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

An onsite recertification survey was conducted 2/23/26-2/25/26. No deficiencies related to the Emergency Preparedness Plan were identified.

An unannounced, onsite recertification survey was conducted 2/23/26-2/25/26. Standard level deficiencies to the Medicare CoP were identified.

Accuracy of encoded OASIS data CFR(s): 484.45(b) Standard: The encoded OASIS data must accurately reflect the patient's status at the time of assessment. This STANDARD is not met as evidenced by: Based on agency policy, clinical record review and staff interviews, clinicians failed to document OASIS [Outcome and Assessment Information Set - mandatory, standardized data collection tool for Medicare-certified home health agencies to assess patient functional status and health condition] question N0415 [high risk drug classes] correctly for 5 of 13 [#1, 3, 6, 9 and 10] patients. The findings included: The policy, OASIS Collection and Reporting [last revised 12/2025], was provided by the agency administrator on 2/25/26 at 8:30 am. The policy stated, "...OASIS dated must accurately reflect the patient's condition at the time of the assessment...." 1. Patient # 1 had a Start of Care date of 2/5/25 with an admitting diagnosis of Sepsis [infection in the blood stream]. Review of the Plan of Care [POC] for the certification period 2/5/25-4/5/25 revealed the patient was ordered Aspirin [antiplatelet] 81 mg daily. Review of the clinical record revealed RN # 6 conducted the OASIS [Outcome and Assessment Information Set - a mandatory, standardized data collection tool for Medicare-certified home health agencies to assess patient functional status and health condition] visit on 2/5/25. Review of OASIS documentation [N0415-high risk drug classes] revealed RN # 6 failed to include the use of the aspirin [antiplatelet]. Further review of the clinical record revealed a Resumption of Care [ROC-visit after inpatient stay] visit with an OASIS was conducted on 3/17/25. The ROC medications included Bactrim [antibiotic] 800-160 mg. Take 2 tablets two times a day for 10 days and Aspirin 81 mg daily. Review of the ROC OASIS [N0415-high risk drug classes] revealed RN # 3 failed to include the use of an antibiotic and the use of the antiplatelet. 2. Patient # 3 had a Start of Care [SOC] date of 1/15/25 with an admitting diagnosis of Aftercare following joint replacement surgery. Review of the Plan of Care [POC] for the certification period 1/15/25-3/15/25 revealed the patient was ordered Cefadroxil [antibiotic] 500 mg daily for 3 days. Review of the clinical record revealed PT # 6 completed the SOC OASIS [Outcome and Assessment Information Set - a mandatory, standardized data collection tool for Medicare-certified home health agencies to assess patient functional status and health condition] on 1/15/25. Review of OASIS documentation [N0415-high risk drug classes] revealed PT # 6 failed to include the use of an antibiotic. 3. Patient # 6 had a Start of Care [SOC] date1/23/26 with an admitting diagnosis of Urinary Tract Infection. Review of the Plan of Care [POC] for the certification period 1/23/26-3/23/26 revealed the patient was ordered Cefdinir [antibiotic] 300 mg twice a day for 5 days for a UTI [urinary tract infection]. Review of the clinical record revealed RN # 5 conducted the OASIS [Outcome and Assessment Information Set - a mandatory, standardized data collection tool for Medicare-certified home health agencies to assess patient functional status and health condition] visit on 1/23/26. Review of OASIS documentation [N0415-high risk drug classes] revealed RN # 5 failed to include the use of an antibiotic. 4. Patient # 9 had a Start of Care date of 1/7/26 with an admitting diagnosis of hypertensive heart and chronic kidney disease with heart failure [high blood pressure damaging the vessels in the kidneys] and chronic congestive heart failure [heart does not pump adequately]. Review of the Plan of Care [POC] for the certification period 1/7/26-3/7/26 revealed the patient was ordered Cefdinir [antibiotic] 300 mg twice daily and Aspirin [antiplatelet] 81 mg each day. Review of the clinical record revealed PT # 2 completed the SOC OASIS [Outcome and Assessment Information Set - a mandatory, standardized data collection tool for Medicare-certified home health agencies to assess patient functional status and health condition] on 1/7/26. Review of the OASIS documentation [N0415-high risk drug classes] revealed PT #2 failed to include the use of an antibiotic and antiplatelet when answering the OASIS question. 5. Patient # 10 had a Start of Care date of 1/27/26 with an admitting diagnosis of Alzheimer’s Disease. Review of the Plan of Care [POC] for the certification period 1/27/26-3/27/26 revealed the patient was ordered Aspirin [antiplatelet] 81 mg each day, Cefdinir [antibiotic] 300 mg twice a day and Quetiapine [antipsychotic] 25 mg daily. Review of the clinical record revealed PT # 2 completed the SOC OASIS [Outcome and Assessment Information Set - a mandatory, standardized data collection tool for Medicare-certified home health agencies to assess patient functional status and health condition] on 1/27/26. Review of the OASIS documentation [N0415-high risk drug classes] revealed PT #2 failed to include the use of an antibiotic and antiplatelet when answering the OASIS question. During an interview with the agency administrator on 2/25/26 at approximately 2 pm, the administrator confirmed the OASIS question N0415 was answered incorrectly.

5 calendar days after start of care CFR(s): 484.55(b)(1) The comprehensive assessment must be completed in a timely manner, consistent with the patient's immediate needs, but no later than 5 calendar days after the start of care. This ELEMENT is not met as evidenced by: Based on agency policy, clinical record review, and staff interviews the agency failed to complete the occupational therapy [OT] evaluation within 5 days for 2 of 8 patients [#6 and 7] with OT orders . The findings included: The policy, Comprehensive Assessment [last revised 9/2025], was provided by the agency administrator on 2/25/26 at 8:30 am. The policy stated, “...If additional disciplines are ordered the initial evaluations ordered at Start of Care [SOC] are completed withing 5 days of the SOC visit...” 1.Patient # 6 had a Start of Care [SOC] date1/23/26 with an admitting diagnosis of Urinary Tract Infection. A review of the referral dated 1/22/26 revealed an order for OT [occupational therapy] to eval and treat. Review of the clinical record revealed the OT evaluation was not conducted until 2/5/26. The clinical record revealed no evidence that the physician was notified of the late OT evaluation. 2.Patient # 7 had a Start of Care date of 1/16/26 with an admitting diagnosis of Chron’s Disease [a chronic inflammatory bowel disease causing inflammation anywhere along the digestive tract, most commonly the end of the small intestine]. A review of the hospital discharge orders dated 1/14/26 revealed an order for OT [occupational therapy] to eval and treat. Review of the clinical record revealed the OT evaluation was not completed until 1/23/26. There was no evidence that the physician was notified of the delay of the OT evaluation. During an interview with the agency administrator on 2/25/26 at 2:30 pm, the administrator confirmed the OT evaluations were completed outside the required timeframe.

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, clinically record review, home visits, and staff interviews, the Plan of Care failed to included the correct/current medications for 5 of 5 patients who received home visits [#9, 10, 11, 12 and 13]. The findings included: The policy, Medication Management [last reviewed 12/2024], was provided by the agency administrator on 2/25/26 at 8:30 am. The policy stated, "...Any changes to the medications...are conveyed to the ordering physician, and changes are made..." 1. Patient # 9 had a Start of Care date of 1/7/26 with an admitting diagnosis of hypertensive heart and chronic kidney disease with heart failure [high blood pressure damaging the vessels in the kidneys] and chronic congestive heart failure [heart does not pump adequately]. Review of the Plan of Care [POC] for the certification period 1/7/26-3/7/26 included orders for PT [physical therapy] 1 time a week for 1 week, 2 times a week for 2 weeks, 1 time a week for 6 weeks. Patient # 9 resided in an assisted living facility [ALF]. On 2/24/26 at approximately 9:30 am a joint visit was made with PTA [physical therapy assistant] 1. During the visit a medication review was conducted using a medication profile provided by the agency. The following discrepancies were noted: The medication profile provided by the agency listed Cetirizine [allergies] 10 mg. Take 1 daily. The medication administration mar [MAR] provided by the ALF listed Cetirizine 5 mg. Take 1 tablet daily with a start date of 12/8/25. The medication profile provided by the agency listed Torsemide [edema] 20 mg. Take 1 tablet daily. The MAR provided by the ALF listed Torsemide 20 mg. Take 1 daily as needed [PRN] for edema with start date of 12/8/25. The medication profile provided by the agency listed Simvastatin [cholesterol] 10 mg daily. This medication was not listed on the MAR provided by the ALF. The medication profile provided by the agency listed Pyridostigmine [weakness] 60 mg. Take 1 table two times a day. The MAR provided by the agency listed Pyridostigmine 60 mg. Take 1 tablet two times per day. May take 1 tablet 3 times a day as needed for weakness with a start date of 12/8/25. 2. Patient # 10 had a Start of Care date of 1/27/26 with an admitting diagnosis of Alzheimer’s Disease. Review of the Plan of Care [POC] for the certification period 1/27/26-3/27/26 included order for PT [physical therapy] 1 time a week for 9 weeks. Patient # 10 resided in an assisted living facility [ALF]. On 2/24/26 at 10 am a joint visit was made with PT # 2. During the visit a medication review was conducted using a medication profile provided by the agency. The following discrepancies were noted: The medication profile provided by the agency listed Klonopin [anxiety]. Take 1 mg every 4 hours for seizures. The MAR provided by the ALF listed Klonopin 1mg. Take 1 tablet every 4 hours as needed [PRN] for anxiety with a start date of 12/8/25. The MAR provided by the ALF listed Acetaminophen [over the counter pain reliever] 500 mg. Take 1 tablet every 4 hours as needed for headache or fever with a start date of 12/8/25. The medication profile provided by the agency did not include Acetaminophen. The MAR provided by the ALF listed Zofran [nausea] 4 mg. Take 1 tablet every 6 hours as needed for nausea/vomiting with a start date of 12/8/25. The medication profile provided by the agency did not include Zofran. The MAR provided by the ALF listed Mirtazapine [antidepressant] 15 mg. Give ½ tablet at bedtime with a start date of 12/8/25. The medication profile provided by the agency did not include Mirtazapine. 3. Patient # 11 had Start of Care date of 12/24/25 with an admitting diagnosis of Chronic Venous Hypertension with ulcer and inflammation of left lower extremity and non-pressure chronic ulcer of unspecified part of left lower leg. Review of the Plan of Care for the certification period 2/22/26-4/26/26 included orders for SN [Skilled nursing] 2 times a week for 9 weeks. On 2/24/26 at 12 noon a joint visit was made with RN # 3. A medication review was conducted using a medication profile provided by the agency. The following discrepancy was noted: The medication list included Lantus [insulin] 100 unit/ml. Take 30 units twice a day. During an interview with the patient, she stated, “I only take 50 units every day now. “ 4. Patient # 12 had a Start of Care date of 1/23/26 with an admitting diagnosis of Chronic Obstructive Pulmonary Disease [COPD-respiratory condition]. Review of the Plan of Care [POC] for the certification period 1/23/26-3/23/26 included orders for SN [skilled nursing] 1 time a week for 1 week, 3 times a week for 8 weeks. On 2/25/26 at approximately 11 am a joint visit was made with RN # 5. During the visit a medication review was conducted using a medication list profile by the agency. The following discrepancies were noted: The medication profile provided by the agency included Pantoprazole [reflux] 20 mg daily. Take 1 tablet daily. During the visit the patient presented a bottle of Pantoprazole 40 mg. Take 1 tablet daily. The patient reported taking 40 mg daily with a start date of 11/5/25. The patient presented a bottle of Docusate [stool softener] 100 mg. Take 1 capsule two times a day with a start date of 1/22/26. The medication profile provided by the agency did not include Docusate. 5. Patient # 13 had a Start of Care date of 1/18/26 with an admitting diagnosis of Chronic Obstructive Pulmonary Disease [COPD-respiratory condition]. Review of the Plan of Care for the certification period 1/18/26-3/18/26 included orders for OT [occupational therapy] 1 time a week for 5 weeks. On 2/25/26 at approximately 10 am a joint visit was made with OT # 4. During the visit a medication review was conducted using a medication profile provided by the agency. The following discrepancies were noted: The medication profile provided by the agency did not include Slow Fe [iron supplement] 45 mg. Take 1 daily. The patient reported taking this medication for about 2 months. The medication profile did not include Oxycodone/acetaminophen 10 mg-325 mg [pain medication]. Take 1 tablet every 6 hours as needed for pain. The patient reported she had been using the pain medicine for “a very long time.” During an interview with the agency administrator on 2/25/26 at approximately 1 pm, she confirmed the POCs for the joint visits did not include the correct/current medications.

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 Registered Nurse failed to obtain wound measurements for 1 of 2 patients with a wound [2]. The findings included: The policy, Wound Care Standards [last revised 7/2025], was provided by the agency administrator on 2/25/26 at 8:30 am. The policy stated, “...Measure and document the wound at least weekly, unless the plan of care states otherwise...” Patient # 2 had a Start of Care [SOC] date of 3/15/25 with admitting diagnoses of encounter for other orthopedic aftercare, acute osteomyelitis [infection of the bone], and encounter for adjustment and management of VAD [catheter or tube inserted into a vein or artery to deliver fluids, blood products, nutrients, or medication directly into the bloodstream over an extended period]. Review of the Plan of Care for the certification period 3/15/25-5/15/25 included orders for SN [skilled nursing] 1 time a week for 1 week, 2 times a week for 8 weeks and “ ...L [left] plantar [area of the foot used for walking] Cleanse with NS [normal saline] or wound cleanser, pat dry with gauze, apply Xeroform gauze, cover with 4x4 gauze, wrap with kerlix, cast padding and ACE wrap...Perform twice weekly...” RN # 8 conducted the SOC visit on 3/15/25. Review of the documentation revealed no wound measurements. Follow up SN visits were conducted on 3/18/25, 3/21/25, 3/24/25, 3/27/25, 3/31/25, 4/3/25, 4/7/25, 4/10/25, 4/14/25, and 4/14/25. The visit documentation for those visits revealed no wound measurements. During an interview with RNs # 9 and 10 on 3/25/26 at approximately 12 noon, the RN’s reported, “I would expect to see at least measurements of the incision line at each visit.”

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 agency policy review, clinical record review, and staff interviews the Registered Nurse failed to follow the physician's order related to the amount of heparin used for flushing a PICC line [a thin, flexible tube inserted into a large arm vein and threaded toward the heart to deliver long-term treatments like antibiotics, chemotherapy, or nutrition] for 1 of 1 patient with a PICC line [#2]; and failed to follow the physician's order related to wound care for 1 of 2 patients with a wound [#2]. The findings included: The policy, Physician Telephone/Verbal Orders [last revised 11/2025] was provided by the agency administrator on 2/25/26 at 8:30 am. The policy stated, "...__________ [name of the agency] provides all care, treatment, and services only according to current, signed, and authorized orders..." 1A. Patient # 2 had a Start of Care [SOC] date of 3/15/25 with admitting diagnoses of encounter for other orthopedic aftercare, acute osteomyelitis [infection of the bone], and encounter for adjustment and management of VAD [catheter or tube inserted into a vein or artery to deliver fluids, blood products, nutrients, or medication directly into the bloodstream over an extended period]. Review of the Plan of Care [POC] for the certification period 3/15/25-5/15/25 included orders for SN [skilled nursing] 1 time a week for 1 week, 2 times a week for 8 weeks and...”SN to change PICC line [a thin, flexible tube inserted into a large arm vein and threaded toward the heart to deliver long-term treatments like antibiotics, chemotherapy, or nutrition] dressing...weekly... SN to educate pt [patient]/caregiver on SASH [ Saline, Administration, Saline, Heparin- a method used to safely flush, administer medication, and maintain PICC lines at home, reducing the risk of blockages] administer 10 ml of normal saline administer heparin [anticoagulant] 100 u [unit]/ml...” The medication section of the POC included the following order...” Heparin Sodium...100 units/ml 2 ml via PICC...” Review of the clinical record revealed RN # 11 conducted routine visits on 3/18/25, 3/21/25, 3/24/25, 3/27/25, 3/31/25, 4/3/25, 4/7/25, 4/10/25, 4/14/25, and 4/14/25. Further review of RN # 11’s documentation revealed she flushed the PICC line with 5 ml of heparin instead of the physician’s order of 2 ml. During an interview with RN # 9 on 3/25/26 at approximately 12 noon, RN # 9 confirmed the RN failed to follow the physician’s order. 1B. Patient # 2 had a Start of Care [SOC] date of 3/15/25 with admitting diagnoses of encounter for other orthopedic aftercare, acute osteomyelitis [infection of the bone], and encounter for adjustment and management of VAD [catheter or tube inserted into a vein or artery to deliver fluids, blood products, nutrients, or medication directly into the bloodstream over an extended period]. Review of the Plan of Care for the certification period 3/15/25-5/15/25 included orders for SN [skilled nursing] 1 time a week for 1 week, 2 times a week for 8 weeks and “ ...L [left] plantar [area of the foot used for walking] Cleanse with NS [normal saline] or wound cleanser, pat dry with gauze, apply Xeroform gauze, cover with 4x4 gauze, wrap with kerlix, cast padding and ACE wrap...Perform twice weekly...” RN # 11 conducted a routine visit on 3/18/25 and documented the following information, “...Patient saw the surgeon yesterday...we [SN] don’t need to change the dressing until he goes back there in a week...” RN # 11 conducted a routine visit on 3/24/25 and documented the following regarding wound care, “...Wrapped the top of the ACE wrap tighter on left foot, but patient is to leave dressing on until next appointment with surgeon...” RN # 11 conducted a routine visit on 3/27/25 and documented the following, “...Patient saw surgeon today...wife reports she [physician] removed every other suture and dressed his foot...said that dressing can stay on until he returns in 1 week...” RN # 11 documented the following on 3/31/25, “...Foot [sic] dressing not changed as it again [sic] non removable [sic] until he sees surgeon...” Review of the clinical record revealed no change in the physician’s order related to wound care after the SOC. RN # 9 confirmed the RN failed to follow the physician’s order related to wound care to the left foot.

An onsite recertification and follow up survey was conducted 02/13/23 to 02/15/23. No deficiencies to the Emergency Preparedness Program were identified. ABH

An onsite recertification and follow up survey was conducted 02/13/23-02/15/23. Deficiencies to the Medicare Conditions of Participation were identified. The following citations were put back into compliance effective 02/15/23- G544 and G578.

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, observation, clinical record review, and staff interview, the agency failed to include all medications on the plan of care for 4 of 6 home visits (#17,11,14,16), and failed to have complete wound care orders for 1 of 1 wound care records reviewed (#7). Findings included: 2. Patient # 11 had a Start of Care date of 1/1/23 and admitting diagnoses of Atrial Fibrillation [irregular, often rapid heart rate that commonly causes poor blood flow] and Chronic Obstructive Pulmonary Disease [COPD-lung disease]. Review of the Plan of Care [POC] for the certification period 1/1/23 to 3/1/23 revealed orders for PT [physical therapy] 2 times a week for 4 weeks, 1 time a week for 4 weeks. The following PT intervention was included on the POC “Compare current and newly ordered/acquired medications and instruct in newly added medications during therapy visits as needed”. On 2/13/23 at approximately 12 pm a joint visit was conducted with PTA [physical therapy assistant] # 11. 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 Metoprolol Tartrate [blood pressure] 50 mg. 1.5 tablets [75 mg] by mouth daily. An interview was conducted with the caregiver during the visit, the caregiver reported the patient is taking 75 mg. of Metoprolol Tartrate 2 times per day. The caregiver reported the patient had been on this dose of medication since 12/31/22. The caregiver also reported the patient was taking Lasix [fluid] 20 mg. every other day. The caregiver stated the patient was using this medication at the time of admission to the agency. During an interview with the agency director on 2/14/23 at approximately 11 am, Vice President [VP]of Operations confirmed the medications listed on the POC were not correct. 3. Patient # 14 had a Start of Care date of 5/29/22 and admitting diagnoses of Vitamin B12 Deficiency Anemia and Drug Induced Subacute Dyskinesia [involuntary movements of the face, arms or legs]. Review of the Plan of Care [POC] for the certification period 1/24/23 to 3/24/23 included orders for PT [physical therapy] 2 times a week for 5 weeks, 1 time a week for 4 weeks. A joint visit was made on 2/13/23 to _______ [name of assisted living facility-(ALF)] with PT # 8 at approximately 3:30 pm. During the visit, a medication review was conducted using a medication profile provided by the agency. The following discrepancies were noted: Omeprazole [stomach] 40 mg daily was not listed on the medication profile. An interview with the ALF staff revealed the patient had been using this medication since 6/24/21. The medication profile listed Loperamide HCL [diarrhea] 2 mg. Take 2 tables every 6 hours as needed for diarrhea and Methylphenidate HCL [attention deficit disorder] 5 mg. Take 1 tablet every day. During an interview with the ALF staff, the staff reported the patient was not on this medication. The staff was unsure when the patient had been on the medications. During an interview with the Vice President [VP] of Operations on 2/25/23 at approximately 11 am, the VP confirmed the POC did not include all/correct medications the patient was using. 4. Patient # 16 had a Start or Care date of 2/4/23 and an admitting diagnosis of Urinary Tract Infection. Review of the Plan of Care [POC] for the certification 2/4/23 to 4/4/23 included orders for SN [skilled nursing] 2 times a week for 3 weeks, 1 time a week for 5 weeks and “Educate caregivers [sic] purpose, dosing, common side effects of all prescribed, high risk and OT [over the counter] medication.” On 2/14/23 at approximately 11:30 am, a joint visit was made with RN # 7. 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 Magnesium Oxide [supplement] 200 mg. 2 tablets every day. During an interview with the ALF [assisted living facility] staff during the visit, the staff reported the patient was taking Magnesium Oxide 200 mg. 1 tablet each day with a start date of 1/31/2023. An interview was conducted with the Vice President [VP] of Operations on 2/15/23 at approximately 11 am. The VP confirmed the POC did not include all the medications/correct medications the patient was using. 5. Patient # 7 had a Start of Care [SOC] date of 1/14/23 and admitting diagnoses of pressure ulcer of right heel, stage 2 [superficial ulcer] and hypertensive chronic kidney disease [damage to the blood vessels in the kidneys caused by high blood pressure]. Review of the Plan of Care [POC] for the certification period 1/14/23-3/14/23 included orders for SN [skilled nursing] 2 times a week for 2 weeks, 1 time a week for 6 weeks and “…Clean with Dakins’ [sic] solution, apply calcium alginate, cover with calcium alginate and foam…Clean with Dakins [sic] solution, apply Santyl ointment daily, cover with calcium alginate and foam…” The location of the wound was not included in the order. During an interview with the Vice President [VP] of Operations on 2/15/23 at approximately 9:10 am, it was confirmed the wound care orders on the POC were incomplete [lacked location of the wound/wounds]. Review of policy, “Assessment HH2005”, revised 03/22, was received from the agency administrator on 02/14/23 at 1:39 p.m. The policy stated”, …a comprehensive review and history of prescribed, over the counter medications and herbal supplements…” 1.Patient #17 was admitted was admitted on 01/05/23 with diagnoses of pressure ulcer of sacral region, unstageable, essential hypertension, hypercholesterolemia (high cholesterol), depression, and osteoarthritis. The plan of care for 01/05/23 to 03/05/23 had orders for physical therapy 1 time a week for 1 week, 2 times a week for 4 weeks, and 1 time a week for 4 weeks. A home visit with the physical therapist was observed on 02/14/23 at 9:30 a.m. The medication review during the home visit revealed the following discrepancy: famotidine 10 mg (milligrams) 1 tablet by mouth daily as needed for heartburn was not included on the medication profile. Interview with the caregiver confirmed the patient has been taking this medication for a while as needed for heartburn.

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 obtain an order for wound care for 3 of 9 patients with a wound [#3, 7 and 18]. The findings included: The policy, Physician Telephone/Verbal Orders HH2018, [last revised 6/21], was provided by the agency administrator on 2/14/23 at 2:14 pm. The policy stated, “…_______ [name of agency] provides care, treatment and/or services to patients according to a physician’s or licensed practitioner’s most recent order or prescription…” 1. Patient # 3 had a Start of Care date of 7/14/22 and admitting diagnoses of displaced intertrochanteric fracture left femur [thigh bone] and nondisplaced fracture of olecranon process [bone which forms the most pointed portion of the elbow]. Review of the Plan of Care [POC] for the certification period 7/14/22 to 9/11/22 included orders for PT [physical therapy] 1 time a week for 1 week, 2 times a week for 3 weeks, 1 time a week for 5 weeks; OT [occupational therapy] 1 time a week for 9 weeks; SN [skilled nursing] to evaluate. Patient refused the nursing evaluation on 7/15/22. A supplementary order was written on 8/2/22 by RN # 10. The order stated, “…SN eval [evaluate] related to heel wound…SN to call MD [doctor] office with assessment of wound for specific wound care orders.” Review of the clinical record revealed LPN # 9 made routine visits on 8/31/22 and 9/7/22 and documented Patient # 3’s left heel had an open wound. The LPN documented the following information, “Wound 1- Left heel, Status-Open…Type-Pressure Injury…Size 0.25 cm x 1 cm x 0.1 cm…” Further review of the visit notes for 8/31/22 and 9/7/22 revealed the following information, “…Patient applying triple antibiotic and dry dressing…” Review of the medical record revealed no order for wound care to the left heel. LPN # 9 was no longer employed by the agency. During an interview with the Vice President [VP] of Operations on 2/15/23 at approximately 10:15 am, the VP confirmed there was no order for the wound care. 2. Patient # 7 had a Start of Care [SOC] date of 1/14/23 and admitting diagnoses of pressure ulcer of right heel, stage 2 [superficial ulcer] and hypertensive chronic kidney disease [damage to the blood vessels in the kidneys caused by high blood pressure]. Review of the Plan of Care [POC] for the certification period 1/14/23-3/14/23 included orders for SN [skilled nursing] 2 times a week for 2 weeks, 1 time a week for 6 weeks. The SOC OASIS [Outcome and Assessment Information Set] identified 2 wounds. Wound 1-Left 5th toe; Wound 2-Right heel. Review of the clinical record revealed RN # 14 documented the following information on 1/14/23 related to wound care, “Wound 1…Daughter demonstrated cleanse [sic] with Dakins [sic], applied calcium alginate, covered with bordered gauze as she was instructed by the staff at the SNF [skilled nursing facility prior to discharge…Wound 2… Daughter demonstrated cleanse [sic] with Dakins [sic], applied Santyl to slough, applied calcium alginate, covered with border [sic] foam as instructed by the nurses at the SNF prior to discharge…” Further review of the clinical record revealed there was no specific order for wound care. During an interview with the Vice President [VP] of Operations on 2/15/23 at approximately 9:15 am, it was confirmed there was no order for wound care. 3. Patient # 18 had a Start of Care date of 1/21/23 and an admitting diagnosis of fracture upper end of left humerus [long bone in the arm]. Review of the Plan of Care [POC] for the certification period 1/21/23-3/21/23 included orders for SN [skilled nursing] 1 time a week for 4 weeks, 1 time every other week for 4 weeks; PT [physical therapy] 2 times a week for 4 weeks, 1 time a week for 4 weeks; OT[occupational therapy] 1 time a week for 1 week, 0 times a week for 2 weeks, 1 time a week for 6 weeks. On 2/14/23 at approximately 9 am, a joint visit was made with OT # 12. During an interview with the caregiver the caregiver reported the patient had developed a “sore” on her left arm from the splint. The caregiver reported “the nurse came out last week and put on a dressing. I am changing it 2 times a day. The nurse said to change it 2-3 times a day.” The caregiver provided a tube of Mupirocin [ointment] and stated, “this is what we are putting on her arm”. Review of the clinical record revealed RN # 7 had conducted a routine visit on 2/8/23. Further review of the clinical record revealed there was no order for the wound care to the elbow. During an interview with RN # 7 on 2/15/23 at approximately 9 am, the RN stated, “No, there is no order in the chart yet.”

Review and revision of the plan of care CFR(s): 484.60(c) Standard: Review and revision of the plan of care. This STANDARD is not met as evidenced by: Based on agency policy, clinical record review and staff interviews the agency failed to have Resumption of Care [ROC-comprehensive assessment completed after an in-patient stay] orders for 2 of 2 patients with ROC assessments [#9 and 15]. The findings included: The policy, Physician Telephone/Verbal Orders HH2018, [last revised 6/21], was provided by the agency administrator on 2/14/23 at 2:14 pm. The policy stated, “…_______ [name of agency] provides care, treatment and/or services to patients according to a physician’s or licensed practitioner’s most recent order or prescription…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… 1.Patient # 9 had a Start of Care date of 1/13/23 and admitting diagnoses of infection/inflammatory reaction due to indwelling urethral catheter [carries urine out of the bladder], Sepsis [infection of blood] and type 2 diabetes mellitus with diabetic chronic kidney disease [damage to kidneys due to high blood sugars]. Review of the Plan of Care for the certification period 1/13/23 to 3/13/23 included orders for SN [skilled nursing] 1 time a week for 1 week, 2 times a week for 8 weeks and “SN to change 18 French/30 ml foley monthly and prn [as needed] disruption. Will be due first week of each month if no prn changes are made.” Review of the clinical record revealed the patient was admitted to ________ [name of the hospital on 1/27/23. RN # 6 completed a Resumption of Care [ROC-comprehensive assessment completed after an inpatient stay] on 2/2/23. Review of the ROC documentation revealed RN # 6 planned to see the patient 1 time a week for 1 week, 2 times a week for 5 weeks, 1 time a week for 1 week. RN # 6 made routine visits on 2/6/23 and 2/10/23. Review of the clinical record revealed no ROC orders as of 2/15/23 at 11 am. During an interview with the Vice President [VP] of Operations on 2/15/23 at approximately 10:45 am, the VP stated, “We are behind on that process [process related to getting individualized orders/goals/interventions pulled from the discipline evaluations and sending ROC orders to the physician].” 2. Patient # 15 had a Start of Care date of 1/18/23 with admitting diagnoses of mechanical complication of internal fixation device of vertebrae [backbone] and post laminectomy syndrome [condition when patient continues to feel pain after corrective surgery]. Review of the Plan of Care for the certification period 1/18/23-3/18/23 included orders for SN [skilled nursing] to evaluate and treat. PT [physical therapy] 1 time a week for 1 week, 2 times a week for 3 weeks, 1 time a week for 3 weeks; OT [occupational therapy] 1 time a week for 1 week, 2 times a week for 2 weeks, 1 time a week for 6 weeks. Review of the clinical record revealed Patient # 15 was admitted to _____ [name of hospital] with a diagnosis of Clostridioides difficile [C Diff-infection of the large intestines] on 1/22/23. The patient was discharged home on 1/27/23. On 1/30/23, OT # 12 completed the Resumption of Care [ROC-comprehensive assessment completed after an inpatient stay]. OT # 12 documented the following information during the ROC visit, “During assessment patient presents with decreased strength…Patient would benefit from skilled OT to address…” OT made follow up visits on 2/3/23, 2/8/23 and 2/9/23. The clinical record revealed no ROC orders for OT. PT completed an evaluation on 1/31/23. PT # 8 documented on the evaluation a new frequency of 2 times a week for 4 weeks, then 2 times a week for 3 weeks. The clinical record contained no ROC orders related to PT visits/interventions/goals. RN # 7 completed an evaluation on 2/1/23. Review of the evaluation revealed the patient would be seen 1 time a week for 7 weeks. The clinical record contained no ROC related to SN visits/interventions/goals. During an interview with the Vice President [VP] of Operations on 2/15/23 at approximately 10:30 am, it was confirmed there were no individualized orders obtained after the ROC assessment. The VP stated, “We are behind on that process [process related to getting individualized orders/goals/interventions pulled from the discipline evaluations and sending ROC orders to the physician].”

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 agency policy, clinical record review and staff interviews the agency failed to notify the physician of a new wound for 2 of 9 patients with a wound [#3 and 18]. The findings included: The policy, Care Planning and Coordination HH2014 [last revised date 12/21], was provided by the agency administrator on 2/14/23 at 2:14 pm. The policy stated, “…The physician is contacted with reports of changes in the plan of care including patient’s clinical status and/or needs, and for necessary orders…” 1. Patient # 3 had a Start of Care date of 7/14/22 and admitting diagnoses of displaced intertrochanteric fracture left femur [thigh bone] and nondisplaced fracture of olecranon process [bone which forms the most pointed portion of the elbow]. Review of the Plan of Care [POC] for the certification period 7/14/22 to 9/11/22 included orders for PT [physical therapy] 1 time a week for 1 week, 2 times a week for 3 weeks, 1 time a week for 5 weeks; OT [occupational therapy] 1 time a week for 9 weeks; SN [skilled nursing] to evaluate. Patient refused the nursing evaluation on 7/15/22. A supplementary order was written on 8/2/22 by RN # 10. The order stated, “…SN eval [evaluate] related to heel wound…SN to call MD [doctor] office with assessment of wound for specific wound care orders.” Review of the clinical record revealed LPN # 9 made routine visits on 8/31/22 and 9/7/22 and documented Patient # 3’s left heel had an open wound. The LPN documented the following information, “Wound 1- Left heel, Status-Open…Type-Pressure Injury…Size 0.25 cm x 1 cm x 0.1 cm…” Further review of the clinical record revealed no evidence the LPN communicated the open wound with the MD. LPN # 9 was no longer employed by the agency. An interview was conducted with the Vice President [VP] of Operations on 2/15/23 at approximately 10:20 am. During the interview, the VP confirmed the LPN failed to notify the MD of the open wound. 2. Patient # 18 had a Start of Care date of 1/21/23 and an admitting diagnosis of fracture upper end of left humerus [long bone in the arm]. Review of the Plan of Care [POC] for the certification period 1/21/23-3/21/23 included orders for SN [skilled nursing] 1 time a week for 4 weeks, 1 time every other week for 4 weeks; PT [physical therapy] 2 times a week for 4 weeks. Review of the clinical record revealed PTA documented the following information during the 2/9/23 visit, “…patient has a sore on left elbow. Nurse coming today…” Further review of the clinical record revealed no communication with the physician related to the new wound. During an interview with the Vice President [VP] of Operations on 2/15/23 at 9:10 am, it was confirmed there was no evidence the physician was notified of the new wound.

Communication with all physicians CFR(s): 484.60(d)(1) Assure communication with all physicians or allowed practitioners involved in the plan of care. This ELEMENT is not met as evidenced by: Based on policy and procedure review, clinical record review and staff interview the agency failed to coordinate with the physician for blood pressures outside of parameters for 1 of 5 discharged records reviewed (#2), failed to follow up with the physician related to the patient being seen at the wound clinic for 1 of 1 wound records reviewed (#3), and failed to notify the physician the SN (skilled nurse) visits were not made in accordance with the POC (plan of care) (#7). Findings included: 2. Patient # 3 had a Start of Care date of 7/14/22 and admitting diagnoses of displaced intertrochanteric fracture left femur [thigh bone] and nondisplaced fracture of olecranon process [bone which forms the most pointed portion of the elbow]. Review of the Plan of Care [POC] for the certification period 7/14/22 to 9/11/22 included orders for PT [physical therapy] 1 time a week for 1 week, 2 times a week for 3 weeks, 1 time a week for 5 weeks; OT [occupational therapy] 1 time a week for 9 weeks; SN [skilled nursing] to evaluate. Patient refused the nursing evaluation on 7/15/22. A supplementary order was written on 8/2/22 by RN # 13. The order stated, “…SN eval [evaluate] related to heel wound…SN to call MD [doctor] office with assessment of wound for specific wound care orders.” RN # 13 contacted the physician’s office on 8/4/22 and obtaining the following order, “…Referral to _____ [name of wound clinic] has been made for evaluation and treatment of left heel wound…” Patient # 3 received 9 SN visits from 8/4/22 through 9/7/22 [time of discharge]. Review of the clinical record revealed no evidence the patient’s heel wound was evaluated by the wound clinic. Further review of the clinical record revealed no evidence the SN followed up/communicated with physician related to the time frame the patient should be seen at the wound clinic for the evaluation ordered on 8/4/22. RN # 13 was not available for interview. An interview was conducted with the Vice President [VP] of Operations on 2/15/23 at approximately 11 am. During the interview, it was confirmed the nurse failed to follow up with the physician related to the patient being seen at the wound clinic. 3. Patient # 7 had a Start of Care [SOC] date of 1/14/23 and admitting diagnoses of pressure ulcer of right heel, stage 2 [superficial ulcer] and hypertensive chronic kidney disease [damage to the blood vessels in the kidneys caused by high blood pressure]. Review of the Plan of Care [POC] for the certification period 1/14/23-3/14/23 included orders for SN [skilled nursing] 2 times a week for 2 weeks, 1 time a week for 6 weeks. Review of the clinical record revealed the only 1 SN visit was made the week of 1/14/23. There was no evidence the physician was notified of the visit frequency. During an interview with the Vice President [VP] of Operations on 2/15/23 at approximately 8:30 am, it was confirmed SN failed to notify the physician the SN visits were not made in accordance with the POC. Review of policy,” Coordination of Services HH2020, revised, 12/2001, was received from the agency administrator on 02/14/23 at 1:39 p.m. The policy stated”, …MSA (Medical Services of America) home health agency staff promptly contacts the physician …when there are changes in the patient’s condition…” 1.Patient #2 was admitted on 04/14/22 with diagnoses of Pneumonia, copd (chronic obstructive pulmonary disease), malnutrition, atrial fibrillation (heart flutter), and essential hypertension. The plan of care for 04/14/22 to 06/12/22 included orders for skilled nursing 1 time a week for 9 weeks, and physical therapy 2 times a week for 5 weeks, and 1 time a week for 4 weeks. Orders were to notify the physician if systolic (top number/pressure in your arteries) blood pressure is greater than 170 or less than 100. Review of skilled nursing visit for 05/16/22 revealed the patients blood pressure was documented as 90/50 and on 05/23/22 the patients blood pressure was documented as 92/50. No documentation was in the record that the physician was notified of the blood pressure outside of parameters. Interview with the skilled nurse on 02/15/23 at 8:33 a.m. revealed, “I can’t guarantee that I notified the doctor, I usually call the doctor if its below 100”.

Infection Prevention CFR(s): 484.70(a) Standard: Infection Prevention. The HHA must follow accepted standards of practice, including the use of standard precautions, to prevent the transmission of infections and communicable diseases. This STANDARD is not met as evidenced by: Based on policy review, client record review, direct observation and staff interview the agency staff failed to use proper hand hygiene for 1 of 6 home visits (#17). Findings included: Review of policy “Hand Hygiene HH4012”, revised 12/2021 was received from the vice president on 02/15/23 at 10:38 a.m. The policy stated,” …CDC (centers for disease control) recommendations for hand hygiene…” Review of policy “Bag Technique HH4020”, revised 12/2022 was received from the vice president on 02/15/23 at 10:38 a.m. The policy stated,” …the bag is not reentered with gloves on…”. 1.Patient #17 was admitted was admitted on 01/05/23 with diagnoses of pressure ulcer of sacral region, unstageable, essential hypertension, hypercholesterolemia (high cholesterol), depression, and osteoarthritis. The plan of care for 01/05/23 to 03/05/23 had orders for physical therapy 1 time a week for 1 week, 2 times a week for 4 weeks, and 1 time a week for 4 weeks. A home visit was conducted on 02/14/23 at 9:30 a.m. with the physical therapist. Employee #3 was observed using hand sanitizer on gloved hands during the home visit with bag technique (before and after cleaning equipment), and putting the equipment back into the bag and while performing exercises with patient. Interview with the administrator and vice president on 02/14/23 at 10:59 a.m. revealed “she’s new and hasn’t been with us long and didn’t work in home health before”.

Interdisciplinary assessment of the patient CFR(s): 484.75(b)(1) Ongoing interdisciplinary assessment of the patient; This ELEMENT is not met as evidenced by: Based on clinical record review and staff interviews the RN [registered nurse] failed to communicate with ST [speech therapy] information related to possible swallowing difficulties for 1 of 1 patients [#9]. The findings included: Patient # 9 had a Start of Care date of 1/13/23 and admitting diagnoses of infection/inflammatory reaction due to indwelling urethral catheter [carries urine out of the bladder], Sepsis [infection of blood] and type 2 diabetes mellitus with diabetic chronic kidney disease [damage to kidneys due to high blood sugars]. Review of the Plan of Care for the certification period 1/13/23 to 3/13/23 included orders for SN [skilled nursing] 1 time a week for 1 week, 2 times a week for 8 weeks. Review of the clinical record revealed RN # documented the following information on 1/20/23, “CG [caregiver] reports she [patient] has been holding food in her mouth, soups are running out…” On 1/23/23 RN 6 documented, “CG reports pt [patient] continues to hold food in her mouth…” Further review of the clinical record revealed no communication with speech therapy related to the caregiver’s reports. During an interview with RN # 6 on 2/15/23 at approximately 10 am, RN # 6 confirmed she did not speak with speech therapy about the caregiver’s concerns. “She seemed to get a little better the next time I saw her.”

Preparing clinical notes CFR(s): 484.75(b)(6) Preparing clinical notes; This ELEMENT is not met as evidenced by: Based on clinical record review and staff interviews the RN [registered nurse] documented the presence of a wound with no wound present for 1 of 18 patients [#15] ; and failed to document a wound assessment for 1 of 9 patients with a wound [#18]. The findings included: 1. Patient # 15 had a Start of Care date of 1/18/23 with admitting diagnoses of mechanical complication of internal fixation device of vertebrae [backbone] and post laminectomy syndrome [condition when patient continues to feel pain after corrective surgery]. Review of the Plan of Care for the certification period 1/18/23-3/18/23 included orders for SN [skilled nursing] to evaluate and treat. The patient was hospitalized on 1/22/23 with a diagnosis of Clostridioides difficile [C Diff-infection of the large intestines]. RN # 7 completed the SN evaluation on 2/1/23. Review of the clinical record revealed RN # 7 documented the following information on the wound worksheet, “Wound 1- Location: Low back/spine-Status: Open…Drainage: Purulent [drainage containing pus] …” The clinical record contained no orders for wound care. During an interview with RN # 7 on 2/15/23 at approximately 9:30 am, RN # 7 stated, “There was no open area that I saw. I don’t know why I documented that.” 2. Patient # 18 had a Start of Care date of 1/21/23 and an admitting diagnosis of fracture upper end of left humerus [long bone in the arm]. Review of the Plan of Care [POC] for the certification period 1/21/23-3/21/23 included orders for SN [skilled nursing] 1 time a week for 4 weeks, 1 time every other week for 4 weeks; PT [physical therapy] 2 times a week for 4 weeks, 1 time a week for 4 weeks; OT[occupational therapy] 1 time a week for 1 week, 0 times a week for 2 weeks, 1 time a week for 6 weeks. On 2/14/23 at approximately 9 am, a joint visit was made with OT # 12 . During an interview with the caregiver the caregiver reported the patient had developed a “sore” on her left arm from the splint. The caregiver reported “the nurse came out last week and put on a dressing. I am changing it 2 times a day. The nurse said to change it 2-3 times a day.” Review of the clinical record revealed RN # 7 had conducted a routine visit on 2/8/23. Further review of the clinical record revealed the wound assessment was not entered into the clinical record until 2/15/23 after 9 am. During an interview with RN # 7 on 2/15/23 at approximately 9 am, the RN confirmed the wound assessment was not documented in the patient’s chart.

Required items in clinical record CFR(s): 484.110(a)(1) The patient's current comprehensive assessment, including all of the assessments from the most recent home health admission, clinical notes, plans of care, and physician or allowed practitioner orders; This ELEMENT is not met as evidenced by: Based on agency policy, clinical record review and staff interviews the agency failed to document accurate indwelling urinary catheter sizes for 1 of 1[#9] patients with an indwelling urinary catheter; and failed to complete documentation for a routine visit for 1 of 18 patients [#18]. The findings included: The policy, Assessments HH2005 [last revised 3/22], was provided by the agency administrator on 2/14/23 at 2:14 pm. The policy stated, “…All documentation should occur during the patient visit or as soon as possible thereafter (at least within 24 hours unless there is an extenuating circumstance that is approved by the clinical management staff) …” 1. Patient # 9 had a Start of Care date of 1/13/23 and admitting diagnoses of infection/inflammatory reaction due to indwelling urethral catheter [carries urine out of the bladder], Sepsis [infection of blood] and type 2 diabetes mellitus with diabetic chronic kidney disease [damage to kidneys due to high blood sugars]. Review of the Plan of Care for the certification period 1/13/23 to 3/13/23 included orders for SN [skilled nursing] 1 time a week for 1 week, 2 times a week for 8 weeks and “SN to change 18 French [fr] /30 ml foley [indwelling catheter] monthly and prn [as needed] disruption. Will be due first week of each month if no prn changes are made.” Review of the clinical record revealed the following discrepancies related to the indwelling catheter size: 1/16/23 and 1/20/23 RN # 6 documented the catheter size as 18 fr/ 10 ml. 1/23/23 RN # 6 documented the foley size as 16 fr/5 ml. During an interview with RN # 6 on 2/15/23, the RN confirmed the clinical record contained discrepancies related to the size of the foley catheter. The RN stated, “I am sure she had a 18 fr/30 ml foley in place.” 2. Patient # 18 had a Start of Care date of 1/21/23 and an admitting diagnosis of fracture upper end of left humerus [long bone in the arm]. Review of the Plan of Care [POC] for the certification period 1/21/23-3/21/23 included orders for SN [skilled nursing] 1 time a week for 4 weeks, 1 time every other week for 4 weeks; PT [physical therapy] 2 times a week for 4 weeks, 1 time a week for 4 weeks; OT[occupational therapy] 1 time a week for 1 week, 0 times a week for 2 weeks, 1 time a week for 6 weeks. On 2/14/23 at approximately 9 am, a joint visit was made with OT # 12. During an interview with the caregiver the caregiver reported the patient had developed a “sore” on her left arm from the splint. The caregiver reported “the nurse came out last week and put on a dressing. I am changing it 2 times a day. The nurse said to change it 2-3 times a day.” Review of the clinical record revealed RN # 7 had conducted a routine visit on 2/8/23. The visit note remained incomplete on 2/15/23 at 8:30 am. During an interview with RN # 7 on 2/15/23 at approximately 9 am, the RN stated, “Yes, I did go out. I just haven’t completed my documentation yet.” During an interview with the Vice President [VP] of Operations on 2/15/23 at approximately 9:10 am, it was confirmed documentation related to routine visits are to be completed within 24 hours after the visit.

An unannounced onsite complaint investigation was conducted 12/13/21-12/14/21. The allegation was substantiated and standard level deficiencies to Medicare CoPs 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 clinical record review and staff interviews the Plan of Care failed to include the frequency in which a treatment was to be performed for 1 of 3 charts [#1]. The findings included: Patient # 1 had a Start of Care [SOC] date of 8/28/21 and diagnoses of Cellulitis of right lower limb, cellulitis of left lower limb, osteomyelitis, and alcoholic cirrhosis of liver with ascites. A review of the Plan of Care [POC] for the certification period 8/28/21 to 10/26/21 revealed orders for SN [skilled nursing] 1 time a week for 9 weeks; 2 PRN [as needed] for wound care complications, labs and "RLE [right lower extremity] wound: cleanse with normal saline, apply xerfoam [sic] to right lower extremities open areas and small blistery areas on top of foot. Cover with kerlix and ACE bandage until patient goes to wound care and hyperbaric medicine in ______[location]..." Further review of the clinical record revealed no clarification order related to the frequency of the dressing changes. An interview was conducted with the agency director on 12/14/21. During the interview, the agency director confirmed the Plan of care failed to include the frequency of the dressing changes.

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 clinical record review and staff interviews the agency failed to obtain orders for wound care for 1 of 3 charts [#1]. The findings included: Patient # 1 had a Start of Care [SOC] date of 8/28/21 and diagnoses of cellulitis of right lower limb, cellulitis of left lower limb, osteomyelitis, and alcoholic cirrhosis of liver with ascites. A review of the Plan of Care [POC] for the certification period 8/28/21 to 10/26/21 revealed orders for SN [skilled nursing] 1 time a week for 9 weeks; 2 PRN [as needed] for wound care complications, labs. A supplemental order was written 9/23/21 for SN 2 times a week for 4 weeks after hospitalization from to 9/16/21 to 9/22/21 . A review of the clinical record revealed a routine visit was made by LPN # 2 on 10/7/21. The LPN documented the following finding's, " Location: Right buttock...Onset date: 10/7/21...Type: Pressure Ulcer...Stage: IV...Size: 7 cm x 5 cm x 8 cm...Treatment: Clean with normal saline, pack with calcium alginate and secure with border foam dressing each visit until patient goes to wound care doctor..." A review of the clinical record revealed no physician's order for the treatment.

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 review and staff interviews the Registered Nurse failed to assess a wound for 1 of 1 patient during the resumption of care visit [#1]. The findings included: Patient # 1 had a Start of Care [SOC] date of 8/28/21 and diagnoses of Cellulitis of right lower limb, cellulitis of left lower limb, osteomyelitis, and alcoholic cirrhosis of liver with ascites. A review of the Plan of Care [POC] for the certification period 8/28/21 to 10/26/21 revealed orders for SN [skilled nursing] 1 time a week for 9 weeks; 2 PRN [as needed] for wound care complications, labs. A supplemental order was written 9/23/21 for SN 2 times a week for 4 weeks after hospitalization from to 9/16/21 to 9/22/21 [PT completed the ROC visit on 9/22/21 and the SN did the evaluation for SN services on 9/23/21]. A review of the SN visit note dated 9/23/21 revealed the RN documented the following information, “patient right buttocks stage 4 wound was not assessed at SN eval [evaluation] patient was unable to stand or transfer and is sitting on a small loveseat unable to roll to side so SN can assess wound nor was a caregiver present …”A review of the clinical record revealed the RN did no assess the area on the patient's right buttock during the evaluation visit. An interview was conducted with RN # 1 on 12/14/21 at 11:30 am. During the interview the RN confirmed she did not assess the right buttock. "I wasn't able to get her to stand or roll to look at the area. I called the hospital to see about sending her back to the hospital and I called management for help. I just wasn't able to assess the area."

Communication with physicians CFR(s): 484.75(b)(7) Communication with all physicians involved in the plan of care and other health care practitioners (as appropriate) related to the current plan of care; This ELEMENT is not met as evidenced by: Based on agency policy review, clinical record review and staff interviews the RN/LPN failed to report changes related to a wound to the physician for 1 of 3 charts [# 1]. The findings included: The policy, Coordination of Services [12/20], was provided by the agency director on 12/14/21. The policy stated, "...______ [name of agency] Home Health Agency staff promptly contacts the physician... When there are changes in the patient's condition...When changes occur in caregiver support or the environment, When ____[name of agency] Home Health Agency can no longer adequately meet the patient's medical, nursing and or social needs in the patient's place of residence..." Patient # 1 had a Start of Care [SOC] date of 8/28/21 and diagnoses of cellulitis of right lower limb, cellulitis of left lower limb, osteomyelitis, and alcoholic cirrhosis of liver with ascites. A review of the Plan of Care [POC] for the certification period 8/28/21 to 10/26/21 revealed orders for SN [skilled nursing] 1 time a week for 9 weeks; 2 PRN [as needed] for wound care complications, labs. A supplemental order was written on 9/23/21 for SN 2 times a week for 4 weeks after hospitalization from to 9/16/21 to 9/22/21 [PT completed the ROC visit on 9/22/21 and the SN did the evaluation for SN services on 9/23/21]. A review of the SN visit note dated 9/23/21 revealed RN # 1 documented the following information, “patient right buttocks stage 4 wound was not assessed at SN eval [evaluation] patient was unable to stand or transfer and is sitting on a small loveseat unable to roll to side so SN can assess wound nor was a caregiver present [sic] …” Further review of the clinical record revealed no evidence the patient’s physician was notified related to RN # 1 ‘s findings. An interview was conducted with RN # on 12/14/21 at approximately 1130 am. During the interview the RN stated, “I called everyone I could think of to tell them about the situation at hand. I called and spoke to the agency management, to the hospital and several other people. I guess I didn’t document it." Further review of the clinical record revealed on 10/7/21 LPN # 2 was able to assess the decubitus to the right buttock and documented the following information, "Location: Right buttock...Onset date: 10/7/21...Type: Pressure Ulcer...Stage: IV...Size: 7 cm x 5 cm x 8 cm..." There is no evidence the physician was notified of the LPN's findings. An interview was conducted with the LPN on 12/14/21. During the interview the LPN stated, "I called the wound center and left a message..." An interview was conducted with the agency director on 12/14/21. During the interview the agency director confirmed there was no evidence the physician was notified.