Every finding on record at Ozarks Medical Center

The Emergency Preparedness regulations were reviewed as part of the Medicare recertification survey completed on 02/21/2024. 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.

An an extended survey for Medicare recertification for the home health provider was completed on 02/21/2024. The provider had 36 current patients. One condition level deficiency was identified during this survey at §484.60 Condition of Participation: Care planning, coordination of services, and quality of care. A home health provider that is found out of compliance with any Condition of Participation evaluated as part of a standard survey may not train or competency evaluate their home health aides for a period of two (2) years following the date of this survey. A deficiency has been cited at Tag G788.

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 the medications in the home matched the provider's medication list in one of three home visits conducted (Record/Patient #2). This deficient practice has the potential to affect all patients served by the provider. Findings included: Review of the provider's policy titled, "Medication Procurement, Management, Reconciliation and Administration," showed in part, the following: -Home Care Program nursing staff will create and maintain a current medication profile and a current medication administration record for each client served by the agency; and -Home Care Program nursing staff must review all medications with the client and provide education to client as appropriate regarding medication administration, purpose, side effects, drug allergies, contraindications and any special instructions specific to each medication being administered or that the client is taking. RECORD/PATIENT #2: Observation and interview on 02/20/2024 at 12:00 PM, during the patient's home visit, showed the following discrepancies when compared with the provider's medication profile report, dated 02/20/2024: -Metronidazole (used to treat bacterial infections in different areas of the body typically taken for seven to 10 days) 500 milligrams (mg), take one tablet every eight hours with a start date of 11/30/2023. The patient stated that he/she stopped taking the medication "months ago"; -Hydromorphone (used to treat moderate to severe pain) 2 mg, take one tablet as needed daily for one month prior to wound vac (Vacuum-assisted closure (VAC) is a method of decreasing air pressure around a wound to assist the healing) changes, ordered on 12/15/2023. The patient stated that he/she stopped taking the medication "months ago" when the wound vac was discontinued; and -Probiotic Acidophilus, 2 billion active cultures per capsule, take one capsule daily; this medication was not on the provider's medication list. During an interview on 02/21/2024 at 11:00 AM, the administrator stated that he/she would expect the medications to match between the provider list and the home medications and he/she would expect the medication lists to be reconciled.

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 home health provider failed to: - Ensure that patient specific education was included on the plan of care (G574); - Ensure that the plan of care was followed (G578); - Ensure that care was coordinated between caregivers, patient, and professionals (G608); - Ensure that the patient’s home folder contained a visit schedule (G614); - Ensure that the patient’s home folder contained a provider medication list (G616); and - Ensure that the patient’s home folder contained the name and contact information of the clinical manager (G622). The cumulative effect of these deficient practices has the potential to affect individualized and physician ordered care provided to all the provider’s patients.

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 home health provider failed to ensure that patient specific education was included on the plan of care for one of five full records reviewed (Record/Patient #1). This deficient practice has the potential to affect all patients served by the provider. Findings included: Review of the provider’s policies showed the provider failed to include a policy for including patient specific education on the plan of care. RECORD/PATIENT #1: Review of the clinical record showed that the patient was admitted to home health services on 01/02/2024 with a secondary diagnosis of history of urinary tract infections (UTI- an infection in any part of the urinary system). Review of a physical therapist (PT) note dated 02/01/2024, showed that the patient reported having a UTI the past week and had completed a course of antibiotics. The patient also reported having weakness and bladder urgency. Review of a PT note dated 02/08/2024, showed the patient reported finishing an antibiotic for UTI on the morning of 02/08/2024 and was continuing to have symptoms of UTI with burning with urination. The patient also reported having increasing difficulty completing standing activities and inability to ambulate since developing the UTI. Review of the plan of care dated 01/02/2024 to 03/01/2024, failed to include any education provided to the patient or caregiver related to prevention of urinary tract infections. During an interview on 02/21/2024 beginning at 11:10 AM, the administrator stated that he/she would have expected interventions for prevention of a UTI to be included on the plan of care for the patient.

Conformance with physician orders CFR(s): 484.60(b) Standard: Conformance with physician or allowed practitioner orders. This STANDARD is not met as evidenced by: Based on policy review, record review, and interview the home health provider failed to ensure that the plan of care was followed in two of five full records reviewed (Records/Patients #3 and #5). This deficient practice has the potential to affect all patients served by the provider. Findings included: Review of the provider’s policy, “Physician Management and Orders,” dated 02/2021, showed in part: - A registered nurse (RN) will obtain written orders from a physician or authorized licensed independent practitioner for all medications and medical treatments managed or administered by home care and for any changes to such orders; - Prescriptions and nonprescription (over the counter) drugs, devices, medications, and treatments shall be administered by home care staff in accordance with the written orders of the physician or authorized practitioner; - Medications and treatments shall be administered as prescribed by the RN or licensed practical nurse (LPN) and shall be recorded in the client’s clinical record, as administered; and - Home care responsibilities to the physician include provide ordered home health services and interventions. All services and interventions should be provided in a timely manner. RECORD/PATIENT #5: Review of the clinical record showed that the patient was admitted to home health services on 01/17/2024 with a principal diagnosis of Type 2 Diabetes Mellitus with hyperglycemia (a group of diseases that results in too much sugar in the blood) and a secondary diagnosis of heart failure unspecified (a decrease in the ability of the heart to pump blood which often leads to swelling and weight gain). Review of the plan of care dated 01/17/2024 to 03/16/2024 showed the following: - Frequency of visits: 1 every week X 1 week (one every week for one week), 2 every week X 2 weeks (two every week for two weeks, 1 every week X 2 weeks (one every week for two weeks, and PRN (pro re nata- as needed) for 5 visits for change in condition; - Nursing to draw a basic metabolic panel (BMP- a blood test that gives important information about the current status of your kidneys, electrolytes, and acid/base, blood sugar, and calcium levels) on next visit and fax the results to the patient’s primary physician; - "The patient is on several diuretics to assist in congestive heart failure (CHF; a decrease in the ability of the heart to pump blood) management" (the only diuretic shown on the patient’s plan of care was metolazone (a medication used to decrease swelling and manage the symptoms of heart failure) 2.5 milligrams (mg) one tablet every other day); - The patient was on a fluid restriction which he/she reported he/she was compliant with (the diet section of the nursing admission assessment dated 01/17/2024, stated that the patient’s diet was cardiac and diabetic and failed to mention the fluid restriction); and - Weigh the patient at each visit. Further review of the clinical record, showed the following: - The physical therapist (PT) evaluation dated 01/19/2024, failed to include documentation of a weight for the patient; - The PT visit dated 01/24/2024, failed to include documentation of a weight for the patient; - The registered nurse (RN) nursing visit dated 01/25/2024, showed the patient had his/her blood drawn from his/her left hand on first attempt with no issues noted and the blood was take to the lab. The nurse failed to document a failed a weight for the patient; - The home health aide (HHA) visit dated 01/25/2024, failed to include documentation of a weight for the patient; - A communication note dated 01/25/2024, showed that the BMP results showed that the patient’s potassium level was low and the physician ordered to increase Potassium (a medication used to supplement potassium in the body) to 20 milliequivalents (mEq) twice per day and to redraw the BMP in two weeks; - The plan of care failed to show an order for the Potassium; - A communication note dated 01/25/2024 showed that the caregiver was notified of the change in Potassium; - The RN nursing visit dated 01/30/2024, failed to include documentation of a weight for the patient and that the “meds were reconciled with no changes per patient and caregiver”; - The HHA visit dated 01/31/2024, failed to include documentation of a weight for the patient; - The PT visit dated 01/31/2024, failed to include documentation of a weight for the patient; - The RN nursing visit dated 02/02/2024, failed to include documentation of a weight for the patient and that the medications were reconciled in the home and no changes were noted; - The HHA visit dated 02/05/2024, failed to include documentation of a weight for the patient; - The RN nursing visit dated 02/06/2024, failed to include documentation of a weight for the patient and that the RN was “able to reconcile all of the patient’s meds” and that a lab draw was completed with two attempts in the right antecubital space and taken to the lab; - A communication note dated 02/06/2024, showed that the BMP results showed that the patient’s potassium was a critical value of 2.2 (normal range for a potassium level is 3.6 to 5.2) and that the physician was notified and ordered the nurse to ensure that the patient was taking the previously ordered potassium dose of 20 mEq twice per day. If the patient was compliant with medications, then the potassium dose should be increased to 40 mEq twice per day; - Documentation failed to show anyone contacted the patient/caregiver on 02/06/2024 regarding the potassium order; - A communication note dated 02/07/2024, showed that the nurse attempted to notify the patient’s caregiver with no answer and then attempted to call the patient with no answer and was unable to leave a voicemail on either number; - Documentation failed to show that the patient/caregiver were notified of the new medication orders; - The PT discharge visit dated 02/07/2024, showed that the patient complained of having severe chest pain earlier in the day and the caregiver gave the patient a Nitro (a medication used to control chest pain and the plan of care failed to contain an order for Nitro); and - The PT failed to notify a nurse or the physician of the patient's earlier complaint of severe chest pain. The clinical record failed to show any further documentation or visits regarding the potassium order or the chestpain. During an interview on 02/21/2024 beginning at 10:50 AM, the administrator stated that he/she could not find a specific number documented for the patient’s weight and that he/she would expect the weights to be completed. He/she would have expected the nurse to continue to try to notify the patient or caregiver of the medication changes and that the PT reported that he/she had reported the complaints of chest pain to the physician’s office but that there was no documentation of it. The administrator also stated that he/she would expect the PT to report the complaint of chest pain to a nurse and to document calling the physician’s office. RECORD/PATIENT #3: Review of the clinical record showed that the patient was admitted to home health services on 02/09/2024 with a principal diagnosis of Type 2 diabetes mellitus with diabetic peripheral angiopathy without gangrene (a complication from chronic diabetes that can lead to damage of the skin or other organs). Review of the plan of care dated 02/09/2024 to 04/08/2024, showed a physician’s order to monitor vital signs including BG (blood glucose) 60 to 350 call if symptomatic or >350 (greater than 350) or <60 (less than 60). Further review of the clinical record, showed the following: - The PT evaluation dated 02/12/2024, failed to show documentation of a blood glucose level in the vital signs section; - The occupational therapist (OT) evaluation dated 02/13/2024, failed to show documentation of a blood glucose level in the vital signs section; - The RN nursing visit dated 02/16/2024, failed to show documentation of a blood glucose level in the vital signs section; and - The PT visit note dated 02/16/2024, failed to show documentation of a blood glucose level in the vital signs section. During an interview on 02/21/2021 beginning at 10:50 AM, the administrator stated that he/she could not find any documentation of blood glucose levels and that he/she would expect blood sugars to be checked and documented.

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 home health provider failed to ensure that care was coordinated between caregivers, patients, and professionals in one of five full records reviewed (Record/Patient #1). This deficient practice has the potential to affect all patients served by the provider. Findings included: Review of the provider’s policy titled, “Medication Procurement, Management, Reconciliation, and Administration,” dated 09/2020, showed in part: - The registered nurse (RN) case manager is responsible for reconciliation of all medications on admission and whenever there are new or changed medications added to the plan of care. Documentation in the patient's medical record will include direct communication and written confirmation of reconciliation with the patient's attending physician and/or medical director in consultation with the pharmacist, as necessary; - A medication profile is part of the initial and comprehensive assessment performed by a home care program RN. Qualified RN/licensed practical nurse (LPN) personnel review all of the client’s prescriptions and over-the-counter drugs, herbal remedies, and other alternative treatments that could effect drug therapy on an ongoing basis; and - Home care nursing staff will create and maintain a current medication profile for each client served by the agency. Review of the provider’s policy titled, “Care Coordination,” dated 02/2021, showed in part: - It is the policy of home care to ensure that there is communication and case coordination on every client receiving services to ensure that services are coordinated effectively and support the objectives outlined in the plan of care or service plan; - Information regarding each client’s health status and the plan of care or service plan is communicated among relevant care providers, including the home health aide and the client’s physician; - Clinical staff will communicate with the home health clinical manager when there is a change in the medical condition or family situation, which warrants further action by home health care or referral to the client’s physician or another organization; and - The RN or therapist will document in the client record all case conferences between all professional staff, the clinical director, and others involved in the client’s plan of care or service plan. The documentation will demonstrate that effective interchange, reporting, and coordination of client care does occur. RECORD/PATIENT #1: Review of the clinical record showed that the patient was admitted to home health services on 01/02/2024 with a principal diagnosis of Multiple Sclerosis (a disease that eats away at the protective covering of the nerves and causes nerve damage that disrupts the communication between the brain and the body). Further review of the clinical record, showed the following: - A physical therapist (PT) visit note dated 01/09/2024, showed that the patient’s primary physician had ordered a new blood pressure medication, but the patient had not picked up the medication from the pharmacy (the note failed to contain the name of the medication and failed to show any documentation the PT notified the clinical manager of the new blood pressure medication); - An occupational therapist (OT) visit note dated 01/10/2024, showed there were no new medication changes and the patient was taking all prescribed medications as directed by the physician; - A PT visit note dated 01/11/2024, showed there were no medication changes noted; - An OT discharge visit dated 01/15/2024, showed that there were no medication changes and the patient was taking all prescribed medications as directed by the physician; - A PT visit note dated 01/16/2024, showed there were no medication changes noted; and - A PT visit note dated 02/01/2024, showed that a new blood pressure medication was added to the provider’s medication list (the note failed to contain the name of the medication). During an interview on 02/21/2024 beginning at 10:50 AM, the administrator stated that the medication list showed that the medication was added to the provider’s list on 01/24/2024 by the PT and was found on a visit to the home. He/she further stated that the process for adding a medication to the provider’s medication list should have started on 01/09/2024 when the PT was notified that a new medication was ordered and the PT should have started researching the medication to add it to the list and contacted the clinical manager to add the medication to the medication list. The administrator stated that he/she would have expected the medication to be added to the provider’s list before 01/24/2024.

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 policy review, record review, observation, and interview the home health provider failed to ensure that the home folder contained a visit schedule in two of three home visits (Records/Patients #1 and #3). This deficient practice has the potential to affect all patients served by the provider. Findings included: Review of the provider’s policy titled, “Client Rights and Responsibilities,” dated 07/2020, showed in part, that the client has the right to: - Receive information about the scope and services that home care will provide and any specific limitations to those services; - Participate in all aspects of care/service, including care planning and any changes in the services and care, frequency of visits and cessation of services; and - To be informed, in advance about the care to be furnished, and any changes in the care to be furnished. Home care will advise the clients in advance of the disciplines that will be providing care and the planned frequency and hours of services provided. RECORD/PATIENT # 1: Review of the clinical record showed that the patient was admitted to home health services on 01/02/2024 and was receiving services from occupational therapy (OT) and physical therapy (PT). Observation on 02/20/2024 beginning at approximately 11:45 AM, during the patient’s home visit, showed the home health folder contained blank visit calendars for January and February. RECORD/PATIENT #3: Review of the clinical record showed that the patient was admitted to home health services on 02/09/2024 and was receiving services from nursing, OT, and PT. Observation on 02/20/2024 beginning at 3:30 PM, during the patient’s home visit, showed the home health folder contained a blank visit calendar for February. During an interview on 02/21/2024 at 11:15 AM, the administrator stated that he/she would expect both folders to contain completed visit calendars.

Patient medication schedule/instructions CFR(s): 484.60(e)(2) Patient medication schedule/instructions, including: medication name, dosage and frequency and which medications will be administered by HHA personnel and personnel acting on behalf of the HHA. 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 the home folder contained a provider medication list in one of three home visits (Record/Patient #3). This deficient practice has the potential to affect all patients served by the provider. Findings included: Review of the provider’s policy titled, “Medication Procurement, Management, Reconciliation, and Administration,” dated 09/2020, showed in part: - A medication profile is part of the initial and comprehensive assessment performed by a home care program registered nurse (RN). Qualified RN/licensed practical nurse (LPN) personnel review all of the client’s prescriptions and over-the-counter drugs, herbal remedies, and other alternative treatments that could effect drug therapy on an ongoing basis; and - Home care nursing staff will create and maintain a current medication profile for each client served by the agency. RECORD/PATIENT #3: Review of the clinical record showed that the patient was admitted to home health services on 02/09/2024 and was receiving services from nursing, occupational therapy, and physical therapy. Observation on 02/20/2024 beginning at 3:30 PM, during the patient’s home visit, showed the home health folder failed to include a provider medication list. During an interview with the patient’s caregiver on 02/20/2024 at approximately 4:15 PM, the caregiver stated that he/she had not seen a medication list from the provider but did have a list provided by the patient’s son/daughter. During an interview on 02/21/2024 at 11:15 AM, the administrator stated that he/she would expect the home folder to contain a current medication list from the provider.

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 policy review, record review, observation, and interview the home health provider failed to ensure that the home folder contained the name and contact information of the clinical manager in two of three home visits (Records/Patients #1 and #3). This deficient practice has the potential to affect all patients served by the provider. Findings included: Review of the provider’s policies showed the provider failed to include a policy for providing the name and contact information of the clinical manager to patients. RECORD/PATIENT # 1: Review of the clinical record showed that the patient was admitted to home health services on 01/02/2024 and was receiving services from occupational therapy (OT) and physical therapy (PT). Observation on 02/20/2024 beginning at approximately 11:45 AM, during the patient’s home visit, showed the home health folder failed to include the clinical manager’s name and contact information. RECORD/PATIENT #3: Review of the clinical record showed that the patient was admitted to home health services on 02/09/2024 and was receiving services from nursing, OT, and PT. Observation on 02/20/2024 beginning at 3:30 PM, during the patient’s home visit, showed the home health folder failed to include the clinical manager’s name and contact information. During an interview on 02/21/2024 at 11:15 AM, the administrator stated that he/she would expect both folders to contain the clinical manager’s 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, observation, and interview, the home health provider failed to ensure proper hand hygiene and bag technique were followed in one of three home visits conducted (Record/Patient #2). This deficient practice has the potential to affect all patients served by the provider. Findings included: Review of the provider's policy titled, "Hand Washing: Hand Hygiene," dated 10/2020, showed, in part, the following: -At a minimum, hands must be cleaned: *before and after contact with a patient, patient care equipment, or patient belongings, *after removing gloves, and *when moving from a contaminated body site or activity to a clean body site or activity. Review of the provider's policy titled, "Care Provider Bag Technique," dated 11/2020, showed clinicians were to clean used equipment when soiled following infection control policy and to then replace cleaned equipment into bag. RECORD/PATIENT #2: Observation on 02/20/2024 at 12:00 PM, during the patient's home visit, showed registered nurse (RN)A completed the following: - Performed hand hygiene and put on clean gloves; - Removed old dressing from wound; - Removed soiled gloves and put on clean gloves; - Failed to perform hand hygiene between glove change; - Measured the wound; - Cleansed the wound with saline wash and gauze, RN-A failed to remove soiled gloves after cleansing wound; - Then opened a new foam dressing; - Placed medication gel on the wound bed with cotton tipped applicators; - Cut foam dressing and placed the dressing on the wound; - Then taped the dressing down; - Discarded all used materials; - Gathered unused materials and put them back with wound supplies; - Put scissors back in his/her bag without cleaning; and - Then removed gloves and performed hand hygiene. Observation on 02/20/2024 at 12:30 PM, during the patient's home visit, showed RN-A completed the following while taking the patient's vitals: - Performed hand hygiene and removed the vital sign equipment from his/her bag; - Took the patient's vital signs and placed all the equipment back into his/her bag without cleaning the equipment; and - Handed computer to patient to sign for visit and failed to clean the computer after handing it to the patient. During an interview on 02/21/2024 at 11:00 AM, the home health administrator stated that he/she would be conducting in-services regarding the hand hygiene and bag policy with the clinical staff and he/she would expect their clinical staff to follow the policies.

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 the results of this extended level survey, resulting in noncompliance with one Condition of Participation: §484.60 Care planning, coordination of services, and quality of care, the home health provider 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 02/21/2026.

The Emergency Preparedness regulations were reviewed as part of the Medicare certification survey completed on 08/26/2021. During the survey it was determined Ozarks Healthcare at Home, Home Health is in compliance with the requirements of 42 CFR 484.102 Condition of Participation: Emergency Preparedness for Home Health Agencies.

A partial extended survey for Medicare certification for Ozarks Healthcare at Home, Home Health was completed on 08/26/2021. The agency had 78 current patients. A COVID-19 Focused Infection Control Survey was completed in conjunction with the survey. One deficiency was identified related to the Focused Infection Control Survey.

RN performs assessment CFR(s): 484.55(a)(1) A registered nurse must conduct an initial assessment visit to determine the immediate care and support needs of the patient; and, for Medicare patients, to determine eligibility for the Medicare home health benefit, including homebound status. The initial assessment visit must be held either within 48 hours of referral, or within 48 hours of the patient's return home, or on the physician or allowed practitioner - ordered start of care date. This ELEMENT is not met as evidenced by: Based on policy review, record review, and interview, the agency failed to complete the initial assessment of the patient within 48 hours of the referral to home care, or 48 hours after the patient's return home, or on the physician ordered start of care date in one (Patient/Record #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, "Screening and Acceptance of Client for Services," revised 02/2021, showed in part the initial home visit will be conducted within 48 hours of referral or within 48 hours of clients return home, or on a date identified by the physician unless home care had written documentation that client or family refused such visit. RECORD/PATIENT #1: Review of the physician referral dated 06/22/2021 showed an order for physical therapy (PT) to evaluate and treat. Review of a communication note dated 07/06/2021 showed a call was made to the physician's office and obtained a verbal ok for the start of care to be 07/07/2021. Review of the record showed the PT did not perform the initial assessment until 07/07/2021. Review of the record showed no documentation of physician notification within 48 hours of the referral or the reason for the delay in the start of care. During an interview on 08/25/2021 beginning at 8:50 AM the quality resource manager stated that there needed to be a reasonable reason to delay the start of care, and the physician should be contacted to get an order for the start of care. During an interview on 08/25/2021 at 12:05 PM with the quality resource manager and RN intake coordinator, the RN intake coordinator stated that the delay in the start of care was most likely due to the availability of staff to start services. No further information was provided.

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 #1, #5 and #8) of five full records reviewed. This deficient practice has the potential to affect all patients served by the agency. Findings included: Review of the agency policy titled, "Medication Procurement, Management, Reconciliation and Administration," revised 09/2020, showed in part: -The RN (registered nurse) case manager is responsible for reconciliation of all medications on admission and whenever there are new or changed medications added to the plan of care (POC); -Documentation in the patient's medical record will include direct communication and written confirmation of reconciliation with the patient's attending physician and/or medical director in consultation with the pharmacist, as necessary; -A medication profile is part of the initial and comprehensive assessment performed by a home care program RN. Qualified RN/LPN (licensed practical nurse) personnel review all of the client's prescriptions and over-the-counter drugs, herbal remedies and other alternative treatments that could effect drug therapy on an ongoing basis: -Home care program nursing staff will create and maintain a current medication profile for each client served by the agency; and -Home care program nursing staff monitoring and/or administering medications must use the medication list to identify and monitor for possible ineffective drug therapy or adverse reactions, significant side effects, drug allergies, contraindications and shall promptly report to the physician medication discrepancies, side effects, problems or reaction. Review of the agency policy titled, "Comprehensive Initial Assessment of Clients," revised 02/2021, showed in part the comprehensive assessment includes a review of all medications the client is currently using, both prescription and non-prescription. The review includes, but not limited to, effectiveness of drug therapy, drug side effects, immediate desired effects, actual or potential drug interactions, duplicate drug therapy, non-adherence with drug therapy, drug therapy currently associated with laboratory monitoring, allergic reactions or sensitivities, and changes in the patient's condition that contraindicates continued administration of the medication. Review of the agency policy titled, "Ongoing Assessment," revised 02/2021, showed in part for all home care clients, the nurse or therapist assesses every client on each visit, for his/her response as applicable to client's status, services provided and care needs. A review of the medication profile, including review of all medications the client is currently using, both prescription and non-prescription. This review includes, but is not limited to, effectiveness of drug therapy, drug side effects, immediate desired 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. RECORD/PATIENT #1: During a home visit observation on 08/24/2021 beginning at 10:22 AM showed the following medication discrepancies with the current medication profile, POC and patient medication list: -The medication profile showed an order for rosuvastatin (cholesterol reducing medication, brand name is Crestor) 20 milligrams (mg) one tablet daily. The POC showed an order for rosuvastatin 20 mg daily and Crestor 20 mg daily. The patient's bottle dated 06/05/2021 showed 40 mg one tablet at bedtime. The patient stated that he/she had taken this for a long time. The patient's medication list dated 07/27/2021 showed an order for rosuvastatin 20 mg daily and Crestor 20 mg daily; -The medication profile and POC showed an order for vitamin D3 (supplement, another name is cholecalciferol) 10 micrograms (mcg) (400 units) two times a day. The patient's bottle showed 50 mcg (2000 units) daily. The patient's medication list showed an order for vitamin D3 10 mcg two times a day and cholecalciferol 10 mcg two times a day; -The medication profile showed an order for Rapaflo (used for urinary retention) four mg daily. The patient's bottle dated 07/12/2021 showed to take four mg at bedtime. The patient's medication list showed an order for silodosin (Rapaflo) eight mg daily and an order for Rapaflo four mg daily; -The patient stated that he/she used AYR saline mist nasal spray as needed. This was not included on the medication profile; and -The patient stated that he/she used Fisherman's cough drops as needed. This was not included on the medication profile. During an interview on 08/25/2021 at 12:05 PM, the quality resource manager stated that the clinician looks at all the medications in the home and reconciles the medications with the list from the referral source. If discrepancies are noted, the therapist calls a nurse at the office and the physician to discuss the discrepancies. The RN calls the patient to review medications and discuss discrepancies. He/she would need to clarify why the patient's medication list showed the same name of the medications. During an interview on 08/25/2021 at 3:05 PM, the quality resource manager said the nurses should edit duplicate medications on the medication list when they perform the drug regimen review. RECORD/PATIENT #5: Review of the current medication profile showed the following discrepancies with the physician medication list dated 07/13/2021 and POC dated 07/23/2021: -The medication profile and POC showed an order for cranberry extract 500 milligrams (mg) 1500 mg once daily. The physician list did not include this medication; -The medication profile and POC showed an order for a multivitamin daily. The physician list did not include this medication; -The medication profile and POC showed an order for Provigil (used to treat sleep disorders) 100 mg every morning. The physician list did not include this medication; -The medication profile showed an order for vitamin D3 50,000 units weekly. The POC showed an order for vitamin D3 125 mcg 50,000 units weekly and an order for vitamin D3 25 mcg every evening. The physician list showed an order for vitamin D3 25 mcg (1000 units) every evening; -The medication profile showed an order for methocarbamol 500 mg one tablet at noon as needed for spasms and an order for methocarbamol 500 mg three times a day as needed for spasms. The POC showed an order for methocarbamol 500 mg three times a day as needed for spasms. The physician list showed an order for methocarbamol 500 mg three times a day as needed for muscle spasms; -The medication profile and POC showed an order for atorvastin (reduces cholesterol) 40 mg daily and an order for atorvastin 40 mg daily at 10:00 PM. The physician list showed an order for atorvastin 40 mg at 10:00 PM; -The medication profile and POC showed an order for Fosamax (for osteoporosis) 70 mg once weekly. The physician list did not include this medication; -The medication profile showed an order for tirosint (levothyroxine, thyroid medication) 150 mcg daily. The POC showed an order for tirosint 150 mcg daily and an order for levothyroxine 125 mcg daily. The physician list showed an order for levothyroxine 125 mcg daily; -The medication profile and POC showed an order for Baclofen (muscle relaxant) ten mg one tablet four times a day. The physician list did not include this medication; -The medication profile and POC showed an order for ondansetron four mg one tablet every six hours as needed for nausea. The physician list did not include this medication; -The medication profile showed an order for methenamine (used to prevent urinary tract infections) one gram two times a day, take 1000 mg vitamin C with each dose of methenamine. The POC showed an order for methenamine one gram two times a day, take 1000 mg vitamin C with each dose and an order for methenamine one gram two times a day, take 500 mg of vitamin C with each dose. The physician list showed an order for methenamine one gram two times a day, take 1000 mg vitamin C with each dose of methenamine; and -The medication profile and POC showed an order for eye itch ocular one drop in each eye as needed for itch relief. The physician list did not include this medication. Review of the nursing admission visit dated 07/23/2021 showed: -Medications reconciled with bottles found in the home against the medication profile sent by the physician; -Issues were found during the drug regimen review; -The nurse answered yes to the question of did the agency contact a physician by midnight of the next calendar day and complete prescribed/recommended actions in response to the identified potential clinically significant medication issues; and -No documentation of what issues were identified or that medication discrepancies were clarified with the physician. During an interview on 08/25/2021 at 8:50 AM with the clinical manager and quality resource manager, the quality resource manager stated that on admission the staff look at the list from the physician or hospital and compare it with the medications in the home. If there are discrepancies, they notify the physician. This issue with medication reconciliation was recently identified in their quality assurance review and they were working on the issue. During an interview on 08/25/2021 at 3:05 PM with the clinical manager and quality resource manager, the clinical manager looked at the drug regimen review in the computer system. The clinical manager stated that the nurse should not have checked in the computer system that he/she reconciled the medications. When doing the drug regimen review, the nurse should click on duplicate therapies then go to the medication profile and delete one of the duplicate medications. The drug regimen review also showed a level two interaction was a severe interaction between Levaquin and quetiapine, Levaquin and odanestron, butalibitol-aspirin-caffeine and quetiapine and butalibitol-acetaminophen-caffeine with quetiapine. The clinical manager stated that the agency notifies the physician of all interactions found during the drug regimen review. There was no documentation that the nurse notified the physician of the interactions. During an interview on 08/25/2021 at 4:40 PM the quality resource manager stated that they did not have a specific policy regarding when to notify the physician of drug interactions. RECORD/PATIENT #8: During a home visit on 08/25/2021 beginning at 12:55 PM showed the following medication discrepancies: -The medication profile showed an order for warfarin (anticoagulant) 4 milligram (mg) by mouth daily at 2:00 PM. The bottle showed 3 mg by mouth daily. The patient's spouse stated he/she was taking 3 mg daily since Saturday, 8/21/2021; -The medication profile showed Lantus Solostar U-100 Insulin (man-made insulin to control blood sugars) 100 unit/milliliter (3 ml) subcutaneous insulin pen, give 5 units daily. Instructions: If blood glucose level is less than 80 decrease Lantus dose by 2 units, if blood glucose level is above 130 increase Lantus dose by 2 units. The Lantus box showed 5 units every day. The patient's spouse stated he/she takes 5 units daily and didn't know about an adjustment per the blood sugar results; -The medication profile showed an order for aspirin 81 mg extended release by mouth at bedtime. The patient's spouse stated he/she stopped the aspirin when he/she started the warfarin at discharge from the hospital 8/12/2021; -The medication profile showed magnesium (supplement) two tablets by mouth daily. The patient's spouse stated he/she had not been taking magnesium since returning home from the hospital; -The medication profile showed an order for tamsulosin (treats symptoms of enlarged prostate) 0.4 mg take 0.8 mg by mouth at bedtime. The patient's spouse stated he/she takes 0.4 mg daily; and -The medication profile showed an order for multivitamin one tablet by mouth daily. The patient's spouse stated he/she was taking two vita gummies daily but hasn't taken any for a week. The last skilled nurse visit prior to 08/25/2021 was 08/23/2021. During an interview on 08/26/2021 at 10:07 AM, the quality resource manager stated the medication profile should match what the patient is taking.

Only as ordered by a physician CFR(s): 484.60(b)(1) Drugs, services, and treatments are administered only as ordered by a physician or allowed practitioner. This ELEMENT is not met as evidenced by: Based on policy review, record review, and interview, the agency failed to ensure the physical therapy (PT) plan of care (POC) was reviewed with the physician after the initial evaluation visit and failed to ensure physician orders were obtained for the use of cold therapy in 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 Service Plans," revised 02/2021, showed in part: -When the POC cannot be established until after an evaluation visit, the staff consults with the physician in developing the POC and obtains physician approval; and -Therapy service POC and physician orders must include the specific procedures, modalities, the amount, frequency, and duration of their use. RECORD/PATIENT #1: Review of the physician referral dated 06/22/2021 showed an order for PT to evaluate and treat. Review of the PT initial evaluation visit dated 07/07/2021 showed the patient was referred for PT following a fall he/she had three weeks ago. The patient has been doing his/her exercises from his/her previous PT. In reviewing what the patient has been doing, he/she needs some modification to work on his/her gait posture, gluteal strength for stability to relieve back pain and overall strength. The evaluation note showed no discussion with the physician regarding the POC. Review of the PT notes showed: -On 08/17/2021, the patient reported he/she fell onto his/her hands and knees yesterday with pain in the right groin area today. A call was made to the physician to notify of the fall and ask about pain relievers and about need for X-ray. It appeared to be a pulled groin muscle but would like the physician to advise on the need for physician assessment or X-ray. The patient was educated on the use of cold therapy to reduce pain and swelling. The PT recommended the patient use the wheelchair rather than ambulate until they heard back from the physician about having an X-ray. The patient was educated to use cold therapy for 20 to 30 minutes every hour to help with the pain; and -On 08/19/2021 the patient saw the nurse practitioner and had an X-ray which was negative. The patient and caregiver was educated on use of ice for pain management. Review of the physician orders showed no order for the use of cold therapy for pain management. During an interview on 08/25/2021 at 12:05 PM, the quality resource manager stated that he/she expected there to be a physician order for the cold therapy. During an interview on 08/25/2021 at 2:00 PM, the quality resource manager stated that he/she would expect the PT to review the POC with the physician. He/she also stated there was not a physician order for the cold therapy.

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 record review, home visit observation, and interview, the agency failed to ensure each patient received written information related to visit schedule/instructions in one (Record/Patient #8) of three home visits made. This deficient practice has the potential to affect all patients served by the agency. Findings included: RECORD/PATIENT #8: Review of the clinical record showed the patient was admitted to home health services on 08/13/2021 with aneurysm of heart (heart wall areas not contracting) and stage 2 (Partial thickness skin loss involving, epidermis, dermis, or both. The ulcer is superficial and presents clinically as an abrasion, blister, or shallow crater.) sacral (bony structure that is located at the base of the lumbar vertebrae and that is connected to the pelvis) wound. Patient continued to receive services for skilled nursing to do wound care, INR (international normalized ratio - type of calculation based on PT (prothrombin time - test that measures how long it takes for a clot to form in a blood sample) monitoring and medication education. Review of the plan of care (POC) dated 08/13/2021 through 10/11/2021, showed that the physician ordered skilled nursing (SN) three times a week for one week and four times a week times one week alternating weekly. Orders for discipline and treatments showed medication education and wound treatments. Physical therapy two times a week for eight weeks for mobility treatment, transfers from sitting, gait training (forward) and stairs. The home visit made on 08/25/2021 starting at 12:55 PM, showed the home folder was reviewed and the agency failed to provide a written frequency of visits for the skilled nurse and physical therapy. The patient's spouse stated the agency calls to notify when they are coming. During an interview on 08/26/2021 at 10:07 AM, the quality resource manager acknowledged the findings and no further information was provided.

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, home visit observation, and interview, the agency failed to ensure staff followed acceptable standards of practice for infection control 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: Review of the agency policy titled, "Care Provider Bag Technique," revised 11/2020, showed in part to establish a clean surface and place equipment to be used on the clean surface. RECORD/PATIENT #1: During a home visit observation on 08/24/2021 beginning at 10:22 AM showed the physical therapist wore a facial mask during the home visit. For most of the visit, the facial mask did not cover the clinician's nose. RECORD/PATIENT #2: During a home visit observation on 08/24/2021 beginning at 1:00 PM showed the nurse placed his/her computer on the patient's coffee table without establishing a clean surface or placing a barrier beneath the computer. During an interview on 08/25/2021 at 12:15 PM the quality resource manager stated that he/she expected the clinician's facial mask to cover the nose and expected the computer to be placed on a barrier.

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 one (Record/Patient #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, "Wound Assessment and Treatment," revised 02/2021, showed in part: -The nurse will document wound appearance, drainage amount, drainage type, signs/symptoms of infection, as well as education provided, physician notifications and other relevant data at every visit; and -The wound size, including shape, diameter, and depth will be measured and documented at least weekly by the nurse in the clinical record using a wound flow sheet or nursing visit note. Review of the agency policy titled, "Ongoing Assessments," dated 02/2021 showed ongoing assessments are performed during each visit by each discipline, in accordance with the plan of care (POC), which includes the client's problems, needs, goals and outcomes. The POC will be reviewed and revised accordingly by the registered nurse (RN) case manager responsible for the care in conjunction with other professional providers of care as well as the client/family/caregiver. RECORD/PATIENT #5: Review of the POC dated 07/23/2021 showed an order for nursing to provide wound care to the left gluteal fold (the fold at the lower area of the buttocks and the upper thigh) and to assess the skin condition and wound two times a week for one week then once a week for six weeks. Review of the SN visits showed: - On 07/23/2021 the patient had a Stage 2 (partial thickness skin loss) pressure sore to the midline coccyx (tailbone) that measured 0.1 x 0.1 x 0.5 centimeters (cm) with a circular shape and scant amount of drainage. The nurse failed to document a description of the wound bed, whether odor was present and type and color of drainage. The nurse documented he/she provided wound care to the left gluteal fold but provided an assessment of the coccyx (which is a different area); - On 07/26/2021 the nurse documented he/she provided wound care to the left gluteal fold but failed to document an assessment of the wound; and - On 07/27/2021 the spouse reported a new wound to the midline gluteal fold. Orders received for an SN (skilled nurse) visit to assess the wound and perform procedure orders. Wound care to pressure wound on the buttock. Clean with normal saline (salt solution) and 4 x 4 gauze and cover with an Optifoam (foam) dressing. The middle gluteal fold wound measured 0.75 inches x 0.16 inches x 0.04 inches (wounds should be measured in centimeters) with no drainage. The nurse failed to document the type of wound, description of the wound bed, and whether odor was present. The left gluteal fold pressure ulcer was irregular in shape with a small amount of yellow drainage and skin area was pink. The nurse failed to document a description of the wound bed or whether odor was present. The nurse also documented under the section to assess splint/orthopedic device that the patient had a brace on the left leg for fracture protection and the fit was correct (this was the first SN note that noted the patient had a leg brace). There was no documentation of an assessment of the skin under the brace or whether the brace could be removed. Review of the POC dated 07/23/2021 showed diagnoses that included age-related osteoporosis with current pathological fracture, left femur, subsequent encounter for fracture with routine healing. The POC did not include orders related to care/assessment of the brace on the left leg. Review of the physician orders from the wound clinic showed an order effective 08/01/2021 for wound care to the left gluteus that consisted of cleansing with normal saline, Promogran Prisma (antimicrobial dressing composed of collagen and silver) apply to wound bed first then moisten with normal saline, Aquacel (antimicrobial) extra hydrofiber dressing-apply to the top of moistened collagen silver, Allevyn foam dressing, change three times a week. Home health to see patient weekly and caregiver may be taught, an order for wound care to the coccyx that consisted of cleansing with normal saline and apply Allevyn foam dressing, change three times a week, home health to see patient weekly and caregiver may be taught, and an order for wound care to the right lower quadrant of the abdomen which consisted of cleansing with normal saline, apply Nystatin powder and calcium alginate (antimicrobial). Home health to see patient weekly and caregiver may be taught to change. Review of the SN visits showed: -On 08/02/2021 the left gluteal wound measured 1.4 x 0.4 x 0.2 cm, irregular in shape with scant serosanguineous drainage (bloody and clear yellowish serum), skin area pink and no signs of infection. The nurse failed to document a description of the wound bed or whether odor was noted. The patient also had a pressure ulcer to the coccyx that measured 0.2 x 0.3 x 0.1 cm, irregular in shape, skin area pink, no drainage or signs of infection. The nurse failed to document a description of the wound bed or whether odor was present. The patient had a wound to the right lower quadrant of the abdomen. The nurse provided wound care but failed to document an assessment of the wound. No documentation related to the brace on the left leg; -On 08/09/2021 the nurse documented he/she provided wound care to the left gluteus but failed to document an assessment of the wound. The patient refused wound care to the right abdomen. There was no documented assessment of the coccyx, whether wound care was provided, or whether the coccyx area had healed. No documentation related to the brace on the left leg; -On 08/16/2021 the nurse documented he/she provided wound care but failed to document an assessment of the patient's wounds. No documentation related to the brace on the left leg; and -On 08/23/2021 the nurse documented an assessment of the right (unsure if this was to be left) buttocks. The wound was circular in shape and measured 0.8 x 0.6 x 0.5 cm, skin area clean, tissue bed color pink, no drainage or signs of infection. The coccyx pressure ulcer measured 1.0 x 1.0 x 0.0 cm, skin area reddened, tissue bed color pink, no drainage or signs of infection. The patient refused wound care to the right abdomen. The nurse documented the patient was going to physician that day regarding the fracture to the left leg. His/her leg was in an orthopedic brace, and the patient reported not being able to have surgery due to brittle bones. No documentation regarding assessment of the brace or whether the brace could be removed for skin assessment. During an interview on 08/25/2021 beginning at 8:50 AM the quality resource manager stated that a wound assessment should include measurements, a description of the wound bed, periwound (surrounding skin), drainage, odor and signs of infection. Measurements should be in centimeters and taken at least once a week. During an interview on 08/26/2021 at 11:50 AM with the quality resource manager, RN intake coordinator, and community care nurse, the RN intake coordinator stated that he/she spoke with the wound clinic. When they saw the patient on 07/29/2021 the patient had a wound on the coccyx then on 08/05/2021 it had healed. On 08/19/2021 a small area had reopened on the coccyx. The quality resource manager stated that the nurses should document when a wound healed. The community care nurse stated that he/she spoke with the nurse that saw the patient on 08/23/2020. He/she documented right buttock instead of left buttock by accident.

Patient and caregiver education CFR(s): 484.75(b)(5) Patient and caregiver education; This ELEMENT is not met as evidenced by: Based on policy review, record review, home visit observation, and interview, the agency failed to ensure the skilled nurse (SN) documented that patient/caregiver education was provided with return demonstration to ensure the caregiver's understanding and capability in performing wound care in one (Record/Patient #5) of five records reviewed and failed to ensure that complete/accurate education was provided in one (Record/Patient #8) 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, "Client Education," revised 02/2021, showed in part: -The client and family shall receive education and training specific to the client's assessed needs, abilities, knowledge deficits and readiness as appropriate to the care and services provided by home care; and -Document who was taught the information/instructions, description of what was taught, the client/family/caregiver response to teaching, receipt of all written and verbal instructions must be documented in the client's clinical record. Review of Medlineplus.gov, a recognized drug reference showed: Lantus is (insulin glargine - a long-acting, manmade version of human insulin. Insulin glargine works by replacing the insulin that is normally produced by the body and by helping move sugar from the blood into other body tissues where it is used for energy. It also stops the liver from producing more sugar) used to treat type 1 and type 2 diabetes. Insulin glargine comes as a solution (liquid) to inject subcutaneously (under the skin). It is injected once a day. You should use insulin glargine at the same time every day. Follow the directions on your prescription label carefully, and ask your doctor or pharmacist to explain any part you do not understand. Use insulin glargine exactly as directed. Do not use more or less of it or use it more often than prescribed by your doctor. RECORD/PATIENT #5: Review of the plan of care (POC) dated 07/23/2021 showed an order for wound care to the left gluteal fold which consisted of cleansing with normal saline (salt solution), Promogran-Prisma matrix (antimicrobial dressing composed of collagen and silver), comfort border, change daily. The caregiver was to be taught and can perform. Review of the nursing admission visit dated 07/23/2021 showed under the section for wound procedure the nurse documented left gluteal fold, clean with saline, Promogran-Prisma matrix, comfort border, change daily. The caregiver was to be taught and can perform. The nurse documented this procedure was accomplished but failed to document whether a return demonstration was completed by the caregiver and the caregiver's response/ability to perform the wound care. Review of the physician orders from the wound clinic showed an order effective 08/01/2021 showed: - An order for wound care to the left gluteus that consisted of cleansing with normal saline, Promogran Prisma apply to wound bed first then moisten with normal saline, Aquacel (antimicrobial) extra hydrofiber dressing-apply to the top of moistened collagen silver, Allevyn foam dressing, change three times a week. Home health to see patient weekly and caregiver may be taught, - An order for wound care to the coccyx (tailbone) that consisted of cleansing with normal saline and apply Allevyn foam dressing, change three times a week, home health to see patient weekly and caregiver may be taught, and - An order for wound care to the right lower quadrant of the abdomen which consisted of cleansing with normal saline, apply Nystatin powder and calcium alginate. Home health to see patient weekly and caregiver may be taught to change. Review of the SN visit dated 08/02/2021 under the section for wound procedure the nurse documented: - Left gluteal fold, clean with saline, Promogran-Prisma matrix, comfort border, change daily. The caregiver was to be taught and can perform. The nurse documented this procedure was accomplished but failed to document whether a return demonstration was completed by the caregiver and the caregiver's response/ability to perform the wound care; - Coccyx, clean with normal saline and apply Allevyn foam dressing, change three times a week, home health to see patient weekly and caregiver may be taught; - Right lower quadrant of the abdomen which consisted of cleansing with normal saline, apply Nystatin powder and calcium alginate. Home health to see patient weekly and caregiver may be taught to change; and - The nurse documented these procedures were accomplished but failed to document whether a return demonstration was completed by the caregiver and the caregiver's response/ability to perform the wound care. During an interview on 08/25/2021 beginning at 8:50 AM the quality resource manager stated that he/she would expect the nurse to document if a return demonstration was done and the caregiver's understanding of what was taught. RECORD/PATIENT #8: Review of the clinical record showed the patient was admitted to home health services on 08/13/2021 with aneurysm of heart (heart wall areas not contracting), stage 2 (Partial thickness skin loss involving, epidermis, dermis, or both. The ulcer is superficial and presents clinically as an abrasion, blister, or shallow crater.) sacral (bony structure that is located at the base of the lumbar vertebrae and that is connected to the pelvis) wound and uncontrolled diabetes. During a home visit observation on 08/25/2021 beginning at 12:55 PM, review of the patient's medications profile sheet from the agency showed patient was prescribed Lantus Solostar U-100 Insulin (man-made insulin to control blood sugars) 100 unit/milliliter (3 ml) subcutaneous insulin pen, give 5 units daily. Instructions: If blood glucose level is less than 80 decrease Lantus dose by 2 units, if blood glucose level is above 130 increase Lantus dose by 2 units. The Lantus box showed 5 units every day. The patient had an order for tamsulosin (treats symptoms of enlarged prostate) 0.4 milligram (mg) take 0.8 mg by mouth at bedtime. The patient's spouse stated he/she gives the patient Lantus insulin 5 units daily and didn't know about an adjustment per the blood sugar results and the patient takes tamsulosin 0.4 mg daily. The patient's spouse states he/she was never educated to add or decrease amount of insulin given depending on the blood sugar results and had always gave the patient one tablet of tamsulosin 0.4 mg. During an interview on 08/26/2021 at 10:07 AM, the quality resource manager acknowledged the findings and no further information was provided.

Administrator appointed by governing body CFR(s): 484.105(b)(1)(i) (i) Be appointed by and report to the governing body; This ELEMENT is not met as evidenced by: Based on review of agency administrative information, and interview, the agency failed to ensure/document the administrator was appointed and approved by the governing body. This deficient practice has the potential to affect the health and safety of all the patients served by the agency. Findings included: Review of the agency's organization chart showed the current director of home health (administrator) listed. During the entrance interview on 08/23/2021 at 03:17 PM, the current administrator was present for questions. During an interview on 08/26/2021 at 12:30 PM, the director of quality stated there was no documentation in the board governing minutes that the administrator had been appointed and approved by the governing body.

Ensures qualified pre-designated person CFR(s): 484.105(b)(2) When the administrator is not available, a qualified, pre-designated person, who is authorized in writing by the administrator and the governing body, assumes the same responsibilities and obligations as the administrator. The pre-designated person may be the clinical manager as described in paragraph (c) of this section. This ELEMENT is not met as evidenced by: Based on observation and interview, the agency failed to ensure a qualified, pre-designated person who is authorized in writing by the administrator and the governing body assumes the same responsibilities and obligations as the administrator when the administrator is not available. This deficient practice has the potential to affect the health and safety of all the patients served by the agency. Findings included: Review of a letter dated, April 15, 2020, provided by the administrator showed: -A letter addressed to the Bureau of Home Care and Rehabilitative Standards program manager; -This is to inform you that as of April 6, 2020, the quality resource manager will assume the role of Alternative Administrator for Ozarks Medical Center, Riverways Home Care of Ozarks Medical Center; and -The administrator signed the letter. The agency failed to provide documentation from the governing body regarding the appointment of the pre-designated, qualified person to act in the absence of the administrator. During interview on 08/26/2021 at 12:00 PM, the administrator and quality resource manager said there was nothing in writing from the governing body appointing the quality resource manager as the administrator designee.

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 State Code of Regulations, policy review, record review, and interview, the agency failed to ensure staff obtained a copy of a Durable Power of Attorney (DPOA, enables a trusted person to handle affairs if one becomes mentally incapable of making decisions) upon admission to the home health agency in, but not limited to, three (Record/Patient #1, #2, and #8) of five records reviewed. This deficient practice has the potential to affect all patients served by the agency. Findings included: Per 404.840.1, RSMo: "A copy of a power of attorney for health care decisions shall be made a part of the patient's medical record when the existence of the power of attorney becomes known to the patient's health care provider and prior to the provider's taking any action pursuant to the decision of the attorney in fact." Review of the agency policy titled, "Advance Directives," dated 02/2021, showed in part: -Each client (or if the client is incapable of responding, the client's agent, a family member or caregiver) shall be asked if the client has an advance directive; and -If the client has an advance directive, and is not already part of the client's medical record, the admitting clinician shall request that the client provide a copy and make that copy a part of the medical record RECORD/PATIENT #1: Review of the patient consent form showed the patient had an advance directive (Medical Durable Power of Attorney). Review of the plan of care (POC) dated 07/07/2021 showed the patient had a healthcare power of attorney. Review of the record showed no copy of the advance directive or documentation of attempts to obtain a copy. During an interview on 08/25/2021 at 1:45 PM the quality resource manager stated that they did not find documentation of follow up attempts to obtain a copy of the advance directive. RECORD/PATIENT #2: Review of the patient consent form showed the patient had an advance directive (Medical Durable Power of Attorney). Review of the plan of care (POC) dated 07/23/2021 showed the patient had a healthcare power of attorney. Review of the record showed no copy of the advance directive or documentation of attempts to obtain a copy. During an interview on 08/25/2021 at 11:15 AM the quality resource manager stated that they did not have a copy of the advance directive or documentation of attempts to obtain a copy. He/she would teach the clinician's to ask for a copy at admission and document follow up attempts to get a copy. RECORD/PATIENT #8: Review of the clinical record showed the patient was admitted to home health services on 08/13/2021 with aneurysm of heart (heart wall areas not contracting), stage 2 (Partial thickness skin loss involving, epidermis, dermis, or both. The ulcer is superficial and presents clinically as an abrasion, blister, or shallow crater.) sacral (bony structure that is located at the base of the lumbar vertebrae and that is connected to the pelvis) wound and uncontrolled diabetes. Review of the admission comprehensive assessment dated 08/13/2021 showed, in part, the following: -Advance Directive: Advance Directive in place; -Assess Advance Directive: *Proposed Changes: *Action: Add; *Advance Directive: Healthcare Power of Attorney; *Reason: New Finding; and -No documentation that the nurse requested a copy of the advance directive. Review of the clinical record did not include a copy of the advance directive on file at the agency. Review of the plan of care (POC) dated 08/13/2021 to 10/11/2021 showed, in part, advance directives: healthcare power of attorney. During an interview on 08/26/2021 at 10:07 AM the quality resource manager stated that they did not have a copy of the advance directive in the clinical record.

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 sent to the receiving facility within two days of becoming aware of the transfer in one (Record/Patient #6) of two discharge/transfer records reviewed and failed to ensure a comprehensive transfer summary that included relevant information was sent to the receiving facility in one (Record/Patient #7) of two discharge/transfer records reviewed. This deficient practice has the potential to affect all patients served by the agency. Findings included: Review of the agency policy titled, "Coordination with other Providers/Transfer," revised 02/202,1 showed in part the referral/transfer summary process will provide for the exchange of appropriate client care and clinical information as coordinated with the authorized practitioner. The referral/transfer summary information will include, at a minimum the following information - Date of transfer, patient identifying information, emergency contact, destination of client transferred, date and name of person receiving report, client's physician and phone number, diagnosis related to the transfer, significant health history, advance directive information, transfer orders and instructions, a brief description of services provided and ongoing needs that cannot be met, and status at time of transfer. The transferring clinician will complete an OASIS transfer/discharge within 48 hours if applicable. (The policy did not address the time frame in which a transfer summary should be sent to the receiving facility when becoming aware of a transfer.) RECORD/PATIENT #6: Review of the OASIS (Outcome Assessment and Information Set) transfer dated 07/30/2021 showed the patient had been admitted to the hospital. Review of the record showed no completed transfer summary. During an interview on 08/25/2021 at 1:00 PM the quality resource manager stated that the transfer summary had not been completed. During an interview on 08/26/2021 at 11:40 AM the quality resource manager stated that a transfer summary should be sent to the receiving facility within two days of becoming aware of the transfer. RECORD/PATIENT #7: Review of a communication note dated 06/16/2021 showed the patient was admitted to the hospital. Review of the OASIS transfer assessment dated 06/16/2021 showed the patient was admitted to the hospital on 06/15/2021. Review of the transfer summary report dated 06/16/2021 showed the patient was transferred to the hospital for weakness and atrial fibrillation. All home health orders will be placed on hold. No other information was documented During an interview on 08/25/2021 at 1:00 PM the quality resource manager stated that the transfer summary should have included a lot more information.