiv) Patient-specific interventions and education; measurable outcomes and goals identified by the HHA and the patient; (xv) Information related to any advanced directives; and (xvi) Any additional items the HHA or physician or allowed practitioner may choose to include. This ELEMENT is not met as evidenced by: Based on agency policy, direct observations, staff/patient/caregiver interviews, the Plan of Care failed to include all the current/correct medications for 3 of 6 patients who received home visits (#14,16,17). Findings included: The policy, Medication Monitoring (revised 04/2024), provided by the Director of Professional Services on 4/29/2025 at 3:11 pm stated, “Whenever new medications are added a medication reconciliation is completed. Medication reconciliation will also occur, at a minimum, with each OASIS [Outcome and Assessment Information Set] time point…in conjunction with RN [Registered Nurse] supervisory visits for aide or LPN [Licensed Practical Nurse], and with any change in medications to assess any potential adverse reactions.” 1. Patient #14 had a Start of Care date of 1/30/2025 with an admitting diagnosis of Cutaneous abscess of left lower limb (A localized collection of pus that develops within the skin and underlying tissues of the leg or foot). The Plan of Care for 3/31/2025-5/29/2025 included orders for SN (Skilled Nurse) visits 3 times a week for 1 week, 2 times a week for 2 weeks, 1 time a week for 6 weeks. During a home visit conducted on 4/29/2025 at approximately 11:30 am with LPN (Licensed practical nurse) #8, a medication review was performed and the following discrepancies were noted: The agency medication profile included Hydroxyzine HCL (used to treat anxiety) 10 mg every 12 hours, patient #14 stated that she was taking a 10mg and a 50mg tablet together for a total of 60mg 3 times per day as needed. The agency medication profile failed to include the following long term medications: Furosemide (used to treat fluid retention) 80mg, 1 tablet daily, Potassium (mineral supplement) 20meq 1 tab every other day PRN (as needed), PreserVision AREDS 2 (vitamin and mineral supplement that promotes eye health) 1 tablet daily and Calcium Citrate+D3 (vitamins that promote bone strength) 1 tablet daily. 2. Patient #16 had a Start of Care date of 3/25/2025 with an admitting diagnosis of Fracture of unspecified part of neck of left femur (left hip fracture). The Plan of Care for 3/25/2025-5/23/2025 included orders for SN 1 time a week for 7 weeks. During a home visit conducted on 4/29/2025 at approximately 1:30 pm with RN (Registered Nurse) # 6, a medication review was performed and the following discrepancies were noted: The agency medication profile included Warfarin Sodium (used to prevent blood clots) 7.5mg and 10mg to be taken together to equal a total of 17.5mg daily. The patient stated the dose was 17.5mg on Tuesdays, Thursdays, and Saturdays. 20mg on Mondays, Wednesdays, Fridays, and Sundays. The agency medication profile listed Insulin Glargine (injectable long-lasting insulin used to treat high blood sugar) 10 units at bedtime. The patient stated he no longer administers insulin and is now on Glipizide (oral tablet used to lower blood sugar) 10mg 2 times daily. The medication profile listed Gabapentin (used to treat nerve pain) 100mg 1 tablet 2 times a day, the frequency is 3 times a day. The medication profile included the following discontinued medications: Nephro-Vite (used to prevent vitamin deficiency) 0.8 mg, Iron (used to treat anemia) 325mg, and Fluticasone Propionate nasal spray (used to treat allergies)50mcg. 3. Patient #17 had a start of care date of 3/18/2025 with an admitting diagnosis of other complications of procedures (Patient has a non-healing wound on left foot). The Plan of Care (POC) for 3/8/2025-5/6/2025 included orders for SN (Skilled Nurse) 2 times a week for 8 weeks. During a home visit on 4/29/2025 at approximately 8:30 am with LPN #4 a comprehensive medication review revealed that patient #17 has been administering Insulin Lispro (used to treat high blood sugar) 6 units before meals if blood sugar is over 160. This medication was not listed on the medication profile. An interview conducted on 04/30/2025 at 2:28 pm with the Agency Director revealed that the expectation is that a comprehensive medication review is to be completed with all medication changes.

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, observations, clinical record review, and staff interviews, the agency failed to include contact precautions in the plan of care for 1 of 1 patient requiring contact precautions (patient # 4) and failed to perform hand hygiene between glove changes for 1 of 2 registered nurse home visits (patient #10). Findings included: A policy, Exposure Control Plan (revised 05/2024) received on 04/29/2025 at 3:53 pm from the clinical manager stated, “Preventing and controlling occupational exposures is a shared responsibility of [Agency Name] and all employees…The following controls will be utilized at all [Agency Name] facilities…After removal of personal protective gloves, employees shall perform proper hand hygiene on hands and any other potentially contaminated skin area immediately or as soon as feasible with soap and water and or alcohol based hand rub/cleanser.” A policy, Infection Control Program (revised 06/2024) received on 04/29/2025 at 3:11 pm from the clinical manager stated, “[Agency Name] has established a comprehensive Infection Control Program to…improve patient outcomes by identifying and reducing the risk of infection in patients and [Agency Name] staff…[Agency Name] follows 6 core practices, identified by the CDC…hand hygiene…appropriate use of personal protective equipment”. A policy, Infection Control (revised 10/2024) received on 4/30/2025 at 10:14 am from the clinical manager stated, “To monitor and control the risk of healthcare associated infections throughout the patient population and staff by utilizing the following…hand hygiene before and after direct contact with the patient…before and after use of gloves…after handling potentially contaminated items…between different tasks or procedures on the same patient”. Patient #10 had an admission date of 4/17/2025 with a diagnosis of Vascular dementia with psychotic disturbances (a decline in cognitive function due to impaired blood flow to the brain affecting how a person perceives their environment and interacts with others) and Pressure ulcer of sacral region, stage 2 (partial thickness skin loss on the tail bone due to pressure). The plan of care for 4/17/2025 – 6/15/2025 included orders for skilled nurse (SN) visits 1 time a week for 9 weeks with 3 PRN (as needed) and “Clean wound with wound cleaner. Apply zinc oxide ointment daily and prn”. During a joint visit on 4/29/2025 at approximately 11:30 am with RN #14, it was observed that RN#14 did not perform hand hygiene after removing gloves soiled with feces and before putting on clean gloves to perform wound care. During a phone interview conducted on 04/30/2025 at approximately 2:05 pm, RN #14 stated, “If you say so I guess I didn’t clean my hands after removing gloves. Honestly, I do not normally wash my hands with glove changes.” During an interview conducted on 04/30/2025 at approximately 2:30 pm, the agency director stated, “she should have cleaned her hands” and agreed that hand hygiene between glove changes is the expectation of the agency. A policy, Nursing Standards (revised 10/2024) received on 04/30/2025 at 1:10 PM from the clinical manager stated, “The Home Health Nurse will develop a plan of nursing care… Implementation of nursing activities will include: … Implementation of nursing interventions and medical orders.” A policy, Procedures (revised 04/2024) received on 04/30/2025 at 12:45 PM from the clinical manager stated, “Table 31-1 Multidrug-Resistant Organisms (MDROs) Methicillin-resistant Staphylococcus aureus (MRSA)… Transmitted via direct and indirect contact… Prevention… Use of gloves and gowns for patient contact...” A policy, Infection Control Program (revised 06/2024) received on 04/29/2025 at 3:11 PM from the clinical manager stated, “[Agency Name] has established a comprehensive Infection Control Program to…. To reduce the risk of acquired and transmitted infections… [Agency Name] incorporates the following in a continuing cycle… Selection and implementation of best practices to minimize adverse outcomes.” Patient #4 was admitted on 10/01/2024 with a diagnosis of Cellulitis (bacterial skin infection) of the right lower limb. The plan of care for 03/30/2025-05/28/2025 included orders for skilled nurse (SN) visits 2 times a week for 8 weeks with 4 PRN (as needed), “Clean wound to right heel with normal saline, mupirocin 2% ointment [topical antibiotic] to cover wound with gauze wrap with kerlix [gauze bandage roll] secure with tape.” And “SN to do wound care to right heel 2 times a week…” Review of the clinical record revealed that on 03/31/2025 licensed practical nurse (LPN) #13 documented, “MRSA [Methicillin-resistant Staphylococcus aureus requiring contact precautions] positive due to lesions on arms and legs.” Further review revealed that there was no documentation in the plan of care for contact precautions.During an interview conducted on 04/30/2025 at approximately 2:30 PM LPN #13 stated, “We received a culture [of the wound as MRSA positive]. Yes, I would expect to see that [contact precautions] in the care plan. Well, I guess I would look at the policy and procedure. We would contact the doctor and get an order [for contact precautions] and add it to the plan of care.” During an interview conducted on 04/30/2025 at 2:37 PM the agency director stated, “They should have called the doctor and put an order in for contact precautions.”

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 agency policy, clinical record review, and staff interviews, the agency failed to obtain and document weekly wound measurements for 1 of 6 patients with wounds. (patient #14) Findings included: A policy Wound Care Standards (revised 08/2024) received on 04/29/2025 at 2:26 PM from the agency director stated, “Any patient with an open wound will have the sites measured weekly.” Patient #14 was admitted on 01/30/2025 with a diagnosis of cutaneous abscess of left lower limb (skin infection left lower leg). The plan of care for 03/31/2025-05/29/2025 included orders for skilled nurse (SN) visits 3 times a week for 1 week, 2 times a week for 2 weeks, 1 time a week for 6 weeks, and “SN to clean with normal saline insert iodoform to open wounds, cover with foam dressing. SN to do dressing change 3 times weekly and PRN.” Review of the documentation for the SN home visit on 03/31/2025 revealed that LPN (licensed practical nurse) #10 documented “N/A [not applicable]” for wound measurements. Review of the documentation for the registered nurse (RN) visit on 04/02/2025 revealed that RN #15 documented, “Size: Not Applicable.” Review of the documentation for the SN visit on 04/04/2025 revealed that LPN #4 documented, “Size: Not Applicable”. An interview conducted on 04/29/2025 at 2:05 PM with the Director of Professional Services (DOPS) revealed that the wounds were not measured during the week of 03/30/25. During an interview on 04/29/25 at 2:14 PM the DOPS stated, “The expectation is for the staff [nurses] to measure the wounds 1 time a week.”

Preparing clinical notes CFR(s): 484.75(b)(6) Preparing clinical notes; This ELEMENT is not met as evidenced by: Based on agency policy, direct observations, and staff interviews, the nurse failed to include medication discrepancies in the visit documentation for 3 of 6 patients with home visits conducted (#14,16,17). Findings included: The policy, Medication Monitoring (revised 04/2024), provided by the Director of Professional Services on 4/29/2025 at 3:11 pm stated, “Whenever new medications are added, a medication reconciliation is completed…the findings, conclusions, and recommendations of medication monitoring are documented in the patient’s medical record”. Patient #14 had a Start of Care date of 1/30/2025 with an admitting diagnosis of Cutaneous abscess of left lower limb (A localized collection of pus that develops within the skin and underlying tissues of the leg or foot). The Plan of Care for 3/31/2025-5/29/2025 included orders for SN (Skilled Nurse) visits 3 times a week for 1 week, 2 times a week for 2 weeks, 1 time a week for 6 weeks. During a home visit conducted on 4/29/2025 at approximately 11:30 am with LPN (Licensed practical nurse) #8, a medication review was performed and 5 discrepancies were revealed. Review of the clinical record revealed that LPN #8 documented “no discrepancies” for the visit of 4/29/2025.Patient #16 had a Start of Care date of 3/25/2025 with an admitting diagnosis of Fracture of unspecified part of neck of left femur (left hip fracture). The Plan of Care for 3/25/2025-5/23/2025 included orders for SN 1 time a week for 7 weeks. During a home visit conducted on 4/29/2025 at approximately 1:30 pm with RN #6, a medication review was performed and 6 discrepancies were revealed. Review of the clinical record revealed that RN #6 documented “no discrepancies” for the visit on 4/29/2025.Patient #17 had a start of care date of 3/18/2025 with an admitting diagnosis of other complications of procedures (Patient has a non-healing wound on left foot). The Plan of Care for 3/8/2025-5/6/2025 included orders for SN 2 times a week for 8 weeks. During a home visit conducted on 4/29/2025 at approximately 8:30 am with LPN #4, a medication review was performed and 1 discrepancy was revealed. Review of the clinical record revealed that LPN #4 documented “no discrepancies” for the visit on 4/29/2025. An interview conducted on 04/30/2025 at 2:28 pm with the Agency Director revealed that the expectation is that medication discrepancies should be documented in the visit note.

An recertification survey was conducted June 6, 2022-June 9, 2022. There were no deficiencies identified to the Emergency Preparedness Program.

A recertification survey was conducted June 6, 2022-June 9, 2022. Standard level deficiencies to the Medicare Conditions of Participation were identified.

Plan of care must include the following CFR(s): 484.60(a)(2)(i-xvi) The individualized plan of care must include the following: (i) All pertinent diagnoses; (ii) The patient's mental, psychosocial, and cognitive status; (iii) The types of services, supplies, and equipment required; (iv) The frequency and duration of visits to be made; (v) Prognosis; (vi) Rehabilitation potential; (vii) Functional limitations; (viii) Activities permitted; (ix) Nutritional requirements; (x) All medications and treatments; (xi) Safety measures to protect against injury; (xii) A description of the patient's risk for emergency department visits and hospital re-admission, and all necessary interventions to address the underlying risk factors. (xiii) Patient and caregiver education and training to facilitate timely discharge; (xiv) Patient-specific interventions and education; measurable outcomes and goals identified by the HHA and the patient; (xv) Information related to any advanced directives; and (xvi) Any additional items the HHA or physician or allowed practitioner may choose to include. This ELEMENT is not met as evidenced by: Based on policy review, clinical record review and staff interview, the Plan of Care did not include weight bearing status for 1 of 1 patient with an arm fracture (#15); complete orders for a urinary catheter for 1 of 1 patient with an indwelling urinary catheter (#2); include all medications on the plan of care for 4 of 7 patients that received virtual home visits (#7, 8, 9, 11). Findings include: A policy, “Care Planning and Coordination” revised 12/2021, was provided by the agency administration on 6/9/22 at 4:14 p.m. The policy stated, “An individualized plan of care is developed by Agency licensed staff for each patient based upon a comprehensive assessment that reflect the patient’s identified problems and needs…consistent with physician or licensed independent practitioner’s orders or prescriptions…The initial plan of care includes at least the following…interventions…Treatments/orders…The types of equipment and supplies required…Functional limitations…Activities Permitted…All medications including dose/frequency and route…Safety Measures to protect against injury…” A policy, “Medication Management-Patient Information” revised 8/2021, was provided by the human resource director on 6/9/22 at 3:45 p.m. The policy stated, “During the initial assessment visit, the Registered Nurse/Therapist generates a list of the patient’s current medications, including prescription and over-the-counter (OTC) medications and herbal remedies…The patient’s medications are reviewed and assessed during each skilled visit. Any changes to the medications, severe interactions or changes in the patient's response to the medications are conveyed to the ordering physician… 1. Patient #15 was admitted on 3/12/21 with diagnoses of right humerus (upper arm) fracture, Alzheimer’s disease, and diabetes. The Plan of Care for 3/12/21-5/10/21 included orders for skilled nursing one time per week for one week, two times per week for three weeks, and one time per week for five weeks; physical therapy two times per week for four weeks, then one time per week for two weeks; occupational therapy beginning 3/19/21 for one time for one week, then two times per week for six weeks. The physical therapy evaluation was conducted on 3/16/21. The caregivers were unsure of any weight bearing restrictions to the fractured arm. There was no evidence the physical therapist obtained a weightbearing status. An occupational therapy (OT) evaluation was conducted on 3/19/21. The OT note confirmed the caregiver was still unaware of the weightbearing status of the arm. An interview with the clinical director on 6/9/22 at 2:15 p.m. confirmed there was no evidence of physician notification for weightbearing status for the right arm. An interview with the PT #9 on 6/9/22 revealed that a weightbearing status was never obtained. 2. Patient #2 was admitted on 8/19/21 with a diagnosis of neuromuscular dysfunction of the bladder. The Plan of Care (POC) for 4/16/22-6/14/22 included orders for skilled nursing (SN) twice weekly for eight weeks and then one time for one week. The POC also included orders for the “SN to use 18 fr 5-10 cc SILICONE Foley catheter [brand of indwelling catheter], instead of latex…SN to change the foley catheter every 4 weeks and as needed if clogged/blocked.” The visit note on 4/19/22 stated, “Patient currently has a three way catheter that is used for bladder flushing.” The POC did not include orders for a 3-way catheter. An interview with RN #4 on 6/9/22 at 2:55 p.m. confirmed the patient was using a 3-way catheter. 3. Patient #7 was admitted on 5/3/22 with a diagnosis of atherosclerosis to the arteries of the right leg with ulcer to the foot. The Plan of Care (POC) for 5/3/22-7/1/22 included orders for skilled nursing visits twice weekly for nine weeks; physical therapy one time weekly for two weeks, twice weekly for two weeks, then one time for one week; and occupational therapy evaluation. A virtual home visit was conducted with RN #6 on 6/8/22 at 9:30 a.m.. A review of the medications during the home visit revealed the following discrepancies:The patient was taking Diltiazem ER 180 mg twice daily (used to treat blood pressure and some heart arrhythmias). This was omitted from the POC. The patient was taking an over-the-counter supplement for eyes. This was omitted from POC. An interview with the caregiver was conducted during the virtual visit. The caregiver stated the patient “has been on them since at least October” of 2021. An interview with RN #6 on 6/9/22 at 3:15 confirmed Diltiazem and the eye supplement were not included on the POC. 4. Patient #8 was admitted on 3/5/22 with a diagnosis of an intertrochanteric fracture of the right femur. The Plan of Care (POC) for 5/4/22-7/2/22 included orders for physical therapy three times per week for one week, then two times weekly for five weeks. A virtual visit was conducted on 6/8/22 at 10:45 a.m. with PTA #7. The patient resided in an assisted living facility (ALF). The agency provided the ALF medication records. The following discrepancies were identified:The POC listed Myrbetriq 25 mg daily for urinary urgency. The ALF medication list was for 50 mg beginning 4/8/22.The medication profile provided by the agency at the time of the virtual visit included Methocarbamol 750 mg every 6 hours as needed for pain. This was included on the medication profile two separate times with on start date of 5/2/22 and another start date on 6/3/22. The POC listed Coreg 3.125 mg twice daily for hypertension and Carvedilol 3.125 mg twice daily. Coreg was a trade name for the generic Carvedilol. This was duplicate therapy.The medication profile provided by the agency included Colace 100 mg twice daily for constipation. The ALF medication list revealed this as discontinued effective 5/24/22. The agency medication profile included ferrous sulfate 325 mg daily as an iron supplement. This was not included on the ALF medication list.The agency medication profile included Prednisone 20 mg daily for arthritis. The ALF medication list did not include Prednisone. An interview with the clinical manager on 6/8/22 following the virtual visit confirmed the agency medication profile did not accurately reflect what the patient was taking. An interview with PTA #7 on 6/9/22 at 3:20 p.m. revealed the PTA asks the ALF medication tech and the patient about medication changes. 5. Patient #9 was admitted on 4/6/22 with diagnoses of laceration to the right knee, open wound to right great toe, open wound to left great toe, and diabetes. The Plan of Care (POC) for 6/5/22-8/3/22 included orders for skilled nursing three times per week for eight weeks, then twice per week for one week. A virtual visit was conducted with LPN #13 on 6/8/22 at 11:45 a.m. A review of the medications was conducted during the virtual visit. The following discrepancies were identified:The POC included Glimepiride (for diabetes) 4 mg daily ordered on 10/4/20 and Glimepiride 2 mg daily ordered on 3/12/22. An interview with the caregiver during the home visit confirmed the Glimepiride was decreased to 2 mg daily. The POC contained duplicate drug therapy.The POC included an order for Insulin Lispro (for diabetes) subcutaneous injection (given into fatty tissue) 2-6 ml. Inject per sliding scale. The POC did not include the sliding scale nor the frequency. 6. Patient #11 was admitted on 5/4/22 with a diagnosis for aftercare following a right knee replacement The Plan of Care (POC) for 5/4/22-7/2/22 included orders for physical therapy two times weekly for one week, three times per week for two weeks, then two times weekly for four weeks. A virtual visit was conducted with Physical Therapist (PT) #8 on 6/8/2 at 2:45 p.m.. A review of the medication list revealed the following discrepancies: Vitamin D3 (supplement) 50 mcg (2000 units) daily was on the POC. During the virtual visit that patient stated, “I haven’t taken it since I had surgery.” An interview with PT #8 on 6/9/22 at 3:30 p.m. revealed the PT thought the patient was taking this again.MiraLAX 17 gm daily for constipation was on the POC. During the virtual visit the patient confirmed she was not taking daily. She was taking it only as needed.PreserVision 2 caps twice daily for vision was on the POC. During the virtual visit the patient confirmed she was taking 1 cap twice daily and this was not new. An interview with PT #8 on 6/9/22 at 3:30 p.m. confirmed there were medication discrepancies on the POC.

All orders recorded in plan of care CFR(s): 484.60(a)(3) All patient care orders, including verbal orders, must be recorded in the plan of care. This ELEMENT is not met as evidenced by: Based on policy review, clinical record review and staff interview, the medical social worker failed to obtain an order for services for 1 of 1 patient that received a medical social work visit (#2). Findings include: A policy, “Physician Telephone/Verbal Orders” revised 6/2021, was provided by the agency administration on 6/9/22 at 4:15 p.m. The policy stated, “Orders are obtained from the physician or other authorized individual according to applicable laws and regulations and professional practice acts prior to providing care, treatment and/or services…” Patient #2 was admitted on 8/19/21 with a diagnosis of neuromuscular dysfunction of the bladder. The Plan of Care for 4/16/22-6/14/22 included orders for skilled nursing twice weekly for eight weeks and then one time for one week. On 4/29/22, the medical social worker conducted a visit. There was no order in the current certification period for a medical social worker. An interview with the clinical manager on 6/9/22 at 11:45 a.m. confirmed there was no order for medical social worker.

Promptly alert relevant physician of changes CFR(s): 484.60(c)(1) The HHA must promptly alert the relevant physician(s) or allowed practitioner(s) to any changes in the patient's condition or needs that suggest that outcomes are not being achieved and/or that the plan of care should be altered. This ELEMENT is not met as evidenced by: Based on policy review, clinical record review and staff interview, the nurse failed to notify the physician of changes related to potential infection (#2, 13, 15); to notify the physician of a need for home health aide services for approximately one month in 1 of 2 patient identified as needing home health aide service (#2). Findings include: A policy, “Coordination of Services” revised 12/2021, was provided by the agency administration on 6/9/22 at 4:15 p.m. The policy stated, “…Agency staff promptly contacts the physician: When there are changes in the patient’s condition…” Patient #2 was admitted on 8/19/21 with a diagnosis of neuromuscular dysfunction of the bladder. The Plan of Care (POC) for 4/16/22-6/14/22 included orders for skilled nursing (SN) twice weekly for eight weeks and then one time for one week. The POC also included orders for the “SN to use 18 fr 5-10 cc SILICONE Foley catheter [brand of indwelling catheter], instead of latex…SN to change the foley catheter every 4 weeks and as needed if clogged/blocked.” On 5/23/22 RN #4 conducted a home visit because the patient stated the catheter was clogged. The visit note stated, “Cath removed and white fluid came out on tip. Area cleansed and new #18Fr with 30 mL balloon reinserted, no urine return noted. Wife stated that catheter needed to be inserted the whole way in, cath removed and bloody drainage noted. Another catheter was inserted up to the Y and urine return noted…Wife state to only insert 20 ml of saline.” There was no evidence the nurse notified the physician of the white fluid on the tip of the removed catheter of the bloody drainage. There was also no notification that the nurse inserted 20 ml of saline as instructed by the patient’s wife. On 5/31/22 during the skilled nurse visit, the nurse noted the patient had gone to the hospital the previous weekend and was being treated for a urinary tract infection. An interview with RN #4 on 6/9/22 at 2:55 p.m. confirmed the physician was not notified of the white fluid or the alteration of the balloon inflation orders. 1B. Patient #2 was admitted on 8/19/21 with a diagnosis of neuromuscular dysfunction of the bladder. The Plan of Care for 4/16/22-6/14/22 included orders for skilled nursing twice weekly for eight weeks and then one time for one week. On 4/29/22, the medical social worker (MSW) conducted a visit. The MSW evaluation stated, “Patient is…needing assistance with care in the home…Patient is in need of an aid [sic] to assist with ADL’s [activities of daily living] …MSW will provide a list of agencies who may have an aid [sic] available to go into the home and assist patient with needs.” Orders for home health aide services two times weekly to assist with ADL’s was ordered on 5/26/22 with an effective date of 5/31/22. An interview with the clinical director on 6/9/22 at 11:45 a.m. revealed she was unsure of why it took from 4/29/22 to 5/26/22 to begin aide services. 2. Patient #13 was admitted on 7/18/21 with a diagnosis of type 2 diabetes with foot ulcer. The Plan of Care for 1/14/22-3/14/22 included orders for skilled nursing one time for one week, three times per week for eight weeks, and one time for one week. On 1/15/22, a transfer summary was completed that stated the patient was admitted to the hospital with sepsis. A resumption of care visit was conducted on 1/25/22 with orders for skilled nursing three times weekly for seven weeks. SN was to change the PICC line dressing weekly and change the caps weekly and with lab draws. The patient refused the PICC line care on 1/25/22. The nurse visited again on 1/26/22. The patient refused PICC line dressing change again. The note for 1/26/22 stated, “Has firm swelling of elbow and surrounding tissue. Patient stated the was “bursitis”. Nonpainful. No redness noted. Tissue surround PICC insertion site bruised in appearance.” There was no evidence the physician was notified of the refusal of the PICC line dressing or the swelling of the elbow area. An interview with RN #2 on 6/9/22 at 1:30 p.m. confirmed there was no evidence of physician notification. 3. Patient #15 was admitted on 3/12/21 with diagnoses of right humerus (upper arm) fracture, Alzheimer’s disease, and diabetes. The Plan of Care for 3/12/21-5/10/21 included orders for skilled nursing one time per week for one week, two times per week for three weeks, and one time per week for five weeks; physical therapy two times per week for four weeks, then one time per week for two weeks; occupational therapy beginning 3/19/21 for one time for one week, then two times per week for six weeks. The initial assessment conducted on 3/12/21 noted that breath sounds were diminished throughout lungs, and the patient was short of breath with minimal exertion. The visit note also stated, “VSS [vital signs stable] during visit except temp of 101. Unwrapped patient and temp did come down to 99.9 before I left but patient still felt warm. Patient family expressed that they check her blood sugars daily and could not remember what it was this am but it was ‘higher than her normal’”. The nursing note for 3/15/21 revealed lungs sounds remained diminished. On 3/17/22, the nurse visit note revealed the lower lobes remained diminished, and the upper lobes had wheezes. The occupational therapy conducted a visit on 3/22/21. The temperature was 101.2, the therapy contributed the elevation to the patient’s room temperature. On 3/23/22, the nurse found lungs sounds were diminished throughout. The physical therapist on 3/23/21. The PT stated, “Overall therapy session limited due to increased drowsiness of the patient.” The PT documentation on 3/30/21 stated, Caregiver states pt [patient] has been extremely drowsy and may not work with therapy…Overall, pt with limited tolerance to therapy session today due to increased drowsiness A PT visit on 3/31/21 stated that the drowsiness continued. On 4/5/21, the visit noted stated, “arrived at patient’s home and patient was in wheelchair in the living room. Slumped to the left with towel propped between head and shoulder. Patient has drool from her mouth. Aide stated that patient is “Playing Opposum [sic].” When I felt of patient, patient was cold and clammy. Immediately applied pulse ox and it was 94% on RA [room air] and pulse IR [irregular] and in 60s. Blood sugar was checked and was 476. Patient would not open eyes and communicate. Attempted blood pressure and I was unable to get a manual blood pressure. Doppler pressure obtain and it was Systolic 40. Rescue squad called due to emergent condition, patients daughter called by aide. Rescue squad arrived and they were not ablet [sic] obtain blood pressure either, and blood sugar was 610 when they checked it.” Patient admitted to hospital. The Resumption of Care assessment on 5/7/21 revealed the patient had pneumonia. RN #10 stated in an interview on 6/9/22 at 3:45 p.m., “I do not see where I notified the doctor” of the lung sounds. She also revealed she thought the temperature was elevated on the initial visit because the patient’s house was warm and the patient was wrapped up in a blanket.

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 clinical record review, observation, and interview, the nurse failed to maintain infection prevention standards during 1 of 4 virtual wound care observations (#12). Findings include: Patient #12 was admitted on 1/12/22 with type 2 diabetes mellitus with foot ulcer. The Plan of Care (POC) for 5/12/22-7/10/22 included orders for skilled nursing visits weekly. The nurse was to provide wound care to the right great toe: cleanse with normal saline, pat dry, apply iodosorb, over with gauze, wrap with kerlix and secure with tape. The nurse was to provide wound care to the right lateral foot: Cleanse with normal saline. Apply Vashe moistened gauze to wound bed, cover with gauze, wrap with kerlix and secure with tape. A virtual home visit was conducted on 6/9/22 at approximately 10:00 with RN #4. When the nurse changed her gloves throughout the wound care observation, she removed the gloves from the box without performing had hygiene prior to entering the clean box. The nurse also provided wound care on the right great toe and right lateral foot without performing hand hygiene between two wounds to prevent cross contamination. The nurse was also observed cutting off the soiled dressing with scissors and placing the scissors with the clean wound supplies. The scissors were later used to cut the clean kerlix without cleaning the scissors. An interview with the clinical director was conducted on 6/9/22 immediately following with observation. The clinical director confirmed the infection prevention standards were not followed. An interview RN #4 was conducted on 6/9/22 at 3:00 p.m. The nurse stated she typically performs hand hygiene “at the end” of the wound care.

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 clinical record review and staff interview, the agency failed to check a fingerstick PT/INR for 1 of 1 patient with PT/INR orders (lab that checks blood clotting time) orders (#14); to measure the mid-arm circumference and the length of a PICC line as ordered for 1 of 1 patient with a PICC line (#17). Findings include: 1. Patient #14 was admitted on 11/6/21 with diagnoses of pulmonary embolism, chronic atrial fibrillation, and type 2 diabetes. The Plan of Care (POC) for 11/6/21-1/4/22 included orders for skilled nursing (SN) visits weekly for nine weeks. The POC also included orders to check a PT/INR via fingerstick on 11/6/21 and 11/8/21. The initial assessment conducted on 11/6/21 revealed the PT and INR was checked on 11/6/21 and was 3.9. The note also confirmed that the PT/INR was due again 11/8/22. There was not another visit conducted until 11/11/21. The lab results on 11/11/21 were: PT greater than 96.9 and INR greater than 8.0. The physician was notified and ordered to hold Coumadin and obtain another PT/INR on 11/15/21. On 11/15/21, the PT/INR were the same as 11/11/21. The patient also reported bright red blood in her stool and abnormal vaginal bleeding. The physician was notified, and the patient was instructed to go to the emergency department. An interview with the clinical director on 6/9/22 at 1:05 p.m. confirmed the PT/INR was not obtained on 11/8/21, nor was a visit made as ordered on the POC. 2. Patient #17 was admitted on 5/20/22 with diagnoses including infection/inflammation due to an internal left knee prosthesis, encounter for adjustment and management of a vascular access device, and diabetes. The Plan of Care (POC) for 5/20/22-7/18/22 included orders for skilled nursing three times per week for two weeks, two times per week for one week, and weekly for six weeks, with 3 additional as needed visits. The POC also included orders to “perform PICC [peripherally inserted central catheter] line site care: using sterile technique, cleanse with anti-septic scrub solution, apply bio-patch, apply transparent, occlusive dressing with no gauze weekly and as needed for loosening or soiling. Change PICC Line cap every 7 days, and ad needed and after each blood draw. Measure length of external /exposed catheter from insertion site to the hub and measure MAC (mid-arm circumference).” There was no evidence of the mid-arm circumference and the external length of the catheter until 6/1/21.