Every finding on record at Novus Lifecare Home Health of Clinton, LLC

The Emergency Preparedness regulations were reviewed as part of the Medicare recertification survey completed on 06/03/2026. During the survey it was determined the home health provider is in compliance with the requirements of 42 CFR 484.102 Condition of Participation: Emergency Preparedness for Home Health Providers.

A partial extended survey for Medicare recertification for the home health provider was completed on 06/03/2026. The provider had 54 current patients.

Access to auxiliary aids and language service CFR(s): 484.50(c)(12) Be informed of the right to access auxiliary aids and language services as described in paragraph (f) of this section, and how to access these services. This ELEMENT is not met as evidenced by: Based on admission packet review and interview, the home health provider failed to ensure patients were informed of the right to have access to auxiliary aids and how to access these services. This deficient practice has the potential to affect all patients served by the provider. Findings included: Review of the providers admission packet titled, “Home Health Admission Booklet,” dated 2026-2027 showed in part: - Patient rights and resposibilities: * The patient has the right/responsibility: * To be given the option of an interpreter if needed by the completion of second visit. To be informed that language assistance will be provided using competent bilingual staff, staff interpreters, contracts, formal arrangements with local organizations providing interpretation services, or technology and telephonic interpretation services; and * The agency failed to include patients have the right to be informed of the right to access auxiliary aids (essential devices, services and technologies that ensure effective communication for individuals with disabilities) and how to access these services. During an interview on 06/03/2026 at 3:58 PM, the administrator stated that auxiliary aids were essential devices and technology for individuals with disabilities and that it was not included in the handbook.

Accessibility CFR(s): 484.50(f)(1,2) Standard: Accessibility. Information must be provided to patients in plain language and in a manner that is accessible and timely to— (1) Persons with disabilities, including accessible web sites and the provision of auxiliary aids and services at no cost to the individual in accordance with the Americans with Disabilities Act and Section 504 of the Rehabilitation Act. (2) Persons with limited English proficiency through the provision of language services at no cost to the individual, including oral interpretation and written translations. This STANDARD is not met as evidenced by: Based on admission packet review and interview, the home health provider failed to ensure patients were informed of the right to have access to patient rights information that was provided and accessible to persons with disabilities. This deficient practice has the potential to affect all patients served by the provider. Findings included: Review of the admission folder, provided to the state agent coordinator on 06/01/2026, showed the notice of patient rights and other information given to a patient during the initial visit, failed to contain information regarding this patient right. During an interview on 06/03/2026 at 3:58 PM, the administrator stated that the patient rights failed to contain the right to contain provision of auxiliary aids and how to access auxiliary aids. It was not included in the handbook.

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 review, record review, observation, and interview, the home health provider failed to ensure that all medications the patient was taking were current in one of three home visit observation records reviewed (Record/Patient #2). This deficient practice has the potential to affect all the patients served by the provider. Findings included: Review of the provider’s undated policy titled, “Medication Profile,” showed in part the following: - To ensure all patients and clients have a current list of medications; - The comprehensive assessment includes a review of all medications the patient is currently using, both prescription and non-prescription; - The drug regimen review occurs as an ongoing part of the care to the patient; - The medication profile must contain all current patient medication(s); - Medication profiles must be updated at least every 60 days, and whenever there is a change in the medication regimen; - The nurse performs ongoing medication monitoring; - A medication profile will be filled out upon initial evaluation of each patient/client. A copy is kept in the patient/client home and updated as personnel are made aware of any changes; - The copy that is placed in the patient/client’s chart will be updated, as appropriate, but no less than every recertification period; and - The profile will include both prescription and non-prescription medications. RECORD/PATIENT #2: Review of the clinical record showed the patient was admitted to home health services on 05/11/2026 with a primary diagnosis of acute and chronic respiratory failure with hypoxia (body's tissues and organs do not receive enough oxygen to function properly), secondary diagnosis includes hypertensive heart and chronic kidney disease with heart failure and unspecified chronic kidney disease (CKD) (high blood pressure, stage 1, 2, 3, 4, or unspecified CKD, and damage to the heart that results in the heart’s inability to pump effectively) and congestive heart failure (CHF; a decrease in the ability of the heart to pump blood). The patient resided at home with his/her spouse. Review of the plan of care (POC), dated 05/11/2026 through 07/09/2026, showed the skilled nurse (SN) was to visit the patient 1w1 (one time a week for one week), 2w1 (two times a week for one week), and 1w7 (one time a week for seven weeks). The SN made weekly visits. Observation and interview on 06/02/2026 at 1:44 PM, showed the following discrepancies between the provider's current medication profile (printed on 06/01/2026) and the patient's home medication bottles: - The provider’s current medication profile showed the patient was to use MiraLax (constipation) Oral 17 gram (GM)/scoop in 8 ounces fluid daily as needed. The spouse/caregiver stated that he/she took in the AM and afternoon after seeing the physician; - The provider’s current medication profile showed the patient’s trazodone (antidepressant) hydrochloride (HCL) oral 50 milligrams (mg) one tablet at night for sleep was discontinued 05/22/2026. The spouse/caregiver stated that he/she restarted the trazodone; - The provider’s current medication profile showed the patient’s amlodipine (blood pressure) besylate oral 10 mg one tablet in AM was discontinued 05/22/2026. The spouse/caregiver stated that he/she restarted the amlodipine after seeing the physician; - The patient’s spouse/caregiver stated he/she takes nephplex (vitamin and mineral supplement formulated specifically for patients undergoing kidney dialysis) one by mouth every twenty-four hours (filled 05/12/2026 and takes midday). The provider’s medication profile failed to include nephplex; - The patient’s spouse/caregiver stated he/she takes zinc picolinate (zinc supplement) 50 mg one by mouth in the AM. The provider’s medication profile failed to include zinc picolinate; - The patient’s spouse/caregiver stated he/she takes torsemide (diuretic) 20 mg one by mouth in AM and PM. The provider’s medication profile failed to include torsemide; - The patient’s spouse/caregiver stated he/she takes hydroxyzine (antihistamine) 25 mg one by mouth three times a day as needed. The provider’s medication profile failed to include hydroxyzine; and - The patient’s spouse/caregiver stated he/she takes magnesium oxide (magnesium supplement) 400 mg one by mouth two times a day. The provider’s medication profile failed to include magnesium oxide. During an interview on 06/03/2026 beginning at 12:45 PM, the administrator stated that the SN reconciled medications at the start of care and with any medication changes.

Plan of care CFR(s): 484.60(a)(1) Each patient must receive the home health services that are written in an individualized plan of care that identifies patient-specific measurable outcomes and goals, and which is established, periodically reviewed, and signed by a doctor of medicine, osteopathy, or podiatry acting within the scope of his or her state license, certification, or registration. If a physician or allowed practitioner refers a patient under a plan of care that cannot be completed until after an evaluation visit, the physician or allowed practitioner is consulted to approve additions or modifications to the original plan. This STANDARD is not met as evidenced by: Based on policy review, record review, and interview, the home health provider failed to ensure that each patient received the home health services that were written in the individualized plan of care (POC), in but not limited to, one of five records reviewed (Record/Patient #5). This deficient practice has the potential to affect all the patients on service. Findings included: Review of the provider’s undated policy titled, "Care Plan,” showed in part: - Each patient will have an individualized plan of care that specifies the care and services necessary to meet the patient's specific needs as identified in the comprehensive assessment; and - Home health services for members of the agency (provider) staff, as well as those under contractual arrangements, shall be provided in accordance with the plan of treatment and the patient care plan. RECORD/PATIENT #5: Review of the clinical record showed the patient was admitted to home health services on 01/12/2026 with a primary diagnosis of fracture of the lower end of the left femur, subsequent for closed fracture with routine healing (a break in the lower part of the thigh bone above the knee). The patient resided at home with their spouse. Review of the POC, dated 01/12/2026 to 03/12/2026 showed physical therapy 2 wk 3 (twice a week for three weeks), 1 wk 6 (once a week for six weeks). Further review of week one of the clinical record showed: - A physical therapy evaluation on 01/12/2026; - A note dated 01/16/2026 with “This physical therapy assistant (PTA) was unavailable and couldn't see the patient with schedule conflict and limited staffing. Other clinicians were not able either.”; and - Physical therapy failed to perform a second visit for the week of 01/11/2026 to 01/17/2026, as ordered in the POC.. During an interview on 06/03/2026 beginning at 3:14 PM the clinical manager stated that this PTA (the one that documented the 01/16/2026 note) failed to notify the provider and had been terminated.

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, record review, observation, and interview, the provider failed to ensure that each patient's written individualized plan of care (POC) included patient-specific interventions and education, all safety measures regarding high-risk medications, and the physical therapy (PT) frequency and duration of visits to be made, and measurable outcomes and goals as identified in the comprehensive assessment, in four of five full records reviewed (Records/Patients #1, #2, #3, and #4). This deficient practice has the potential to affect all the patients served by the provider. Findings included: Review of the provider’s undated policy titled, “Care Plan,” showed in part: - Each patient will have an individualized POC that specifies the care and services necessary to meet the patient-specific needs as identified in the comprehensive assessment, including identification of the responsible discipline(s) and the measurable outcomes that the agency anticipates will occur; - The care plan is started upon initiation of service by the registered nurse (RN), based upon the plan of treatment and an assessment of the patient's needs, resources, family and environment; - Continuing evaluation and service modifications are to be provided as indicated as an integral part of the ongoing provision of agency (provider) services; - Home health services for members of the provider’s staff, as well as those under contractual arrangements, shall be provided in accordance with the plan of treatment and the patient's care plan; - The patient care plan shall be written by appropriate members of the home health services team based upon the plan of treatment and an assessment of the patient’s needs, resources, family and environment; - The patient care plan shall be updated as often as the patient's/ client's condition indicates but at least every 60 days; and - Steps to be taken in developing the care plan include: * Collection of baseline data including all pertinent diagnoses, including mental status, types of services, identification any services furnished by other providers and how those services are coordinated, equipment required, frequency and duration of visits, prognosis, rehab potential, functional limitations, ability to perform basic activities of daily living, activities permitted, the family or other caregivers ability to provide care, patient/client and family’s teaching needs, instructions for timely discharge or referral and any other appropriate items; * Identification of the clients continuing need for home care and meet the clients medical, nursing, rehabilitative, social and discharge planning needs including health needs/ problems with which a patient/family needs assistance; * All patient care orders, including verbal orders, must be recorded in the plan of care; * Determination of the nature of the home care service(s) needed, with consideration of applicable medical orders, the specific needs of the patient, measures required for comfort, safety, and prevention of complications, Actions that must be taken to achieve goals; * Staff responsible for each element of service; * Anticipated outcome of service approach with an estimated time frame for completion; * The establishment of a schedule for the provision of services which lists the description and frequency of each healthcare service, the required treatment and procedure, as well as the medication and diet regimen to be provided; and * Revision of the POC as frequently as necessary to reflect the changing care needs of the patient/ client but no less frequently than every 60 days. Review of the provider’s undated policy titled, “Medication Profile,” showed in part: - The comprehensive assessment includes a review of all medications the patient is currently using; - Agency staff reviews all medicines a patient/client may be taking to identify effectiveness of drug therapy, drug side effects, immediate desired effects, unusual and unexpected effects, actual or potential drug interactions, duplicate drug therapy, non-adherence with drug therapy, drug therapy currently associated with laboratory monitoring, allergic reactions, and changes in the patient's condition that contraindicates continued administration of the medication; - The medication profile must contain all current patient medications and potential side effects; - The nurse performs ongoing medication monitoring to determine their action, indications, special precautions, patient/client’s response to therapy, side effects, allergies and contraindications, and ensure appropriateness and continuity of care and includes the information necessary for creating an accurate medication history and a complete medication profile and to identify the potential complications from the therapy being provided and to help ensure the safety of the medication use process as follows: * Significant side effects; * Special precautions; and - The profile will also serve as a tool for the purpose of patient/client/caregiver education. RECORD/PATIENT #1: Review the clinical record showed the patient was admitted to home health services on 05/18/2026 with a primary diagnosis of a urinary tract infection. He/she lived in a small shed converted into a home next door to family who provided support. Review of a referral with a fax cover sheet titled discharge (DC) and home health (HH) orders, dated 05/15/2026, showed: recommend basic metabolic panel (BMP- A standard blood test that measures eight key substances in your blood including kidney markers) in one week to follow up on renal (kidney) function. Review of an OASIS (Outcome and Assessment Information Set; a standardized data collection tool) start of care (SOC) assessment dated 05/18/2026 showed on page 36 0f 37: “Ensure follow-up BMP and physician appointments are completed.” Review of the physical therapy (PT) evaluation note that was sent to the physician for signature, dated 05/18/2026, showed: - Frequency and duration were once a week for six weeks; - A treatment plan for therapeutic exercise, establish or upgrade a home exercise program, transfer training, gait training, pulmonary physical therapy, balance training, muscle re-education, stairs/steps training, home safety training, assistive device training, and O2 (oxygen) saturation (the level of oxygen in the bloodstream) monitoring as needed; and - Treatment goals (This information failed to be included on the initial POC). Review of the Initial POC dated 05/18/2026 to 07/16/2026 showed: - SN to instruct patient on measures to detect and alleviate edema (swelling of the tissues); and - PT eval and treat. - The initial POC failed to include BMP in one week, and patient-specific PT interventions and education, measurable outcomes and goals, and the PT visit frequency and duration. Further review of the clinical record showed: - A SN visit note dated 05/21/2026 with documentation that the patient had compression stockings removed at the time of the visit; - The record failed to include BMP results or any documentation of coordination with the physician’s office regarding the BMP; and - The POC failed to be updated with the use of the compression stockings. During an interview on 06/03/2026 starting at 3:14 PM the clinical manager stated that: - He/she would have expected the BMP to have been addressed on the POC or documentation of communication about the BMP; - The POC should have been updated about the use of the compression stockings when the nurse found out that the patient was wearing them; and - The provider has POCs per each discipline because their EMR doesn’t allow them to be combined. RECORD/PATIENT #3: Review of the clinical record showed the patient was admitted to home health services on 04/14/2026 with a primary diagnosis of Stage 4 pressure ulcer (a full thickness loss of the skin with extensive destruction, exposing muscle, bone, tendon, or ligaments) of sacral (area at the base of the spine, just above the tailbone) region. The patient resided alone in their own home. Review of an OASIS (Outcome and Assessment Information Set; a standardized data collection tool) start of care (SOC) assessment dated 04/14/2026 showed Veterans Administration (VA) orders included medication management, however, at the time of admission, the patient declined skilled nursing assistance with medication setup. Patient reported medications were kept in the bathroom medicine cabinet and were organized by his preference. Skilled nursing would continue to assess patients understanding and medication regimen and willingness to allow assistance with medication management to ensure safety and compliance. Review of the next SN visit note dated 04/17/2026 (three days later and within the five-day comprehensive assessment window) showed “pillbox (medication planner box) filled again today.” The patient is showing compliance when filled by SN. Review of the POC dated 04/14/2026 to 06/12/2026 failed to show SN to fill the medication planner box. Further review of the clinical record failed to show orders to update the POC with orders for SN to fill the medication planner box. During an interview on 06/03/2026 starting at 3:14 PM the clinical manager stated that he/she would expect the filling of the medication planner on the POC. RECORD/PATIENT #1: Review the clinical record showed the patient was admitted to home health services on 05/18/2026 with a primary diagnosis of a urinary tract infection. He/she lived in a small shed converted into a home next door to family who provided support. Review of a referral with a fax cover sheet titled discharge (DC) and home health (HH) orders, dated 05/15/2026, showed: recommend basic metabolic panel (BMP- A standard blood test that measures eight key substances in your blood including kidney markers) in one week to follow up on renal (kidney) function. Review of an OASIS (Outcome and Assessment Information Set; a standardized data collection tool) start of care (SOC) assessment dated 05/18/2026 showed on page 36 0f 37: “Ensure follow-up BMP and physician appointments are completed.” Review of the physical therapy (PT) evaluation note that was sent to the physician for signature, dated 05/18/2026, showed: - Frequency and duration were once a week for six weeks; - A treatment plan for therapeutic exercise, establish or upgrade a home exercise program, transfer training, gait training, pulmonary physical therapy, balance training, muscle re-education, stairs/steps training, home safety training, assistive device training, and O2 (oxygen) saturation (the level of oxygen in the bloodstream) monitoring as needed; and - Treatment goals (This information failed to be included on the initial POC). Review of the Initial POC dated 05/18/2026 to 07/16/2026 showed: - SN to instruct patient on measures to detect and alleviate edema (swelling of the tissues); and - PT eval and treat. - The initial POC failed to include BMP in one week, and patient-specific PT interventions and education, measurable outcomes and goals, and the PT visit frequency and duration. Further review of the clinical record showed: - A SN visit note dated 05/21/2026 with documentation that the patient had compression stockings removed at the time of the visit; - The record failed to include BMP results or any documentation of coordination with the physician’s office regarding the BMP; and - The POC failed to be updated with the use of the compression stockings. During an interview on 06/03/2026 starting at 3:14 PM the clinical manager stated that: - He/she would have expected the BMP to have been addressed on the POC or documentation of communication about the BMP; - The POC should have been updated about the use of the compression stockings when the nurse found out that the patient was wearing them; and - The provider has POCs per each discipline because their EMR doesn’t allow them to be combined. RECORD/PATIENT #2: Review of the clinical record showed the patient was admitted to home health services on 05/11/2026 with a primary diagnosis of acute (sudden onset) and chronic (lasting more than 12 months) respiratory failure (lungs can’t get enough oxygen into your blood) with hypoxia (body or a specific region of your tissue doesn't receive enough oxygen to function properly), secondary diagnosis includes hypertensive heart and chronic kidney disease with heart failure and unspecified chronic kidney disease (CKD) (high blood pressure, stage 1, 2, 3, 4, or unspecified CKD, and damage to the heart that results in the heart’s inability to pump effectively) and congestive heart failure (CHF; a decrease in the ability of the heart to pump blood). The patient resided at home with his/her spouse. Review of an OASIS SOC assessment dated 05/11/2026 showed in part, the following: - Item N0415 High-Risk Drug Classes: Use and indication – Check if the patient is taking any medications by pharmacological classification, not how it is used, in the following classes: E. Anticoagulant - checked; and - Item M2010 (Has the patient/caregiver received instructions on special precautions for all high-risk medications such as hypoglycemics (medication that lowers blood sugar levels), anticoagulants (medication that thins the blood), and how and when to report problems that may occur? Coded as one- yes. Review of the initial POC, dated 05/11/2026 to 07/09/2026 showed: - Dabigatran etexilate mesylate oral 150 milligrams (mg) one capsule two times a day for heart/blood thinner (anticoagulant); and - The POC failed to include specific safety measures regarding high-risk medications (dabigatran etexilate mesylate). Observation and interview on 06/02/2026 at 1:44 PM, showed on the provider's current medication profile (printed on 06/017/2026) and the patient's home medication bottles: Dabigatran etexilate mesylate oral 150 milligrams (mg) one capsule two times a day. During an interview on 06/03/2026 at 3:34 PM, the clinical manager stated orders for all care are to be on the plan of care. RECORD/PATIENT #3: Review of the clinical record showed the patient was admitted to home health services on 04/14/2026 with a primary diagnosis of Stage 4 pressure ulcer (a full thickness loss of the skin with extensive destruction, exposing muscle, bone, tendon, or ligaments) of sacral (area at the base of the spine, just above the tailbone) region. The patient resided alone in their own home. Review of an OASIS (Outcome and Assessment Information Set; a standardized data collection tool) start of care (SOC) assessment dated 04/14/2026 showed Veterans Administration (VA) orders included medication management, however, at the time of admission, the patient declined skilled nursing assistance with medication setup. Patient reported medications were kept in the bathroom medicine cabinet and were organized by his preference. Skilled nursing would continue to assess patients understanding and medication regimen and willingness to allow assistance with medication management to ensure safety and compliance. Review of the next SN visit note dated 04/17/2026 (three days later and within the five-day comprehensive assessment window) showed “pillbox (medication planner box) filled again today.” The patient is showing compliance when filled by SN. Review of the POC dated 04/14/2026 to 06/12/2026 failed to show SN to fill the medication planner box. Further review of the clinical record failed to show orders to update the POC with orders for SN to fill the medication planner box. During an interview on 06/03/2026 starting at 3:14 PM the clinical manager stated that he/she would expect the filling of the medication planner on the POC. RECORD/PATIENT #4: Review of the clinical record showed the patient was admitted to home health services on 05/15/2026 with a primary diagnosis of osteoporosis with current pathologic fracture of the left pelvis (osteoporosis-related (fragility) pelvic fracture occurs from low-energy trauma or a simple fall due to weakened bones), and secondary diagnosis included congestive heart failure (a decrease in the ability of the heart to pump blood), and peripheral venous insufficiency (happens when leg vein valves become weak or damaged and prevents blood from flowing efficiently back to the heart, causing it to pool in the legs and increase vein pressure). The patient lived in his/her own home with caregivers/family. Review of an OASIS SOC assessment dated 05/15/2026 showed the following: - Item M1400 – Cardiovascular: Edema – coded as yes, (bilateral feet/ankle); and - Skin assessment completed with bilateral lower extremities assessed and patient noted to have venous insufficiency with two plus pitting edema present. Patient currently wears compression stockings and uses compression pumps throughout the day to assist with venous return. Review of the initial POC, dated 05/15/2026 to 07/13/2026 showed: - Furosemide 20 mg (milligrams) one every morning for fluid retention; - Skilled nurse (SN) to instruct patient on measures to detect and alleviate edema; and - The initial POC failed to include patient-specific interventions and education, measurable outcomes and goals, to alleviate edema. During an interview on 06/03/2026 at 1:03 PM, the administrator stated the compression stockings are not on the plan of care. During an interview on 06/03/2026 at 3:34 PM, the clinical manager stated orders for all care are to be on the plan of care.

In accordance with current clinical practice CFR(s): 484.105(f)(2) All HHA services must be provided in accordance with current clinical practice guidelines and accepted professional standards of practice. This ELEMENT is not met as evidenced by: Based on review of Missouri statute, policy review, employee file review, Alzheimer’s training content review, and interview, the home health provider failed to ensure that a check of the Employee Disqualification List (EDL) was performed prior to hire and a Family Care Safety Registry (FCSR) was performed prior to first patient contact on in two of four employee files reviewed (Employees #1 and #3) and failed to ensure Alzheimer’s and dementia training, provided on orientation and annually to all employees, contained education on understanding and dealing with family issues. These deficient practices have the potential to affect all the patients served by the provider. Findings included: Review of Section 192.2490.12 RSMo: "No person, corporation, organization, or association who received the employee disqualification list under subdivisions (1) to (7) of subsection 11 of this section shall knowingly employ any person who is on the employee disqualification list." Review of Section 192.2495 RSMo, requires employees of licensed home health agencies under contract with the Missouri Department of Health and Senior Services, to register with the Family Care Safety Registry regardless of hire date. This section also requires home health agencies to conduct criminal background screenings by checking the Family Care Safety Registry. Review of Section 192.2495.6, RSMo: “A provider is guilty of a class A misdemeanor if the provider knowingly hires or retains a person to have contact with patients or residents and the person has been found guilty in this state or any other state or has been found guilty of a crime, which if committed in Missouri would be a class A or B felony violation of chapter 565, 566 or 569, or any violation of subsection 3 of section 198.070 or section 568.020.” Review of Section 192.2495.7, RSMo (effective August 28, 2018): “Any in-home services provider agency or home health agency shall be guilty of a class A misdemeanor if such agency knowingly employs a person to provide in-home services or home health services to any in-home services client or home health patient and such person either refuses to register with the family care safety registry or if such person: (1) Has any of the disqualifying factors listed in subsection 6 of this section; (2) Has been found guilty of or pleaded guilty or nolo contendere to any felony offense under chapter 195 or 579; (3) Has been found guilty of or pleaded guilty or nolo contendere to any felony offense under section 568.045, 568.050, 568.060, 568.175, 570.023, 570.025, 570.030, 570.040 as it existed prior to January 1, 2017, 570.090, 570.145, 570.223, 575.230, or 576.080; (4) Has been found guilty of or pleaded guilty or nolo contendere to a violation of section 577.010 or 577.012 and who is alleged and found by the court to be an aggravated or chronic offender under section 577.023; (5) Has been found guilty of or pleaded guilty or nolo contendere to any offense requiring registration under section 589.400; (6) Is listed on the department of health and senior services employee disqualification list under section 192.2490; (7) Is listed on the department of mental health employee disqualification registry under section 630.170; or (8) Has a finding on the child abuse and neglect registry under sections 210.109 to 210.183.” Review of 19 CSR 30-26.010 (1) (B) required: "Licensed home health agencies shall provide dementia-specific training about Alzheimer's disease and related dementias to their employees and those persons working as independent contractors who provide direct care to or may have daily contact with residents, patients, clients or consumers with Alzheimer's disease or related dementias. 1. The training for persons providing direct care shall address the following areas, at a minimum: (A) An overview of Alzheimer's disease and related dementias; (B) Communicating with persons with dementia; (C) Behavior management; (D) Promoting independence in activities of daily living; and (E) Understanding and dealing with family issues. 2. Employees or independent contractors who do not provide direct care for, but may have daily contact with, persons with Alzheimer's disease or related dementias shall receive dementia-specific training that includes, at a minimum: (A) An overview of Alzheimer's disease and related dementias; and (B) Communicating with persons with dementia. 3. Dementia-specific training about Alzheimer's disease and related dementias shall be incorporated into orientation for new employees with direct patient contact and independent contractors with direct patient contact. The training shall be presented by an instructor who is qualified by education, experience, and knowledge in the current standards of practice regarding individuals with Alzheimer's disease and other related dementias. The training shall be provided annually and updated as needed. " Review of the provider’s undated policy titled, “Screening and Hiring,” showed in part that that the policy failed to contain any information about EDL or FCSR screenings. Review of the provider’s undated policy titled, “Development and Continuing Education Including In-services,” showed in part that: -All direct care staff must have a minimum of 12 hours of in-services per year. These in-services would include, but were not limited to Alzheimer’s Disease; and - The minimum dementia specific training for employees and contracted staff involved in the delivery of care to persons with Alzheimer’s or related dementias training would include: * An overview of Alzheimer’s and related dementias; * Communicating with persons with dementia; * Behavior management; * Promoting independence in activities of daily living; and * Understanding and dealing with family issues. EMPLOYEE #1: Review of the employee file showed: - Date of hire: 06/23/2025; - Date of first patient contact: 06/23/2025; - The EDL check was received on 06/24/2025 (one day after hire); and - The FCSR check was received on 06/24/2025 (one day after first patient contact). EMPLOYEE #3: Review of the employee file showed: - Date of hire: 06/23/2025; - Date of first patient contact: 06/23/2025; - The EDL check was received on 06/24/2025 (one day after hire); and - The FCSR check was received on 06/24/2025 (one day after first patient contact). Review of the Alzheimer’s training content, provided to all employees, failed to include information on understanding and dealing with family issues. During an interview on 06/02/2026 at 1:55 PM, the administrator stated that: - They were unable to find information on understanding and dealing with family issues in the Alzheimer’s module used for training new hires and annual education; and - They have used the same training module for years. During an interview on 06/03/2026 at 3:14 PM, the administrator stated that he/she would have expected the EDL to have been done prior to hire and the FCSR prior to first patient contact on all new employees.

Discharge and transfer summaries CFR(s): 484.110(a)(6)(i-iii) (i) A completed discharge summary that is sent to the primary care practitioner or other health care professional who will be responsible for providing care and services to the patient after discharge from the HHA (if any) within 5 business days of the patient's discharge; or (ii) A completed transfer summary that is sent within 2 business days of a planned transfer, if the patient's care will be immediately continued in a health care facility; or (iii) A completed transfer summary that is sent within 2 business days of becoming aware of an unplanned transfer, if the patient is still receiving care in a health care facility at the time when the HHA becomes aware of the transfer. This ELEMENT is not met as evidenced by: Based on policy review, record review, and interview, the home health provider failed to provide a completed transfer summary to the receiving health care facility providing care to the patient within two (2) days of becoming aware of the transfer in one of five full records reviewed (Record/Patient #3). This deficient practice has the potential to adversely affect the post discharge care of all the patients served by the provider. Findings included: Review of the provider’s undated policy titled, "Discharge/Transfer Policy," showed in part: - The agency (provider) will maintain a process for the ongoing assessment of each patient/client’s continuing care and discharge planning needs; - Call transferred patients will have required documentation to ensure appropriate communication is provided to the receiving agency (provider); - A transfer form is required for patients who are temporarily admitted to the hospital for exacerbation of illnesses if it is expected that home care will be resumed after hospitalization; and - The transfer summary is sent within two business days of planned transfer, or two business days after becoming aware of unplanned transfer if the patient is still receiving health care services. RECORD/PATIENT #2: Review of the clinical record showed the patient was admitted to home health services on 04/14/2026 with a primary diagnosis of Stage 4 pressure ulcer (a full thickness loss of the skin with extensive destruction, exposing muscle, bone, tendon, or ligaments) of sacral (area at the base of the spine, just above the tailbone) region. The patient resided alone in their own home. Review of the transfer summary, dated 05/11/2026, showed the patient was transferred to the hospital on 05/11/2026. Further review of the clinical record showed the provider failed to send a transfer summary to the receiving institution. Review of a log kept by the clinical manager (not part of the clinical record) showed under the column titled “transfer summary faxed (name, time, date, fax #)” with a response of “yes” documented. During an interview on 06/02/2026 at 2:00 PM, the clinical manager stated that: - He/she had a log that was kept that showed the transfer summary was sent to the receiving institution. (This log failed to show the date and time the transfer summary was sent).

The Emergency Preparedness regulations were reviewed as part of the Medicare certification survey completed on 05/27/2021. During the survey it was determined Golden Valley Memorial Healthcare Home Services is in compliance with the requirements of 42 CFR 484.102 Condition of Participation: Emergency Preparedness for Home Health Agencies.

An extended survey for Medicare certification for Golden Valley Memorial Healthcare Home Services was completed on 05/27/2021. The agency had 90 current patients. One condition-level deficiency was identified during this survey: - 484.60 Condition of Participation: Care Planning, Coordination of Services, and Quality of Care. A COVID-19 Focused Infection Control survey was completed in conjunction with the survey and no deficiencies were identified related to the Focused Infection Control survey.

HHA administrator contact information CFR(s): 484.50(a)(1)(ii) (ii) Contact information for the HHA administrator, including the administrator's name, business address, and business phone number in order to receive complaints. This ELEMENT is not met as evidenced by: Based on home visit observation and interview the agency failed to provide in writing the name and contact number of the administrator in three (Record/Patient #1, #2 and #3) of three home visits conducted. This deficient practice has the potential to affect all patients served by the agency. Findings included: RECORD/PATIENT #1: Observation on 05/26/2021 at 10:45 AM, during the patient's home visit, the surveyor observed the patient's home folder. The agency failed to provide the name and contact information of the administrator. RECORD/PATIENT #2: Observation and interview on 05/25/2021 at 3:00 PM, during the patient's home visit, the surveyor observed the patient's home folder. The agency failed to provide the name and contact information of the administrator. The patient and spouse stated they did not know the name of the administrator. RECORD/PATIENT #3: Observation and interview on 05/25/2021 at 11:30 AM, during the patient's home visit, the surveyor observed the patient's home folder. The agency failed to provide the name and contact information of the administrator. The patient and spouse stated they did not know the name of the administrator. During an interview on 05/26/2021 at 9:45 AM. the administrator thought they could get stickers with the contact information to put on the patient folders.

Written notice within 4 business days CFR(s): 484.50(a)(4) Provide written notice of the patient's rights and responsibilities under this rule and the HHA's transfer and discharge policies as set forth in paragraph (d) of this section to a patient-selected representative within 4 business days of the initial evaluation visit. This ELEMENT is not met as evidenced by: Based on policy review and review of the agency's current patient rights information, the agency failed to update the written notice of patient rights to meet the requirements of the new federal home health regulations effective 01/13/18 to include the written notice to the patient regarding their right to have a copy of the patient's rights and responsibilities provided to a patient-selected representative within four business days of the initial evaluation visit. This deficient practice has the potential to affect all patients served by the agency. Findings included: Review of the agency policy titled, "Patient Bill of Rights," revised 02/06/2019, showed that the home health agency will provide the patient with a written notice of the patient's rights in advance of furnishing care to the patient or during the initial evaluation visit before the initiation of treatment. The policy failed to address that the patient has the right to have a copy of the patient's rights and responsibilities provided to a patient-selected representative within four business days of the initial evaluation visit. Review of the agency's patient admission packet showed it failed to include the written notice to the patient regarding their right to have a copy of the patient's rights and responsibilities provided to a patient-selected representative within four business days of the initial evaluation visit. The findings were reviewed with the accreditation safety and compliance officer on 05/26/2021 at 11:00 AM. No additional information was provided.

Payment from federally funded programs CFR(s): 484.50(c)(7)(i, ii, iii, iv) Be advised, orally and in writing, of- (i) The extent to which payment for HHA services may be expected from Medicare, Medicaid, or any other federally-funded or federal aid program known to the HHA, (ii) The charges for services that may not be covered by Medicare, Medicaid, or any other federally-funded or federal aid program known to the HHA, (iii) The charges the individual may have to pay before care is initiated; and (iv) Any changes in the information provided in accordance with paragraph (c)(7) of this section when they occur. The HHA must advise the patient and representative (if any), of these changes as soon as possible, in advance of the next home health visit. The HHA must comply with the patient notice requirements at 42 CFR 411.408(d)(2) and 42 CFR 411.408(f). This ELEMENT is not met as evidenced by: Based on policy review and review of the agency's current patient rights information the agency failed to update the written notice of patient rights to meet the requirements of the new federal home health regulations effective 01/13/18 to include the patient has the right to be advised of financial liability changes as soon as possible, in advance of the next home health visit. This deficient practice has the potential to affect all patients served by the agency. Findings included: Review of the agency policy titled, "Patient Bill of Rights," revised 02/06/2019, showed in part: - Patient liability for payment: The patient has the right to be advised orally and in writing of any changes in the information provided in accordance of this section when they occur. The home health agency must advise the patient of these changes orally and in writing as soon as possible, but no later that 30 calendar days from the date that the home health agency becomes aware of a change. Review of the agency's patient rights information given to the patient's on admission to the agency showed that the patient has the right to be advised orally and in writing of any changes previously given to them. The agency must advise the patient orally and in writing of these changes as soon as possible, but no later than 30 calendar days from the date the agency becomes aware of the change. The information failed to include that the patient and representative are advised of the changes as soon as possible, in advance of the next home visit. The findings were reviewed with the accreditation safety and compliance officer on 05/26/2021 at 11:00 AM. He/she provided their patient rights policy which showed the same information as above. No additional information was provided.

Contact info Federal/State-funded entities CFR(s): 484.50(c)(10)(i,ii,iii,iv,v) Be advised of the names, addresses, and telephone numbers of the following Federally-funded and state-funded entities that serve the area where the patient resides: (i) Agency on Aging (ii) Center for Independent Living (iii) Protection and Advocacy Agency, (iv) Aging and Disability Resource Center; and (v) Quality Improvement Organization. This ELEMENT is not met as evidenced by: Based on review of the agency's current patient rights information and interview, the agency failed to update the written notice of patient rights to meet the requirements of the updated Federal home health regulations effective 11/29/2019 to include the name, address and phone number of the current Quality Improvement Organization (QIO) that serves the area where the patient resides. This deficient practice has the potential to affect all patients served by the agency. Findings included: Review of the current patient rights information failed to include the current QIO organization. The agency listed Kepro as the current QIO organization for their area. The current QIO is Livanta LLC. During an interview on 05/26/2021 at approximately 11:30 AM, the director of home services stated that they were in the process of having new booklets made for the patients, and the contact information for the current QIO organization would be included.

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 review, record review, home visit observation, and interview, the agency failed to ensure a complete/accurate medication review and/or update of the patient's medications was completed in, but not limited to, three (Record/Patient #2, #3 and #5) of five records reviewed. This deficient practice has the potential to affect all patients served by the agency. Findings included: Review of the agency policy titled, "Drug Regimen Review/Reconciliation," revised 10/28/2020, showed in part: - The home health nurse reviews the drug regimen with the patient or patient representative, as part of the admission assessment process and at any ROC (resumption of care), after physician appointment, follow-up/recertification, discharge and as needed. The drug regimen review will include all medications the patient is actually taking. The information is then used to determine which medications the patient should be taking per physician orders. The 3-step reconciliation process is utilized: *Verify - collect an accurate medication list, looking at all the medication bottles in the medications, dietary supplements, vitamins and herbal products; *Clarify - clarify any questions about drug/dose/frequency. Perform the drug screening via medispan (computer program) and evaluate for major interactions, effectiveness, identify, potentially serious interactions, therapeutic duplication, adverse effects, allergies and potentially inappropriate medications; *Reconcile - communicate with the physician about any identified medication questions or concerns (if any questions, contact the physician within one calendar day and obtain revised orders or clarification; may also contact hospital pharmacist for medication questions; if no questions, enter medication on the plan of care (POC) and send to the physician for verifications and signature; - On rehabilitation-only patients, the therapist will obtain a current medication list from medications in the home from the patient or representative. It will be given to a nurse in the office who will perform the drug regimen review and perform any teaching that needs to be done at the start of care, resumption of care, follow up and discharge. If there are problems found, the physician will be notified, and an order for nursing services may be obtained if appropriate; and - The admitting registered nurse (RN) is responsible for medication reconciliation. Look at the patient's actual medication bottles to compile the list. The intake staff will do their best to see that you have something from inpatient facilities or physician's offices for you to start with. Contact the physician if there are any issues identified during the reconciliation process. RECORD/PATIENT #2: Review of the RN evaluation comprehensive assessment dated 04/03/2021 showed there were no issues found during the drug regimen review. Observation and interview during the patient's home visit observation on 05/25/2021 at 3:35 PM showed the following discrepancies with the agency's medication profile and hospital discharge medication list: - The medication profile showed levothyroxine (thyroid medication) 150 mcg (micrograms) one capsule daily. The patient's bottle dated 05/14/2021 showed levothyroxine 100 mcg one capsule daily. The patient said the physician decreased it after he/she had labwork and forgot to tell the nurse; - The hospital discharge medication list showed an order for nitroglycerin (for chest pain) 0.4 mg place under the tongue every five minutes as needed. The patient said he/she did not have to take nitroglycerin anymore. The RN told the patient it was good to keep some on hand. This was not included on the medication profile. The RN said he/she did not have it on his/her medication list; and - The patient had a bottle of vitamin E 180 milligrams (mg). The patient said he/she had taken this morning and night for years. This was not included on the medication profile and hospital discharge list. During an interview on 05/26/2021 at 9:23 AM with the administrator and clinical supervisor, the clinical supervisor stated that at admission the nurse reviews the discharge medication list to see if they match the patient's medication bottles. They look at all medications. including over the counter medications. When the therapist is in the home they will ask if there has been any medication changes. If there has been changes, they send the changes to a nurse in the office. The administrator stated that he/she would expect the nurse to clarify the nitroglycerin order with the physician. RECORD/PATIENT #3: Review of a physical therapy assistant note (PTA) dated 05/05/2021 showed the patient had a new prescription of hydrocodone/acetaminophen (narcotic pain medication that contains Tylenol) 5-325 mg every four to six hours. Review of a skilled nurse (SN) note dated 05/06/2021, showed the patient's hydrocodone was decreased to 5/325 mg one to two tablets every four to six hours. Observation and interview during the patient's home visit observation on 05/25/2021 at 12:05 PM showed the following discrepancies with the agency's medication profile: - The medication profile showed hydrocodone/acetaminophen 10-325 mg every six hours as needed The patient had a bottle of hydrocodone/acetaminophen 5/325 mg one to two tablets every four to six hours as needed dated 05/04/2021; - The medication profile showed an order for pantoprazole (decreases stomach acid) 40 mg daily. The patient said his/her physician approved he/she discontinue this a few days after he/she left the hospital because the medication made him/her sick; and - The medication profile showed an order for diclofenac sodium (a non-steriodal anti-inflammatory pain medication) 50 mg two times a day. The patient said they took him/her off this in the hospital because he/she was taking the other pain medication. During an interview on 05/26/2021 at 10:18 AM with the administrator and clinical supervisor, the administrator stated that if medication discrepancies are found, they fax it to the physician and attach it to the chart in the computer system. He/she expected staff to clarify medication discrepancies with the physician. He/she did not find where the medication discrepancies were clarified with the physician. He/she did not find where the nurse or PTA updated the medication profile. RECORD/PATIENT #5: Review of the physical therapy (PT) evaluation comprehensive assessment dated 05/10/2021 showed: - Able to reconcile all medications; and - No issues found during the drug regimen review. Review of a non-visit documentation phone call dated 05/10/2021 showed the licensed practical nurse (LPN) documented the drug regimen review was completed with interactions noted and faxed to the physician. No discrepancies in medications noted. The patient's family member was a pharmacist and filled the patient's medication planner weekly. Review of the referral medication list sent from the physician's office dated 04/29/2021 showed the following discrepancies with the agency's medication profile and POC: -The physician's office list showed an order for ibuprofen 200 mg every six hours as needed. The medication profile and POC showed an order for ibuprofen 400 mg twice a day; - The physician office note and medication list dated 04/29/2021 showed that they were going to decrease the prednisone (decreases inflammation) to 2.5 mg daily. The medication profile and POC showed prednisone 5 mg daily; - The physician office list showed an order for omega 3 (fish oil) 1000 mg twice a day. The medication profile and POC showed omega 3 2000 mg twice a day; - The physician office list showed duloxetine (anti-depressant) 20 mg daily. This was not included on the medication profile and POC; - The physician office list showed an order for Lisinopril (high blood pressure medication) 20 mg daily. The medication profile and POC showed 10 mg daily; - The physician office list showed an order for diclofenac (used to treat joint pain) topical get 4 grams topical gel four times a day as needed. This was not included on the medication profile or POC; - The physician office list showed odanestron (used to treat nausea and vomiting) 4 mg every eight hours as needed. The medication profile and POC showed odanestron 4 mg every four to six hours as needed; - The physician office list showed calcium citrate one as needed. The medication profile and POC showed calcium citrate two tablets twice a day; and - The patient's record showed no documentation that the medication discrepancies were clarified with the physician. During an interview on 05/26/2021 at 10:00 AM, the administrator stated that he/she would expect the medication to be reconciled with the physician's medication list and discrepancies clarified with the physician.

Care planning, coordination, quality of care CFR(s): 484.60 Condition of participation: Care planning, coordination of services, and quality of care. Patients are accepted for treatment on the reasonable expectation that an HHA can meet the patient's medical, nursing, rehabilitative, and social needs in his or her place of residence. Each patient must receive an individualized written plan of care, including any revisions or additions. The individualized plan of care must specify the care and services necessary to meet the patient-specific needs as identified in the comprehensive assessment, including identification of the responsible discipline(s), and the measurable outcomes that the HHA anticipates will occur as a result of implementing and coordinating the plan of care. The individualized plan of care must also specify the patient and caregiver education and training. Services must be furnished in accordance with accepted standards of practice. This CONDITION is not met as evidenced by: Based on policy review, record review, and interview, the agency failed to meet the requirements for the Condition of Participation: Care Planning, coordination of services and quality of care when the agency failed to: - Ensure the patients received an individualized plan of care (G574); - Promptly alert the relevant physician of changes in the patient's condition that may suggest a need to alter the plan of care (G590); - Ensure staff updated/revised the plan of care (G592); - Ensure coordination of patient care delivery (G608); - Ensure staff provided the patient and/or caregiver a copy of written instructions outlining the visit schedule, including frequency of visits by agency personnel (G614); - Ensure the patient/caregiver received written instructions regarding treatments/wound care (G618); and - Provide in writing the name and contact number of the clinical manager (G622). The cumulative effect of these deficient practices has the potential to affect the care of all patients served by the agency.

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, record review and interview the agency failed to ensure each patient received a complete individualized plan of care (POC) that contained all the required elements in four (Record/Patient #1, #2, #3 and #4) of five records reviewed. Findings included: Review of the agency policy titled, "Plan of Care and Care Plan," revised 10/16/2020, showed in part: - The OASIS (outcome and assessment information set) assessment will be completed per regulation guidelines. This information is used in the planning of the initial POC and, on an ongoing basis; - Individualized care plans are created for each patient; - Each discipline has a place in its documentation for care planning, but the primary registered nurse (RN) or physical therapist (PT) are responsible for goals and interventions of the POC; - Orders for therapy services must include the specific procedures and modalities to be used, and the amount, frequency and duration of services; and - Care planning begins with the initial evaluation visits and a problem list is developed beginning with that visit, then the care plan will be reviewed and updated each visit as needed. RECORD/PATIENT #1: -Review of the registered nurse (RN) evaluation comprehensive assessment dated 04/17/2021 showed: - The patient had a suprapubic catheter (a urinary catheter that empties the bladder through an incision in the abdomen) that the caregiver flushed twice a day, and a dressing over the tracheotomy site that the caregiver changed every three days; - Assessed as high risk for development of pressure sores; and - Slight edema in both lower extremities. The patient wore compression hose and reported the edema subsides when his/her legs are elevated in bed. Review of the POC dated 04/17/2021 showed: - Urinary catheter care as ordered but no specific orders regarding what size catheter/balloon, when to change the catheter or flushing of the catheter; - No interventions or goals related to the patient's high risk for development of pressure sores; and - No interventions and goals related to the patient's edema and use of compression hose. Review of an RN visit note dated 05/18/2021 showed the nurse changed the suprapubic catheter using a 16 french (diameter of the catheter) with a 10 milliliter (ml) balloon (the balloon is filled to hold the catheter in place) filled with sterile saline. Review of a physician order dated 05/12/2021 showed an order effective 05/18/2021 for one visit to change the suprapubic catheter. The order failed to include the catheter/balloon size and solution for filling the balloon. The findings were reviewed on 05/26/2021 at 12:50 PM, with the administrator, clinical supervisor, director of home care services and resource nurse. The clinical supervisor stated that the POC orders were not specific. RECORD/PATIENT #2: Review of the hospital discharge medication list and the current agency medication profile showed an order for amlodipine (high blood pressure medication) 2.5 milligrams (mg) daily and vitamin D3 50 micrograms (mcg) daily. Review of the POC dated 04/03/2021 showed: - No order for amlodipine; - An order for vitamin D3 25 mcg daily; - Orders included daily wound packing of sternal (chest) wound with wet to dry dressing; - The order did not include cleansing orders or what solution and dressings to use. Observation and interview during a home visit observation on 05/25/2021, beginning at 3:00 PM, showed: - The patient took amlodipine 2.5 mg daily and vitamin D3 50 mcg daily; - The patient's incision had healed; and - The patient said they used wound cleanser to clean with, packed with strips of gauze wet with normal saline and covered with gauze. During an interview on 05/26/2021 at 9:23 AM with the administrator and clinical supervisor, the administrator stated that he/she did not know why the medications did not pull over to the plan of care. The medications should pull over from the medication profile. He/she said it had to be a system issue that they would have to look into. During an interview on 05/26/2021 at 9:40 AM, with the administrator and clinical supervisor, the administrator stated that the wound care orders should be very detailed and should include cleansing, what to pack with and cover with. RECORD/PATIENT #3: Review of the POC dated 04/28/2021 showed an order for physical therapy treatment modality - Cold. The order did not include include frequency and duration of the cold modality. Review of the physical therapy assistant (PTA) note dated 05/03/2021 showed the PTA instructed the patient and caregiver on the use of ice packs. During an interview on 05/26/2021 at 10:18 AM, the administrator said he/she would check their policy regarding frequency and duration of modalities. RECORD/PATIENT #4: Review of the registered nurse (RN) evaluation comprehensive assessment dated 03/24/2021 showed the patient had 2+ pitting edema (when the skin is pressed an indentation is left) to both feet; Review of the POC dated 03/27/2021 showed no interventions or goals related to the patient's edema. During an interview on 05/27/2021 at 8:40 AM the administrator stated that they recognized the care plans were not individualized and they were working on the care plans.

Promptly alert relevant physician of changes CFR(s): 484.60(c)(1) The HHA must promptly alert the relevant physician(s) or allowed practitioner(s) to any changes in the patient's condition or needs that suggest that outcomes are not being achieved and/or that the plan of care should be altered. This ELEMENT is not met as evidenced by: Based on policy review, record review, and interview, the agency failed to promptly alert the physician to changes in the patient's condition that may suggest a need to alter the plan of care (POC) in two (Record/Patient #1 and #4) of five records reviewed. This deficient practice has the potential to affect all patients served by the agency. Findings included: Review of the agency policy titled, "Assessment and Reassessment," revised 06/02/2020, showed in part, the physician is promptly notified of any assessment findings requiring medical intervention. Review of the agency policy titled, "Plan of Care and Care Plans," revised 10/16/2020, showed: - The POC is reviewed on a periodic basis by the attending physician and agency personnel; - Agency professional staff promptly alerts the physician to any changes that suggest a need to alter the POC, and - The need for review is based on the patient's health status, environment and support system. RECORD/PATIENT #1: Review of an registered nurse (RN) visit note dated 04/23/2021 showed the patient had a blister to the left heel. Calmoseptine (skin protectant) and Band-Aid applied. There was no documentation the physician was notified of the blister to the left heel to obtain treatment orders. Review of the physician orders showed no order for treatment to the left heel. During an interview on 05/27/2021 at 9:00 AM, the administrator stated that he/she would expect the nurse to notify the physician of the pressure area on the left heel. RECORD/PATIENT #4: Review of a physician order dated 02/28/2021 showed to cleanse the wounds to the right leg with wound cleanser, pat dry, apply collagen (stimulates new tissue growth) to wound bed and cover with a dry dressing. Wound care to be done every Monday, Wednesday and Friday by nursing and as needed by caregiver/patient when needed. Review of the skilled nursing (SN) visit notes showed: - On 03/12/2021 the patient's right calf wound had moderate serosanguineous (bloody, yellowish) drainage (no assessment of wound bed or odor) with no signs and symptoms of infection; - On 03/15/2021 the patient's right leg had swelling, redness, warmth to touch, and signs of new fluid filled blisters. The nurse contacted the primary care physician's (PCP) office. The office nurse said he/she would contact the patient to make an appointment to see the physician. The nurse also noted there was a slight odor from the wound; - On 03/19/2021 the patient's right calf ulcer had moderate serosanguineous drainage (no assessment of wound bed or odor) with no signs and symptoms of infection. The patient saw the physician the previous day. The nurse at the physician's office wrapped the patient's wound and the patient's right leg had swollen around the wrap. A new fluid filled blister had opened above the wrapping on the shin area. Will continue to monitor; - On 03/22/202 the ulcer to the right shin is open again. Unable to measure. No signs and symptoms of infection noted. No documented assessment/measurement of the ulcer on the right calf or right shin. No documentation that the PCP or surgeon was notified the ulcer on the right shin opened again; and - On 03/24/2021 the registered nurse (RN) evaluation recertification assessment showed the patient had a diabetic ulcer to the right calf, and the diabetic ulcer on the right shin had reopened. No further assessment of the right calf and right shin ulcers. No documentation the physician was notified the right shin ulcer had reopened. Review of a physician order dated 03/24/2021 showed to cleanse the wounds to the right leg with wound cleanser, pat dry, apply collagen (stimulates new tissue growth) to wound bed and cover with a dry dressing. Wound care to be done every Monday, Wednesday and Friday by nursing and as needed by caregiver/patient when needed. Review of the SN visit note dated 03/26/2021 showed the RN documented the anterior (front) right calf has a point (unsure what this means), red wound bed with granulation (healing) noted. The wound to the posterior (back) right calf is large and has a pale pink wound bed. Large amount of serosanguineous drainage. There is a stale odor noted. Wound was dressed per order. There was no documentation that the physician or RN case manager was notified of the stale odor of the wound. Review of the recertification plan of care dated 03/27/2021 showed: - Diagnoses that included type 2 diabetes mellitus with foot ulcer and lymphedema (swelling in the arms or leg caused by a lymphatic system blockage); and - Interventions included to cleanse the wounds (location not included) with wound cleanser, pat dry, apply collagen (stimulates new tissue growth) to wound bed and cover with a dry dressing. Wound care to be done every Monday, Wednesday and Friday by nursing and as needed by caregiver/patient when needed. Review of the SN note dated 03/29/2021 the front of the right lower leg measured 2.36 inches x 1.18 inches and the right calf had a large open area. No further assessment noted. Unable to measure due to patient positioning. No signs and symptoms of infection noted. Review of a general surgery visit wound follow up note dated 03/31/2021 showed: - The physician had seen the patient one month ago for a wound check; - He/she has been getting home health care for his/her wound on the right lower extremity; - He/she has been getting collagen dressings every Monday, Wednesday and Friday; - His/her last dressing change was two days ago; - The patient states that the wound is healing, but there is still quite a bit of drainage; - The patient is no longer on water pills and tries to keep his/her leg up as much as possible when at home; - Exam showed the right lower extremity wounds are healing really nicely. The right anterior distal leg wound is 98% healed but new epithelial needs to be done. The posterior right leg wound is about 60% healed and the right lateral foot wound is about 100% healed; and - The plan was to continue current care with collagen Monday, Wednesday and Friday. Review of the SN visit notes showed: - On 04/02/2021, the patient had ulcerations to the right lower extremity, stable, and moderate amount of drainage. No further assessment was documented; - On 04/05/2021 the wound on the front right lower leg measured 2.36 inches by 1.57 inches and the right calf wound measured 3.15 inches by 6.3 inches with no signs and symptoms of infection noted. No further assessment was documented; - On 04/07/2021 the right calf had a small amount of serosanguineous drainage with no signs and symptoms of infection. No further assessment of the right calf ulcer and no documented assessment of the right shin area; - On 04/09/2021 the right shin had a moderate amount of serosanguineous drainage with no signs of infection. No further assessment of the right shin and no documented assessment of the right calf ulcer; - On 04/12/2021 the front right lower leg measured 2.36 inches by 1.18 inches. The dressing was saturated. The wound had a large amount of brown, yellow drainage. No assessment of the wound bed or presence of odor. The right calf measured 3.15 inches by 6.3 inches. No signs of infection noted. The wound continues to have a large amount of drainage (unsure which wound this referred to or whether it referred to both wounds). No documentation the physician was notified of the brown, yellow drainage; - On 04/14/2021 the right shin and calf ulcer had a small amount of serosanguineous drainage with no signs of infection. No further assessment was documented; - On 04/16/2021 the right shin and right calf ulcer showed no signs of infection. No further assessment documented; - On 04/19/2021 the right shin ulcer measured 2.36 inches by 1.18 inches with a large amount of brown drainage. No assessment of the wound bed or odor. The right calf ulcer measured 3.15 inches by 6.3 inches. No further assessment was documented. No documentation the physician was notified of the brown drainage from the right shin ulcer; and - On 04/21/2021 the right shin ulcer had a large amount of brown, yellow drainage. No further assessment documented. No signs of infection. No documentation that the physician was notified of the brown drainage. No documented assessment of the right calf ulcer. Review of a communication note dated 04/23/2021 showed the patient told the nurse he/she would not be available for a visit until 04/26/2021. Review of the SN visit note dated 04/26/2021 the right shin ulcer measured 2.36 inches by 1.18 inches and the right calf ulcer measured 3.15 inches by 6.3 inches with no signs of infection noted. There was no documented assessment of the wound bed, drainage or odor. Review of the general surgery wound follow-up note dated 04/28/2021 showed: - The patient stated that the home health care nurses states that the wound is not closing up very fast and not at all over the last month; - Exam showed the anterior and posterior right leg wounds have good granulation (healing) tissue. They have not gotten smaller over the last month. There appears to be a slight pungent smell and green hue on the dressings. It is unclear if this is a pseudomonas (bacterial) looking infection. Cultures (a test of the drainage to determine what bacteria/infection is present) were taken; - Assessment and plan included that it appeared the chronic right leg wound appeared the progression had stalled. Generally this means that there is infection as the wound itself looks fairly good. There is a slight pungent smell and a green hue to suggest potential infection. The patient will be placed on Bactrim (antibiotic) for now. If the cultures come back as pseudomonas, the patient may need intravenous antibiotics. In the meantime, I would like to switch the patient to medihoney/therahoney (antimicrobial) dressing changes to decrease the bacterial load and help the wound heal faster. Review of a physician order dated 04/29/2021 showed an order to cleanse wounds to the right leg with wound cleanser, pat dry, apply medihoney to wound bed, cover with dry gauze, wrap with Kerlix (gauze wrap) then coban (self adherent compression wrap). Daily dressing change for seven days by the skilled nurse. Review of the SN visit notes showed: - On 04/30/2021 the right calf and right shin diabetic ulcer was immeasurable and irregular in shape. No signs of infection. No documented assessment of wound bed, drainage or presence of odor; - On 05/01/2021 no assessment of the right leg wounds; - On 05/02/2021 showed yellow drainage from anterior posterior leg wound but no signs of infection. No further assessment or whether there was presence of odor. No documentation that the physician was notified of the yellow drainage; - On 5/03/3021 the right shin and calf ulcers showed no signs of infection; and - On 05/04/2021 the right shin and calf diabetic ulcers were not measurable and had no signs of infection. Review of the general surgery wound follow up note dated 05/05/2021 showed: - The physician saw the patient about a week ago and the right lower extremity wound appeared to have a pseudomonas type smell, therefore I started the patient on daily therahoney dressings instead of the collagen; - The wound had been stagnant for about a month and the infection appeared to be the reason why; - The physician related to the patient that the cultures came back positive for pseudomonas aeruginosa as suspected; - The anterior and posterior right leg wounds have good granulation tissue. They actually look slightly better than last week. There is no more pungent smell or pseudomonas looking infection. There is not green tinge on the dressings; and - If by next week the wound looks good with no signs of infection, he/she may go back to Monday, Wednesday, Friday collagen dressing changes. Review of a physician order dated 05/08/2021 showed an order to cleanse both wounds on the right lower leg with wound cleanser, pat dry, apply medihoney to wound bed, cover with dry gauze, wrap with kerlix, secure with coban. Dressing change to be done daily by skilled nurse until the patient sees the wound clinic. Review of a general surgery visit note dated 05/12/2021 showed: - The chronic right leg wound is slowly getting better; - It is improving since the infection appears to be gone away; and - The patient may go back to Monday, Wednesday and Friday dressing changes with collagen; and - The physician would see the patient in one month for follow-up or sooner if there are any issues especially signs of possible infection once again. Review of the SN notes showed: - On 05/14/2021 the right calf and shin diabetic ulcers had no signs of infection; - On 05/17/2021 no signs of infection noted; - 05/19/2021 right calf and shin diabetic ulcers had a moderate amount of serosanguineous drainage with no signs of infection; - On 05/21/2021 the RN evaluation comprehensive assessment showed the right calf ulcer had a small amount of green, yellow drainage. No documentation regarding odor or whether the physician was notified of the green, yellow drainage. No assessment of the right shin ulcer; and - On 05/24/2021 both wounds are not measurable due to different healing areas throughout the wounds. No signs of infection noted. No assessment of the wound bed, drainage or odor. During an interview with the administrator and clinical supervisor on 05/26/2021 at 1:45 PM , the clinical supervisor stated that generally he/she would expect staff to notify the physician of changes. The administrator stated that he/she did not have documentation to show the nurses notified the physician regarding the wound between 03/22/2021 and 04/26/2021. During an interview on 05/27/2021 at 8:17 AM, the RN case manager stated that: - The patient had slow healing wounds; - The patient has always had a massive wound on the back of the right calf and an oval shaped wound on the front shin; - At one time it seemed like none of it was open on the shin but the skin was very frail; - When the wound reopened on 03/22/2021, he/she thought that was expected with the patient. It wasn't worse; - The patient saw the PCP a couple of days before because the surgeon was out of town. The licensed practical nurse (LPN) thought the patient's leg swelling was worse and looked red so they sent the patient to the PCP. The PCP thought the the legs looked good. The LPN had reported to him/her that the PCP wrapped the patient's leg tightly. The PCP did not change any orders. The wound care orders typically came from the surgeon; - The patient always had a lot of drainage with an odd smell; - When asked about what should be included in the wound assessment, the RN stated that the patient's wounds were hard to measure, they were not defined and the patient did not cooperate with holding his/her leg up; - He/she expected each visit the documentation would include location of wounds, odor, signs and symptoms of infection. The brown colored drainage was normal for the patient; and - When asked when the physician should be notified, he/she stated that for this patient he/she watched for signs of infection such as redness, green drainage, fever, and a large increase in swelling.

Revised plan of care CFR(s): 484.60(c)(2) A revised plan of care must reflect current information from the patient's updated comprehensive assessment, and contain information concerning the patient's progress toward the measurable outcomes and goals identified by the HHA and patient in the plan of care. This ELEMENT is not met as evidenced by: Based on policy review, record review, and interview, the agency failed to ensure the plan of care was revised/updated to address the patients needs for one (Record/Patient #1) of five records reviewed. This deficient practice has the potential to affect all patients served by the agency. Findings included: Review of the agency policy titled, "Plan of Care and Care Plan," revised 10/16/2020, showed in part: - The OASIS (outcome and assessment information set) assessment will be completed per regulation guidelines. This information is used in the planning of the initial POC and, on an ongoing basis; - Individualized care plans are created for each patient; - Care planning begins with the initial evaluation visits and a problem list is developed beginning with that visit, then the care plan will be reviewed and updated each visit as needed; - The POC is reviewed on a periodic basis by the attending physician and agency personnel; and - The need for review is based on the patient's health status, environment and support system. RECORD/PATIENT #1: Review of a registered nurse (RN) visit note dated 04/23/2021 showed the patient had a blister to the left heel. Calmoseptine (skin protectant) and Band-Aid applied. There was no documentation the physician was notified of the blister to the left heel and treatment orders obtained. Review of the physician orders showed no order for treatment to the left heel. Review of a family practice/general visit note dated 04/27/2021 showed the patient stated he/she has a dark spot on his/her left heel and has had it for the past three days. Exam showed the right heel (the RN visit showed left heel) had a 3.5 cm darkish area that was soft and boggy (can indicate tissue destruction). Assessment and plan showed stage 1 pressure ulcer (reddened, intact skin that does not blanch) of the heel and heel protectors for both feet. Review of a hospital discharge summary dated 05/06/2021 showed: - Date of admission 05/04/2021; - The patient presented to the emergency room with complaint of increased secretions, cough and shortness of breath; and - He/she was admitted on observation for further evaluation and management. Review of a wound consult dated 05/05/2021 showed the patient had an unstageable (unable to determine depth due to presence of slough (dead tissue) or eschar (dead tissue) pressure injury to the left heel. The injury presents as a dry eschar that is dry and slightly lifting at the margin, dessicating (dry). It is approximately 3.0 x 1.0 centimeters (cm). There is no drainage, redness or signs of soft tissue infection. The patient's feet are elevated with heel elevators. The patient reports he/she has two pair at home he/she used. We will continue with elevation and will keep the eschar clean and dry. Review of the RN final visit (discharge) note dated 05/10/2021 showed the blister with hardened skin on the left heel. Advised the caregiver to keep lotion on this. There was no documentation regarding education/assessment of keeping the heels elevated with heel elevators and keeping the eschar clean and dry. During an interview on 05/27/2021 at 9:00 AM, the administrator stated that the care plan should have been updated with interventions for the heel.

Coordinate care delivery CFR(s): 484.60(d)(4) Coordinate care delivery to meet the patient's needs, and involve the patient, representative (if any), and caregiver(s), as appropriate, in the coordination of care activities. This ELEMENT is not met as evidenced by: Based on policy review, record review, and interview, the agency failed to ensure coordination of patient care delivery in two (Records/Patients #1 and #3) of five records reviewed. This deficient practice has the potential to affect all patients served by the agency. Findings included: Review of the agency policy titled, "Assessment and Reassessment," revised 06/02/2020, showed in part, if a patient returns home from the hospital during the certification period, schedule the first visit as an evaluation visit in order to create the assessment verbal order for resumption of care, which will include the medication list, orders, frequency and duration. RECORD/PATIENT #1: Review of the plan of care (POC) showed: - The patient was admitted to the agency on 04/17/2021; and - Diagnoses included quadriplegia (paralysis of the arms and legs). Review of a hospital discharge summary dated 05/06/2021 showed: - Date of admission 05/04/2021; - The patient presented to the emergency room with complaint of increased secretions, cough and shortness of breath; - He/she was admitted on observation for further evaluation and management; and - The patient was discharged with cough assist (a machine that helps clear mucus from the lungs) and respiratory suction machine. Further education and instruction was provided to the patient and family regarding diaphragm support and exercise prior to discharge. Additional education and instruction will be provided with home health and with respiratory therapy visit at home. The patient was discharged with home health for physical and occupational therapy as well as skilled nursing. Review of a wound consult dated 05/05/2021 showed the patient had an unstageable (unable to determine depth of the injury due to coverage by slough (dead tissue) or eschar (dead tissue)) pressure injury to the left heel. The injury presents as a dry eschar that is dry and slightly lifting at the margin, dessicating (dry). It is approximately 3.0 x 1.0 centimeters (cm). There is no drainage, redness or signs of soft tissue infection. The patient's feet are elevated with heel elevators. The patient reports he/she has two pair at home he/she used. We will continue with elevation and will keep the eschar clean and dry. Review of the registered nurse (RN) final visit note dated 05/10/2021 showed the patient had a blister with hardened skin on the left heel. Advised the caregiver to keep lotion on this (the wound consult showed to keep it clean and dry). There was no documentation regarding education/assessment of keeping the heels elevated with heel elevators, keeping the eschar clean and dry, or the use of cough assist and suction equipment. Per interview conducted during observation on 05/26/2021 beginning at 11:00 AM, the caregiver stated that: - The patient was in the hospital two nights; - After he/she came home from the hospital, they received a cough assist and suction machine; - The home health agency did not do anything with the cough assist or suction machine; - The equipment company taught him/her how to use the machines; - Everything was overwhelming; - The insurance would only allow so many home health visits; and - He/she would be receiving in home care services. During an interview on 05/26/2021 at 12:57 PM, the clinical supervisor said when a patient is in the hospital, they are in contact with the hospital and get emails from the hospital when they are on observation. He/she did not know why the patient was discharged without discussing the discharge with the nurse. During an interview on 05/26/2021 at 1:25 PM, the RN case manager stated that the patient was in the hospital as observation for pneumonia. If a patient is admitted to the hospital, all charting goes to the clinic physicians, then the home health agency would be notified that the patient was in the hospital and they would do a resumption of care. If there are changes, they will update the plan of care. The patient's insurance only allowed a total of six nursing visits. At times the caregiver refused the visits because he/she wanted to stretch the visits out. He/she was not aware the patient had a suction machine. He/she looked at the electronic medical record and said he/she was not sure he/she got the information from the hospital. During an interview on 05/27/2021 at 10:52 AM, the administrator stated that: - When the patient was discharged from the hospital, the nurses should review the information in their computer system to see what had occurred; - The nurse should either call the physician or look at the discharge paperwork sent with the patient. If they had read the information, they should follow the physician instructions; and - When changes occur, they would try to get more visits authorized to see the patient. RECORD/PATIENT #3: Review of the POC dated 04/28/2021 included for physical therapy to report signs of hypertensive (high blood pressure) or hypotensive (low blood pressure) symptoms to the physician. Review of a physical therapy assistant (PTA) note dated 05/03/2021 showed: - The patient noted he/she occasionally got dizzy when changing positions. He/she was educated on the effect of low blood pressure and how it can cause dizziness when changing positions. The patient only drank coffee during the day. The therapist encouraged the patient to increase his/her water intake and to take short breaks when changing positions to allow the dizziness to subside; and - No documentation that the RN case manager or physician was notified of the patient's dizziness. Review of a skilled nurse (SN) note dated 05/03/2021 showed no documentation regarding the patient reporting occasional dizziness to the PTA. During an interview on 05/26/2021 at 10:18 AM, the clinical supervisor stated that the PTA probably should have at least reported the dizziness to the nurse.

Visit schedule CFR(s): 484.60(e)(1) Visit schedule, including frequency of visits by HHA personnel and personnel acting on behalf of the HHA. This ELEMENT is not met as evidenced by: Based on home visit observation, patient home folder review, and interview, the agency failed to provide the patient and/or caregiver a copy of written instructions outlining the visit schedule, including frequency of visits by agency personnel in one (Record/Patient #1) of three home visits conducted. This deficient practice has the potential to affect all patients served by the agency. Findings included: RECORD/PATIENT #1: Per interview conducted during a home visit observation with the occupational therapist (OT) on 05/26/2021 beginning at 11:00 AM, showed: - A review of the information in the patient's home folder showed no written instructions outlining the visit schedule; - The caregiver stated that he/she did not have a written schedule of visits. Staff called on the days they were coming; and - The OT stated that they did not have a written schedule due to things changing frequently. During an interview on 05/27/2021 at 10:11 AM, the administrator said they provide a copy of the plan of care with the frequency of visits and verbally confirm the schedule with the patient. (The home folder for patient #1 failed to include a copy of the plan of care.)

Treatments and therapy services CFR(s): 484.60(e)(3) Any treatments to be administered by HHA personnel and personnel acting on behalf of the HHA, including therapy services. This ELEMENT is not met as evidenced by: Based on record review, home visit observation and interview, the agency failed to ensure the patient/caregiver received written instructions regarding treatments/wound care in two (Record/Patient #1 and #2) of three home visit observations. This deficient practice has the potential to affect all patients served by the agency. Findings included: RECORD/PATIENT #1: Review of the registered nurse (RN) evaluation comprehensive assessment dated 04/17/2021, showed the patient had a new colostomy and a suprapubic catheter. Per interview conducted during a home visit observation on 05/26/2021 beginning at 11:00 AM, showed: - Review of the patient's home folder showed no written care instructions; and - The caregiver stated that it would have been helpful to have written information on colostomy and catheter care. During an interview on 05/26/2021 at 1:25 PM, the RN case manager stated that he/she did not leave anything written on paper. He/she discussed care with the caregiver. The only information he/she left in the home was the medication list. RECORD/PATIENT #2: Review of the plan of care dated 04/03/2021 showed an order for daily wound packing of sternal (chest) wound with wet to dry dressing; Per interview conducted during a home visit observation on 05/25/2021, beginning at 3:00 PM, showed: - The patient's home folder contained no written instructions for wound care; - The RN said he/she did not leave written instructions because the physician had went over the instructions with the patient; and - The patient said he/she had written instructions from the hospital. During an interview on 05/26/2021 at 9:45 AM, the clinical supervisor stated that he/she would expect staff to leave written instructions if the patient needed it. The patient should have had more detailed instructions.

Name/contact information of clinical manager CFR(s): 484.60(e)(5) Name and contact information of the HHA clinical manager. This ELEMENT is not met as evidenced by: Based on home visit observation and interview the agency failed to provide in writing the name and contact number of the clinical manager in three (Record/Patient #1, #2 and #3) of three home visits conducted. This deficient practice has the potential to affect all patients served by the agency. Findings included: RECORD/PATIENT #1: Observation on 05/26/2021 at 10:45 AM, during the patient's home visit, the surveyor observed the patient's home folder. The agency failed to provide the name and contact information of the clinical manager. RECORD/PATIENT #2: Observation and interview on 05/25/2021 at 3:00 PM, during the patient's home visit, the surveyor observed the patient's home folder. The agency failed to provide the name and contact information of the clinical manager. The patient and spouse stated they did not know the name of the clinical manager. RECORD/PATIENT #3: Observation and interview on 05/25/2021 at 11:30 AM, during the patient's home visit, the surveyor observed the patient's home folder. The agency failed to provide the name and contact information of the clinical manager. The patient and spouse stated they did not know the name of the clinical manager. During an interview on 05/26/2021 at 9:45 AM. the administrator thought they could get stickers to put on patient folders with the contact information.

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, record review, home visit observation, and interview, the agency failed to ensure staff followed infection control standards of practice in two (Record/Patient #2 and #3) of three home visit observations. This deficient practice has the potential to affect all patients served by the agency. Findings included: Review of the agency policy titled, "Clinical Bag Technique," revised 03/29/2021, showed in part: - The inside of the bag is considered a clean area. Do not place contaminated articles inside the clinical bag; - Take all needed items out of the clinical bag and place on a prepared clean area (may use a barrier); and - Wipe all reusable equipment such as a laptop with an approved antiseptic wipe after use and prior to placing into the clinical bag each visit. RECORD/PATIENT #2: Review of the plan of care dated 04/03/2021 showed an order for daily wound packing of the sternal (chest) wound with wet to dry dressings. During a home visit observation on 05/25/2021 beginning at 3:00 PM, showed: - The patient's incision had healed; - The nurse opened a bottle of normal saline (a salt solution) and placed the gauze pad against the opening of the container to wet the gauze then cleaned the incision; and - The nurse placed his/her computer on the patient's kitchen table without cleansing the surface or placing a barrier to set the computer on. At the end of the visit, the nurse failed to clean the computer before placing it in his/her nursing bag. During an interview on 05/26/2021 at 9:56 AM, the clinical supervisor said he/she expected staff to place a barrier under their tablets and clean them before placing them back in their nursing bag. During an interview on 05/27/2021 at 9:10 AM, the administrator said it would not be appropriate to place the gauze pad against the bottle of saline to wet. Staff should pour the solution onto the gauze. RECORD/PATIENT #3: During a home visit observation on 05/25/2021 beginning at 11:30 AM, the occupational therapy assistant checked the patient's blood pressure then laid the blood pressure cuff and stethoscope on the patient's chair without a barrier underneath. During an interview on 05/26/2021 at 9:56 AM, the clinical supervisor said he/she would expect a barrier to be placed under the blood pressure cuff and stethoscope.

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 policy review, record review, and interview, the agency failed to ensure the skilled nurse (SN) documented ongoing assessments in two (Record/Patient #1 and #4) of five records reviewed. This deficient practice has the potential to affect all patients served by the agency. Findings included: Review of the agency policy titled, "Wound Assessment," revised 03/10/2021, showed in part: - All disciplines involved in the care of the patient are responsible for notifying the case manager if they observe a new/changed wound on their visit; - Assessment of wound by case manager will include length, width, depth, tunneling, drainage (color, amount, odor), signs of infection, surrounding tissue, and wound edges; - The policy did not address how often wound measurements would be obtained and whether the measurements would be in inches or centimeters; and - All wound documentation will be maintained in the patient's chart. RECORD/PATIENT #1: Review of a registered nurse (RN) visit note dated 04/23/2021 showed the patient had a blister to the left heel. Calmoseptine (skin protectant) and Band-Aid applied. There was no documentation the physician was notified of the blister to the left heel and treatment orders obtained. Review of the physician orders showed no order for treatment to the left heel. Review of a family practice/general visit note dated 04/27/2021 showed the patient stated he/she has a dark spot on his/her left heel and has had it for the past three days. Exam showed the right heel (the RN visit showed left heel) had a 3.5 centimeter (cm) darkish area that was soft and boggy (can indicate tissue destruction). Assessment and plan showed stage 1 pressure ulcer (reddened, intact skin that does not blanch) of the heel and heel protectors for both feet. Review of a communication note dated 04/28/2021 sent from the physical therapist (PT) to the licensed practical nurse (LPN) and RN case manager showed the patient had an area of pressure on the left heel. The skin is intact. The physician told the patient yesterday to stop wearing shoes during the day, so we placed his/her open backed slippers on when transferring to the bed. The patient was wearing pressure relief boots in bed when the PT arrived. Review of the skilled nurse (SN) visit note dated 04/30/2021 showed no assessment of the patient's heels. Review of a hospital discharge summary dated 05/06/2021 showed: - Date of admission 05/04/2021; - The patient presented to the emergency room with complaint of increased secretions, cough and shortness of breath; and - He/she was admitted on observation for further evaluation and management. Review of a wound consult dated 05/05/2021 showed the patient had an unstageable (unable to determine depth due to presence of slough (dead tissue) or eschar (dead tissue) pressure injury to the left heel. The injury presents as a dry eschar that is dry and slightly lifting at the margin, dessicating (dry). It is approximately 3.0 x 1.0 cm. There is no drainage, redness or signs of soft tissue infection. The patient's feet are elevated with heel elevators. The patient reports he/she has two pair at home he/she used. We will continue with elevation ad will keep the eschar clean and dry. Review of the RN final (discharge) visit note dated 05/10/2021 showed the blister with hardened skin on the left heel. Advised the caregiver to keep lotion on this. There was no documentation regarding education/assessment of keeping the heels elevated with heel elevators and keeping the eschar clean and dry. During an interview on 05/27/2021 at 9:00 AM, the administrator stated that he/she would expect the nurse to notify the physician of the pressure area on the left heel. The care plan should have been updated with interventions for the heel. He/she would expect the nurses to assess the heels during their visits. RECORD/PATIENT #4: Review of the SN visit notes showed: - On 03/12/2021 the patient's right calf wound had moderate serosanguineous (bloody, yellowish) drainage (no assessment of wound bed, odor or surrounding tissue) with no signs and symptoms of infection; - On 03/15/2021 the patient's right leg had swelling, redness, warmth to touch, and signs of new fluid filled blisters. The nurse contacted the primary care physician's (PCP) office. The office nurse said he/she would contact the patient to make an appointment to see the physician. The nurse also noted there was a slight odor from the wound; - On 03/19/2021 the patient's right calf ulcer had moderate serosanguineous drainage (no assessment of wound bed, odor, or surrounding tissue) with no signs and symptoms of infection. The patient saw the physician the previous day. The nurse at the physician's office wrapped the patient's wound and the patient's right leg had swollen around the wrap. A new fluid filled blister had opened above the wrapping on the shin area. Will continue to monitor; - On 03/22/202 the ulcer to the right shin is open again. Unable to measure. No signs and symptoms of infection noted. No documented assessment/measurement of the ulcer on the right calf or right shin; - On 03/24/2021 the registered nurse (RN) evaluation showed the patient had a diabetic ulcer to the right calf and the diabetic ulcer on the right shin had reopened. No further assessment of the right calf and right shin ulcers; - On 03/26/2021 the RN documented the anterior (front) right calf has a point (unsure what this means), red wound bed with granulation (healing) noted. The wound to the posterior (back) right calf is large and has a pale pink wound bed. Large amount of serosanguineous drainage. There is a stale odor noted. Review of the recertification plan of care dated 03/27/2021 showed: - Diagnoses that included type 2 diabetes mellitus with foot ulcer and lymphedema (swelling in the arms or legs caused by a lymphatic system blockage); and - Interventions included to cleanse the wounds (location not included) with wound cleanser, pat dry, apply collagen (stimulates new tissue growth) to wound bed and cover with a dry dressing. Wound care to be done every Monday, Wednesday and Friday by nursing and as needed by caregiver/patient when needed. Review of the SN visit notes showed: - On 03/29/2021 the front of the right lower leg measured 2.36 inches x 1.18 inches and the right calf had a large open area. No further assessment documented. Unable to measure due to patient positioning. No signs and symptoms of infection noted. - On 04/02/2021 the patient had ulcerations to the right lower extremity, stable, and moderate amount of drainage. No further assessment documented; - On 04/05/2021 the wound on the front right lower leg measured 2.36 inches by 1.57 inches and the right calf wound measured 3.15 inches by 6.3 inches with no signs and symptoms of infection noted. No further assessment documented; - On 04/07/2021 the right calf had a small amount of serosanguineous drainage with no signs and symptoms of infection. No further assessment of the right calf ulcer and no documented assessment of the right shin area; - On 04/09/2021 the right shin had a moderate amount of serosanguineous drainage with no signs of infection. No further assessment of the right shin and no documented assessment of the right calf ulcer; - On 04/12/2021 the front right lower leg measured 2.36 inches by 1.18 inches. The dressing was saturated. The wound had a large amount of brown, yellow drainage. No assessment of the wound bed or presence of odor. The right calf measured 3.15 inches by 6.3 inches. No signs of infection noted. The wound continues to have a large amount of drainage (unsure which wound this referred to or whether it referred to both wounds); - On 04/14/2021 the right shin and calf ulcer had a small amount of serosanguineous drainage with no signs of infection. No further assessment was documented; - On 04/16/2021 the right shin and right calf ulcer showed no signs of infection. No further assessment documented; - On 04/19/2021 the right shin ulcer measured 2.36 inches by 1.18 inches with a large amount of brown drainage. No assessment of the wound bed or odor. The right calf ulcer measured 3.15 inches by 6.3 inches. No further assessment was documented; and - On 04/21/2021 the right shin ulcer had a large amount of brown, yellow drainage. No further assessment documented. No signs of infection. No documented assessment of the right calf ulcer. Review of a communication note dated 04/23/2021 showed the patient told the nurse he/she would not be available for a visit until 04/26/2021. Review of the SN visit note dated 04/26/2021 the right shin ulcer measured 2.36 inches by 1.18 inches and the right calf ulcer measured 3.15 inches by 6.3 inches with no signs of infection noted. There was no documented assessment of the wound bed, drainage or odor. Review of the general surgery wound follow up note dated 04/28/2021 showed: - The patient stated that the home health care nurses states that the wound is not closing up very fast and not at all over the last month; - Exam showed the anterior and posterior right leg wounds have good granulation (healing) tissue. They have not gotten smaller over the last month. There appears to be a slight pungent smell and green hue on the dressings. It is unclear if this is a pseudomonas (bacterial) looking infection. Cultures (a test to determine what bacteria is present) were taken; - Assessment and plan included that it appeared the chronic right leg wound appeared the progression had stalled. Generally this means that there is infection as the wound itself looks fairly good. There is a slight pungent smell and a green hue to suggest potential infection. Review of the SN visit notes showed: - On 04/30/2021 the right calf and right shin diabetic ulcer was immeasurable and irregular in shape. No signs of infection. No documented assessment of wound bed, drainage or presence of odor; - On 05/01/2021 no documented assessment of the right leg wounds; - On 05/02/2021 the patient had yellow drainage from anterior posterior leg wound but no signs of infection. No further assessment or whether there was presence of odor. No documentation that the physician was notified of the yellow drainage; - On 05/03/3021 the right shin and calf ulcers showed no signs of infection. No further documented assessment; - On 05/04/2021 the right shin and calf diabetic ulcers were not measurable and had no signs of infection. No further documented assessment; - On 05/06/2021 the right calf and shin ulcers had no signs of infection; - On 05/07/2021 no assessment of the right calf and shin ulcers; - On 05/08/2021 the right calf and shin ulcers had a small amount of drainage. No signs of infection present; - On 05/09/2021 there was a small amount of drainage from each wound. No documentation whether odor was present. No signs of infection; - On 05/10/2021 no signs and symptoms of infection, No documentation regarding drainage or odor; - On 05/11/2021 no signs of infection; - On 05/14/2021 the right calf and shin diabetic ulcers had no signs of infection; - On 05/17/2021 no signs of infection noted; - 05/19/2021 right calf and shin diabetic ulcers had a moderate amount of serosanguineous drainage with no signs of infection; - On 05/21/2021 the RN evaluation comprehensive assessment showed the right calf ulcer had a small amount of green, yellow drainage. No documentation regarding odor or whether the physician was notified of the green, yellow drainage. No assessment of the right shin ulcer; and - On 05/24/2021 both wounds are not measurable due to different healing areas throughout the wounds. No signs of infection noted. No assessment of the wound bed, drainage or odor. Review of the SN visit notes from 03/12/2021 through 05/24/2021 showed the skilled nurses consistently failed to document complete wound assessments to include a description of the wound bed, surrounding tissue, drainage amount, color and presence of odor. During an interview on 05/27/2021 at 8:17 AM, the RN case manager stated that: - The patient had slow healing wounds; - The patient has always had a massive wound on the back of the right calf and an oval shaped wound on the front shin; - At one time it seemed like none of it was open on the shin but the skin was very frail; - When the wound reopened on 03/22/2021, he/she thought that was expected with the patient. It wasn't worse; - The patient always had a lot of drainage with an odd smell; - When asked about what should be included in the wound assessment, the RN stated that the patient's wounds were hard to measure, they were not defined and the patient did not cooperate with holding his/her leg up; - He/she expected each visit the documentation would include location of wounds, odor, and signs and symptoms of infection.

Org. had partial/extended survey CFR(s): 484.80(f)(3) Was subjected to an extended (or partially extended) survey as a result of having been found to have furnished substandard care (or for other reasons as determined by CMS or the state); or This ELEMENT is not met as evidenced by: Based on an extended level survey, the agency has been found out of compliance in one Condition of Participation: Care Planning, Coordination of Services, and Quality Care. The agency may not train or competency evaluate their home health aides for a period of two (2) years following the date of this survey. The restriction ends 05/27/2023.

Discharge and transfer summaries CFR(s): 484.110(a)(6)(i-iii) (i) A completed discharge summary that is sent to the primary care practitioner or other health care professional who will be responsible for providing care and services to the patient after discharge from the HHA (if any) within 5 business days of the patient's discharge; or (ii) A completed transfer summary that is sent within 2 business days of a planned transfer, if the patient's care will be immediately continued in a health care facility; or (iii) A completed transfer summary that is sent within 2 business days of becoming aware of an unplanned transfer, if the patient is still receiving care in a health care facility at the time when the HHA becomes aware of the transfer. This ELEMENT is not met as evidenced by: Based on policy review, record review, and interview, the agency failed to ensure a transfer summary was completed and sent within two business days of a transfer if the patient's care will be immediately continued in a health care facility in one (Record/Patient #6) of two discharge records reviewed and failed to ensure a completed comprehensive discharge summary that included all required components was sent to the primary care physician or other professional who would be responsible for providing care and services to the patient in one (Record/Patient #7) of two discharge records reviewed. This deficient practice has the potential to affect all patients served by the agency. Findings included: Review of the agency policy titled, "Discharge and Unilateral Termination," revised 03/10/2021 showed in part the patient's record will include a discharge summary by each skilled service involved. Review of the agency policy titled, "Transfers," revised 07/23/2019 showed in part: - A transfer form can be initiated by professional or clerical staff. The professional is responsible for verbal or written contact with the hospital, nursing home, etc. Our goal is to do this within 24 hours of our knowledge of the placement; and - When the patient is admitted to the hospital (other than Golden Valley Memorial Hospital), a notification form will be completed by the secretary, who will then fax it to the social service department of the appropriate hospital. When possible, this should be done within one working day of our notification. RECORD/PATIENT #6: Review of the non-visit documentation: OASIS (outcome assessment and information set) assessment dated 05/04/2021 showed the patient was admitted to the hospital on 05/04/2021. Review of the medical record showed no completed transfer summary. During an interview on 05/25/2021 at 3:00 PM, the clinical supervisor stated that when a patient transfers they do a transfer OASIS, but no transfer summary is sent to the hospital. RECORD/PATIENT #7: Review of the plan of care showed the certification period was from 04/07/2021 to 05/08/2021. Review of the discharge OASIS showed the patient was discharged from service on 04/16/2021. Review of medical record showed no discharge order from the physician, and the discharge summary sent to the physician failed to include the type of services, frequency of services, admission date, and a medication list. During an interview on 05/26/2021 at 12:45 PM, the clinical supervisor stated that they do not get a discharge order from the physician, and a medication list was not sent with the discharge summary.