Every finding on record at North Carolina in Hiome Partner-IX LLC

An onsite recertification survey was conducted March 17, 2026 thru March 19, 2026. No deficiencies to the Emergency Preparedness Program were identified.

An onsite recertification survey was conducted March 17, 2026 thru March 19, 2026. A deficiency to the Medicare Conditions of Participation was identified.

A review of all current medications CFR(s): 484.55(c)(5) A review of all medications the patient is currently using in order to identify any potential adverse effects and drug reactions, including ineffective drug therapy, significant side effects, significant drug interactions, duplicate drug therapy, and noncompliance with drug therapy. This ELEMENT is not met as evidenced by: Based on policy and procedure, clinical record review, observation, and patient interview the agency failed to review all current medications for 1 of 1 home visits conducted (#3). Findings included: Review of policy “Monitoring Medications”, revised 07/01/2024 was received from the agency alternate director on 03/19/2026 at 0800. The policy stated,” …the discipline responsible for the drug regimen will…review all medications including over the counter medications…” Patient #18 was admitted on 12/22/2025 with diagnoses of pressure ulcer of left heel, stage 3; fracture unspecified part of left femur (leg); and paroxysmal atrial fibrillation (heart flutter). The plan of care for 02/20/2026 to 04/20/2026 included the following orders: skilled nursing 1 time a week for 9 weeks with 2 as needed for cardiac and wound complications. A home visit was conducted on 03/18/2026 at 1400 with the registered nurse. A review of current medications was conducted with the patient during the home visit. The review revealed the following discrepancies: Golden Guard supplement take 1 tablet daily by mouth for inflammation was not included on the home medication list or medication profile. Arthrozene supplement take 1 tablet daily by mouth for inflammation was not included on the home medication list or medication profile. Interview with the patient and caregiver on 03/18/2026 at 1415 “I’ve been taking these supplements for a couple of months now”.

An onsite recertification and follow up survey was conducted 04/17/23-04/19/23. No deficiencies were identified to the Emergency Preparedness Program.

An onsite recertification and follow up survey was conducted 04/17/23-04/19/23. Deficiencies to the Medicare Conditions of Participation were identified. The following tag was put back into compliance effective 04/19/23- G606.

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 7 of 17 patients (#8,12,2, 7, 9, 11,13); failed to update the Plan of Care with the current/correct medications for 1 of 2 patients with a ROC [resumption of care-comprehensive assessment completed after an inpatient stay] (#2). Findings included: 3A. Patient # 2 had a Start of Care date of 8/19/22 and an admitting diagnosis of pneumonia. Review of the Plan of Care [POC] for the certification period 8/19/22 to 10/17/22 included orders for SN [skilled nursing] 1 time a week for 9 weeks. Review of the POC revealed Aspirin 81 mg take 1 daily listed 2 separate times. During an interview with RN # 1 on 4/19/23 at approximately 11 am, the RN confirmed the POC should not have listed Aspirin twice. 3B. Patient # 2 had a Start of Care date of 8/19/22 and an admitting diagnosis of pneumonia. Review of the Plan of Care [POC] for the certification period 8/19/22 to 10/17/22 included orders for SN [skilled nursing] 1 time a week for 9 weeks. Patient # 2 had an inpatient stay from 8/24/22-9/2/22. The ROC [resumption of care-comprehensive assessment completed after an inpatient stay] was initiated by RN # 10 on 9/9/22. Review of the ROC POC listed Aspirin 81 mg. Take 1 tablet each day. Aspirin was listed twice on the ROC POC. The ROC POC also listed Prednisone [steroid] 10 mg [tapering dose] with a start date of 8/19/22. RN # 10 was not available for interview. An interview was conducted with RN # 1 on 4/19/23 at approximately 11 am. RN # 1 stated, “Those medications should not have carried over to the ROC. They should have been discontinued.” 4. Patient # 7 had a Start of Care date of 3/26/23 and an admitting diagnosis of encounter for surgical aftercare following surgery on the digestive system. Review of the Plan of Care [POC] for the certification period 3/26/23 to 5/24/23 included orders for PT [physical therapy] 1 time a week for 5 weeks. A joint visit was conducted with PTA [physical therapy assistant] # 6 on 4/17/23 at approximately 11:30 am. A medication review was conducted during the visit using a medication profile provided by the agency. The medication profile listed Diazepam [antianxiety medication] 5 mg 1 tablet as needed [no frequency] and Zolpidem [sedative] 5 mg at bedtime. An interview was conducted with the patient during the visit. The patient advised the Diazepam could be taken every 6-8 hours as needed [this was verified by the bottle of medication]. The patient reported, “I haven’t taken the Ambien [Zolpidem] for a very long time. I stopped taking it way before I had surgery.” During an interview with PTA # 6 on 4/19/23 at approximately 10 am, she confirmed the POC did not include the correct medications/dosage the patient was using. 5. Patient # 9 had a Start of Care date of 4/3/23 and an admitting diagnosis of hypertensive heart disease with heart failure. Review of the Plan of Care [POC] for the certification period 4/3/23 to 6/1/23 included orders for PT [physical therapy] 1 time a week for 3 weeks. A joint visit was made on 4/18/23 at approximately 11:30 am with PT # 9. During the visit a medication review was conducted using a medication profile provided by the agency. The medication profile and POC listed Ciprofloxacin [antibiotic] 500 mg take 1 tablet for 3 days with a start date of 4/1/23 and Metronidazole [antibiotic] 500 mg take 1 tablet 3 times a day with a start date of 4/1/23. An interview was conducted with PT # 9 during the visit. PT # 9 confirmed the antibiotics should have been discontinued and removed from the POC. 6. Patient # 11 had a Start of Care date of 4/10/23 and admitting diagnosis of saddle embolus of pulmonary artery [ blood clot that can lead to sudden hemodynamic collapse and death]. Review of the Plan of Care [POC] for the certification period 4/10/23 to 6/8/23 included orders for SN [skilled nursing] 1 time a week for 9 weeks. On 4/18/23 at approximately 9:30 am, a joint visit was made with RN # 2. During the visit, a medication review was conducted using a medication profile provided by the agency. The medication profile listed Metoprolol Succinate [blood pressure] ER 50 mg daily twice. During an interview with RN # 2 on 4/19/23 at approximately 9 am, RN # 2 confirmed the POC listed the medication twice and the medication should have only been listed 1 time. 6. Patient # 13 had a Start of Care [SOC] date of 3/26/23 and admitting diagnoses of acute and chronic respiratory failure with hypoxia [low oxygen levels in the blood], chronic obstructive pulmonary disease [COPD-lung disease], pressure ulcer of sacral region [area below the spine] stage 2 [intact blister or a small crater]. The Plan of Care [POC] for the certification period 3/26/23 to 5/24/23 included an order for Acetaminophen [over the counter pain relief] Extra Strength 500 mg 1-2 tablets as needed. There was no dose or frequency for the medication included on the POC. During an interview with RN # 1 on 4/19/23 at approximately 11 am, the RN confirmed the frequency and indication for the medication was not included on the POC. Review of policy, “Plan of Care”, revised 12/01/21, was received from the agency executive director on 04/18/23 at 2:35 p.m. The policy stated”, …the plan of care includes… medications and treatments… required equipment and supplies 1.Patient #8 was admitted was admitted on 01/14/22 with diagnoses of type 2 diabetes with other skin ulcer, unspecified congestive heart failure, chronic kidney disease, and essential tremor. The plan of care for 03/10/23 to 05/08/23 had orders for skilled nursing 1 time a week for 1 week, and 3 times a week for 8 weeks, and 1 time a week for 1 week. A home visit with the registered nurse was observed on 04/18/23 at 11:10 a.m. The medication review during the home visit revealed the following discrepancy: bisacodyl 5mg (milligrams) 1 tablet by mouth daily as needed for constipation was not included on the medication profile. Interview with the patient/caregiver confirmed the patient has been taking this medication for a while. 2.Patient #12 was admitted on 04/11/23 with diagnoses of osteomyelitis, (bone infection) unspecified, type 2 diabetes, pure hypercholesterolemia, (high cholesterol), and essential hypertension. The plan of care for 04/11/23 to 06/09/23 had orders for skilled nursing 1 time a week for 9 weeks. A home visit was observed on 04/17/23 at 2:45 p.m. with the registered nurse. The medication review during the home visit revealed the following discrepancy: arnica (herbal supplement for pain) twice a day as needed by mouth. Interview with the patient confirmed the patient has been taking this supplement for a long time.

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 clinical record review and staff interviews the agency failed to include all orders in the plan of care for 1 of 10 active patients [#13]. The findings included: 1A. Patient # 13 had a Start of Care [SOC] date of 3/26/23 and admitting diagnoses of acute and chronic respiratory failure with hypoxia [low oxygen levels in the blood], chronic obstructive pulmonary disease [COPD-lung disease], pressure ulcer of sacral region [area below the spine] stage 2 [intact blister or a small crater]. The Plan of Care [POC] for the certification period 3/26/23 to 5/24/23 included orders for PT [physical therapy] 1 time a week for 9 weeks. Review of the clinical record revealed a severe medication interaction [requires the physician to be notified and wait for a response from the physician per the directions noted on the medication interaction template] between Escitalopram [antidepressant] and Hydroxyzine [antihistamine]. Review of the Client Coordination Notes Report revealed an entry dated 3/30/23 by PT # 11. PT # 11 documented, “Notified patient and daughter of MD [physician] notified on order to discontinue Hydroxyzine per MD SBAR [a type of note that included situation, background, assessment and recommendation]. Daughter voices understanding.” Further review of the clinical record revealed no physician’s order to discontinue the medication. An interview was conducted with PT # 11 on 4/19/23 at approximately 10 am. During the interview PT # 11 stated, “The SBAR was emailed, and I advised the daughter the doctor wanted the patient to stop taking the medication. I just assumed the order was already written. I didn’t write the order.” RN # 1 confirmed there was no written order to stop the medication. 1B. Patient # 13 had a Start of Care [SOC] date of 3/26/23 and admitting diagnoses of acute and chronic respiratory failure with hypoxia [low oxygen levels in the blood], chronic obstructive pulmonary disease [COPD-lung disease], pressure ulcer of sacral region [area below the spine] stage 2 [intact blister or a small crater]. The Plan of Care [POC] for the certification period 3/26/23 to 5/24/23 included orders for PT [physical therapy] 1 time a week for 9 weeks. Review of the clinical record revealed routine visits were conducted by PTA [physical therapy assistant] # 6 on 4/4/23 and 4/11/23. On 4/4/23, PTA # 6 documented the following information, “Patient tolerated session…02 [oxygen] drops to the low to mid 80 percentile with activity. Patient requires frequent rest breaks…” During the 4/11/23 visit PTA #6 documented, “Pt [patient] reports he is getting SOB [short of breath] more easily requiring more frequent rest periods…Oxygen [O2] dropping to 85-88%...Patient saw _____ [name of physician] yesterday and 02 was increased to 4 LPM [liters per minute] …” Further review of the clinical record revealed no evidence of an order to increase the 02 flow to 4 liters. During an interview with PTA # 6 on 4/19/23 at approximately 10:15 am, the PTA stated, “No, I didn’t write the order to increase the oxygen flow.”

Conformance with physician orders CFR(s): 484.60(b) Standard: Conformance with physician or allowed practitioner orders. This STANDARD is not met as evidenced by: Based on agency policy, clinical record review and staff interviews the agency failed to follow the Plan of Care [POC] related to obtain lab work for 1 of 10 active patients [#14]; failed to follow the POC related to amount of blood to discard [dispose] of when obtaining blood from a PICC [peripherally inserted central catheter] for lab work for 1 of 2 patients with a PICC line [#14]. The findings included: The policy, Plan of Care [12/1/21], was provided by the agency director on 4/18/23 at 2:10 pm. The policy stated, “…To assure an appropriate plan of care is developed…To ensure that physician/authorized practitioner’s orders are followed…” 1A. Patient # 14 had a Start of Care date of 3/17/23 and admitting diagnoses of dilated cardiomyopathy [heart becomes enlarged and is unable to pump blood effectively], acute on chronic systolic heart failure and encounter for adjustment and management of VAD [vascular access device-allow long term access to the bloodstream]. Review of the Plan of Care [POC] for the certification period 3/17/23 to 5/15/23 included orders for SN [skilled nursing] 2 times a week for 1 week, 1 time a week for 9 weeks and “Skilled nurse to perform lab draw from central line red port access device…obtain weekly on Wednesdays…”Review of the clinical record revealed the law work was not obtained on 4/12/23 in accordance with the POC, but the labs were drawn on 4/13/23 [Thursday]. During an interview with RN # 3 on 4/19/23 at approximately 9 am. During the interview, RN # 3 confirmed the labs were not obtained in accordance with the POC. “He wasn’t at home.” 1B. Patient # 14 had a Start of Care date of 3/17/23 and admitting diagnoses of dilated cardiomyopathy [heart becomes enlarged and is unable to pump blood effectively], acute on chronic systolic heart failure and encounter for adjustment and management of VAD [vascular access device-allow long term access to the bloodstream]. Review of the Plan of Care [POC] for the certification period 3/17/23 to 5/15/23 included orders for SN [skilled nursing] 2 times a week for 1 week, 1 time a week for 9 weeks and “Skilled nurse to flush with 10 ml of normal saline prior to specimen draw. Discard 10 ml of blood…” Review of the clinical record revealed SN visits were made on 3/22/23, 3/29/23, 4/5/23 and 4/13/23. Further review of the clinical record revealed the SN documented she discarded [wasted] 6 cc of blood at each visit. During an interview with RN # 3 0n 4/19/23 at 9 am, the RN confirmed she had wasted 6 cc of blood instead of the 10 cc, as the POC ordered.

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 low oxygen saturations for 1 of 2 patients with supplemental oxygen orders [#13]. The findings included: The policy, Coordination of Care [4/1/23], was provided by the agency director on 4/18/23 at 2:10 pm. The policy stated, “…Coordination of care with physicians…at admission, throughout care, and at discharge…When changes occur in the patient’s condition or response to treatment… Patient # 13 had a Start of Care [SOC] date of 3/26/23 and admitting diagnoses of acute and chronic respiratory failure with hypoxia [low oxygen levels in the blood], chronic obstructive pulmonary disease [COPD-lung disease], pressure ulcer of sacral region [area below the spine] stage 2 [intact blister or a small crater]. The Plan of Care [POC] for the certification period 3/26/23 to 5/24/23 included orders for PT [physical therapy] 1 time a week for 9 weeks. Review of the clinical record revealed routine visits were conducted by PTA [physical therapy assistant] # 6 on 4/4/23 and 4/11/23. On 4/4/23, PTA # 6 documented the following information, “Patient tolerated session…02 [oxygen] drops to the low to mid 80 percentile with activity. Patient requires frequent rest breaks…” During the 4/11/23 visit PTA #6 documented, “Pt [patient] reports he is getting SOB [short of breath] more easily requiring more frequent rest periods…Oxygen dropping to 85-88%...” Further review of the clinical record revealed no evidence the physician was notified of PTA # 6’s findings. During an interview with PTA # 6 on 4/19/23 at approximately 10:15 am, PTA # 6 stated, “The daughter said she would take care of telling the doctor on 4/4/23. The patient had gone back to the doctor on 4/10/23 and the oxygen was increased to 4 liters. I didn’t notify the physician myself.”

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 clinical record review and staff interviews the agency failed to ensure level 2 medication interactions [severe interaction-requires the physician to be notified and wait for a response from the physician] were addressed by the physician for 2 of 5 discharged patients [#2,5]. The findings included: 1. Patient # 2 had a Start of Care date of 8/19/22 and an admitting diagnosis of pneumonia. Review of the Plan of Care [POC] for the certification period 8/19/22 to 10/17/22 included orders for SN [skilled nursing] 1 time a week for 9 weeks. Review of the Client Coordination Notes Report revealed a level 2 [severe interaction-requires the physician to be notified and wait for a response from the physician] medication interaction between Albuterol Sulfate [inhaler used for shortness of breath] and Carvedilol [blood pressure/heart rate] was identified. There was no evidence the agency followed up on the severe interaction with the physician. The patient was inpatient from 8/26/22 until 9/2/22. Review of the ROC [resumption of care-comprehensive assessment completed after an inpatient stay] POC dated 9/9/22 revealed the Albuterol Sulfate inhaler and Carvedilol were listed on the POC. Further review of the clinical record revealed no medication interaction review was conducted at the ROC. During an interview with RN # 1 on 4/19/23 at approximately 11 am, the RN stated, “We do the review and send the level 2’s to the physician. If we do not get a response, we should contact him until there is some type of response. I do not see where we attempted to contact him after the first coordination note.” 2. Patient # 5 had a Start of Care date of 10/30/22 with an admitting diagnosis of other sequelae of cerebral infarction [stroke]. Review of the Plan of Care for the certification period 10/30/22 to 12/28/22 included orders for SN [skilled nursing] 1 time a week for 3 weeks. Review of the Client Coordination Notes Report revealed on 10/31/22 RN # 13 identified a level 2 [severe interaction-requires the physician to be notified and wait for a response from the physician] medication interaction between Fluoxetine [antidepressant] and Plavix [blood thinner]. There is no evidence of a follow-up with the physician related to the severe medication interaction. RN # 13 was not available for interview. An interview with RN # 1 was conducted on 4/19/23 at approximately 11 am, the RN stated, “We do the review and send the level 2’s to the physician. If we do not get a response, we should contact him until there is some type of response. I do not see where we attempted to contact him after the first coordination note.”

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 aseptic technique while collecting a blood specimen during a home visit for 1 of 7 visits observed (#12). Findings included: Review of policy “Blood Sampling via Peripheral or Central Venous Access Route”, revised 07/01/2010 was received from the executive director on 04/18/23 at 2:35 p.m. The policy stated,” …use aseptic technique and observe standard precautions throughout blood specimen collection procedure, including sharps disposal…” 1.Patient #12 was admitted on 04/11/23 with diagnoses of osteomyelitis, (bone infection) unspecified, type 2 diabetes, pure hypercholesterolemia, (high cholesterol), and essential hypertension. The plan of care for 04/11/23 to 06/09/23 had orders for skilled nursing 1 time a week for 9 weeks. The registered nurse was observed not having a barrier under venipuncture supplies of saline, heparin and clean gloves on the patients table during the home visit on 04/17/23 at 3:10 p.m. The registered nurse also put blood in a plastic bag and placed it on the couch cushion prior to putting it in the cooler with ice at 3:44 p.m. on 04/17/23. Interview with registered nurse #3 on 4/19/23 at 8:56 a.m. revealed, “no, I usually put a barrier under the supplies, and I am organized…I usually put the blood into the bag directly, not lay it on something”.

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 view and staff interviews the SN [skilled nurse] failed to obtain wound measurements for 1 of 3 patients with a wound [#13]. The findings included: Review of a policy “Wound Assessment, Documentation, and Photography”, revised 08/01/22 was received from the executive director on 04/18/23 at 2:10 p.m. The policy stated,” …. assessment includes measurement of length, width, and depth, undermining and tunneling, wound bed description, wound edges, exposed tissue types, draining and the condition of the peri wound…Unless otherwise ordered by the physician, the qualified clinician will assess wounds at least…every other week for patients receiving wound care by the agency at a frequency less than daily…” Patient # 13 had a Start of Care date of 3/26/23 and admitting diagnoses of acute and chronic respiratory failure with hypoxia [low oxygen levels in the blood], chronic obstructive pulmonary disease [COPD-lung disease], pressure ulcer of sacral region [area below the spine] stage 2 [intact blister or a small crater]. The Plan of Care [POC] for the certification period 3/26/23 to 5/24/23 included orders for SN [skilled nursing] 1 time a week for 5 weeks and “SN to perform/instruct/reinforce patient/caregiver procedure of wound care to sacrum three times weekly…” Review of the clinical record revealed on 3/26/23 the wound measured 0.3 cm x 0.3 cm x 0.1 cm [sacral stage 2]. SN visits were made on 4/6/23 and 4/14/23. Further review of the clinical record revealed no wound measurements for those visits. During an interview with RN # 1 on 4/19/23 at approximately 11 am, the RN confirmed no measurements were obtained.

Preparing clinical notes CFR(s): 484.75(b)(6) Preparing clinical notes; This ELEMENT is not met as evidenced by: Based on policy review, client record review, and staff interview the agency failed to measure wounds for 1 of 3 patients with wounds (#3) failed to document patient/caregiver education related to wound care for 1 of 3 patients with a wound (#13); failed to document correct PICC line measurements for 1 of 2 patients with a PICC line [peripherally inserted central catheter] (#14). Findings included: 2. Patient # 13 had a Start of Care [SOC] date of 3/26/23 and admitting diagnoses of acute and chronic respiratory failure with hypoxia [low oxygen levels in the blood], chronic obstructive pulmonary disease [COPD-lung disease], pressure ulcer of sacral region [area below the spine] stage 2 [intact blister or a small crater]. The Plan of Care [POC] for the certification period 3/26/23 to 5/24/23 included orders for SN [skilled nursing] 1 time a week for 5 weeks and “SN to perform/instruct/reinforce patient/caregiver procedure of wound care to sacrum three times weekly and PRN [as needed] soiled [sic]. Cleanse with warm soap [sic] and water/wound cleanser. Apply zinc oxide cover with foam dressing…” RN # 10 initiated the SOC on 3/26/23. The next visit was made on 4/6/23. Review of the clinical record revealed no evidence the RN educated the patient/caregiver on how to complete the dressing change. RN # 10 was not available for interview. During an interview with RN # 1 on 4/19/23 at approximately 11 am, RN # 1 stated the information should have been documented in the visit note. 3A. Patient # 14 had a Start of Care date of 3/17/23 and admitting diagnoses of dilated cardiomyopathy [heart becomes enlarged and is unable to pump blood effectively], acute on chronic systolic heart failure and encounter for adjustment and management of VAD [vascular access device-allow long term access to the bloodstream]. Review of the Plan of Care [POC] for the certification period 3/17/23 to 5/15/23 included orders for SN [skilled nursing] 2 times a week for 1 week, 1 time a week for 9 weeks an “SN to provide routine PICC [peripherally inserted central catheter] care…SN for observation and assessment of IV [intravenous] access site…” Review of the clinical record revealed RN # 10 completed the start of care visit and documented the length of PICC line catheter from insertion site to catheter hub as 4.5 cm. On 3/22/23, RN # 3 documented 4.5 cm as the exposed length of PICC line catheter from insertion site to catheter hub. On 4/5/23, RN # 3 documented 14 cm as the exposed length of PICC line catheter from insertion site to catheter hub. RN # 10 was not available for interview. RN # 3 was interviewed on 4/19/23 at 9 am. During the interview, the RN stated the correct measurement was 14 cm, not 4.5 cm. 3B. Patient # 14 had a Start of Care date of 3/17/23 and admitting diagnoses of dilated cardiomyopathy [heart becomes enlarged and is unable to pump blood effectively], acute on chronic systolic heart failure and encounter for adjustment and management of VAD [vascular access device-allow long term access to the bloodstream]. Review of the Plan of Care [POC] for the certification period 3/17/23 to 5/15/23 included orders for SN [skilled nursing] 2 times a week for 1 week, 1 time a week for 9 weeks an “SN to provide routine PICC [peripherally inserted central catheter] care…SN for observation and assessment of IV [intravenous] access site…” Review of the clinical record revealed no PICC line measurements for the visit on 3/29/23. During an interview with RN # 3 on 4/19/23 at 9 am, the RN stated, “I thought I measured the line. I guess I didn’t chart it.” Review of a policy “Wound Assessment, Documentation, and Photography”, revised 08/01/22 was received from the executive director on 04/18/23 at 2:10 p.m. The policy stated,” …. assessment includes measurement of length, width, and depth, undermining and tunneling, wound bed description, wound edges, exposed tissue types, draining and the condition of the periwound….”. The policy, Dressing Change Procedure for Central Venous, Midline, and Peripherally Inserted Central Catheters [10/1/16], was provided by the agency director on 4/18/23 at 2:10 pm. The policy stated, “…Inspect catheter, catheter exit site…Measure external length of catheter from the insertion site to the catheter hub…” 1.Patient #3 was admitted on 07/21/22 with diagnoses of type 2 diabetes with foot ulcer, non-pressure chronic ulcer to other right foot, COVID-19, and heart failure. The plan of care for 07/21/22 to 09/18/22 had orders for skilled nursing 1 time a week for 1 week, 2 times a week for 1 week, and 1 time a week for 7 weeks. Orders for skilled nursing to perform/instruct/reinforce patient caregiver procedure of wound care to the dorsal (back) aspect of right foot daily. Cleanse with soap and water, rinse and dry well, apply Silvadene cream (used for burns and wounds) and leave open to air. Review of skilled nursing notes for dates of 07/22/22, 07/26/22, 07/29/22, 08/06/22, 08/09/22, 08/17/22, and 08/22/22 revealed measurements were not obtained for the week of 07/26/22 nurse visits. Interview with Nurse #2 on 4/19/23 at 9:15 a.m. revealed, “I guess I didn’t do it, I should have measured them, I guess I failed to measure that week”

Supervision of home health aides CFR(s): 484.80(h) Standard: Supervision of home health aides. This STANDARD is not met as evidenced by: Based on policy review, client record review, and staff interview the agency failed to provide home health aide supervision for 1 of 1 home health aide records reviewed (#6). Findings included: Review of policy “Home Health Aide Supervision”, approved 04/01/2023 was received from the executive director 4/18/23 at 2:35 p.m. The policy stated,” …at least every 14 days, with or without aide present; in home supervision is required during initial visit by the aide or when there is a change in personnel…” Patient #6 was admitted on 11/27/22 and included diagnoses of infection/inflammation reaction due to internal fracture of spine, type 2 diabetes, osteomyelitis of vertebra, spinal stenosis and pressure ulcer of left heel, unstageable. Review of the plan of care for 03/27/23 to 05/25/23 had orders for the home health aide for 1 time a week for 9 weeks. Review of the home health aide visits for 03/27/23, 04/03/23, and 04/10/23 revealed a supervision visit was not done the week of 04/03/23. Interview with the executive director on 4/19/23 at 10:39 a.m. confirmed that 2 weeks of the aide supervisory visits were not completed.

An unannounced onsite complaint investigation was conducted on 09/07/21. The complaint was substantiated. A deficiency to the Medicare Conditions of Participation was identified. ABH

Integrate all services CFR(s): 484.60(d)(3) Integrate services, whether services are provided directly or under arrangement, to assure the identification of patient needs and factors that could affect patient safety and treatment effectiveness and the coordination of care provided by all disciplines. This ELEMENT is not met as evidenced by: Based on agency policy and procedure, clinical record review, complaint log review, and staff interviews the agency failed to coordinate care between staff for 1 of 3 patients records reviewed (#1). Findings included: A policy, “Coordination of Care, From Admit Through Discharge”, revised 04/01/2021 was received from the executive director on 09/07/21 at 12:39 p.m. The policy stated, “patient care is coordinated among various disciplines and services through care planning processes to ensure continuity of care from admission to discharge: this includes…completed visit notes will be submitted to the agency via synchronization within 24 hours of visit for point of care agencies…appropriate, timely communication with the patient, caregivers, and staff involved in the patient’s care regarding patient needs, goals, and care as well as changes in these”. Patient #1 had a SOC (start of care) of 08/25/2021 and included diagnoses of non-st elevation myocardial infarction, and weakness. Orders were for physical therapy 1 time a week for 1 week, 2 times a week for 3 weeks, 1 time a week for 2 weeks, 1 every 2 weeks for 2 week; skilled nursing 1 time a week for 1 week effective 08/29/21, and occupational therapy 1 time a week for 1 week effective 08/29/21. Review of on call coordination note for 08/28/21 revealed the caregiver for Patient #1 called on 08/28/21 to see when a nurse was coming out to visit. The admission visit was conducted by the physical therapist on 08/25/21 and the documentation was not completed as of 08/28/21. The registered nurse on call could not see Patient #1’s information in her tablet and called the office manager. The office manager told the registered nurse the patient was on the schedule for 08/30/21 to be seen by a nurse. The registered nurse called the caregiver back and told her that a nurse was scheduled for a visit on 08/30/21. Per the coordination note the caregiver was agitated and said that she did not understand why it was taking so long and was this normal. The registered nurse told the caregiver- I did not think it was normal procedure and asked the caregiver was there anything that she could help her with over the phone. The caregiver stated no. The registered nurse did not call the agency administer on call. Review of the agency complaint log revealed Patient #1 called in a complaint to the agency on 08/30/21 and refused further treatment from the agency. 9/7/21 at 12:34 p.m. Interview with business manager on 09/07/21 at 12:34 p.m. revealed, “ I handle the non-clinical aspects of the schedule, I can look to see when patients are due to be seen”. Interview with the physical therapist on 09/07/21 at 12:48 p.m. revealed, “I didn’t fill out the schedule in the handbook folder because I saw on the calendar in the computer that a nurse was scheduled to come out on 08/27/21 , and I told them that the nurse would call them and set that up”. Interview with executive director on 9/7/21 at 12:54 p.m. revealed, “ our software creates a hard stop that if someone doesn’t have the documentation in the system timely within 24 hours the clinical record information can’t be seen by other clinicians”.

An onsite recertification was conducted 03/15/21 to 03/17/21. No deficiencies were identified to the Emergency Prepardeness Program. ABH

An onsite recertification survey was conducted 03/15/21 to 03/17/21. Deficiencies were identified to the Medicare Conditions of Participation. ABH

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, client record review, and staff interview the agency failed to include all medications on the plan of care for 1 of 3 patients on oxygen (#9). Findings included: Review of a policy "Plan of Care", revised 01/01/21 was received from the executive director on 03/17/21 at 10:37 a.m. The policy stated," ....the plan of care includes ... medications and treatments ...". Patient #9 was admitted on 02/08/21 with diagnoses of copd (chronic obstructive pulmonary disease), COVID-19, essential hypertension, unspecified kidney failure, hypothyroidism, long term use of steroids, and long-term use of anticoagulants. Review of the start of care oasis visit on 02/08/21, and skilled nursing visit 02/22/21 revealed the patient was on oxygen therapy, but it was not included on the plan of care. Interview with Employee # 4 on 03/17/21 at 9:02 a.m. revealed " it should be on his med list if it not on there". Interview with Employee #5 on 03/17/21 at 10:09 a.m. revealed " I forgot to put oxygen on the med list he is on oxygen".

Preparing clinical notes CFR(s): 484.75(b)(6) Preparing clinical notes; This ELEMENT is not met as evidenced by: Based on policy review, client record review, and staff interview the agency failed to measure wounds for 5 of 10 patients with wounds (#1,11,12,13, & 20). Findings included: Review of a policy "Wound Assessment, Documentation, and Photography", revised 02/01/21 was received from the executive director on 03/16/21 at 8:56 a.m. The policy stated," ....assessment includes measurement of length, width, and depth, undermining and tunneling, wound bed description, wound edges, exposed tissue types, draining and the condition of the periwound ....". 1. Patient #1 was admitted on 01/25/21 with diagnoses of COVID-19, pneumonia , copd(chronic obstructive pulmonary disease), acute respiratory failure, essential hypertension, and type 2 diabetes The plan of care for 01/25/21 to 03/25/21 had orders for skilled nursing 3 times a week for 1 week, then 1 times a week for 8 weeks with 2 as needed visits. Orders for skilled nursing to perform/instruct/reinforce patient caregiver procedure of wound care orders to the right lateral lower leg were skilled nurse to cleanse with wound cleanser, pat dry, apply xeroform, cover with bordered dressing using clean technique. Review of skilled nursing notes for dates of 01/25/21, 01/27/21, 01/29/21, 02/02/21, 02/09/21, 02/16/21, 02/23/21, 03/02/21, and 03/09/21 revealed measurements were not obtained for the week of 01/25/21 skilled nurse visits. Interview with the Employee #2 on 3/17/21 at 8:46 a.m. revealed" I didn't get any measurements on those visits". Interview with Employee #3 at 9:09 a.m. revealed " I honestly don't remember; I usually get measurements on the soc". 2. Patient #11 was admitted was admitted on 10/01/20 with diagnoses of laceration without foreign body, left lower leg, heart disease, old MI, heart failure, type 2 diabetes, acquired absence of left leg below the knee, long term use of anticoagulants. The plan of care for 01/29/21 to 03/29/21 had orders for skilled nursing 1 time a 1 week for 1 week, 2 times a 1 week, and 1 time a week for 7 weeks. Orders for skilled nursing to perform/instruct/reinforce patient caregiver procedure of wound care to left below knee amputation stump daily-cleanse with normal saline or wound cleanser apply moist to dry gauze to wound bed cover with dry gauze wrap with conform gauze and secure with coban using clean technique. Review of skilled nursing notes for dates of 01/25/21, 01/29/21, 02/01/21, 02/04/21, 02/09/21, 02/15/21, 02/22/21, 03/03/21, 03/09/21, and 03/15/21 revealed measurements were not obtained for 02/01/21, 02/04/21, and 02/09/21. Interview with Employee #2 on 03/17/21 at 8:48 a.m. revealed " I didn't' measure on either of those visits, I didn't see a buddy code, we are supposed to measure on the first visit of the week". Interview with Employee #3 on 03/17/21 at 9:12 a.m. revealed "I try measure on the first day of the week, I must have thought the patient was going to be seen again this week". 3. Patient #12 was admitted on 02/16/21 with diagnoses of Type 2 diabetes, pressure ulcer of right buttock stage 2, pressure ulcer of left buttock stage 2, heart disease, essential hypertension, sleep apnea, bipolar disorder, and anxiety disorder. The plan of care for 02/16/21 to 04/16/21 had orders for skilled nursing 2 times a week for 2 weeks, 1 time a week for 4 weeks, and 1 time every 2 week for 4 weeks. Orders for skilled nursing to perform/instruct /reinforce patient/caregiver procedure of wound care to bilateral lower buttocks daily and prn cleanse with mild soap and water apply barrier cream using clean technique. Review of skilled nursing notes for dates of 02/16/21, 02/19/21, 02/23/21, 02/26/21, 03/01/21, 03/08/21, and 03/15/21 revealed no measurements were obtained for 03/01/21, and 03/08/21. Interview with Employee #4 on 3/17/21 at 9:03 a.m. revealed "unable to measure, almost healed". Interview on 3/17/21 at 9:04 a.m. with the executive director revealed "...the nurse should have made a note in the record if she wasn't able to measure the wounds..." 4. Patient #13 was admitted on 01/24/21 with diagnoses of aftercare following surgery, essential hypertension, type 2 diabetes, chronic atrial fibrillation, hyperlipemia, long term use of anticoagulants, acquired absence of left foot, and a history of falling. The plan of care for 01/24/21 to 03/24/21 had order for skilled nursing 2 times a week for 1 week and 1 time a week for 8 weeks. Orders for skilled nursing to perform/instruct/reinforce patient/caregiver procedure of wound care to left foot every other day cleanse with wound cleanser apply calcium alginate ag (silver) cover with bordered gauze suing clean sterile technique. Review of skilled nursing notes for dates of 01/24/21, 01/28/21, 2/4/21, 2/11/21, 2/17/21, 2/25/21, 3/4/21, and 3/11/21 revealed no measurements were obtained for 2/4/21, 2/11/21, 2/17/21, and 3/4/21. Interview with Employee #2 on 3/17/21 at 8:50 a.m. revealed " no measurements are there for 2/4/21". Interview with Employee #6 on 3/1/21 at 10:12 a.m. revealed " I didn't get a buddy code to remind me to measure on those days". 5. Patient #20 was admitted on 07/10/20 with diagnoses of type 2 diabetes, heart failure, end stage renal disease, anemia, pulmonary hypertension, uti (urinary tract infection), atrial fibrillation, pressure ulcer of sacral region stage 2, pressure ulcer of right buttock stage 2, and dependence on oxygen. The plan of care for 07/10/20 to 09/07/20 had orders for skilled nursing 1 time a 1 for 1 week, 2 times a week for 2 weeks, and 1 time a week for 6 weeks with 2 as needed visits. Orders for skilled nursing to perform/instruct/reinforce patient/caregiver procedure of wound care to sacral area 3 times a week and as need for soiled dressing cleanse with wound cleanser apply angel paste, cover with sacral mepilex bordered dressing using clean technique. Review of skilled nursing notes for dates of 07/10/20, 07/15/20, 07/17/20, 07/22/20, 07/24/20, 07/29/20, and 08/03/20 revealed no measurements were obtained for 07/24/20. Interview with Employee #8 on 3/17/21 at 10:08 a.m. revealed " I'm pretty sure I measured the other wounds, I put in new orders, I got twisted up, I missed documenting the other measurements".