Every finding on record at North Carolina In-Home Partner-VIII, LLC

An unannounced on-site recertification survey was conducted on 03/24/2025-03/25/2025. No deficiencies to the Medicare Conditions of Participation for Emergencies Preparedness were identified.

An unannounced on-site recertification survey was conducted on 03/24/2025-03/25/2025. Standard level deficiencies to the Medicare Conditions of Participation were identified.

Plan of care must include the following CFR(s): 484.60(a)(2)(i-xvi) The individualized plan of care must include the following: (i) All pertinent diagnoses; (ii) The patient's mental, psychosocial, and cognitive status; (iii) The types of services, supplies, and equipment required; (iv) The frequency and duration of visits to be made; (v) Prognosis; (vi) Rehabilitation potential; (vii) Functional limitations; (viii) Activities permitted; (ix) Nutritional requirements; (x) All medications and treatments; (xi) Safety measures to protect against injury; (xii) A description of the patient's risk for emergency department visits and hospital re-admission, and all necessary interventions to address the underlying risk factors. (xiii) Patient and caregiver education and training to facilitate timely discharge; (xiv) Patient-specific interventions and education; measurable outcomes and goals identified by the HHA and the patient; (xv) Information related to any advanced directives; and (xvi) Any additional items the HHA or physician or allowed practitioner may choose to include. This ELEMENT is not met as evidenced by: Based on agency policy, clinical record review, observation, and staff interviews, the agency failed to include a complete list of medications for 2 of 4 patients with home visits conducted. (#7 and # 8) Findings included: 2. Patient #8 was admitted on 03/05/2025 with a diagnosis of atherosclerosis of the native arteries of the left leg with ulcer (plaque buildup inside the arteries of the leg resulting in a wound). The plan of care for 03/05/2025-05/03/2025 included orders for skilled nurse visits 1 time a week for 1 week, 2 times a week for 1 week, 3 times a week for 7 weeks with 2 PRN (as needed), physical therapy 1 time a week for 9 weeks and “Skilled nurse to instruct on new and changed medication.” During a home visit that was conducted on 03/24/2025 at approximately 3:00 PM physical therapy assistant (PTA) #6 conducted a complete medication review. The medication review found the following medications were not included in the plan of care: Clopidogrel (prevents blood clots) 25 mg take by mouth daily. Furosemide (treats fluid retention) 20mg take by mouth daily. Linzess (treats constipation) 72 mcg take by mouth daily. A review of the clinical record revealed that registered nurse (RN) #9 documented that a medication review was completed on 03/24/2025 prior to the PTA visit. During an interview conducted on 03/25/2025 at approximately 9:40 AM PTA #6 stated, “Every visit I ask about medications and reconcile. I do [update the medication list] if there is something new. Yes, I look at all of the bottles periodically.” During an interview on 03/25/2025 at approximately 2:22 PM RN #9 stated, “I look at whatever the referral says [at admission] and I only put the medication on from that. I asked for an updated med rec [medication reconciliation] sheet from PCP [primary care physician]. Agency policy is to only use med from the discharge list.” During an interview conducted on 03/25/2025 at approximately 2:27 PM when asked about the expectation for medication reconciliation the agency director stated, “Should be reviewed entirely at least once a week and ask every visit and make changes as necessary.” During an interview conducted on 03/25/2025 at approximately 2:30 PM the clinical manager stated, “They [clinical staff] are comparing the list [medication] in [documentation software name] and the bottles.” A policy, Monitoring Medications (revised 07/01/2024), received on 03/25/2025 at 4:30 PM from the agency director stated, “A drug regimen review will be performed on all patients in conjunction with all comprehensive assessments. Additionally, all clinicians will participate in medication review and reconciliation throughout the episode.” Patient #7 was admitted on 11/11/24 with a diagnosis of type 2 diabetes mellitus with foot ulcer (is a disease of inadequate control of blood levels of glucose). The plan of care for 03/11/2025-05/09/2025 included orders for skilled nurse visits (SN) 2 times a week for a week, 3 times a week for 8 weeks, and 2 PRN (as needed) and “Skilled nurse to instruct on new and changed medication.” During a home visit that was conducted on 03/24/2025 at approximately 2:30 PM registered nurse (RN) # 9 conducted a complete medication review. The medication review found the following medications were not included in the plan of care: Folic Acid (electrolyte balance) 400mg take by mouth daily. Hydralazine (treats fluid retention) 25mg take by mouth three times daily. Xarelto (prevention of blood clots) 2.5mg take by mouth twice daily. Carvedilol (treats high blood pressure and heart failure) 6.25mg twice daily. Valsartan (treats high blood pressure and heart failure) 160mg twice daily. During an interview on 03/25/2025 at approximately 2:22 PM RN #9 stated, “I look at whatever the referral says [at admission] and I only put the medication on from that. I asked for an updated med rec [medication reconciliation] sheet from PCP [primary care physician]. Agency policy is to only use from the discharge list.” During an interview conducted on 03/25/2025 at approximately 2:27 PM the agency director stated, “The medication reconciliation should be reviewed entirely at least once a week and at every visit ask a about medication changes and make changes as necessary.”

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 alert the physician of a change of condition for 2 of 2 patients with a documented change of condition (#3 and 4). Findings included: A policy Coordination of Care, From Admit through Discharge (revised on 09/01/2024), received on 03/25/2025 at 4:30 PM from the agency director stated, “Coordination of care with physician/ authorized practitioner at admission throughout care, and at discharge, coordination of services is promoted through routine communication with the patient’s physician when changes occur in the patient’s condition or response to treatment”. 1. Patient #3 was admitted on 11/22/2024 with diagnoses of Non-PRS (non- pressure) chronic ulcer to left lower leg with fat later exposed and heart failure (a chronic condition in which the heart doesn’t pump blood as well as it should). The plan of care for 11/22/2024- 01/20/2025 included orders for skilled nurse visits 1 time a week for two weeks, 2 times a week for 7 weeks with 2 PRN (as needed) and “Skilled nurse to obtain weight every day and notify MD (medical doctor) of weight gain or loss 2- 3lbs (pounds/weight) within 1 day or 5 lbs in 1 week.” Review of the clinical record revealed the following information on 11/29/2024 Patient # 3 had a 7 lb weight gain compared to the weight documented on 11/27/2024. There was no evidence that the LPN (licensed practical nurse) notified the physician. During an interview conducted on 03/25/2025 at 1:19 PM, LPN# 11 stated, “I normally would call and notify the MD, and assess for heart failure.” An interview conducted on 03/25/2025 at 1:20 PM with the clinical manager revealed that the expectation is for the nurses to notify the physician, assess for heart failure symptoms, and follow up. 2. Patient #4 was admitted on 02/18/2025 with diagnoses of necrotizing fasciitis (flesh- eating disease occurs when bacteria enter the body through a break in skin), Type 2 diabetes mellitus with hyperglycemia (a disease of inadequate control of blood levels of glucose) and heart failure (a chronic condition in which the heart doesn’t pump blood as well as it should). The plan of care for 02/18/2025-04/18/2025 included for skilled nurse (SN) visits 2 a week for a week, and 3 times a week for 8 weeks with 3 PRN (as needed). Review of the clinical record revealed RN (registered nurse) # 12 made a routine visit on 3/10/25 and documented the following information, “patient had diminished lung sounds, elevated blood pressure, and complaints of dizziness and vomiting.” Further review revealed no evidence that RN#10 notified the physician. An interview was conducted on 3/25/25 at 1:26PM with RN #12 stated “That she is pretty new to home health not sure what is needed to be done versus what she feels needs to be done.” RN #12 felt the decision was appropriate and was not aware of the previous visit findings from the prior visit. During an interview on 3/25/25 at 1:34PM the clinical manager stated, “the RN should review prior visits… and the event should’ve been reported to MD.”

Infection Prevention CFR(s): 484.70(a) Standard: Infection Prevention. The HHA must follow accepted standards of practice, including the use of standard precautions, to prevent the transmission of infections and communicable diseases. This STANDARD is not met as evidenced by: Based on agency policy, observation, and staff interviews, the agency failed to take precautions to prevent the spread of infection for 1 of 2 patients who received a skilled nurse home visit (patient #7). Findings included: A policy, Hand Hygiene (revised 05/01/2019), received on 03/24/2025 at 4:30 PM from the agency director stated, “Staff performs hand hygiene by handwashing with soap and water or an alcohol- based hand sanitizer [3] after contact with blood, body fluids or excretions, mucous membranes, non-intact skin, wound dressings, or contaminated surfaces.” Patient # 7 was admitted on 11/11/2024 with a diagnosis of type 2 diabetes mellitus (a disease of inadequate control of blood levels of glucose) with foot ulcer. The plan of care for 03/11/2025- 05/09/2025 included orders for skilled nurse (SN) visits 2 times a week for a week, 3 times a week for 8 weeks, and 2 PRN (as needed) and “Wound care to left dorsal foot cleanse with vashe, apply calcium alginate with silver ( apply to anterior and lateral foot areas), cover with ABD pad, 4x4, wrap in kerlix, secure with tape. To be changed daily. Patient/ CG (Caregiver) may perform in SN absence. Left great toe cleanse with wound cleanser, apply calcium alginate, cover with dry gauze, wrap in kerlix, secure with tape. To be changed daily. Patient/ CG may perform in SN absence.” A home visit was conducted on 3/24/2025 at approximately 2:30PM with registered nurse (RN) 9. RN #9 performed hand hygiene, donned clean gloves, removed the soiled dressing, cleansed the wound, retrieved extra 4x4’s, and applied a clean dressing. RN #9 failed to remove contaminated gloves and perform hand hygiene after removing the soiled dressing, before retrieving supplies, and before applying the clean dressing. During an interview conducted on 03/25/2025 at 2:26 PM RN #9 stated, “Yes, I reached in supply box; and did not replace gloves; there was a few times that hand hygiene was missed”. An interview on 03/25/2025 at 2:30 PM with the agency director revealed that the expectation is for the nurses to “Sanitize their hands, don clean gloves, remove the soiled dressing, remove soiled gloves, perform hand hygiene, cleanse the wound, remove gloves, perform hand hygiene, apply clean gloves and apply clean dressing. Never retrieve any supplies from boxes or bags with contaminated gloves.”

Preparing clinical notes CFR(s): 484.75(b)(6) Preparing clinical notes; This ELEMENT is not met as evidenced by: Based on agency policy, clinical record review, and staff interviews, the agency failed to document blood glucose levels for 1 of 5 patients with diabetes mellitus (disease resulting in too much sugar in the blood). (patient # 9) Findings included: A policy Home Care Record (revised 10/01/2023) received on 03/25/2025 at 2:44 PM from the agency director stated, “The patient home care record shall contain the following clinical information… Diagnostic and therapeutic test, procedures, and treatments and their results.” Patient #9 was admitted on 01/17/2025 with a diagnosis of Type 2 Diabetes Mellitus with foot ulcer. The plan of care for 01/17/2025- 03/17/2025 included orders for skilled nurse (SN) visits 1 time a week for 1 week, 3 times a week for 3 weeks, 2 times a week for 5 weeks, and 2 PRN (as needed). Review of the clinical record revealed that during the SN visits on 02/14/2025 and 02/21/2025 licensed practical nurse (LPN) #10 documented, “Patient- CBG [capillary blood glucose] documented in vital sign section.” Further review revealed that the CBG was not documented in the clinical record. LPN #10 was not available for an interview. An interview conducted on 03/25/25 at 10:52 AM with the agency director revealed that the expectation is for the CBG to be documented at every visit.

An unannounced, onsite recertification survey was conducted 05/23/22-05/25/22. No deficiencies to the Emergency Preparedness program were identified. -MHB

An unannounced, onsite recertification survey was conducted 05/23/22-05/25/22. Standard level deficiencies to the Medicare Conditions of Participation were identified. -MHB

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 policy review, clinical record review, and staff interview the agency failed to include Oxygen on the initial Plan of Care for 1 of 2 patients using Oxygen. [ Patient #8]. Findings included: Agency policy received from Agency Executive Director on 5/24/22 at 10:50 a.m., “Coordination of care, Admission through discharge” revised 8/1/19, stated, “ …provides care and services … by Identifying patient needs through assessment and communication with other health care providers… Coordinating patient care among various disciplines to ensure that services are continuous and coordinated from admission through discharge.” Patient #8 had a Start of Care date 05/6/2022. Diagnoses on the Plan of Care [POC] for the Certification Period 05/06/2022 through 07/04/2022 included Chronic Obstructive Pulmonary Disease with (acute) exacerbation; Chronic Obstructive Pulmonary disease with (acute) lower respiratory infection; Pneumonia, unspecified organism and Dependence on supplemental oxygen. Skilled nursing was scheduled for 1 time per week for 9 weeks, 2 PRN [ as needed] for respiratory complications; Home Health Aide 1 time per week for 4 weeks. A review of the “History and Physical” dated 5/3/22, received from the Agency Executive Director on 5/24/22 at 10:50 a.m. stated “Patient currently requiring 2 L of supplemental oxygen, which appears to be her baseline at home.” The OASIS (Outcome and Assessment Information Set) Admission dated 5/6/22, the nurse reported assessment findings of “oxygen saturation level … on oxygen 2.5L.” On 5/23/22 at 5:23 p.m. an interview with the Agency Executive Director verified Oxygen was not on the initial Plan of Care.

Coordination of Care CFR(s): 484.60(d) Standard: Coordination of care. The HHA must: This STANDARD is not met as evidenced by: Based on policy review, clinical record review, and staff interview, the agency failed to follow a physician’s order to perform a pre-albumin level for 1 of 18 records reviewed (Patient #5), failed to obtain an order for wound care for 1 of 4 patients with wounds (Patient #9), and failed to clarify the type and/or amount of insulin that a patient should take for 1 of 8 patients taking insulin (Patient #16). Findings include: Policy 2.1.017 titled Coordination of Care, From Admit Through Discharge was received from the agency director on 05/24/22 at 10:50 AM. This policy revealed, “The agency provides care and services within an integrated continuum of care system. This is accomplished by…identifying patient needs through assessment and communication with other health care providers…coordinating patient care among various disciplines to ensure that services are continuous and coordinated from admission through discharge…” 1. Patient #5 was admitted to the agency on 05/12/22 with diagnoses including Stage 3 (wound that involves the full thickness of the skin to the subcutaneous or fatty layer) pressure ulcers of back, buttock, hip, atrial fibrillation (abnormal heart rhythm), hypertension, Parkinson’s disease, and dementia. Plan of care from 05/12/22 to 07/10/22 revealed orders for skilled nursing 1 time per week for 1 week, 2 times per week for 8 weeks and 2 PRN (as needed) for wound complications. Referral orders dated 05/09/22 included the order to “…please obtain and take to [name of medical center]” for a pre-albumin level. There was no evidence in the clinical record that the pre-albumin level was drawn at the time of survey. In an interview on 05/24/22 at approximately 4:10 PM, Employee #1, the agency director, confirmed that there was no evidence in the clinical record that the ordered lab was drawn and stated that, “it must have gotten missed on admission…it should have been added to the 485 (plan of care)”. 2. Patient #9 was admitted to the agency on 04/20/22 with diagnoses including Stage 2 (wound that involves the top two layers of skin) pressure ulcer of right heel, chronic obstructive pulmonary disease, hypertension, heart disease, Type 2 diabetes, depression, and anxiety. Plan of care from 04/20/22 to 06/18/22 revealed orders for skilled nursing 1 time per week for 1 week, 2 times per week for 8 weeks, and 2 PRN for diabetic complications. Employee #3, a registered nurse, conducted a skilled nursing visit on 04/27/22. This visit note revealed, “…unable to provide ordered wound care today as supplies were not available. Ordered supplies today. Wound are/[sic] provided today was: cleansed with soap and water, patted dry and covered with adhesive foam…” There was no evidence of a physician’s order for the wound care Employee #3 performed on 04/27/22 at the time of survey. In an interview on 05/24/22 at approximately 4:14 PM, Employee #1, the agency director, confirmed that there was no evidence in the clinical record of an order for the wound care Employee #3 performed on 04/27/22 and stated, “The wound care center would usually put that they can use equivalent products...I don’t see where it has it on this one to use equivalent products.” In an interview on 05/25/22 at approximately 8:38 AM, Employee #3 was asked if a physician’s order was obtained for the wound care performed on 04/27/22. Employee #3 stated, “I did not. I know now that I am supposed to. At the time I just thought that I was supposed to do to what I needed to do to take care of that wound.” 3. Patient #16 was admitted to the agency on 05/19/21 with diagnoses including hypertensive heart disease (heart disease related to high blood pressure) with heart failure, acute on chronic combined systolic and diastolic heart failure, and Type 2 diabetes. Plan of care from 05/19/21 to 07/17/21 revealed orders for skilled nursing 1 time per week for 2 weeks, 2 times per week for 1 week, 1 time per week for 1 week, 1 time every 2 weeks for 4 weeks, and 1 time per week for 1 week. On 06/17/21, Employee #8, a licensed practical nurse, conducted a skilled nursing visit for Patient #16. This visit note revealed, “…Showed pt (patient) SSI (sliding scale for insulin). She needs to be checking FSBS (fasting blood sugar) 3X (3 times) daily and taking additional SSI along with 8 units insulin [sic]. She has not been doing this. Denies use of Levemir. Only Lantus at 44 units. Placed call to PCP (primary care physician) to clarify.” There was no evidence of follow up related to clarifying Patient #16’s use of Levemir. On 07/02/21, Employee #9, a licensed practical nurse, conducted a skilled nursing visit for Patient #16. This visit note revealed, “…Contacted [name of medical center] concerning Lantus and Levemir. Pnt (patient) has both in the home and need to confirm which one she is to be on.” There was no evidence of follow up related to clarifying Patient #16’s use of Lantus versus Levemir. On 07/08/21, Employee #9 conducted a skilled nursing visit for Patient #16. This visit note revealed, “…Pnt had appoint with PCP yesterday and insulin was changed to Humalog…still awaiting call back concerning pnt Lantus and Leveimer [sic]. Pnt states that MD (medical doctor) did not address those meds (medications) the appointment [sic]. There was no evidence of follow up related to clarifying Patient #16’s use of Lantus versus Levemir. Patient #16 was discharged from the agency on 07/16/21 without evidence of any clarification made regarding whether the patient was to take Lantus or Levemir. In an interview on 05/25/22 at 11:15 AM, Employee #1, the agency director, stated, “I don’t see it on any coordination notes or any subsequent visits…We tell our clinicians ‘if you’re not getting calls back, let me or (names of the agency’s patient care managers) try to make those calls for you…or enter an MD SBAR (situation, background, assessment, recommendation) coordination note and we will fax it to them’…”