Every finding on record at Phoenix Home Care, LLC

The Emergency Preparedness regulations were reviewed as part of the Medicare recertification survey completed on 09/04/2025. 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 09/04/2025. The provider had 481 current patients.

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 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 Reconciliation,” revised on 11/2019, showed, in part, the following: - Medication reconciliation is required at Start of Care (SOC) and Discharge, and 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; - Medication reconciliation shall be documented when new medications are prescribed; 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 regimen. RECORD/PATIENT #2: Review of the clinical record showed the patient was admitted to home health services on 08/06/2025 with primary diagnosis of amyotrophic lateral sclerosis (ALS; Lou Gehrig's disease; a nervous system disease that causes loss of muscle control), pseudobulbar affect (PBA) (medical condition that causes crying and or/ laughing that is sudden, frequent, uncontrollable and is exaggerated or doesn't match how you feel. PBA may be caused by neurological damage related to your neurological condition or brain injury but is a separate and treatable condition), cramps and spasm and history of falling. The patient resided at home with significant other and three other roommates as caregivers. Observation and interview on 09/03/2025 at 11:00 AM, showed: - The provider’s medication list had Acetyl-L-Carnitine HCl (supplement that may improve memory loss) 750 milligrams (mg) mix 750 mg in a liquid and take by mouth daily. The patient stated that he/she had been taking the medication twice a day forever; - The provider’s medication list had Alpha-Lipoic acid (supplement that provides protection to the brain and helpful in certain liver diseases) oral 600 mg one tablet by mouth daily. The patient stated that he/she took 700 mg daily; - The provider’s medication list had Ashwagandha (supplement for stress, anxiety and sleep) 500 mg take one capsule by mouth daily. The patient stated that he/she took 600 mg daily; - The provider’s medication list had Gaba powder (supplement to help with anxiety, depression and stress) one gram (gm) by mouth twice a day. The patient stated that he/she took 250 mg twice a day; - The provider’s medication list had L-Serine (supplement to recover cognitive function, improve cerebral blood flow, inhibit inflammation, promote remyelination and exert other neuroprotective effects on neurological injury) 1.5 gm take 1.5 gm twice a day. The patient stated that he/she took 7 gm twice a day; - The provider’s medication list had L-Lysine (supplement building block for making proteins in the body) 1000 mg take one tablet by mouth daily. The patient stated that he/she took 500 mg powder form twice a day; - The provider’s medication list had magnesium oxide (supplement) 400 mg take one tablet by mouth daily. The patient stated that he/she had not taken the medication for about a month and it was a different magnesium than listed; - The provider’s medication list had NAC (supplement to relieve symptoms of respiratory conditions by acting as an antioxidant and expectorant, loosening mucus in your air passageways) oral 500 mg take two capsules (1gm total) daily. The patient stated that he/she took 1 gm of powder form twice a day; - The provider’s medication list had Omega-3 Fatty acids (supplement that serve as energy for the muscles, heart, and other organs as building blocks for cell membranes and as energy storage for the body) oral 500 mg capsules, take three (1.5 gm) capsules by mouth daily. The patient stated that he/she took two daily (1000 mg) and has been since the start of care (SOC); - The provider’s medication list had Radicava ORS (antioxidant that works by neutralizing harmful molecules in the body called free radicals, which are believed to contribute to the progression of ALS) oral 105 mg/5 milliliters (ml) take 5 ml by mouth in a 14 day period times 10 days then off for 14 days. The patient stated that he/she stopped the medication around 8/15/2025 because he/she was seeing no benefit as it was a trial medication; - The patient stated that he/she used NADH (amino acid supplement to generate energy) 20 mg twice a day. The provider’s medication profile failed to include NADH; - The patient stated that he/she took Mito-Q (supplement for energy) 20 mg daily. The provider’s medication profile failed to include Mito-Q; - The patient stated that he/she took Aakg (body building supplement) 1 gm powder twice a day. The provider’s medication profile failed to include Aakg; - The patient stated that he/she took Micro Vitamin (vitamins and minerals needed by the body in very small amounts) five capsules daily with food (started about two weeks ago). The provider’s medication profile failed to include Micro Vitamin; - The patient stated that he/she took Astaxanthin (powerful antioxidant and anti-inflammatory agent, potentially improving skin health, eye health, heart health, and brain function) 12 mg capsule daily (has been on since the SOC). The provider’s medication profile failed to include Astaxanthin. During an interview on 09/04/2025, beginning at 9:50 AM, the administrator stated that all disciplines were to ask about medication changes at every visit.

Discharge and transfer summaries CFR(s): 484.110(a)(6)(i-iii) (i) A completed discharge summary that is sent to the primary care practitioner or other health care professional who will be responsible for providing care and services to the patient after discharge from the HHA (if any) within 5 business days of the patient's discharge; or (ii) A completed transfer summary that is sent within 2 business days of a planned transfer, if the patient's care will be immediately continued in a health care facility; or (iii) A completed transfer summary that is sent within 2 business days of becoming aware of an unplanned transfer, if the patient is still receiving care in a health care facility at the time when the HHA becomes aware of the transfer. This ELEMENT is not met as evidenced by: Based on policy review, record review, and interview, the home health provider failed to provide a completed transfer summary to the health care facility providing care to the patient within two (2) days of becoming aware of the transfer in one of five full records reviewed (Record/Patient #4). This deficient practice has the potential to adversely affect the post discharge care of all the patients served by the provider. Findings included: Review of the provider’s policy titled, "Home Health Transfer and Discharge Policy," dated 11/2019, showed in part: - Purpose: to facilitate the proper transfer and discharge of patients from home health services; and - A completed transfer summary that is sent within two business days of becoming aware of an unplanned transfer, if the patient is still receiving care in a health care facility at the time when the home health agency (HHA) becomes aware of the transfer. RECORD/PATIENT #4: Review of the clinical record, showed, in part: - The patient was admitted to home health services on 08/11/2025 with a primary diagnosis of acute (sudden onset) and chronic (over a long period of time) respiratory failure (a condition where there’s not enough oxygen or too much carbon dioxide in your body) with hypoxia (an absence of enough oxygen in the tissues to sustain bodily functions); and - The patient resided in the home with his/her spouse. Review of the transfer summary, dated 08/16/2025, showed: - The patient was transferred to the hospital on 08/16/2025; - The transfer summary was completed by the physical therapist on 08/16/2025; and - The summary of care section showed, “medication profile to be attached to transfer summary and faxed to receiving facility and attending/following physician.” Review of the fax cover sheet showed the transfer summary was faxed to the primary care provider (PCP) on 08/22/2025. Review of the clinical record failed to show the transfer summary was sent to the receiving health care facility (hospital). During an interview on 09/04/2025 at 09:30 AM, the administrator stated that: - The transfer summary was faxed to the PCP six days after the patient’s transfer; and - He/she could not find that the transfer summary was sent to the hospital.

The Emergency Preparedness regulations were reviewed as part of the Medicare recertification survey completed on 11/17/2022. 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 11/17/2022. The agency had 212 current patients.

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 the agency’s policy review, home visit observation, and interview, the agency failed to provide the patient with contact information for the HHA (home health agency) administrator, in three (Records/Patients #1, #2, and #3) of three home visit observations. This deficient practice has the potential to affect the rights of all the agency patients. Findings included: Review of the agency’s policy, titled, “Patient Rights and Responsibilities Policy” revised, 11/2019, showed: - The HHA must: - Provide the patients and the patient’s legal representative (if any), the following information during the initial evaluation visit, in advance of furnishing care to the patient: * Written notice must be understandable to persons who have limited English proficiency and accessible to individuals with disabilities; and * Contact information for the HHA, including the administrator’s name, business address, and business phone number in order to receive complaints. RECORD/PATIENT #1: Observation on 11/15/2022, beginning at 11:30 AM, during the patient's home visit, showed: - Admission folder was reviewed; and - The Patient’s Bill of Rights had the previous administrator’s name and contact information listed. RECORD/PATIENT #2: Observation on 11/15/2022, beginning at 1:02 PM, during the patient's home visit, showed: - Admission folder was reviewed; and - The Patient’s Bill of Rights had the previous administrator’s name and contact information listed. RECORD/PATIENT #3: Observation on 11/15/2022, beginning at 9:25 AM, during the patient's home visit, showed: - Admission folder was reviewed; and - The Patient’s Bill of Rights had the previous administrator’s name and contact information listed. During an interview on 11/14/2022 at 12:25 PM, the administrator stated: - The name listed in the admission booklet is the previous administrator; and - Admission booklets and Patient Bill of Rights need to be updated with current name and contact information.

Payment from federally funded programs CFR(s): 484.50(c)(7)(i, ii, iii, iv) Be advised, orally and in writing, of- (i) The extent to which payment for HHA services may be expected from Medicare, Medicaid, or any other federally-funded or federal aid program known to the HHA, (ii) The charges for services that may not be covered by Medicare, Medicaid, or any other federally-funded or federal aid program known to the HHA, (iii) The charges the individual may have to pay before care is initiated; and (iv) Any changes in the information provided in accordance with paragraph (c)(7) of this section when they occur. The HHA must advise the patient and representative (if any), of these changes as soon as possible, in advance of the next home health visit. The HHA must comply with the patient notice requirements at 42 CFR 411.408(d)(2) and 42 CFR 411.408(f). This ELEMENT is not met as evidenced by: Based on the agency’s policy review, home visit observation, record review, and interview, the agency failed to ensure that the patients be advised, orally and in writing, of the extent to which payment for HHA (home health agency) services may be expected in, but not limited to, two (Records/Patients #3 and #5) of five full records reviewed. This deficient practice has the potential to affect the rights of all the agency patients. Findings included: Review of the agency’s policy, titled, “Patient Rights and Responsibilities Policy” revised, 11/2019, showed: - Be advised, orally and in writing, of: * The extent to which payment for HHA services may be expected from Medicare, Medicaid, or any other Federally-funded or Federal aid program known to the HHA; * The charges the individual may have to pay before care is initiated; * Any changes as soon as possible, in advance of the next home health visit; and * Receive proper written notice, in advance of a specific service being furnished, if the HHA believes that the service may be non-covered care; or in advance of the HHA reducing or terminating on-going care. RECORD/PATIENT #3: Observation on 11/15/2022, beginning at 9:25 AM, during the patient's home visit, showed: - Admission folder was reviewed; - The Consent for Treatment and Financial Agreement form was left blank; and - Skilled nurse (SN) informed the patient that the computer had issues with the signed consents during the start of care and new consents needed to be signed. RECORD/PATIENT #5: Review of the clinical record, showed: - Referral record noted that the patient believed that he/she did not have benefits for HH (home health) due to the hospital using them up; - Patient referred to home health for physical therapy services due to weakness and debility; - PT (physical therapy) only SOC (start of care) was on 10/06/2022; - Consent for Treatment and Financial Agreement form was left blank; and - The patient’s electronic signature was on the bottom of the blank form, with a date and time of, 10/06/2022, at 11:57 AM. During an interview on 11/16/2022 at 11:25 AM, the administrator stated: - Consent for treatment and financial agreements should be completed; and - Patients should be provided with copies of completed forms.

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 the agency’s preprinted admission booklet, home visit observation, and interview the agency failed to provide written notice of the updated state toll free home health telephone hotline hours of operation (7:00 AM to 8:00 PM, seven days a week), in three (Records/Patients #1, #2, and #3) of three home visit observations. This deficient practice has the potential to affect the rights of all the agency patients. Findings included: Review of the agency’s preprinted admission booklet, Patient Bill of Rights, showed: - The Missouri toll-free hotline, hours are 7AM [7:00 AM] to Midnight [12:00 AM], 7days per week; and - Its purpose for the receipt of complaints and questions regarding home health issues. RECORD/PATIENT #1: Observation on 11/15/2022, beginning at 11:30 AM, during the patient's home visit, showed: - Admission folder was reviewed; and - The state toll-free hotline hours were listed as, 7AM to Midnight, 7days per week. RECORD/PATIENT #2: Observation on 11/15/2022, beginning at 1:02 PM, during the patient's home visit, showed: - Admission folder was reviewed; and - The state toll-free hotline hours were listed as, 7AM to Midnight, 7days per week. RECORD/PATIENT #3: Observation on 11/15/2022, beginning at 9:25 AM, during the patient's home visit, showed: - Admission folder was reviewed; and - The state toll-free hotline hours were listed as, 7AM to Midnight, 7days per week. During an interview on 11/14/2022 at 12:25 PM, the administrator stated that: - The admission booklets need updated; and - Will update the admission packets to include the current hotline hours.

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 the agency’s policy review, record review, and interview, the home health provider failed to ensure a registered nurse (RN) conducted an initial assessment visit to determine the immediate care and support needs of the patient within 48 hours of referral in, but not limited to, one (Record/Patient #1) of five sampled patients. The deficient practice has to potential to affect all patients referred to home health services. Findings included: Review of the provider's policy titled "6.1 Comprehensive Assessment" stated in part that "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 ordered start of care date". RECORD/PATIENT #1: Review of the the patient's home health referral documents showed that a referral for home health services to "evaluate and treat a pressure ulcer R buttock" was faxed from a physician's office to the home health provider on 10/26/2022. There was no specific start of care date on the order. Review of the clinical record and all available physician orders showed no specific start of care date orders after the 10/26/2022 referral. Review of the initial comprehensive assessment showed that the first assessment visit was completed by the home health RN on 11/02/2022. During an interview with the home health administrator on 11/16/2022 at 10:54 AM, he/she stated that initial visits should be within 48 hours of referral unless the physician orders a specific start of care date or the patient requests a delay. He/she stated that there was no evidence of a specific ordered start of care by the physician or specific patient request for the patient.

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 the agency’s policy review, record review, and interview, the agency failed to accurately reflect the patient's status and include relevant patient data in the comprehensive assessment, in, but not limited to, one (Record/Patient #5) of five full records reviewed. This deficient practice has the potential to affect the comprehensive assessments for all agency patients. Findings included: Review of the agency's policy titled, "Comprehensive Assessment," revised 06/2018, showed, in part: - The comprehensive assessment must accurately reflects the client’s status, and must include, at a minimum current health, psychosocial, functional and cognitive status; - The comprehensive assessment will be conducted by a Registered Nurse (RN) if nursing services are ordered and indicated, otherwise a therapist can complete the assessment if rehabilitative services are the only discipline ordered; - The comprehensive assessment shall identify the patient’s need for home care and evaluate the patient’s medical, nursing, rehabilitative, social and discharge planning needs; and - Each patient must receive, and the HHA (home health agency) must provide, a patient-specific, comprehensive assessment. RECORD/PATIENT #5: Review of the referral record showed: - Home health referral for PT (physical therapy) due to weakness and debility; and - Past medical history of, acute on chronic systolic heart failure (happens when the left ventricle of the heart, which pumps most of the blood, becomes weak and unable to pump body efficiently), uncontrolled diabetes mellitus (a condition that affects the way the body processes blood sugar) type 2 (the body either doesn’t produce enough insulin, or it resists insulin), and bilateral leg edema (excess fluid trapped in the body’s tissues). Review of the SOC (start of care) OASIS (Outcome and Assessment Information Set- is a comprehensive assessment used to collect and report assessment data), showed: - Weight with a check mark next to not assessed, and “pt [patient] unable to recall most recent weight measurement and therefore not attained,” was noted in comment section; - Cardiovascular (related to the heart and blood vessels) assessment with edema section left blank; - Endocrine (endocrine system is system of glands in the body that make the hormones. It uses hormones to control and coordinate the body's metabolism, energy level, reproduction, growth and development, and response to injury, stress, and mood) assessment with insulin (hormone created by your pancreas that controls the amount of glucose in your bloodstream) dependent and independent with insulin administration; - Diet section with “regular” diet selected; and - No documentation of assessment of the patient’s health status that included relevant past medical history related to uncontrolled diabetes mellitus, systolic heart failure, and bilateral leg edema management. Review of the POC (plan of care) dated 10/06/2022 to 12/04/2022, showed: - Primary diagnosis of Type 2 diabetes mellitus with hyperglycemia (too much sugar in the blood); - Secondary diagnosis of acute on chronic systolic heart failure, type 2 diabetes mellitus with diabetic chronic kidney disease, and long term use of insulin; - Regular diet; and - No documentation of goals and interventions related to uncontrolled diabetes mellitus, systolic heart failure, and bilateral leg edema. During an interview on 11/16/2022 at 11:10 AM, the administrator stated that: - The comprehensive assessment should include current health status and past medical history; and - Education should have been provided regarding heart failure.

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 the agency's policy review, record review, home visit observation, and interview, the home health provider failed to ensure an effective 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 was completed, in two (Records/Patients #1 and #2) of three home visit observations. The deficient practice has the potential to affect all patients on service. Findings included: Review of the provider’s policy titled “7.2 Coordination of Care” showed in part that medication reconciliation includes comparing all medications found in the home to the most recent physician orders. The medication list should be updated with changes. Medication review should be conducted periodically throughout the episode to determine added or eliminated medications. RECORD/PATIENT #1: Review of the current plan of care and medication profile showed the patient was taking: · Celebrex 200 milligram (MG) by mouth (PO) daily (QD); · Ambien 5 mg PO at bedtime (HS) as needed (PRN); · Melatonin 5 MG daily PRN at HS; and · Lasix 20 MG PO QD. Observation and interview on 11/15/2022 at 11:30 AM, during the patient's home visit, showed the patient’s medications were reviewed. The following is a list of the discrepancies from the medication profile and plan of care: · The patient stopped taking any Celebrex two months ago; · Ambien 5 mg PO at bedtime was taken routinely and not as needed (PRN); · Melatonin 10 MG daily PRN at HS (instead of the 5 MG ordered/listed); · Lasix 40 MG PO QD (instead of the 20 MG ordered/listed); and · The patient was using “Derma Syn AG” cream to treat a pressure area of his/her right buttock daily (This medication was not listed in the plan of care or medication profile). Findings were reviewed with the home health administrator on 11/16/2022 at 10:54 AM. He/she stated that the clinicians should follow agency policy for medication review. No additional information was provided before the survey exit. RECORD/PATIENT #2: Review of the current plan of care and medication profile showed the patient was taking: · Marinol 5 MG by mouth daily; · Oxycodone-Acetaminophen oral 5-325 MG one tablet every six hours routinely; and · B12 injection 1000 micrograms (MCG) every 14 days. Observation and interview on 11/15/2022 at 11:30 AM, during the patient's home visit, showed the patient’s medications were reviewed. The following is a list of the discrepancies from the medication profile and plan of care: · The patient stopped taking Marinol when returned home from the hospital in August, since he/she takes medical marijuana gummies at home; · The patient takes Oxycodone-Acetaminophen as needed (PRN), and not routinely; · The patient was due on 11/14/2022 for the B12 injection 1000 micrograms (MCG) injection, but has not received the medication and does not have the medication available; and · The patient was using Vitamin D 1,000 units daily. (This medication was not listed in the plan of care or medication profile). Findings were reviewed with the home health administrator on 11/16/2022 at 11:06 AM. He/she stated that the clinicians should follow agency policy for medication review. No additional information was provided before the survey exit.

Patients receive education and training CFR(s): 484.60(d)(5) Ensure that each patient, and his or her caregiver(s) where applicable, receive ongoing education and training provided by the HHA, as appropriate, regarding the care and services identified in the plan of care. The HHA must provide training, as necessary, to ensure a timely discharge. This ELEMENT is not met as evidenced by: Based on the agency’s policy review, record review, home visit observation, and interview, the agency failed to ensure that each patient and his or her caregiver(s), received ongoing education and training provided by the HHA (home health agency), regarding the care and services identified in the plan of care in, but not limited to, one (Record/Patient #3) of three home visit observations. This deficient practice has the potential to adversely affect the patient/caregiver’s knowledge of self-care and agency expectations in all patients served by the agency. Findings included: Review of the agency’s policy, titled, “Coordination of Care,” revised 11/2019, showed: - The agency shall coordinate care delivery to meet the patient’s needs, and involve the patient, representative (if any), and caregiver(s), as appropriate, in the coordination of care activities; - The agency will ensure that each patient, and his or her caregiver(s) where applicable, receive ongoing education and training provided by the agency, as appropriate, regarding the care and services identified in the plan of care; and - Integrate orders from all physicians involved in the plan of care to assure the coordination of all services and interventions provided to the patient. Review of the agency’s policy, titled, “Plan of Care,” revised 06/2018, showed: - Each patient must receive an individualized written plan of care, including any revisions or additions; - The individualized plan of care must also specify the patient and caregiver education and training; and - The patient, patient representative (if any), caregiver, and physician must be consulted to approve additions or modifications to the original plan of care. RECORD/PATIENT #3: Review of the POC (plan of care), dated, 11/13/2022 to 01/11/2023, showed: - SN (skilled nurse) to perform wound care to the sacral/coccyx [triangle arrangement of bone that makes up the very bottom portion of the spine below the sacrum], wound every SNV [skilled nurse visit] 3x [three times] weekly as follows; cleanse with NS (Normal saline- nontoxic, isotonic solution that does not irritate or damage healing skin) or wound cleanser and pat dry, apply A&D ointment (ointment that provides a protective barrier to prevent skin breakdown by helping seal out wetness), cover with mepilex (self-adherent, foam dressing that is designed to absorb drainage and maintain moist wound healing environment); - SN to allow 2 PRN (as needed) visits for wound care related to pain, skin breakdown, dressing saturation, non-adhering dressing, accidental removal of dressing, or poor seal; and - SN to apply A&D ointment to left buttock wound each SNV, instruct patient and caregiver to apply three times daily and PRN until healed. Review of the SOC (start of care) OASIS (Outcome and Assessment Information Set- is a comprehensive assessment used to collect and report assessment data), showed: - Two wounds present; - Wound #1 to coccyx, measuring 1.3 cm (centimeters) in length, by 0.3 cm in width, by 0.1 cm in depth; - Treatment to coccyx wound as follows; cleanse with wound cleanser or NS and pat dry, apply A&D ointment, cover with foam pad (padded dressing that absorbs drainage and maintains moist wound healing), change 3x weekly with SNV; - Wound #2 to left buttock (either of the two round fleshy parts that form the lower rear area of a human trunk), measuring 0.2 cm in length, by 0.2 cm in width, by 0cm depth; - Treatment to buttock wound as follows; apply A&D ointment three times daily and as needed by patient or caregiver; - Goals and Interventions section had, “Instructed on shifting weight and standing every 1-2 hours for pressure relief, and use of air cushion when in WC [wheelchair], pt [patient] and CG [caregiver] in agreement,” noted; and - No documentation of education and training provided regarding wound care. Review of a Physician order, dated 11/14/2022, showed, in part: - Stage 3 (sore that gets worse and extends into the tissue beneath the skin, forming a small crater) pressure injury (injury to skin and underlying tissue resulting from prolonged pressure on the skin) of coccyx wound, and stage 2 (when the skin breaks open and the sore expands into deeper layers of the skin) pressure injury to left buttock; - Cleanse wounds with wound cleanser or NS and pat dry, apply A&D ointment with each SNV, cover coccyx wound with mepilex or like product; - Instruct patient and caregiver to apply A&D ointment to left buttock wound three times daily and as needed until wound is healed; and - Increase SNV to 3x weekly for wound care. Observation on 11/15/2022, beginning at 9:25 AM, during the patient's home visit, showed: - The LPN (licensed practical nurse) informed the patient of wound care to be performed by the LPN during visit; - Patient and spouse reported that wound care not being done three times daily due to not knowing what to do with the wounds; - The LPN educated patient and spouse on wound care orders; - Patient and spouse reported not having A&D ointment in the home; - The LPN performed wound care without using A&D ointment due to not having any to apply to wounds; - Admission folder was reviewed; and - No written instructions for wound care were left for the patient and caregiver. During an interview on 11/16/2022 at 10:30 AM, the administrator stated that: - Verbal orders for wound care were obtained on Monday (the day after the SOC visit); and - No wound care education or training provided until LPN visit (11/15/2022).

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 the agency’s policy review, home visit observation, and interview, the home health provider failed to ensure a written HHA (home health agency) personnel visit schedule was provided to patients in, but not limited to, two (Records/Patients #1 and #2) of three home visit observations. The deficient practice has the potential to affect all patients on service. Findings included: Review of the agency’s policy, titled, “Patient Rights and Responsibilities Policy” revised, 11/2019, showed: - The patient has the right to participate in, be informed about, and consent or refuse care in advance of and during treatment, where appropriate, with respect to: * The care to be furnished, based on the comprehensive assessment; * The disciplines that will furnish the care; and * The frequency of visits. RECORD/PATIENT #1: Observation on 11/15/2022 at 11:30 AM, during the patient's home visit, showed the patient’s home folder contained a blank calendar of clinician visits. Per interview conducted during observation, the patient was asked if the home health staff left him/her a visit schedule or days they plan on coming to his/her home, the patient responded “no, but that would be nice”. Findings were reviewed with the home health administrator on 11/16/2022 at 10:54 AM. He/she stated that the clinicians should fill out and leave a visit schedule in the home. No additional information was provided before the survey exit. RECORD/PATIENT #2: Observation on 11/15/2022 at 1:45 PM, during the patient's home visit, showed the patient’s home folder contained a calendar form of clinician visits, but the form/document was blank. Per interview conducted during observation, the patient’s primary caregiver/spouse was asked if the home health staff left him/her a visit schedule or days they plan on coming to his/her home, the caregiver responded “no, I keep my own, I write down when they are coming when they call on a notepad”. Findings were reviewed with the home health administrator on 11/16/2022 at 11:06 AM. He/she stated that the clinicians should fill out and leave a visit schedule in the home. No additional information was provided before the survey exit.

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 the agency’s policy review, record review, home visit observation, and interview, the agency failed to provide the patient/caregiver with a copy of written instructions of any treatments being administered by the agency and personnel acting on behalf of the HHA (home health agency) in, but not limited to, one (Record/Patient #3) of three home visit observations. This deficient practice has the potential to adversely affect the patient/caregiver’s knowledge of self-care and agency expectations in all patients served by the agency. Findings included: Review of the agency’s policy, titled, “Coordination of Care,” revised 11/2019, showed: - The agency shall coordinate care delivery to meet the patient’s needs, and involve the patient, representative (if any), and caregiver(s), as appropriate, in the coordination of care activities; - The agency will ensure that each patient, and his or her caregiver(s) where applicable, receive ongoing education and training provided by the agency, as appropriate, regarding the care and services identified in the plan of care; and - Integrate orders from all physicians involved in the plan of care to assure the coordination of all services and interventions provided to the patient. Review of the agency’s policy, titled, “Plan of Care,” revised 06/2018, showed: - Each patient must receive an individualized written plan of care, including any revisions or additions; - The individualized plan of care must also specify the patient and caregiver education and training; and - The patient, patient representative (if any), caregiver, and physician must be consulted to approve additions or modifications to the original plan of care. RECORD/PATIENT #3: Review of the clinical record, showed: - Patient admitted to services on 11/13/2022; - POC (plan of care) dated, 11/13/2022 to 01/11/2023, showed; * SN (skilled nurse) with visit frequency of 3x1 (3 times a week for 1 week), 2w1 (2 times a week for 1 week), 1w1 (1 time a week for 1 week); * PT (physical therapy) with visit frequency of 2w1, 1w1, 2w1; * OT (occupational therapy) with visit frequency of 2w3 (2 times a week for 3 weeks); - SOC (start of care) OASIS (Outcome and Assessment Information Set- is a comprehensive assessment used to collect and report assessment data) showed: * Two wounds present; * Wound #1 to coccyx (triangle arrangement of bone that makes up the very bottom portion of the spine below the sacrum), measuring 1.3 cm (centimeters) in length, by 0.3 cm in width, by 0.1 cm in depth; * Treatment to coccyx wound as follows; cleanse with wound cleanser or NS [Normal saline- nontoxic, isotonic solution that does not irritate or damage healing skin] and pat dry, apply A&D ointment (ointment that provides a protective barrier to prevent skin breakdown by helping seal out wetness), cover with foam pad (padded dressing that absorbs drainage and maintains moist wound healing), change 3x (3 times) weekly with SNV [skilled nurse visits]; * Wound #2 to left buttock (either of the two round fleshy parts that form the lower rear area of a human trunk), measuring 0.2 cm in length, by 0.2 cm in width, by 0cm depth; * Treatment to buttock wound as follows; apply A&D ointment three times daily and as needed by patient or caregiver; - Physician order, dated 11/14/2022, showed, in part: * Stage 3 (sore that gets worse and extends into the tissue beneath the skin, forming a small crater) pressure injury (injury to skin and underlying tissue resulting from prolonged pressure on the skin) of coccyx wound, and stage 2 (when the skin breaks open and the sore expands into deeper layers of the skin) pressure injury to left buttock; * Cleanse wounds with wound cleanser or NS and pat dry, apply A&D ointment with each SNV, cover coccyx wound with mepilex (self-adherent, foam dressing that is designed to absorb drainage and maintain moist wound healing environment) or like product; * Instruct patient and caregiver to apply A&D ointment to left buttock wound three times daily and as needed until wound is healed; and * Increase SNV to 3x weekly for wound care. Observation on 11/15/2022, beginning at 9:25 AM, during the patient's home visit, showed: - The LPN (licensed practical nurse) informed the patient of wound care to be performed by the LPN during visit; - Patient and spouse reported that wound care not being done three times daily due to not knowing what to do with the wounds; - The LPN educated patient and spouse on wound care orders; - Patient and spouse reported not having A&D ointment in the home; - The LPN performed wound care without using A&D ointment due to not having any to apply to wounds; - Admission folder was reviewed; and - No copy of written instructions of any treatments were left for the patient and caregiver. During an interview on 11/16/2022 at 10:30 AM, the administrator stated that: - Written instructions for treatments should be written and left for the patient and caregiver; and - PT and OT are expected to provide written treatment plan with instructions for exercises.

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 the agency’s policy review, home visit observation, and interview, the agency failed to provide the patient with contact information for the HHA (home health agency) clinical manager, in three (Records/Patients #1, #2, and #3) of three home visit observations. This deficient practice has the potential to affect the rights of all the agency patients. Findings included: Review of the agency’s policy, titled, “Patient Rights and Responsibilities Policy” revised, 11/2019, showed, written contact information for the agency administrator and clinical manager will be provided to the patient and patient representative (if any) at the time of the initial evaluation. RECORD/PATIENT #1: Observation on 11/15/2022, beginning at 11:30 AM, during the patient's home visit, showed: - Admission folder was reviewed; - The Patient’s Bill of Rights had the previous administrator’s name and contact information listed; and - No documentation of clinical manager name and/or contact information found. RECORD/PATIENT #2: Observation on 11/15/2022, beginning at 1:02 PM, during the patient's home visit, showed: - Admission folder was reviewed; - The Patient’s Bill of Rights had the previous administrator’s name and contact information listed; and - No documentation of clinical manager name and/or contact information found. RECORD/PATIENT #3: Observation on 11/15/2022, beginning at 9:25 AM, during the patient's home visit, showed: - Admission folder was reviewed; - The Patient’s Bill of Rights had the previous administrator’s name and contact information listed; and - No documentation of clinical manager name and/or contact information found. During an interview on 11/14/2022 at 12:25 PM, the administrator stated: - The name listed in the admission booklet is the previous administrator; and - Admission booklets and Patient Bill of Rights need to be updated with current name and contact information.

Discharge and transfer summaries CFR(s): 484.110(a)(6)(i-iii) (i) A completed discharge summary that is sent to the primary care practitioner or other health care professional who will be responsible for providing care and services to the patient after discharge from the HHA (if any) within 5 business days of the patient's discharge; or (ii) A completed transfer summary that is sent within 2 business days of a planned transfer, if the patient's care will be immediately continued in a health care facility; or (iii) A completed transfer summary that is sent within 2 business days of becoming aware of an unplanned transfer, if the patient is still receiving care in a health care facility at the time when the HHA becomes aware of the transfer. This ELEMENT is not met as evidenced by: Based on the agency’s policy review, record review, and interview, the agency failed to ensure a completed discharge summary was sent to the primary care practitioner or other health care professional who will be responsible for providing care and services to the patient after discharge, in one (Record/Patient #6) of two discharge records reviewed. This deficient practice has the potential to affect all discharged or transferred patients served by the agency. Findings included: Review of the agency’s policy, titled, “Home Health Transfer and Discharge Policy” revised, 11/2019, showed: - A discharge summary will be sent to the primary care practitioner or other health care professional who will be responsible for providing care and services to the patient after discharge from the agency (if any) within five (5) business days of the dare of the date of the order for discharge from the responsible physician; and - The HHA (home health agency) must send all necessary medical information pertaining to the patient’s current course of illness and treatment, post-discharge goals of care, and treatment preferences, to the receiving facility or health care practitioner, to ensure the safe and effective transition of care. RECORD/PATIENT #6: Review of the clinical record, showed: - Discharge summary with a completion date of 10/26/2022; and - Discharge summary faxed to the physician on 11/04/2022. During an interview on 11/16/2022 at 11:00 AM, the administrator stated that, the discharge summary was sent to the physician late.