Every finding on record at Pinnacle Care Holdings, LLC

The entity is in compliance with the federal emergency preparedness requirements.

Recertification Survey Abbreviations: MEQ- milliequivalent mcg- micrograms mg- milligrams

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 observations, interviews, and record review, the agency failed to ensure each patients’ comprehensive assessment included a review of all medications the patients were currently using. The agency failed to ensure staff reconciled patients’ medications for 4 (#1, #2, #4 and #5) of 5 (#1, #2, #3, #4 and #5) patients reviewed during home visits. Findings: Review of the Agency’s Policy titled, “Medication Reconciliation” dated January 2024 revealed the following, in part: Purpose: Medication Reconciliation is the process of comparing a patient’s medication orders to all of the medications the patient is taking. Procedure: 6. The clinician is to review medications at each visit. Patient #1 Review of the Clinical Record for Patient #1 revealed he began receiving services from the Home Health Agency on 04/27/2024 and had a current Certification Period of 10/24/2024 to 12/22/2024. Patient #1 had diagnoses, which included Hypertension and Generalized Weakness. A home visit was conducted with Patient #1 on 12/03/2024 at 8:30 a.m. with S4LPN present. Patient #1’s medications were reviewed during the home visit. The following medication discrepancies were identified when compared to Patient #1’s Current Medication Profile provided by the Home Health Agency: Klor-Con Extended Release 10 MEQ take two tablets by mouth daily, was on the medication profile with a start date of 04/27/2024. Medication bottle present in the home had instructions to take two tablets in the morning and three tablets at bedtime. Torsemide 20 mg take by mouth daily, was on the medication profile with a start date of 04/27/2024. Medication bottle present in the home with a filled date of 11/07/2024, had instructions to take one tablet in the morning and one tablet in the afternoon before 5:00 p.m. Equate Acetaminophen Arthritis 8 hour 650 mg take one tablet every 8 hours as needed for pain, was present in the home and not on the medication profile. Equate Dry Eye Relief drops instill one drop in each eye as needed for dry eyes, was present in the home and not on the medication profile. Latanoprost 0.005% eye drops instill one drop into each eye once daily at bedtime, was present in the home and not on the medication profile. An interview was conducted with Patient #1’s family member on 12/03/2024 at 8:45 a.m. She said she managed Patient #1’s medications. She said Patient #1’s Klor-Con was changed to include three tablets in the evening “a few months ago”. She said Patient #1’s Toresmide dose was changed “about 6 months ago”. She said she gave Patient #1 Tylenol Arthritis as needed for knee pain and the dry eye relief drops as needed for dry eyes. She said Patient #1 had been using Lantanoprost eye drops for “over one year”. She said occasionally the home health nurses checked the medication bottles during their visits. An interview was conducted with S4LPN on 12/03/2024 at 8:50 a.m. S4LPN confirmed the above medication discrepancies identified during the home visit. S4LPN said medications should be reconciled during every home visit. Patient #2 Review of the Clinical Record for Patient #2 revealed she began receiving services from the Home Health Agency on 10/17/2024 and had a current Certification Period of 10/17/2024 to 12/15/2024. Patient #2 had diagnoses, which included Type 2 Diabetes Mellitus with Hyperglycemia and Hypertension. A home visit was conducted with Patient #2 on 12/02/2024 at 3:00 p.m. with S3RN present. Patient #2’s medications were reviewed during the home visit. The following medication discrepancies were identified when compared to Patient #2’s Current Medication Profile provided by the Home Health Agency: Aspirin 81 mg take one tablet daily by mouth was on the medication profile with a start date of 11/17/2024, which the patient was no longer taking. Metformin 500mg take 2 tablets daily by mouth was on the medication profile with a start date of 10/17/2024, which the patient was no longer taking. An interview was conducted on 12/02/204 at 3:10 a.m. with Patient #2. She said she stopped taking Aspirin 81mg tablets and Metformin 500mg tablets one month ago. She said she ran out of the medications and had not refilled them. An interview was conducted with on 12/02/2024 at 3:15 p.m. with S3RN. S3RN confirmed the above medication discrepancies identified during the home visit. S3RN said medications should be reconciled during every home visit. Patient #4 Review of the Clinical Record for Patient #4 revealed she began receiving services from the Home Health Agency on 11/16/2024 and had a current Certification Period of 11/16/2024 to 01/14/2025. Patient #4 had diagnoses, which included Hypothyroidism. A home visit was conducted with Patient #4 on 12/03/2024 at 10:00 a.m. with S5OT present. Patient #4’s medications were reviewed during the home visit. The following medication discrepancies were identified when compared to Patient #4’s Current Medication Profile provided by the Home Health Agency: Levothyroxine 75 mcg take one tablet daily by mouth in the morning, with a filled date of 10/02/2024, was present in the home and not on the medication profile. Fluticasone Propionate 50 mcg two sprays each nostril twice daily, was present in the home and not on the medication profile. An interview was conducted with Patient #4 on 12/03/2024 at 10:05 a.m. She said the home health staff reviewed her medication bottles once since admission. She said she had been taking the Levothyroxine and the Fluticasone Propionate “for years”. An interview was conducted with S5OT on 12/03/2024 at 10:10 a.m. S5OT confirmed the above medication discrepancies identified during the home visit. S5OT said medications should be reconciled during every home visit. Patient #5 Review of the Clinical Record for Patient #5 revealed she began receiving services from the Home Health Agency on 10/21/2024 and had a current Certification Period of 10/21/2024 to 12/19/2024. Patient #5 had diagnoses, which included Parkinson’s Disease without Dyskinesia and Anxiety Disorder. A home visit was conducted with Patient #5 on 12/03/2024 at 11:00 a.m. with S6PT present. Patient #5’s medications were reviewed during the home visit. The following medication discrepancies were identified when compared to Patient #5’s Current Medication Profile provided by the Home Health Agency: Carbidopa-Levodopa 25-100 mg tablet take by mouth every 8 hours, was on the medication profile with no dose documented. Medication bottle present in the home with a filled date of 10/22/2024, had instructions to take two and a half tablets by mouth three times a day. An interview was conducted with Patient #5 on 12/03/2024 at 11:15 a.m. She said she had been taking two and a half tablets of Carbidopa-Levodopa for “a while”. An interview was conducted with S6PT on 12/03/2024 at 11:20 a.m. S6PT confirmed the above medication discrepancies identified during the home visit. S6PT said medications should be reconciled during every home visit. An interview was conducted with S2DON on 12/03/2024 at 4:00 p.m. She was notified of the medication discrepancies identified during the home visits for Patient #1, #2, #4 and #5. She said each patients’ medications should be reconciled every discipline visit and staff should review the medication bottles each visit. She verified each patients’ Medication Profile should have reflected what the patient was currently taking.

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 observations, interviews, and record review, the agency failed to provide the patient with the Clinical Manager’s name and contact information for 3 (#1, #4, and #5) of 5 (#1, #2, #3, #4, and #5) patients reviewed with home visits. Findings: Patient #1 Review of the Clinical Record for Patient #1 revealed he began receiving services from the Home Health Agency on 04/27/2024 and had a current Certification Period of 10/24/2024 through 12/22/2024. A home visit was conducted with Patient #1 on 12/03/2024 at 8:30 a.m. with S4LPN present in the home. A review of Patient #1’s home health folder revealed no documentation of the name or contact information for the agency’s Clinical Manager. An interview was conducted with S4LPN on 12/03/2024 at 8:50 a.m. during the home visit. She reviewed Patient #1’s home health folder and confirmed there was no documentation of the name or contact information for the agency’s Clinical Manager. Patient #4 Review of the Clinical Record for Patient #4 revealed she began receiving services from the Home Health Agency on 11/16/2024 and had a current Certification Period of 11/16/2024 through 01/14/2025. A home visit was conducted with Patient #4 on 12/03/2024 at 10:00 a.m. with S5OT present in the home. A review of Patient #4’s home health folder revealed no documentation of the name or contact information for the agency’s Clinical Manager. An interview was conducted with S5OT on 12/03/2024 at 10:10 a.m. during the home visit. She reviewed Patient #4’s home health folder and confirmed there was no documentation of the name or contact information for the agency’s Clinical Manager. Patient #5 Review of the Clinical Record for Patient #5 revealed she began receiving services from the Home Health Agency on 10/21/2024 and had a current Certification Period of 10/21/2024 through 12/19/2024. A home visit was conducted with Patient #5 on 12/03/2024 at 11:00 a.m. with S6PT present in the home. A review of Patient #5’s home health folder revealed no documentation of the name or contact information for the agency’s Clinical Manager. An interview was conducted with S6PT on 12/03/2024 at 11:20 a.m. during the home visit. He reviewed Patient #5’s home health folder and confirmed there was no documentation of the name or contact information for the agency’s Clinical Manager. An interview was conducted with S2DON on 12/03/2024 at 1:40 p.m. She verified she was the agency’s Clinical Manager. She confirmed her name and contact information were not provided to the agency’s patients and stated she was not aware it should be. An interview was conducted with S1ADM on 12/03/2024 at 4:00 p.m. He verified S2DON was the agency’s Clinical Manager. He confirmed S2DON’s name and contact information were not provided to the agency’s patients. He stated he was unaware the Clinical Manager’s name and contact information were required to be provided to the agency’s patients.

Provide services in the plan of care CFR(s): 484.75(b)(3) Providing services that are ordered by the physician or allowed practitioner as indicated in the plan of care; This ELEMENT is not met as evidenced by: Based on record review and interviews, the agency failed to provide services that were ordered by the Physician as indicated in the Plan of Care for 3 (#9, #10, and #11) of 13 (#1 - #13) patients reviewed. The agency failed to ensure: 1. The skilled nurse obtained vital signs for Patient #9 and Patient #11 on each home visit; and 2. The skilled nurse obtained a blood pressure for Patient #10 during the home visit. Findings Review of the agency’s policy titled “Care Plan Development”, dated January 2024, revealed the following, in part: Policy: 3. Clinicians involved in the patients care must follow the Plan of Care and report to the ordering physician any barriers to providing care. Procedure: 5. The Plan of Care may include vital sign parameters approved by the Physician. Patient #9 Review of Patient #9’s Clinical Record revealed he was admitted to the agency on 03/25/2024 with diagnoses which included Pressure Ulcer of Ischium Stage 2. Review of Patient #9’s Plan of Care for Certification Period 11/20/2024 through 01/18/2025 revealed Physician Orders which included the following, in part: Notify the Physician of symptomatic vitals: Oxygen Saturation less than 88%, Systolic Blood Pressure greater than 160 or less than 90, Diastolic Blood Pressure greater than 90 or less than 50; Heart Rate greater than 110 beats per minute or less than 40 beats per minute; Respiratory rate greater than 30 breaths per minute or less than 10 breaths per minute; Temperature greater than 101 degrees. Review of the Skilled Nurse visit notes dated 11/22/2024, 11/25/2024 and 11/29/2024 revealed no documented vital signs. An interview was conducted on 12/02/2024 at 3:00 p.m. with S3RN. She confirmed she provided skilled nurse visits on the dates listed above and did not obtain Patient #9’s vital signs. She said according to Patient #9’s Plan of Care, vital signs should have been obtained each nurse visit. Patient #10 Review of Patient #10’s Clinical Record revealed she was admitted to the agency on 01/20/2024, had a Certification Period of 01/20/2024 through 03/19/2024, and was discharged from the agency on 02/29/2024. Patient #10 had diagnoses which included Closed Intertrochanteric Fracture of Right Hip, Status Post Open Reduction and Internal Fixation of Fracture, and Hypertension. Review of Patient #10’s Plan of Care for Certification Period 01/20/2024 through 03/19/2024 revealed Physician Orders which included the following, in part: Notify the Physician of symptomatic vitals: Systolic Blood Pressure greater than 160 or less than 90, Diastolic Blood Pressure greater than 90 or less than 50. Review of the Skilled Nurse visit note dated 01/30/2024 revealed no documented blood pressure. Patient #11 Review of Patient #11’s Clinical Record revealed she was admitted to the agency on 03/17/2024 with diagnoses which included Severe Sepsis, Pressure ulcer of right heel, Unstageable, Necrotizing Soft Tissue Infection, Type II Diabetes Mellitus, and Atrial Fibrillation. Review of Patient #11’s Plan of Care for Certification Period 05/16/2024 through 07/14/2024 revealed Physician Orders which included the following, in part: Notify the Physician of symptomatic vitals: Oxygen Saturation less than 88%, Systolic Blood Pressure greater than 160 or less than 90, Diastolic Blood Pressure greater than 90 or less than 50; Heart Rate greater than 110 beats per minute or less than 40 beats per minute; Respiratory rate greater than 30 breaths per minute or less than 10 breaths per minute; Temperature greater than 101 degrees. Review of the Skilled Nurse visit notes dated 05/20/2024, 05/22/2024, 05/24/2024, 05/28/2024, 06/03/2024, 06/05/2024, 06/12/2024, 06/14/2024, 06/19/2024, 06/26/2024, 06/28/2024, 07/01/2024, 07/03/2024 and 07/12/2024 revealed no documented vital signs. An interview was conducted on 12/02/2024 at 3:00 p.m. with S3RN. She confirmed she provided skilled nurse visits on the dates listed above and did not take Patient #11’s vital signs. She said according to Patient #11’s Plan of Care, vital signs should have been obtained each nurse visit. An interview was conducted on 12/03/2024 at 3:30 p.m. with S2DON. She confirmed S3RN did not document Patient #9 and Patient #11’s vital signs each visit. She said S3RN should have obtained vital signs each visit. S2DON reviewed Patient #10’s Skilled Nurses’ Note dated 01/30/2024 and Clinical Notes for the Certification Period. S2DON confirmed there was no documentation of Patient #10’s blood pressure for the 01/30/2024 skilled nurse visit and there should have been.

Communication with physicians CFR(s): 484.75(b)(7) Communication with all physicians involved in the plan of care and other health care practitioners (as appropriate) related to the current plan of care; This ELEMENT is not met as evidenced by: Based on record review and interviews, the agency failed to ensure a physician was notified regarding a patient's change in condition. The agency failed to ensure the Physician was notified after a patient’s fall, an elevated pain level status and a heart rate out of parameters for 1 (#10) of 13 (#1 - #13) patients record reviewed. Findings: Review of the agency’s policy titled, “Physician Communication”, dated January 2024, revealed the following, in part: Purpose: To define expectations for communication with the physician. Policy: Physician communication will be established and maintained to ensure safe and appropriate care for the patient. Procedures: 1. Professional agency personnel contact the patient’s physician: B. When there are changes in the patient’s condition. 2. All conferences or attempts to communicate with physician will be included but not limited to: the physical chart and/or clinical notes tab, assessment, or schedule notes. Review of Patient #10’s Clinical Record revealed she began receiving services with the agency on 01/20/2024, had a Certification Period of 01/20/2024 through 03/19/2024 and was discharged from the agency on 02/29/2024. Patient #10 had diagnoses, which included Closed Intertrochanteric Fracture of Right Hip, Status Post Open Reduction and Internal Fixation of Fracture, Vascular Dementia with Anxiety and Hypertension. Review of Patient #10’s Plan of Care dated 01/20/2024 revealed the following, in part: Notify physician of symptomatic vitals: Heart Rate greater than 110 beats per minute or less than 40 beats per minute… Instruct Patient/Caregiver in reporting poorly controlled or changes in pain. Patient vitals will be controlled within physician directed range throughout episode of care. Review of Patient #10’s Skilled Nurses’ Notes revealed the following, in part: 01/30/2024- Pulse 117 beats per minute, Pain Rating 10, Patient had a fall around five this morning. Family set up appointment to get her wrist checked out. Patient’s right arm was swollen at the wrist. Signed S7RN. Review of Patient #10’s Clinical Notes for Certification Period 01/20/2024 through 3/19/2024 revealed no notification to the Physician of Patient #10’s fall, pain of 10/10, or heart rate of 117 beats per minute. An interview was conducted with S2DON on 12/02/2024 at 1:10 p.m. S2DON reviewed Patient #10’s Skilled Nurses’ Note dated 01/30/2024 and Clinical Notes for the Certification Period. S2DON confirmed there was no documentation the physician was notified of Patient #10’s abnormal heart rate of 117, pain of 10 out of 10 and a fall. S2DON confirmed the nurse should have contacted the Physician for Patient #10’s change in condition. An interview was conducted with S1ADM on 12/02/2024 at 1:15 p.m. S1ADM reviewed Patient #10’s Skilled Nurses’ Note dated 01/30/2024 and Clinical Notes for the Certification Period. S1ADM confirmed Patient #10 had a fall with reported pain of 10 out of 10, and an elevated heart rate of 117. S1ADM confirmed the nurse should have contacted the Physician for Patient #10’s change in condition.

This entity is in compliance with federal emergency preparedness requirements

Recertification Survey ADM Administrator PTA Physical Therapy Assistant PT Physical Therapist

Verbal orders CFR(s): 484.60(b)(3)(4) (3) Verbal orders must be accepted only by personnel authorized to do so by applicable state laws and regulations and by the HHA's internal policies. (4) When services are provided on the basis of a physician or allowed practitioner's verbal orders, a nurse acting in accordance with state licensure requirements, or other qualified practitioner responsible for furnishing or supervising the ordered services, in accordance with state law and the HHA's policies, must document the orders in the patient's clinical record, and sign, date, and time the orders. Verbal orders must be authenticated and dated by the physician or allowed pracitioner in accordance with applicable state laws and regulations, as well as the HHA's internal policies. This ELEMENT is not met as evidenced by: Based on interviews and record reviews, the agency failed to ensure the plan of care was signed and dated by the patient's physician in a timely manner for 3 ( #1, #6, #11) of 11 (#1-#11) sampled patients. Cross-referenced with State Regulations 9123. Patient Care Standards: C. Plan of Care. The plan of care for each patient must be individualized to address the patient's problems, goals, and required services. 1. The Plan of Care, telephone and/or verbal orders must be signed by the physician within a timely manner, not to exceed 30 days. Findings: Review of the agency’s policy titled” Physician Orders” revealed the following: Purpose: To provide an organized method for obtaining, transcribing, and tracking physician orders. Policy: Physician orders will be obtained at start of care, recertification and when there is a change in the patient’s medical condition. Procedure: 6. Certifications, recertification and telephone/verbal orders must be signed within fourteen days of the receipt of the order. Up to thirty days may be approved if attempts have been made to obtain the order. Patient #1 Review of the clinical record for Patient #1 revealed a start of care date of 09/25/2021. Review of the plan of care for the certification period 11/24/2021 to 01/22/2022 for the patient revealed diagnoses that included Ischemia of Right Lower Extremity, Heal Blister, Hypertension with Chronic Kidney Disease, Pain of Right Lower Extremity Ischemia, Stage 3 Chronic Kidney Disease and Femoral Popliteal Bypass Surgery to Right Lower Extremity. Further review of the plan of care for this certification period revealed it was not signed by the physician. Patient #6 Review of the clinical record for Patient #6 revealed a start of care date of 11/14/2021. Review of the plan of care for the certification period 11/14/2021 to 01/12/2022 for the patient revealed diagnoses that included Cervical Spinal Fusion, Chronic Midline Back Pain, Type II Diabetes Mellitus with use of insulin, Congestive Heart Failure and Hypertensive Heart Disease. Further review of the plan of care for this certification period revealed it was not signed by the physician. Patient #11 Review of the clinical record for Patient #11 revealed a start of care date of 09/14/2021. Review of the plan of care for the certification period 11/13/2021 to 01/11/2022 for the patient revealed diagnoses that included After-care for Amputation Stump, Physical Deconditioning, Absence of Right Leg above Knee, Hemiparesis of Right Side and Type II Diabetes Mellitus. Further review of the plan of care for this certification period revealed it was not signed by the physician. On 12/30/2021 at 10:00 a.m., an interview was conducted with S1ADM. After reviewing the plan of care for Residents #1, #6, and #11, he verified the physicians' orders were not signed for the patients within the required time frame of 30 days. He said he was responsible for ensuring the patient's plan of care was signed by the physician.