Every finding on record at North Carolina in Home Parrtner III, LLC

An onsite recertification survey was conducted 2/24/25-2/26/25. No deficiencies to the Emergency Preparedness Program were identified.

An onsite recertification survey was conducted 2/24/25-2/26/25. Deficiencies to the Medicare Conditions of Participation were identified.

Plan of care must include the following CFR(s): 484.60(a)(2)(i-xvi) The individualized plan of care must include the following: (i) All pertinent diagnoses; (ii) The patient's mental, psychosocial, and cognitive status; (iii) The types of services, supplies, and equipment required; (iv) The frequency and duration of visits to be made; (v) Prognosis; (vi) Rehabilitation potential; (vii) Functional limitations; (viii) Activities permitted; (ix) Nutritional requirements; (x) All medications and treatments; (xi) Safety measures to protect against injury; (xii) A description of the patient's risk for emergency department visits and hospital re-admission, and all necessary interventions to address the underlying risk factors. (xiii) Patient and caregiver education and training to facilitate timely discharge; (xiv) Patient-specific interventions and education; measurable outcomes and goals identified by the HHA and the patient; (xv) Information related to any advanced directives; and (xvi) Any additional items the HHA or physician or allowed practitioner may choose to include. This ELEMENT is not met as evidenced by: Based on policy review, observation, client record review, and patient interview, the agency failed to include all medications on the plan of care for 1 of 4 home visits conducted (14). Findings included Review of a policy “Monitoring Medications”, revised 7/1/2024 was received from the agency director on 2/26/25 at 10:50 AM. The policy stated, “… the discipline responsible for the drug regimen review will review all medications…” 1. Patient #14 was admitted on 1/30/25 with diagnoses of malignant neoplasm of upper lobe, left bronchus or lung; secondary malignant neoplasm of right lung, and cellulitis (infection) of right toe, disorder of the skin. Orders were for skilled nursing 1 time a week for 2 weeks, 2 times a week for 1 week, and 1 time a week for 6 weeks with 2 prns (as needed) visits. A home visit was conducted on 2/25/25 at 1:30 PM with the registered nurse. A review of current medications was conducted with the patient during the home visit. The review revealed the following discrepancy: timolol 0.5% eye drops 1 drop in both eyes 2 times a day for glaucoma was not included on the current medication list. Per interview with the patient “I have been using these drops for about 5 years”.

Only as ordered by a physician CFR(s): 484.60(b)(1) Drugs, services, and treatments are administered only as ordered by a physician or allowed practitioner. This ELEMENT is not met as evidenced by: Based on policy review, client record review, and staff interview, the agency failed to include all vital signs as ordered for 1 of 5 discharged records reviewed (4). Findings included: Review of a policy “Physician Orders”, revised 10/1/2023 was received from the agency director on 2/26/25 at 10:50 AM. The policy stated, “…services are provided according to the most recent orders…” 1. Patient #4 was admitted on 4/24/24 with sepsis (infection), viral infections, chronic bronchitis, and unspecified atrial fibrillation (fast heart rate). Orders were for physical therapy 2 times a week for 3 weeks, and 1 time a week for 2 weeks. Review of the physical therapy visit on 5/21/24 did not include vital signs as ordered by the physician. Interview with the agency director on 2/26/25 at 8:45 AM confirmed the vital signs were missing on the visit note for 5/21/24.

An onsite recertification survey was conducted 03/21/22-03/22/22. No deficiencies to the Emergency Preparedness Program were identified. ABH

An on site recertification survey was conducted 03/21/22- 03/22/22. Deficiencies to the Medicare Conditions of Participation were identified. ABH

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 client record review, and staff interview the agency failed to provide home health aide services as ordered on the plan of care for 1 of 2 home health aide records reviewed (#20), and failed to provide skilled nursing services as ordered on the plan of care for 1 of 15 nursing records reviewed (#18). Findings included: 1.Patient #20 was admitted on 04/24/21 with diagnosis of fracture of vertebra. The plan of care for 04/24/21 to 06/22/21 had orders for home health aide 1 time a week for 5 weeks. Review of the clinical record on 03/22/22 revealed no visit notes were in the record for the home health aide for the week of 5/2/21. An order was in the record to discontinue the home health aide services for the week of 5/13/21 per patient request. Interview with the agency director on 03/22/21 at 2:48 p.m. revealed, “the skilled nursing missed visit was marked but the home health aide was not marked on the missed visit note”. 2.Patient #18 was admitted on 02/26/22 with diagnoses of other specified polyneuropathies (damage to the peripheral nerves), essential hypertension, gerd (gastro esophageal reflux disease), depression, and history of falling. The plan of care for 02/26/22 to 04/26/22 had orders for skilled nursing 1 time a week for 1 week, 2 times a week for 3 weeks, and 1 time a week for 6 weeks. Review of the clinical record on 03/22/22 revealed only 1 skilled nursing visit was conducted for the weeks of 2/28/22 and 03/07/22. Interview with agency director on 3/22/22 at 2:52 p.m. revealed, “ the nurse missed a visit for 3/7 and 3/14 missed visits were marked for the aide only and not for the nurse”.

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 policy review, client record review, and staff interview the clinical record failed to include PICC (peripherally inserted central catheter) line measurements for 1 of 2 records reviewed with a PICC line (#10). Findings included: Review of policy “Insertion of Intravenous Midline and Peripherally Inserted Central Catheters”, revised 02/01/2014 was received from the agency director on 03/22/22 at 8:48 a.m. The policy stated,” …medical record documentation shall include the following…measurement of upper arm circumference…”. 1. Patient #10 was admitted on 03/03/22 with diagnoses of heart disease, atrial fibrillation, type 2 diabetes, copd (chronic obstructive pulmonary disease), and essential hypertension. The plan of care for 03/03/22 to 05/01/22 had orders for skilled nursing 1 time a week for8 weeks, and 2 times a week for 1 week. Review of skilled nursing notes for dates of 03/03/22, 03/07/22, 03/14/22, and 03/21/22 revealed measurements were not obtained on 03/07/22 . Interview with the agency director on 03/22/22 at 8:48 a.m. confirmed PICC line measurements were not in the record for 3/7/22.