Every finding on record at Phoenix Home Care, LLC

The Emergency Preparedness regulations were reviewed as part of the Medicare recertification survey completed on 10/18/2023. During the survey it was determined the home health provider is in compliance with the requirements of 42 CFR 484.102 Condition of Participation: Emergency Preparedness for Home Health Providers.

A partial extended survey for Medicare recertification for the home health provider was completed on 10/18/2023. The provider had 506 current patients.

Written notice within 4 business days CFR(s): 484.50(a)(4) Provide written notice of the patient's rights and responsibilities under this rule and the HHA's transfer and discharge policies as set forth in paragraph (d) of this section to a patient-selected representative within 4 business days of the initial evaluation visit. This ELEMENT is not met as evidenced by: Based on policy review, admission booklet review, and interview the home health provider failed to ensure that the patient’s rights information included the verbiage “provide written notice of the patient’s rights and responsibilities to a patient selected representative within 4 business days of the initial evaluation visit.” This deficient practice has the potential to affect all patients served by the provider. Findings included: Review of the provider’s policy titled, “Patient Rights and Responsibilities,” dated 11/2019, showed in part that, "written notice of patient rights and responsibilities will be delivered to the patient prior to furnishing services, and to the patient representative (if any) within 4 business days of the initial evaluation." Review of the admission booklet on 10/16/2023, showed a written list of Patient Bill of Rights and Responsibilities that included transfer and discharge information. The transfer and discharge information failed to include the verbiage "provide written notice of the patient’s rights and responsibilities to a patient selected representative within 4 business days of the initial evaluation visit." During an interview on 10/16/2023 at 4:00 PM, the administrator stated that the admission booklet failed to contain that the information would be provided within 4 business days.

Make efforts to resolve the problem(s) CFR(s): 484.50(d)(5)(ii) (ii) Make efforts to resolve the problem(s) presented by the patient's behavior, the behavior of other persons in the patient's home, or situation; This ELEMENT is not met as evidenced by: Based on policy review, admission booklet review, and interview the home health provider failed to include the verbiage "make efforts to resolve the problem (s) presented by the patient's behavior, the behavior of other persons in the patient's home, or situation." This deficient practice has the potential to effect all patients served by the provider. Findings included: Review of the provider’s policy titled, “Patient Rights and Responsibilities,” dated 11/2019, failed to include the verbiage “make efforts to resolve the problem(s) presented by the patient’s behavior, the behavior of other persons in the patient’s home, or situation.” Review of the admission booklet on 10/16/2023, failed to include any information related to resolving problems related to the patient’s behavior, the behavior of other persons in the patient’s home, or situation. During an interview on 10/16/2023 at 4:00 PM, the administrator stated that the provider does do individual behavior contracts when there is an issue, but the provider does not have that written down anywhere.

Document efforts to resolve problems CFR(s): 484.50(d)(5)(iv) (iv) Document the problem(s) and efforts made to resolve the problem(s), and enter this documentation into its clinical records; This ELEMENT is not met as evidenced by: Based on policy review, admission booklet review, and interview the home health provider failed to include the verbiage “document the problem(s) and efforts made to resolve the problem(s) and enter this documentation into its clinical records.” This deficient practice has the potential to affect all patients served by the provider. Findings included: Review of the provider’s policy titled, “Patient Rights and Responsibilities,” dated 11/2019, failed to include the verbiage "document the problem(s) and efforts made to resolve the problem(s) and enter this documentation into its clinical records." Review of the admission booklet on 10/16/2023, failed to include any information related to ensuring that problems and efforts made to resolve the problems were documented in the clinical record. During an interview on 10/16/2023 at 4:00 PM, the administrator stated that the admission booklet failed to include the information about resolving problems and ensuring that efforts were documented in the clinical record.

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 home health provider failed to conduct an initial assessment visit to determine the immediate care and support needs of the patient within 48 hours of referral 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. RECORD/PATIENT #5: Review of the clinical record showed the following: - The provider received a referral from the patient’s rehabilitation facility on 08/30/2023, that the patient was going home with family and would need nursing and a bath aide; - A physician order dated 09/05/2023, to admit the patient to home health services; - No communication notes regarding the patient’s admission; and - No physician order within 48 hours of the referral regarding a delay in the start of care (SOC). Review of the initial assessment dated 09/05/2023, (seven days after the referral), showed no specific SOC date ordered by the physician and date of referral was blank. During an interview on 10/17/2023, at 3:45 PM, the administrator stated that they expect a patient to be admitted within 48 hours of the referral. They do call and talk with the physician’s office to let them know if they cannot admit within 48 hours. He/she would look for information from their intake department to see where they talked with the physician about the admission. During an interview on 10/18/2023, at approximately 11:00 AM, the administrator provided a late entry communication note dated 10/17/2023, signed by the clinical manager, that showed he/she received a call from the registered nurse (RN) stating he/she attempted to do the SOC on 09/01/2023 and 09/02/2023 with no answer from the patient. The RN attempted to contact the physician’s office to get an order for the delayed admission. Unable to reach due to it being the weekend. Will call on Tuesday, 09/05/2023 for an order due to Monday, 09/04/2023, being a holiday. The administrator stated that he/she would expect the communication note to be documented when it occurred. Findings included: Review of the provider’s policy titled, “Comprehensive Assessment,” revised 11/2019 showed, in part, “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-ordered start of care date.” RECORD/PATIENT #3: Review of the clinical record showed, in part, the following: - A copy of a written order for physical therapy (PT) to evaluate and treat for a diagnosis of poor balance and frequent falls, dated 09/26/2023; - A copy of a physician’s office visit, dated 08/31/2023 and printed on 09/26/2023 that showed, Plan: We’ll refer him/her to home PT; - An initial assessment dated 09/30/2023; and - A physician’s order dated 09/30/2023 that showed, in part, “Admit patient to home health services on 09/30/2023 due to lumbar disc degeneration. Home health services are to include the following skills: Physical therapy for evaluation and treatment. Plan of care to follow.” The order was digitally signed by the physical therapist on 09/30/2023 but was not signed by the physician. During an interview on 10/18/2023 at 2:00 PM, the administrator stated that he/she could prove that they did not received the home health referral until 9/29/2023. He/she pointed to a document date stamped as printed on 09/29/2023 at 9:09 AM. This document was a physician’s office visit made by the patient on 08/31/2023. The administrator stated that they could not do an admission assessment until they received the “full referral” and they did not receive all of the information until 09/29/2023. This surveyor referenced the order for home health physical therapy that was dated 09/26/2023 and was with other faxed documents that contained the same office visit from 08/31/2023. All were date stamped that they printed on 09/26/2023 at 10:05 AM. The administrator stated that they did not receive the referral from “intake” until 09/29/2023. This surveyor clarified with the administrator that “intake” was the provider’s own referral intake department who forwards the referral on to the provider’s home health or hospice. The administrator stated that it was aggravating that they were receiving a deficiency because another department did not send them the information on time.

Health, psychosocial, functional, cognition CFR(s): 484.55(c)(1) The patient's current health, psychosocial, functional, and cognitive status; This ELEMENT is not met as evidenced by: Based on policy review, record review, and interview the home health provider failed to ensure the comprehensive assessment accurately reflected the patient's status in two of five full records reviewed (Records/Patients #2 and #5). This deficient practice has the potential to affect all patients served by the provider. Findings included: Review of the provider’s policy titled, “Comprehensive Assessment,” revised 11/2019, showed in part: - The initial assessment shall be utilized to establish baseline date and the need for further assessment; and - The comprehensive assessment must accurately reflect the patient’s status and include at a minimum, the patient’s current health, psychosocial, functional, and cognitive status. RECORD/PATIENT #2: Review of the initial comprehensive assessment dated 09/29/2023, showed in part: - Diagnoses that included after care following surgery for neoplasm (abnormal growth of tissue in the body) and acquired absence of part of the lung; - The registered nurse (RN) marked the patient was not diabetic (diabetes, a group of diseases that results in too much sugar in the blood) and -Under the section for skilled intervention, the nurse documented he/she educated the patient on diabetic foot and nail care including assessing feet routinely and proper footwear. During an interview on 10/18/2023, beginning at 11:07 AM, the administrator stated that would not be accurate. The nurse should have taken out the part about diabetic foot care. RECORD/PATIENT #5: Review of the initial comprehensive assessment dated 09/05/2023, showed in part: - Diagnoses that included fracture of the right femur (thigh bone) and type 2 diabetes mellitus with hyperglycemia (high blood sugar); - The patient had not checked his/her blood sugar today; - Educated on diabetic foot and nail care including assessing feet routinely and proper footwear; and - The RN failed to assess/document how often the patient checked his/her blood sugar, information related to the patient's diabetic history including average blood sugar ranges prior to admission and issues with high or low blood sugars. During an interview on 10/18/2023, beginning at 11:07 AM, the administrator stated that he/she expected staff to assess what the patient’s blood sugars had been running and issues with low blood sugars or high blood sugars.

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 staff performed an accurate drug regimen review and maintained an accurate/updated medication profile in four of five full records reviewed (Records/Patients #1, #2, #4, and #5). This deficient practice has the potential to affect all patients served by the provider. RECORD/PATIENT #4: Review of the physician’s referral information, dated 09/12/2023 showed, in part, the following: - A referral order for home health for wound care and physical therapy; and - A medication list that included Lantus Solostar (a long-acting insulin) pen, inject 15 units subcutaneously (an injection beneath the skin) at bedtime and increase the Lantus by three units every three days if bedtime blood sugars are greater than 200. Review of the plan of care (POC), dated 09/14/2023, and the patient’s medication list showed the POC and medication list failed to contain the order to increase the Lantus by three units every three days if the bedtime blood sugars are greater than 200. During an interview on 10/18/2023 at 11:30 AM, the administrator stated that he/she would expect the order for the increase in Lantus to be on the POC/medication list. Findings included: Review of the provider’s policy titled, “Medication Reconciliation,” revised 09/28/2021, showed in part: - Medication reconciliation is required at the start of care (SOC) and discharge, at least every 60 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; and - Medication reconciliation includes comparing all medications found in the home to the most recent medication list available to provider’s staff, along with current physician orders. RECORD/PATIENT #1: Review of the clinical record showed that skilled nursing (SN) visits dated 10/07/2023 through 10/16/2023 included documentation that the patient was taking Tylenol (a mild pain medication) as needed for pain. The medication profile dated 10/05/2023 through 12/03/2023 failed to include this medication. Observation on 10/17/2023 beginning at 9:00 AM, showed that the patient had a bottle of Tylenol Arthritis (a mild pain medication for arthritis) sitting on the counter. When asked, the patient stated that he/she took the Tylenol Arthritis 650mg two tablets as needed for pain. The home health provider failed to include the Tylenol Arthritis on the medication profile. During an interview on 10/18/2023 beginning at 11:00 AM, the administrator stated that he/she would expect the Tylenol Arthritis to be included on the medication profile for the patient. RECORD/PATIENT #2: Review of the clinical record showed staff admitted the patient to service on 09/29/2023. Diagnoses included aftercare following surgery for neoplasm (abnormal growth of tissue) and acquired absence of part of the lung. Review of the initial assessment dated 09/29/2023, showed in part: - No issues were found during the drug regimen review; and - All medications were reconciled and no “major” interactions were reported to the physician. No medication changes were made. Patient to continue to take all medications as listed in the medication profile. Review of the patient medication record dated 09/29/2023, showed the question, "Was the physician contacted regarding medications discrepancies?" The staff marked NA (no discrepancies). Review of the hospital discharge medication list dated 09/28/2023, showed the following discrepancies with the provider’s medication profile/plan of care (POC): - The provider’s medication profile/POC showed an order dated 09/29/2023, for ergocalciferol (vitamin D2) oral 1.25 milligrams (mg) (50,000) units one capsule by mouth daily. The hospital medication list showed an order for ergocalciferol 50,000 units one capsule by mouth every 14 days; - The provider’s medication profile/POC showed an order dated 09/29/2023, for ferrous gluconate (iron supplement) 324 mg one tablet by mouth every other day. The hospital medication list showed an order for ferrous gluconate 240 mg every other day; - The hospital medication list showed an order for sumatriptan (Imitrex, used to treat migraine headache pain) 100 mg one tablet by mouth, may repeat in two hours, maximum dose of 200 mg in 24 hours. The provider’s medication profile/POC failed to include this medication; and - The clinical record failed to address whether these medication discrepancies were clarified with the physician. Observation and interview on 10/17/2023, beginning at 10:55 AM, during the patient's home visit, showed the following discrepancies with the provider’s current medication profile/POC: - The provider’s medication profile/POC showed an order dated 09/29/2023, for ergocalciferol 1.25 mg (50,000) units one capsule by mouth daily. The patient had a bottle of vitamin D2 1250 mcg (micrograms). The patient stated that he/she took one capsule every 14 days; - The patient had a bottle of vitamin D3 50 mcg (2000 units). The patient stated that he/she took this once a day except on the 14th day when he/she took the vitamin D2. The provider’s medication profile/POC failed to include this medication; - The provider’s medication profile/POC showed an order for ferrous gluconate 324 mg one tablet by mouth every other day. The patient had a bottle of iron 45 mg. The patient stated that he/she took one tablet on Mondays and one tablet on Fridays; and - The patient had a box of sumatriptan. The patient stated that he/she kept this on hand if he/she needed it. He/she had not used this in a long time. The provider’s medication profile/POC failed to include this medication. During an interview on 10/18/2023, beginning at 11:07 AM, the administrator stated that the clinical manager called the physician’s office yesterday (10/17/2023) to clarify the discrepancies found during the home visit. RECORD/PATIENT #5: Review of the referral information dated sent 08/30/2023, showed in part: - The patient’s history and physical showed that the patient had surgery on 07/14/2023, for hardware removal to the right femur (thigh bone). The patient was discharged to a rehabilitation facility (RF1) on 07/17/2023. The patient completed rehabilitation but was not able to return home due to non-weight bearing status. The patient was awaiting surgery for a distal femur replacement. The patient was admitted to another rehabilitation facility (RF2) on 08/03/2023; and - Included in the referral information sent by RF2 showed physician orders from RF1. The referral information failed to include the current physician orders from RF2. Review of the medication orders from RF1, RF2, and the provider’s medication profile/POC showed the following discrepancies: - The medication lists from RF1 and RF2 showed the patient was on sliding scale insulin (an injectable medication used to lower blood sugar. The amount of insulin administered is based on the blood sugar reading). The provider’s medication profile/POC failed to include this medication; - The medication lists from RF1 and RF2 showed an order for oxycodone (narcotic pain medication) 5 milligrams (mg) every four hours as needed. The provider’s medication profile/POC failed to include this medication; - The medication lists from RF1 and RF2 showed an order for a fentanyl patch (narcotic pain medication) 12 micrograms (mcg), change every 72 hours. The provider’s medication profile/POC failed to include this medication; and - The medication list from RF2 showed an order for Lantus insulin 5 units in the AM. The provider’s medication profile/POC failed to include this medication dosage. Review of the initial assessment dated 09/05/2023, showed in part: - No issues found during the drug regimen review; and - All medications were reviewed with the patient and reconciled. Review of the patient medication record dated 09/05/2023, showed the question, "Was the physician contacted regarding medications discrepancies?" The staff marked NA (no discrepancies). During an interview on 10/17/2023, at 3:30 PM, the administrator stated that he/she expected staff to reconcile medications to the discharge medication list or medication record from the rehabilitation facility. During an interview on 10/17/2023, at 3:40 PM, the administrator obtained and provided the discharge medication list from RF2. He/she thought that staff thought what was sent in the beginning was the orders from RF2. During an interview on 10/18/2023, at 9:58 AM, the administrator stated that the nurse had information in his/her personal notes. He/she clarified with the physician that the patient was not on a fentanyl patch and was on sliding scale insulin. The nurse was documenting a late entry clarification note today. The administrator stated that he/she would expect staff to document the information in the clinical record at the time it occurred. Review of a medication reconciliation clarification physician order dated 10/18/2023 (the patient was discharged on 09/14/2023), showed the patient was not on a fentanyl patch at the SOC but was on sliding scale insulin. Sliding scale insulin was added to the medication list. During an interview on 10/18/2023, at 11:55 AM, the administrator stated that staff were to ask the patients to have their medications out for them to review on admission. They compare the patient’s medication bottles in the home with the discharge medications on the referral. They ask if there are any other medications the patient is taking that was not on the discharge list. They go over how they are taking the medication, what it is for, and high risk medications. If there are any discrepancies, they call the physician and review any discrepancies and interactions. Staff look at the medications at every visit. They look at the patient’s bottles of medications and compare with what they have in their computer system. If they find further discrepancies, they call the physician and verify the medications. They check to see if the patient had any medication changes after follow-up physician 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, clinical record review, and interview, the provider failed to provide an individualized plan of care (POC) when it failed to include instructions for surgical incision care, the use of a BiPAP machine (bi-level positive airway pressure, a type of non-invasive ventilation), the use of a continuous blood sugar monitoring device, and specific interventions and goals for the assessment and management of diabetes (a group of diseases that results in too much sugar in the blood) in, but not limited to, three of five full records reviewed (Records/Patients #2, #4, and #5). This deficient practice has the potential to affect the provision of individualized care to all patients served by the home health provider. Findings included: Review of the provider’s policy titled, “Plan of Care Development,” revised 11/2019 showed, in part, the following: - Identify and address any immediate care needs; - Educate the patient on any treatments and pertinent instructions that the provider will administer, including medication administration, wound care, catheter care, et cetera; and - Goals and interventions should match coding, focus of care, and face-to face document, identifying the skilled needs of the patient. RECORD/PATIENT #4: Review of the physician’s referral information sent to the provider showed, in part, the following: - A diagnosis of obstructive sleep apnea (OSA, intermittent airflow blockage during sleep) treated with a BiPAP; - The patient used a continuous blood sugar monitoring system with a Dexcom transmitter (a wireless blood sugar monitoring device); and - Orders for the patient’s long acting insulin to be increased by three units every three days if the bedtime blood sugar reading is greater than 200. Review of the initial assessment, dated 09/14/2023 showed, in part: - Breath sounds were diminished in the left lower lobe; - The patient gets short of breath with moderate exertion such as dressing, using the commode, or walking distances less than 20 feet; - The patient had 3+ pitting edema (swelling that leaves an indentation when pressure is applied to the area) to both feet; - The patient wore oxygen at night; - The patient was a diabetic and was insulin dependent; and - The area for a blood sugar entry was left blank. Review of the plan of care (POC), dated 09/14/2023, showed, in part, the following: - The patient’s primary diagnosis was type 2 diabetes mellitus with other skin ulcer; - The POC failed to contain information about the patient’s BiPAP; - The POC failed to include the use of the continuous blood sugar monitoring system; and - The POC failed to contain interventions to assess and record the patient’s blood glucose readings to determine the need for an increase in insulin. During an interview on 10/18/2023 at 11:30 AM, the administrator stated that he/she would expect to see the nurses recording the patient’s blood glucose readings every visit and would expect the blood glucose monitoring system and interventions to assess and record the patient’s blood sugars to be on the individualized POC. He/she stated that the expectation would also be for the clinician to address the BiPAP and, if the patient was using it, put that information on the POC. If the patient was not wearing the BiPAP, he/she would expect the clinician to notify the physician that the patient was not using it and document this in the patient’s medical record. RECORD/PATIENT #2: Review of the referral information dated 09/28/2023, showed in part: - On 09/20/2023, the patient had a left lower lung lobectomy (removal of part of the lung); - Incision care after discharge included to remove the dressing in five days and that the incision may be left open to air, however, if a small amount of drainage persists, or if clothing irritates the incision, a sterile gauze dressing may be used to cover the incision. Change this dressing at least once a day. Review of the plan of care (POC) dated 09/29/2023, failed to include the order that the incision may be left open to air, however, if a small amount of drainage persists, or if clothing irritates the incision, a sterile gauze dressing may be used to cover the incision. Change this dressing at least once a day. Review of the skilled nurse (SN) visits showed: - On 10/03/2023, the dressing came off yesterday. Small amount of drainage noted to incision under left breast covered with gauze to keep area clean and dry and prevent irritation. Spouse instructed to clean and keep dry. The patient saw his/her primary care physician yesterday and to see surgeon on Thursday. The clinical record failed to include a physician order to show what they were to clean with and cover with; - On 10/06/2023, the patient saw the surgeon and they want him/her to keep the incision area clean and dry. The record failed to include a physician order to show what they were to clean with and cover with; - On 10/10/2023, wound care performed per orders. The patient has a dry gauze over the suture area. Dry dressing to be applied over area per the physician assistant at the last appointment on 10/05/2023. The record failed to include a physician order for treatment; and - On 10/12/2023, the wound assessment showed wound care (washed with soap and warm water, rinse, pat dry) and dressing change performed (4x4s (gauze dressing) and medipore tape (surgical tape). The record failed to include an order for this treatment. During an interview on 10/18/2023, beginning at 11:07 AM, the administrator stated that he/she expected the complete incision care order from the referral to be included on the POC. He/she would expect to have a physician order for treatments. RECORD/PATIENT #5: Review of the initial comprehensive assessment dated 09/05/2023, showed in part: - Diagnoses that included fracture of the right femur (thigh bone) and type 2 diabetes mellitus with hyperglycemia (high blood sugar); - The patient had not checked his/her blood sugar today; - Educated on diabetic foot and nail care including assessing feet routinely and proper footwear; and - The RN failed to assess/document how often the patient checked his/her blood sugar, information related to the patient's diabetic history including average blood sugar ranges prior to admission and issues with high or low blood sugars. Review of the POC dated 09/05/2023, showed assessment of patient with type 2 diabetes with hyperglycemia. The POC failed to include specific interventions such as how often the patient was to check his/her blood sugars and assessment for signs and symptoms of high and low blood sugars During an interview on 10/18/2023, beginning at 11:07 AM, the administrator stated that he/she would expect the POC to include how often the patient was to check his/her blood sugar.

Promptly alert relevant physician of changes CFR(s): 484.60(c)(1) The HHA must promptly alert the relevant physician(s) or allowed practitioner(s) to any changes in the patient's condition or needs that suggest that outcomes are not being achieved and/or that the plan of care should be altered. This ELEMENT is not met as evidenced by: Based on policy review, clinical record review, and interview, the home health provider failed to promptly alert the physician that they were unable to get the patient's weight as ordered to assess for fluid retention, in one of five full records reviewed (Record/Patient #4). This deficient practice has the potential to affect all patients served by the provider. Findings included: Review of the provider’s policy titled, “Coordination of Care,” revised 11/2019 showed, in part: - Provider staff will ensure adequate and timely communication with all physicians involved in the patient’s care as often as necessary; - Provider staff will continually assess and identify patient needs and factors that could impact patient safety and will coordinate with other services and the physician to ensure treatment effectiveness; and - Provider staff will coordinate and communicate with the physician regarding any changes in patient condition or changes in the plan of care. Review of the provider’s policy titled, “Physician Orders,” revised 09/28/2021 showed, in part, any order which, in the judgement of a licensed professional, are inconsistent with the needs or condition of a patient will be clarified or challenged in a manner that culminates in the delivery of quality care and service. RECORD/PATIENT #4: Review of the initial assessment, dated 09/14/2023 showed, in part: - Breath sounds were diminished in the left lower lobe; - The patient got short of breath (SOB) with moderate exertion such as dressing, using the commode, or walking distances less than 20 feet; and - The patient had 3+ pitting edema (swelling that leaves an indentation when pressure is applied to the area) to both feet. Review of the plan of care (POC), dated 09/14/2023 showed, in part: - A diagnosis of congestive heart failure (CHF; a decrease in the ability of the heart to pump blood); and - An order for skilled nursing (SN) to assess and instruct the patient on measures to detect fluid retention including increased edema, SOB, and/or weight gain of more than three pounds per day or five pounds in a week. Review of the SN notes showed, in part: - On 09/15/2023, the patient had 3+ pitting edema to both feet and breath sounds were diminished in left lower lobe. The home health nurse failed to document a weight; - On 09/18/2023, the patient had SOB with minimal exertion. The home health nurse failed to document a weight; - On 09/22/2023, the patient had edema in both lower extremities and poor endurance. The home health nurse documented the patient stated that he/she could not stand on a regular scale and got weighed at his/her doctor appointments. The home health nurse failed to notify the physician that they were unable to weigh the patient; - On 09/25/2023, the patient had SOB with minimal exertion and would need to be weighed when he/she went to the doctor because he/she could not stand on a scale at home. The home health nurse failed to notify the physician that they were unable to weigh the patient; - On 09/29/2023, the patient had SOB with moderate exertion and was unable to stand on a scale for a weight. The home health nurse failed to notify the physician that they were unable to weigh the patient; - On 10/02/2023, the patient had SOB with moderate exertion, 1+ edema in both lower extremities, and the home health nurse was unable to get a weight because the patient refused to stand on a scale. The home health nurse failed to notify the physician that they were unable to weigh the patient; - On 10/06/2023, the patient had SOB with moderate exertion and was unable to stand long enough to get an accurate weight. The home health nurse failed to notify the physician that they were unable to weigh the patient; and - On 10/11/2023, the patient had edema to both lower extremities, SOB with moderate exertion, and was unable to stand on scale for daily weight. The home health nurse failed to notify the physician that they were unable to weigh the patient. During an interview on 10/18/2023 at 11:30 AM, the administrator stated that he/she would expect the nurses to notify the physician that their CHF patient with edema and SOB was unable to stand on a scale to be weighed. They could have asked for a different order to measure fluid retention. They may not have gotten one but, at least, the doctor would have been notified.

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 nationally-recognized standards, policy review, observation, and interview the home health provider failed to ensure that accepted standards of practice to prevent transmission of infections and communicable diseases were followed in one of three home visit observations conducted (Record/Patient #1). This deficient practice has the potential to affect all patients served by the provider. Findings included: Review of the Centers for Disease Control (CDC) policy titled, "Hand Hygiene Guidance," dated 01/30/2022, showed healthcare personnel should use an alcohol-based hand rub or wash with soap and water for the following clinical indications: - Immediately before touching a patient; - Before performing an aseptic task; - Before moving from work on a soiled body site to a clean body site on the same patient; - After touching a patient or the patient's immediate environment; - After contact with blood, body fluids, or contaminated surfaces; and - Immediately after glove use. Review of the provider’s policy titled, “Standard Precautions,” dated 07/2018, showed in part that: - Standard precautions include: * Hand Hygiene; * Use of Personal Protective Equipment (PPE) whenever there is an expectation of possible exposure to infectious material including blood, all body fluids, secretions, and excretions (except sweat) regardless of whether they contain visible blood; non-intact skin; and mucous membranes; * Proper handling and cleaning/disinfection of patient care equipment; and * Proper disposal of other infectious waste; - Hands are to be washed after touching blood, body fluids, secretions, excretions and contaminated items. Hands are to be washed immediately after removing gloves, between client contacts and when otherwise indicated, to avoid transfer of microorganisms to clients or environment. Center for Disease Control emphasizes it may be necessary to wash hands between tasks and procedures on the same patient to prevent cross-contamination of different body sites; and - Hand hygiene should be performed at a minimum: * Before contact with a patient; * Before performing an aseptic task; * After contact with the patient or objects in the immediate vicinity of the patient; * After contact with blood, body fluids, or contaminated surfaces; * Moving from a contaminated body site to a clean body site during patient care; and * After removal of PPE. Review of the provider’s policy titled, “Bag Technique,” dated 2008, showed in part that: - The inside of the nursing bag should be regarded and maintained as a clean area; - After providing care, clean equipment with soap and water or a home health agency-approved disinfectant before returning it to the bag; and - Never place used needles, soiled equipment, or dressings in the nursing bag. RECORD/PATIENT #1: Observation on 10/17/2023 beginning at 9:00 AM, during the patient’s home visit, showed that: - Registered nurse (RN) A completed a dressing change on the patient and removed his/her gloves and completed hand hygiene; - RN A then donned a new pair of gloves and began cleaning his/her equipment with a disinfecting wipe; - Prior to cleaning the blood pressure cuff used on the patient, RN A dropped the disinfecting wipe on the patient’s kitchen floor, picked up the wipe, and cleaned the blood pressure cuff and then returned all equipment to the nursing bag; - RN A failed to remove his/her gloves or complete hand hygiene and began picking up the patient’s wound care supplies and returned them to a plastic bag before placing them in the patient’s kitchen cabinet; and - RN A then removed his/her gloves and performed hand hygiene. During an interview on 10/18/2023 at 11:00 AM, the administrator stated that he/she would have expected the RN to get a new disinfecting wipe to finish cleaning his/her equipment and that his/her gloves should have been removed and hand hygiene should have been completed before touching the patient’s wound care supplies.

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 home health provider failed to ensure their skilled professionals provided an ongoing interdisciplinary assessment of the patients when they failed to document an assessment/follow up in one patient (Record/Patient #2), failed to obtain blood glucose readings as ordered in one patient (Record/Patient #4), and failed to obtain wound measurements in two of five full records reviewed (Records/Patients #2 and #4). This deficient practice has the potential to affect all patients served by the provider. Findings included: Review of the provider’s job description titled, “Home Health Registered Nurse (RN),” revised 02/2021 showed, in part: - The RN provides evaluation, direction and application of skilled services to carry out the plan of care (POC) and treatment in the homes of clients and within the realm of accepted standards of practice for a registered professional nurse, as stated in the nurse practice act; - The RN performs an ongoing interdisciplinary assessment of the patient; and - The RN observes, records and reports reaction to treatment and any changes in patient condition to appropriate personnel and/or the physician. Review of the provider’s policy titled, “Wound Assessments,” revised 09/28/2021 showed, in part: - Wound measurements are to be conducted by home health staff at least weekly, preferably on the first visit of the week; - Clinicians must document the layer of skin impacted (skin surface, fatty layer, muscle, or bone) with measurements; and - All wound care patients are to be scheduled a visit by the RN or physical therapist (PT) at least every two weeks, preferably on the first day of the week to allow for wound measurements, wound re-assessment, and physician contact regarding progress or lack thereof and new/changed wound care orders, if indicated. RECORD/PATIENT #4: Review of the physician’s referral information sent to the provider showed, in part, the following: - The patient used a continuous blood sugar monitoring system with a Dexcom transmitter (a wireless blood sugar monitoring device); and - Orders for the patient’s long acting insulin to be increased by three units every three days if the bedtime blood sugar reading is greater than 200. Review of the initial assessment, dated 09/14/2023 showed, in part: - The patient’s primary diagnosis (question M1021 on the Outcome and Assessment Information Set (OASIS) - a standardized data collection tool) showed type 2 diabetes mellitus (a group of diseases that results in too much sugar in the blood); - The patient was dependent on insulin; - A wound on the right shin that measured 5.5 centimeters (cm) long by 6 cm wide by 0.1 cm deep; - A wound described as a stage one pressure injury (a persistent area of skin redness without a break in the skin that does not disappear when pressure is relieved) on the left and right central buttocks; - The wound was described as having a small amount of bloody drainage and the surrounding tissue was described as having erythema (redness); - A photograph of the area showed a missing layer(s) of skin in the center of the redness; and - The home health nurse failed to document the patient’s blood glucose reading and failed to obtain measurements of the open area or of the area of non-blanching redness. Review of the POC, dated 09/14/2023, showed, in part: - A skilled nursing (SN) goal was “wound(s) will decrease in size by 90 (does not indicate what unit of measurement was being used) by 11/12/2023;” and - SN may perform blood glucose testing using patient’s glucometer to assess for signs and symptoms of hypo/hyperglycemia or accuracy of reported blood glucose. Review of the SN notes showed, in part: - On 09/15/2023 and 09/18/2023, the wound was assessed as a stage one pressure injury with a small amount of bloody drainage and the surrounding tissue was excoriated (injury/irritation to the skin such as scratching, an abrasion, or a burn). The home health nurse failed to obtain measurements of the wound and no blood glucose reading was documented; - On 09/22/2023, the patient’s blood glucose was recorded as “140” (eight days after the patient was admitted) and the home health nurse failed to perform an assessment or obtain measurements of the right shin wound and the pressure injury wound on the right and left buttocks; - On 09/25/2023, the patient’s blood glucose was recorded as “190.” The wound on the buttocks was assessed as having a small amount of bloody drainage and the patient only had pain during wound care to the buttocks but the pain medication was effective. The home health nurse failed to obtain measurements of the wound to the buttocks; - On 09/29/2023, the wound on the buttocks was assessed to be red with small amount of bloody drainage. The home health nurse failed to obtain measurements of the wound on the buttocks and failed to document a blood glucose reading; - On 10/02/2023, the patient’s blood glucose reading was “234” and the home health nurse failed to document an assessment of the right shin and the bilateral buttock wounds and no measurements were obtained of the wound on the buttocks; - On 10/06/2023, the right shin wound was closed. The bilateral buttock wound was documented as having bloody drainage. The home health nurse failed to document measurements or any further assessment of the wounds appearance. The home health nurse failed to document the patient’s blood glucose; and - On 10/11/2023, the patient’s blood glucose was “180” and the patient had a blood sugar monitor on their arm (this was the first time the continuous blood sugar monitoring system was mentioned). The note showed the goal for the wound to decrease in size was not met. The home health nurse failed to document an assessment or measurement of the wound on the buttocks. During an interview on 10/18/2023 at 11:30 AM, the administrator stated that he/she would expect the nurses to document the patient’s blood sugar reading at each visit. The nurse should assess wounds every visit and measurements to be taken per policy every two weeks but they like to see them done weekly (the provider's policy actually stated that wound measurements should be taken weekly). They do not usually measure a stage one pressure injury but could not describe how they would be able to know if the wound was improving. They take pictures but could not say that a picture would show a decrease in size (depending on how close the camera was to the wound). They will start measuring stage one wounds length and width so they can be sure. RECORD/PATIENT #2: Review of the initial assessment dated 09/29/2023, showed the patient had a surgical wound with a non-removable dressing. Review of the plan of care (POC) dated 09/29/2023, showed: - Diagnoses that included aftercare following surgery for neoplasm (abnormal growth of tissue in the body) and acquired absence of part of the lung; and - Remove the dressing in five days (10/03/2023). Review of the skilled nurse (SN) visits showed: - On 10/03/2023, the surgical wound assessment showed the measurement as 0 x 0 x 0 centimeters (cm); - On 10/10/2023, the nurse performed wound care per orders. The patient has a dry gauze over the suture area. The patient had bright green drainage coming from area of concern. The patient denied having fever but had chills off and on yesterday. The wound had deteriorated. Measurements larger 1.8 x 1.8 cm with small amount of bright green drainage noted from wound that is 100% covered in yellow green slough (dead tissue in a wound bed). The nurse called the physician’s office and spoke with the receptionist who stated that he/she sent back a high priority note to the physician. SN awaiting return call; and - Review of the record showed no documentation of follow up with the physician and/or patient During an interview on 10/18/2023, beginning at 11:07 AM, the administrator stated that he/she would expect the nurse to have measured the incision on 10/03/2023. He/she would have expected the nurse to follow up with the physician and/or patient after calling the physician for concerns within 24 hours. He/she would look for documentation of follow up regarding the call to the physician on 10/10/2023. Review of a late entry note dated 10/18/2023, from the date of 10/11/2023, provided by the administrator on 10/18/2023, at approximately 1:30 PM, showed the physician called the SN back related to the concern for purulent (infectious) drainage from left chest wall. The nurse stated that they were going to call the patient and schedule a visit for tomorrow. The patient was called and notified at this time. Review of a late entry note dated 10/18/2023, from the date of 10/12/2023, showed the SN called the patient to follow up on appointment with the surgeon yesterday. The patient stated that no antibiotics were given and was to continue to apply dry gauze to the area as previously ordered. During an interview on 10/18/2023, at approximately 1:30 PM, the administrator stated that he/she would expect follow up to be documented at the time it occurred.