Every finding on record at Phoenix Home Care, Inc.

A partial extended survey for Medicare recertification for the home health provider was completed on 12/03/2025. The provider had 289 current patients. The Emergency Preparedness regulations were also reviewed as part of the Medicare recertification survey completed on 12/03/2025. One standard level deficiency was identified.

EP Training Program CFR(s): 484.102(d)(1) §403.748(d)(1), §416.54(d)(1), §418.113(d)(1), §441.184(d)(1), §460.84(d)(1), §482.15(d)(1), §483.73(d)(1), §483.475(d)(1), §484.102(d)(1), §485.68(d)(1), §485.542(d)(1), §485.625(d)(1), §485.727(d)(1), §485.920(d)(1), §486.360(d)(1), §491.12(d)(1). *[For RNCHIs at §403.748, ASCs at §416.54, Hospitals at §482.15, ICF/IIDs at §483.475, HHAs at §484.102, REHs at §485.542, "Organizations" under §485.727, OPOs at §486.360, RHC/FQHCs at §491.12:] (1) Training program. The [facility] must do all of the following: (i) Initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles. (ii) Provide emergency preparedness training at least every 2 years. (iii) Maintain documentation of all emergency preparedness training. (iv) Demonstrate staff knowledge of emergency procedures. (v) If the emergency preparedness policies and procedures are significantly updated, the [facility] must conduct training on the updated policies and procedures. *[For Hospices at §418.113(d):] (1) Training. The hospice must do all of the following: (i) Initial training in emergency preparedness policies and procedures to all new and existing hospice employees, and individuals providing services under arrangement, consistent with their expected roles. (ii) Demonstrate staff knowledge of emergency procedures. (iii) Provide emergency preparedness training at least every 2 years. (iv) Periodically review and rehearse its emergency preparedness plan with hospice employees (including nonemployee staff), with special emphasis placed on carrying out the procedures necessary to protect patients and others. (v) Maintain documentation of all emergency preparedness training. (vi) If the emergency preparedness policies and procedures are significantly updated, the hospice must conduct training on the updated policies and procedures. *[For PRTFs at §441.184(d):] (1) Training program. The PRTF must do all of the following: (i) Initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles. (ii) After initial training, provide emergency preparedness training every 2 years. (iii) Demonstrate staff knowledge of emergency procedures. (iv) Maintain documentation of all emergency preparedness training. (v) If the emergency preparedness policies and procedures are significantly updated, the PRTF must conduct training on the updated policies and procedures. *[For PACE at §460.84(d):] (1) The PACE organization must do all of the following: (i) Initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing on-site services under arrangement, contractors, participants, and volunteers, consistent with their expected roles. (ii) Provide emergency preparedness training at least every 2 years. (iii) Demonstrate staff knowledge of emergency procedures, including informing participants of what to do, where to go, and whom to contact in case of an emergency. (iv) Maintain documentation of all training. (v) If the emergency preparedness policies and procedures are significantly updated, the PACE must conduct training on the updated policies and procedures. *[For LTC Facilities at §483.73(d):] (1) Training Program. The LTC facility must do all of the following: (i) Initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected role. (ii) Provide emergency preparedness training at least annually. (iii) Maintain documentation of all emergency preparedness training. (iv) Demonstrate staff knowledge of emergency procedures. *[For CORFs at §485.68(d):](1) Training. The CORF must do all of the following: (i) Provide initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles. (ii) Provide emergency preparedness training at least every 2 years. (iii) Maintain documentation of the training. (iv) Demonstrate staff knowledge of emergency procedures. All new personnel must be oriented and assigned specific responsibilities regarding the CORF's emergency plan within 2 weeks of their first workday. The training program must include instruction in the location and use of alarm systems and signals and firefighting equipment. (v) If the emergency preparedness policies and procedures are significantly updated, the CORF must conduct training on the updated policies and procedures. *[For CAHs at §485.625(d):] (1) Training program. The CAH must do all of the following: (i) Initial training in emergency preparedness policies and procedures, including prompt reporting and extinguishing of fires, protection, and where necessary, evacuation of patients, personnel, and guests, fire prevention, and cooperation with firefighting and disaster authorities, to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles. (ii) Provide emergency preparedness training at least every 2 years. (iii) Maintain documentation of the training. (iv) Demonstrate staff knowledge of emergency procedures. (v) If the emergency preparedness policies and procedures are significantly updated, the CAH must conduct training on the updated policies and procedures. *[For CMHCs at §485.920(d):] (1) Training. The CMHC must provide initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles, and maintain documentation of the training. The CMHC must demonstrate staff knowledge of emergency procedures. Thereafter, the CMHC must provide emergency preparedness training at least every 2 years. This STANDARD is not met as evidenced by: Based on personnel file review and interview, the provider failed to ensure staff were provided Emergency Preparedness (EP) training on hire in one (Employee #4) of four employee files reviewed. This deficient practice has the potential to adversely affect the care and safety of all patients served by the agency during an emergency. Findings included: EMPLOYEE #4 (E4): Review of E4's personnel file showed: - Date of hire: 08/25/2024; - Position: Certified occupational therapy assistant (COTA); and - The file failed to include evidence of EP training on orientation. During an interview on 12/02/2025 at 2:45 PM, the administrator stated that E4 was an as needed (PRN) staff. EP training is provided on orientation and every two years. Human Resources was not able to find evidence that E4 had completed EP training during orientation.

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 an accurate medication review and/or update of the patient medications was completed, in one of five full 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 policy titled, "Medication Management," last reviewed on 09/08/2025, showed in part the following: -Medication assessments will identify all medications, both prescription and non-prescription and as needed (PRN) that the patient/client is taking and document in the clinical record; -The provider will ensure that the assessments of a patient/client include a review of the medication regimen. This will include, but is not limited to; accuracy of the medication list/profile; -Medication assessments are continuous and ongoing, occur at every scheduled clinical visit and are documented in the clinical record; and -All qualified clinicians will initially and routinely evaluate the medication regimen. A complete and accurate medication profile will be established and monitored as part of the plan of care. RECORD/PATIENT #2: Review of the clinical record showed the patient was admitted to home health services on 08/18/2025 with primary diagnosis of type two diabetes (a chronic disease that affects how the body uses sugar for energy) with other skin complications, non-pressure chronic ulcer (a chronically open wound not caused by pressure) of the left foot and hypothyroidism (under active thyroid). The patient resided at home with his/her spouse. Observation and interview on 12/02/2025 at 09:15 AM, showed: -The provider's medication list had levothyroxine sodium (used to treat hypothyroidism) 25 micrograms (mcg) one table by mouth daily. The patient's medication bottle showed 125 mcg one tablet by mouth daily. The patient's spouse stated that the patient's primary care physician changed the dosage three to four weeks ago because the dosage was too strong; -The provider's medication list had warfarin sodium (Coumadin) 2.5 milligrams (mg) (blood thinning agent) one tablet by mouth every Monday and Wednesday and two tablets the rest of the days in the evening. The patient's spouse stated that the patient was taking two pills daily except on Tuesdays, and he/she took three pills on that day. The patient's international normalized ratio (INR, a blood test commonly used to monitor the effectiveness of warfarin therapy) would be drawn again later today; -The patient stated that he/she used a Flonase nasal spray (cortisone-like medication used to treat runny nose) one to two sprays each nostril twice a day. The provider's medication profile failed to include Flonase; -The patient's spouse stated that he/she applied Silvadene cream (used to treat and prevent wound infections) to the patient's left great toe with daily dressing changes. The provider's medication profile failed to include Silvadene; and -The patient's spouse stated that he/she applied triamcinolone cream (topical steroid cream used to treat inflammatory skin conditions) to the patient's left shin area daily for eczema. The provider's medication profile failed to include the Triamcinolone cream. During an interview on 12/03/2025, beginning at 9:53 AM, the administrator stated that clinicians were to update the patient's medication list every time there was a change.

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 develop a plan of care (POC) with measurable, patient-specific outcomes in two of five full records reviewed (Records/Patients #3 and #4) and failed to ensure that the patient's physician was notified of missed home visits in one of five full records reviewed (Record/Patient #3). This deficient practice has the potential to adversely affect the ordered care provided to all the provider’s patients. Findings included: Review of the provider's policy titled, "Plan of Care," dated 05/02/2024, showed in part the following: - The individualized plan of care must specify the care and services necessary to meet the patient/client specific needs as identified in the comprehensive assessment, including identification of the responsible discipline(s), and the measurable outcomes that the agency (provider) anticipates will occur as a result of implementing and coordinating the plan of care; and - Measurable outcomes and goals identified by the agency and the patient. Review of the providers policy titled, "Monitoring Patient /Client Care/ Coordination of Care," dated 05/02/2024, showed in part the following: - The agency will monitor, evaluate, and report to the patient's/client's physician and/or non­-physician practitioner regarding the patient's/client's progress toward achieving goals established on the plan of care; and · - The agency will collaborate with other organizations providing services (i.e., medical equipment, other home health agencies, out-patient clinics, etc.), the patient/client, and their representative (if applicable) to ensure appropriate coordination of care. RECORD/PATIENT #3: Review of the clinical record showed the patient was admitted to home health services on 09/03/2025 with a primary diagnosis of respiratory failure /chronic obstructive pulmonary disease- (COPD; a group of lung diseases that block airflow and make it difficult to breathe). The patient had secondary diagnoses of hypertension (high blood pressure) and depression (a condition of persistent low mood). The patient resided with a significant other at home. Review of the updated POC dated 10/31/2025, showed the patient had the following goal: - Patient will remain free from signs and symptoms respiratory distress during this episode; and - The provider failed to ensure the POC included individualized, measurable outcomes toward established goals. Review of skilled nursing notes dated 11/14/2025, showed the patient declined a skilled nursing visit on 11/14/2025. The note failed to show documentation that the patient’s primary care physician was notified of the missed visit. Review of skilled nursing notes dated 11/28/2025, showed the patient declined a skilled nursing visit on 11/28/2025. The note failed to show documentation that the patient’s primary care physician was notified of the missed visit. RECORD/PATIENT #4: Review of the clinical record showed the patient was admitted to home health services on 10/31/2025 with a primary diagnosis of infective bursitis (an infection of the bursa, a small sac of synovial fluid that acts as a cushion between bones, tendons, and muscles around joints). The patient had secondary diagnoses of chronic obstructive pulmonary disease- (COPD; a group of lung diseases that block airflow and make it difficult to breath), atrial fibrillation- (abnormal heart rhythm characterized by rapid and irregular heartbeat), and chronic pain. The patient resided at home. Review of the updated POC dated 10/31/2025, showed the patient had the following goal: -Patient's respiratory status will improve with reduced shortness of breath and improved lung sounds; and - The provider failed to ensure the POC included individualized, measurable outcomes toward established goals. During an interview on 12/03/2025 at 10:00 AM, the administrator stated that each patient’s POC should be individualized and should include measurable outcomes for each goal. Additionally, the administrator stated that staff should notify both the nursing supervisor and primary care physician of all missed home care visits.

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 develop an individualized plan of care (POC) that addressed the patient's blindness and deafness in one of five full records reviewed (Record/Patient #1). This deficient practice has the potential to affect all the patients served by the provider. Findings included: Review of the provider's policy titled, "Plan of Care," dated 05/02/2024, showed in part the following: - Purpose: To ensure that care provided is appropriately planned in a timely manner to meet the patient’s/client’s specific needs and problems; - The agency (provider) will use data/information gathered during the patient/client assessments in the care planning process which involves the identification of patient/client goals, actions, or interventions that will resolve or alleviate the patient’s/client’s problems and/or needs; and - Each patient/client 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/client-specific needs as identified in the comprehensive assessment. RECORD/PATIENT #1: Review of the clinical record showed the patient was admitted to home health services on 11/07/2025 with a primary diagnosis of spondylosis without myelopathy (the degeneration of the spine, that occurs without the compression of the spinal cord) of the lumbar region (lower back region of the spine, comprising of five vertebrae. This region is crucial for supporting the upper body’s weight and providing mobility). The patient resided at home with his/her daughter and son-in-law. Review of the OASIS (Outcome and Assessment Information Set; a standardized data collection tool) start of care assessment, dated 11/07/2025, showed in part: - The patient’s hearing was impaired on the left; and - The patient was blind in his/her left eye. Review of the plan of care, dated 11/07/2025, failed to be individualized and include any interventions related to the patient being deaf in his/her left ear and blind in his/her left eye. During an interview on 12/03/2025 at 9:55 AM, the administrator stated that the plan of care should have included interventions related to the patient being deaf in his/her left ear and blind in his/her left eye.

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 each patient received complete/accurate written instructions related to their medication schedule/instructions in, but not limited to, one of three home visit observations conducted (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 policy titled, "Medication Management," last reviewed on 09/08/2025, showed in part the following: -The provider will provide to the patient/client and caregiver (if any) written information regarding the patient's/client's medication regimen based on the results of the medication assessment; and -The medication administration instructions must be written in plain language that does not use medical abbreviations. RECORD/PATIENT #2: Review of the clinical record showed the patient was admitted to home health services on 08/18/2025 with primary diagnosis of type two diabetes (a chronic disease that affects how the body uses sugar for energy) with other skin complications, non-pressure chronic ulcer (a chronically open wound not caused by pressure) of the left foot and hypothyroidism (under active thyroid). The patient resided at home with his/her spouse. Observation on 12/02/2025 at 9:15 AM, showed the home health provider failed to ensure a written medication schedule was placed in the patient's home. Per interview conducted during observation, licensed practical nurse (LPN)-A stated that there was not a current medication list in the patient's home. During an interview on 12/03/2025 at 9:53 AM, the administrator stated that he/she would expect patients to have a current medication list in the home.

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 record review, observation, and interview, the home health provider failed to ensure staff provided the patient and/or caregiver with the name contact information for the provider’s clinical manager in, two of three home visit observations conducted (Records/Patients #1 and #2). This deficient practice has the potential to adversely affect the knowledge of self-care and provider expectations in all the patients served by the provider. RECORD/PATIENT #1: Review of the clinical record showed the patient was admitted to home health services on 11/07/2025 with primary diagnosis of spondylosis without myelopathy (the degeneration of the spine, that occurs without the compression of the spinal cord) of the lumbar region (lower back region of the spine, comprising of five vertebrae. This region is crucial for supporting the upper body’s weight and providing mobility). The patient resided at home with his/her daughter and son-in-law. Observation on 12/02/2025, beginning at 2:00 P.M., showed the home health folder (given to patients on admission) contained the name and contact information of the previous clinical manager. Findings included: RECORD/PATIENT #2 Review of the clinical record showed the patient was admitted to home health services on 08/18/2025 with primary diagnosis of type two diabetes (a chronic disease that affects how the body uses sugar for energy) with other skin complications, non-pressure chronic ulcer (a chronically open wound not caused by pressure) of the left foot and hypothyroidism (under active thyroid). The patient resided at home with his/her spouse. Observation on 12/02/2025, beginning at 9:15 AM, showed the home health folder (given to patients on admission) contained the name and contact information of the previous clinical manager. During an interview on 12/02/2025, beginning at 9:53 AM, the administrator stated there had not been a clinical manager for quite a while and she would expect the admission packets to have the correct contact information. Findings included: RECORD/PATIENT #1: Review of the clinical record showed the patient was admitted to home health services on 11/07/2025 with a primary diagnosis of spondylosis without myelopathy (the degeneration of the spine, that occurs without the compression of the spinal cord) of the lumbar region (lower back region of the spine, comprising of five vertebrae. This region is crucial for supporting the upper body’s weight and providing mobility). The patient resided at home with his/her daughter and son-in-law. Observation on 12/02/2025, beginning at 2:00 PM, showed the home health folder (given to patients on admission) contained the name and contact information of the previous clinical manager. RECORD/PATIENT #2: Review of the clinical record showed the patient was admitted to home health services on 08/18/2025 with a primary diagnosis of type two diabetes (a chronic disease that affects how the body uses sugar for energy) with other skin complications, non-pressure chronic ulcer (a chronically open wound not caused by pressure) of the left foot and hypothyroidism (under active thyroid). The patient resided at home with his/her spouse. Observation on 12/02/2025, beginning at 9:15 AM, showed the home health folder (given to patients on admission) contained the name and contact information of the previous clinical manager. During an interview on 12/02/2025, beginning at 9:53 AM, the administrator stated that there had not been a clinical manager for quite a while and he/she would expect the admission packets to have the correct 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, observation, and interview, the home health provider failed to follow accepted standards of practice to prevent the transmission of infections in, one of three home visit observations conducted (Record/Patient #2). This deficient practice has the potential to affect all the patients served by the home health provider. Findings included: Review of the provider's undated policy titled, "Bloodborne Pathogens and Standard Precautions," showed in part standard precautions must be observed in all situations where there is potential for contact with blood or other potentially infectious body fluids. You should wear the appropriate barriers for the work you are doing. Gown if your clothing or skin could be splashed. Treat all linen soiled with blood or body secretions as potentially infectious. Observation on 12/02/2025 at 9:15 AM, showed licensed practical nurse (LPN)-A knelt on his/her knees on the patient's floor without a barrier and changed the patient's left great toe dressing. During an interview on 12/03/2025 at 9:53 AM, the administrator stated that he/she would expect staff to put down a barrier if a dressing change required staff to kneel or sit on the floor.

Participate in HHA-sponsored in-service CFR(s): 484.75(b)(9) Participation in HHA-sponsored in-service training. This ELEMENT is not met as evidenced by: Based on personnel file review and interview, the provider failed to ensure annual in-service training was completed for one of four employee files reviewed (Employee #4). This deficient practice has the potential to affect all patients served by the provider. Findings included: EMPLOYEE #4 (E4): Review of E4's personnel file showed: - Date of hire: 08/25/2024; - Position: Certified occupational therapy assistant (COTA); and - The file failed to contain evidence of annual in-service training. During an interview on 12/02/2025 at 2:45 PM, the administrator stated that E4 was an as needed (PRN) staff. Infection control training was provided on orientation and annually. Annual in-services were scheduled during the slower months (around July/August) and he/she was unsure why E4 had not completed his/her annual in-services.

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 personnel file review and interview, the provider failed to ensure Alzheimer's/dementia training was completed for one of four employee files reviewed (Employee #4). This deficient practice has the potential to affect all patients served by the provider. Findings included: Review of the provider's policy titled, "Employee Orientation," last reviewed 10/20/2023, showed, in part, the following: -Dementia-specific training about Alzheimer's disease and related dementias will be incorporated into orientation for new employees with direct patient/client contact and independent contractors wit direct patient/client contact; and -The training will be provided annually and updated as needed; EMPLOYEE #4 (E4): Review of E4's personnel file showed: - Date of hire: 08/25/2024; - Position: Certified occupational therapy assistant (COTA); and -The file failed to contain evidence of annual Alzheimer's/dementia training. During an interview on 12/02/2025 at 2:45 PM, the administrator stated that E4 was an as needed (PRN) staff. Alzheimer's/dementia training was provided on orientation and annually. Human Resources was not able to find evidence that E4 had completed the annual Alzheimer's/dementia training.

The Emergency Preparedness regulations were reviewed as part of the Medicare recertification survey completed on 12/07/2022. 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 Agencies.

A partial extended survey for Medicare recertification for the home health provider was completed on 12/07/2022. The agency had 105 current patients. The COVID-19 Health Care Staff Vaccination regulation was reviewed as part of the Medicare recertification survey. During the survey it was determined the agency was in compliance with the regulation.

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 review of the agency's current patient rights information, home visit observation, and interview, the agency failed to update the written notice of patient rights to include the rights of the patient and representative (if any) regarding contact information for the home health agency administrator to receive complaints. This deficient practice has the potential to affect the knowledge and comprehension of the rights and responsibilities for all agency patients/representatives. RECORD/PATIENT #1: Review of the patient’s handbook during a home visit observation on 12/07/2022, beginning at 1:00 PM, failed to include the name and contact information for the current administrator. During an interview on 12/07/2022, beginning at 3:30 PM, the administrator stated that the information should be in the patient’s handbook. The patient had an old handbook. Findings included: The agency provided an admission booklet for review on 12/05/2022. The agency notice of patient rights and other information given to a patient during the initial visit contained no current administrator name for which to receive patient complaints. During an interview on 12/06/2022 at 4:35 PM, the administrator stated that the administrator's name was removed from the patient's handbook and the director of nurses name was placed in the handbook. He/she stated that the administrator's name needed to be placed in the patient handbook also.

State toll free HH telephone hotline CFR(s): 484.50(c)(9) Be advised of the state toll free home health telephone hot line, its contact information, its hours of operation, and that its purpose is to receive complaints or questions about local HHAs. 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 include the patient has the right to be advised of the state hotline hours (7:00 AM to 8:00 PM). This deficient practice has the potential to affect the knowledge and comprehension of the rights and responsibilities of all agency patients. Findings included: The agency provided an admission booklet for review on 12/05/2022. The agency booklet, notice of patient rights and information, given to a patient during the initial patient visit showed inaccurate information regarding the toll-free hotline number hours of operation as "7:00 AM to 12:00 AM, 7 days a week," and failed to identify the correct hours of availability as "7:00 AM to 8:00 PM, 7 days a week". During an interview and review of findings with the administrator, and director of nursing on 12/06/2022 at 4:35 PM, they stated that they did not know the hotline hours had changed.

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.Standard: Accessibility Information must be provided to patients in plain language and in a manner that is accessible and timely to- This STANDARD 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 include the patient's right to have information provided in plain language and in a manner that is accessible and timely to person with disabilities, including accessible web sites. This deficient practice has the potential to affect the knowledge and comprehension of the rights and responsibilities of all agency patients. Findings included: Review of the agency's admission booklet, which included the notice of the Patient's Bill of Rights, and is given to patients at the start of care, failed to provide information that included the patient's right to have information provided in plain language and in a manner that is accessible and timely to persons with disabilities, including accessible web sites. During an interview on 12/06/2022 at 4:30 PM, the Administrator stated that web sites needed to be added to the patients information.

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, two (Records/Patients #1 and #4) of six full records reviewed. This deficient practice has the potential to affect all patients served by the agency. Findings included: Review of the agency’s policy titled, “Medication Reconciliation,” revised 11/2019, showed in part: - Medication reconciliation is required at the start of care and discharge, at least every sixty days, and must be documented in the clinical record. Medications included shall be all prescriptions, over-the-counter and herbal supplements being taken by the patient; - Medication reconciliation includes comparing all medications found in the home, and should be updated, as appropriate with changes, but no less than every sixty days; and - Medication review shall be conducted periodically throughout the episode of care to determine if the consumer has added or eliminated medications or herbal products from the medication regime. RECORD/PATIENT #1: Review of a physician order dated 10/25/2022, showed an order for Lispro (Humalog insulin) 100 milliliters (ml)/milligram (mg) for sliding scale as follows: 70-140 no correction on Lispro insulin, 221-260 give 6 units of insulin, 261-300 give 8 units of insulin, 301-350 give ten units of insulin, and greater than 350 give 12 units of insulin and notify physician. Patient to check blood sugars three times a day. The order failed to include how much insulin to administer for a blood sugar range of 141-220. Observation and interview on 12/07/2022, beginning at 1:00 PM, during the patient's home visit, showed Registered Nurse (RN) A asked the patient if he/she had any medication changes. The patient stated “no”. After RN A finished his/her visit, the surveyor asked RN A and the patient to look at his/her medications. Review of the agency’s current medication record showed the following discrepancies: - The medication record showed an order for furosemide (helps rid the body of excess fluid) 40 mg one tablet by mouth daily. The patient’s medication bottle showed furosemide 40 mg two tablets two times a day. The patient stated that he/she has taken two tablets two times a day for years; - The medication record showed an order for Humalog insulin (used to treat diabetes) subcutaneous (under the skin) 12 units three times daily with meals. The patient stated that he/she had been taking 15 units for quite a while; -The medication record showed an order for sliding scale insulin (the amount of insulin administered is based on the blood sugar reading) as blood sugar minus 100 divide results by three which equals how many units to administer. The order failed to clarify what type of insulin and how often to check his/her blood sugar. The patient stated that he/she checked his/her blood sugar “whenever” and divided the results by two; - The patient had a bottle of Lisinopril (used to treat high blood pressure) 10 mg once daily. The patient stated that he/she had taken this for years. This was not included on the medication record; and - The patient had a bottle of montelukast (anti-inflammatory) 10 mg daily. The patient stated that he/she had taken this for months. This was not included on the medication record. During an interview on 12/07/2022, at 3:30 PM, with the administrator and director of nursing, the administrator stated that medications are reconciled a minimum of every 30 days, at resumption of care, and at discharge. RECORD/PATIENT #4: Review of the medication record dated 11/16/2022, showed the following discrepancy with the plan of care (POC) dated 11/16/2022: - The medication record showed an order for Oxycodone 5 mg every 4-6 hours as needed for pain; - The POC showed an order for hydrocodone-acetaminophen (a pain medication that contains Tylenol) 5-325 mg one tablet every six hours as needed for pain; and -No documentation of clarification with the physician regarding the orders. During an interview on 12/06/2022, beginning at 4:00 PM, the findings were reviewed with the administrator, director of nursing, and vice president of operations. The administrator stated that he/she would look for more information. During an interview on 12/07/2022, beginning at 10:45 AM, at 10:45 AM, with the administrator, director of nursing, and vice president of operations, the vice president of operations stated that he/she would expect the order to have been clarified with the physician at the start of care and a clarification order to have been written. Review of a clarification physician order dated 12/07/2022, showed an order for Oxycodone 5 mg every six hours for surgical pain is correct. Hydrocodone was discontinued prior to the start of care.

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 staff provided services as ordered by the physician in one (Record/Patient #1) of six full records reviewed. This deficient practice has the potential to affect all patients served by the agency. Findings included: Review of the agency’s policy titled, “Medication Reconciliation,” revised 11/2019, showed in part that drugs and treatments shall be administered by agency staff only as ordered by the physician. Review of the agency’s policy titled, “Plan of Care,” revised 06/2018, showed in part that services must be furnished with the plan of care and accepted standards of practice. RECORD/PATIENT #1: Review of a wound clinic physician order dated 11/07/2022, showed wound care consisted of use of Xeroform (non-adhering dressing), Aquacel (antimicrobial foam dressing), cotton, Kerlix (gauze wrap) and Coban (self-adhering compression wrap). Review of an a skilled nurse (SN) visit note dated 11/11/2022 showed wound care consisted of wound cleanser, silvadene (antimicrobial), adaptic (non-adherent dressing), applied ABD (large, absorbent) pad, Kerlix ,and tubigrip (a tubular compression bandage). The record showed no order after 11/07/2022 for this treatment. Review of a wound clinic physician order dated 11/14/2022, showed to cleanse the left lower extremity wound, apply skin protectant to the periwound (outer wound), Hydrofera blue (antibacterial foam dressing), and apply multilayer compression wrap. Review of the SN visit note dated 11/30/2022, showed wound care consisted of wound cleanser, ascend silver to wound, applied adaptic, covered with ABD pad, secured with Merlin (unsure what this is) and Coban. The record showed no order for this treatment. During an interview on 12/07/2022, beginning at 12:12 PM, the director of nursing stated that the orders from the wound clinic are uploaded to the patient’s record and available for all staff to see. The SN visit on 11/11/2022 should have included Aquacel. He/she did not find an order for the 11/30/2022 visit.

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, home visit observation, and interview, the agency failed to ensure each patient received written information related to the visit schedule, in one (Record/Patient #1) 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’s policy titled, “Written Information to the Patient,” revised 06/2018, showed in part the agency must provide the patient and/or caregiver with a copy of written instructions outlining the visit schedule, including frequency of visits by agency personnel and personnel acting on behalf of the agency. RECORD/PATIENT #1: Observation and interview during the patient’s home visit, on 12/07/2022 beginning at 1:00 PM, showed the patient’s handbook failed to contain a visit schedule. Registered nurse (RN) A could not find a visit schedule. The patient stated that the nurse comes on Wednesdays and Fridays. During an interview on 12/07/2022, beginning at 3:30 PM, the administrator stated that the information should be written in the handbook.

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, home visit observation, and interview, the agency failed to ensure each patient received a written medication schedule in one (Record/Patient #1) 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’s policy titled, “Written Information to the Patient,” revised 06/2018, showed in part that the agency must provide the patient and/or caregiver with a copy of written instructions outlining the patient’s medication schedule/instructions, including medication name, dosage, and frequency. RECORD/PATIENT #1: Observation and interview during the patient’s home visit, on 12/072022 beginning at 1:00 PM, showed the patient’s handbook failed to contain a medication schedule. Registered nurse (RN) A stated that they usually leave it in the home, but he/she did not see it. During an interview on 12/07/2022, beginning at 3:30 PM, the administrator stated that the information should be written in the handbook.

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 policy review, home visit observation, and interview, the agency failed to ensure the patient received written wound care instructions in one (Record/Patient #1) 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’s policy titled, “Written Information to the Patient,” revised 06/2018, showed in part that the agency must provide the patient and/or caregiver with a copy of written instructions outlining any treatments to be administered by agency personnel and personnel acting on behalf of the agency. Observation and interview during the patient’s home visit, on 12/07/2022 beginning at 1:00 PM, showed Registered nurse (RN) A provided wound care for the patient. The patient’s handbook failed to contain written wound care instructions for the patient/caregiver. RN A stated that they give verbal instructions. During an interview on 12/07/2022, beginning at 3:30 PM, the administrator stated that he/she would expect the patient to have written wound care 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 policy review, home visit observation, and interview the agency failed to ensure each patient received written information regarding the name and contact information of the agency’s clinical manager in one (Record/Patient #1) 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’s policy titled, “Written Information to the Patient,” revised 06/2018, showed in part that the agency must provide the patient and/or caregiver a copy of written instructions including the name and contact information of the agency clinical manager. Observation and interview during the patient’s home visit, on 12/07/2022 beginning at 1:00 PM, showed the patient’s handbook failed to include the name and contact information of the agency’s clinical manager. Registered nurse (RN) A could not find the information in the handbook. During an interview on 12/07/2022, beginning at 3:30 PM, the administrator stated that he/she expected the patients to have the name and contact information for the clinical manager.

Authentication CFR(s): 484.110(b) Standard: Authentication. All entries must be legible, clear, complete, and appropriately authenticated, dated, and timed. Authentication must include a signature and a title (occupation), or a secured computer entry by a unique identifier, of a primary author who has reviewed and approved the entry. This STANDARD is not met as evidenced by: Based on record review and interview the agency failed to ensure staff documented accurate information in one (Record/Patient #4) of six full records reviewed. This deficient practice has the potential to affect all patients served by the agency. Findings included: RECORD/PATIENT #4: Review of the skilled nurse visit note dated 11/25/2022, showed the wound care documentation included that a track (a narrow opening from a wound underneath the skin, correct spelling is tract) was found at 6 o’clock (identifies location of the tract using a clock example) of the wound. The assessment showed no measurements or notification of the physician of the tract. During an interview on 12/07/2022, beginning at 10:45 AM, the director of nursing stated that he/she spoke with the nurse. The nurse documented the sinus tract on the wrong patient. He/she would expect the documentation to be accurate.