Every finding on record at Residential Clinical Services Inc

This survey was a complaint investigation survey for a home health agency. Survey dates: 2/23/2023 to 3/7/2023 Complaint #95666-substantiated. Federal deficiencies were cited. Facility ID: IN005307 Census: 115 Unduplicated census last 12 months: 486 This deficiency report reflects State Findings cited in accordance with 410 IAC 17. Quality Review completed 03/21/2023

Participate in care CFR(s): 484.50(c)(4)(i,ii,iii,iv,v,vi,vii,viii) Participate in, be informed about, and consent or refuse care in advance of and during treatment, where appropriate, with respect to-- (i) Completion of all assessments; (ii) The care to be furnished, based on the comprehensive assessment; (iii) Establishing and revising the plan of care; (iv) The disciplines that will furnish the care; (v) The frequency of visits; (vi) Expected outcomes of care, including patient-identified goals, and anticipated risks and benefits; (vii) Any factors that could impact treatment effectiveness; and (viii) Any changes in the care to be furnished. This ELEMENT is not met as evidenced by: Based on observation, record review and interview, the agency failed to ensure the skilled professional informed patient and caregiver discharge education in 2 of 10 patient records reviewed (Patient #2, 9). The findings include: 1. Record review of an agency policy titled “Discharge Summary” revised March 2018, stated “Policy A Discharge Summary will be completed for all patients discharged from the agency …. " 2. An observation of a home visit was conducted on 2/24/2023, from 11:02 AM to 11:58 AM, for patient #2, start of care 12/14/2022, where the home admission booklet was reviewed for education provided to include medication instruction, schedule information, and information on the patient’s plan of treatment. Record review failed to evidence educational information about the patient’s care was provided by the skilled professionals. Clinical record review on 3/6/2023, for patient #2, start of care 12/14/2022, diagnoses included but not limited to high blood pressure and dementia, evidenced agency documents titled “SN [skilled nurse] Discharge Summary” electronically signed by Registered Nurse (RN) #2. This document had an area that stated “Discharge instructions given to …” which remained blank, and another area stated “Discharge Instructions ….” which also remained blank. Record review failed to evidence the patient/caregiver received discharge instructions from the skilled nurse. During an interview on 03/07/2023 at 9:54 AM, Clinical Manager #2 stated “OK.” 3. Clinical record review on 3/7/2023, for patient #9, start of care 6/17/2022, primary diagnosis of wound care post surgical amputation, evidenced an agency document titled "Home Health Discharge Summary" electronically signed by Clinical Manager #2 on 2/13/2023. This document evidenced a section subtitled "Transfer Discharge Instructions" which remained incomplete. Record review failed to evidence the patient/caregiver received discharge instruction and education. During an interview on 3/7/2023, at 11:15 AM, Clinical Manager #2 indicated they did not see discharge instructions documented on the discharge summary. 4. During an interview on 3/2/2023, at 2:44 PM, when queried where discharge instructions provided to the patient were documented, Clinical Manager #2 indicated on the Discharge Summary.

Plan of care CFR(s): 484.60(a)(1) Each patient must receive the home health services that are written in an individualized plan of care that identifies patient-specific measurable outcomes and goals, and which is established, periodically reviewed, and signed by a doctor of medicine, osteopathy, or podiatry acting within the scope of his or her state license, certification, or registration. If a physician or allowed practitioner refers a patient under a plan of care that cannot be completed until after an evaluation visit, the physician or allowed practitioner is consulted to approve additions or modifications to the original plan. This STANDARD is not met as evidenced by: Based on observation, record review and interview, the agency failed to follow a plan of care established and reviewed by the physician in 6 of 10 patient records reviewed (Patient #1, 2, 4, 5, 7, 8 ). The findings include: 1. Review of an agency policy titled "Plan of Care - CMS #485 and Physician Orders", revised March 2019, indicated each patient must receive the home health services that are written in an individualized plan of care that has been established and periodically reviewed by the physician. The policy indicated each plan of care must be signed and dated by the physician. Review of an agency policy titled “Home Health Aide Supervision” revised March 2018, stated “Procedure … 4. Home Health Aide supervision must ensure that aides furnish care in a safe and effective manner, including, but not limited to, the following elements: … Following the patient's plan of care for completion of tasks assigned to a Home Health Aide by the registered nurse or other appropriate skilled professional ….” 2. Clinical record review for Patient #1, start of care 2/13/2023, certification period 2/13/2023 to 4/13/2023, failed to evidence a plan of care signed by the physician. During an interview on 3/6/2023 at 2:55 PM, the Clinical Manager indicated the plan of care was created based on the start of care assessment, then sent to the physician to be signed and returned. When queried, the Clinical Manager indicated the agency did not have a signed plan of care for Patient #1. 3. Clinical record review for Patient #4, start of care 1/30/2023, certification period 1/30/2023 to 3/30/2023, failed to evidence a plan of care signed by the physician. During an interview on 3/6/2023 at 3:40 PM, when queried, the Clinical Manager indicated the agency did not have a signed plan of care for Patient #4. 4. Clinical record review for Patient #5 evidenced a start of care assessment dated 1/28/2023. In a subsection titled, "Nutritional Approaches", this assessment indicated the patient was receiving IV feedings. Review of the plan of care for certification period 1/27/2023 to 3/27/2023 indicated the patient was on a low cholesterol, heart healthy, low fat, no added salt diet. Review of the plan of care failed to evidence IV feedings. Clinical record review for certification period 1/28/2023 to 3/28/2023, failed to evidence a plan of care signed by the physician. During an interview on 3/6/2023 at 3:46 PM, the Clinical Manager indicated Patient #5 did not receive IV feedings, and the nurse documented the IV feedings in error. During an interview on 3/6/2023 at 3:57 PM, when queried, the Clinical Manager indicated the agency did not have a signed plan of care for Patient #5. 5. Clinical record review for Patient #7, start of care 5/31/2022, 1/26/2023 to 3/26/2023, failed to evidence a plan of care signed by the physician. On 3/7/2023 at 10:32 AM, when queried, the Clinical Manager indicated the agency did not have a signed plan of care for the certification period 1/26/2023 to 3/26/2023. 6. Clinical record review for Patient #8, start of care 8/25/2022, certification periods 8/25/2022 to 10/23/2022 and 10/24/2022 to 12/22/2022, failed to evidence plans of care signed by the physician. On 3/7/2023 at 10:40 AM, when queried, the Clinical Manager indicated the agency did not have a signed plan of care for either certification period 8/25/2022 to 10/23/2022 or 10/24/2022 to 12/22/2022. 7 . An observation of a home visit was conducted on 2/24/2023, for patient #2, start of care 12/14/2022, from 11:02 AM to 11:58 AM, with home health aide (HHA) #1. At 11:25 AM, HHA #1 picked up a green and yellow aerosol can and stated, “It’s sitting here so [patient #2] must need it.” and sprayed the patient’s feet. When queried what was sprayed on the patient’s feet, HHA #1 stated “Foot spray.” Throughout the visit, observation failed to evidence oral care was provided or offered. Clinical record review on 3/6/2023, for patient #2, evidenced an agency document titled “HHA [home health aide] Care Plan” for episode 2/12/2023 – 4/12/2023, electronically signed by Clinical Manager #2. This document listed tasks for the HHA to complete during every visit which included but was not limited to oral care. Review of the HHA care plan failed to evidence instruction for the HHA to apply foot spray. Record review evidenced an agency document titled “HHA Visit” electronically signed by HHA #1 on 2/24/2023, evidenced oral care was refused by the patient. Record review failed to evidence the application of foot spray was recorded. Observation and record review failed to evidence HHA #1 followed the written instructions on the HHA Care Plan. Clinical record review evidenced agency documents titled “Missed Visit” from 1/7/2023 and 1/14/2023, which were electronically signed by Clinical Manager #2. These documents stated, “Physician Office Notified: No ….” Record review failed to evidence the physician was notified of missed visits. During an interview on 3/2/2023, at 2:45 PM, when queried how missed visits were communicated with the physician, Clinical Manager #2 indicated if multiple visits were missed, they would communicate with the physician and patient’s family/caregiver. Clinical Manager #2 stated “If it’s one visit, no. But more than one, then we would let the doctor know.” 410 IAC 17-13-1(a)

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 observation, record review and interview, the home health agency failed to ensure accepted standards of practice and standard precautions were implemented by all clinicians to prevent the possible spread of infectious diseases in 2 of 3 home visits conducted (Home health aide #1, RN #2) The findings include: 6. Observation of a skilled nurse visit for Patient #4 was conducted on 2/27/2023 at 2:00 PM. RN (registered nurse) #2 entered the patient's room, set up barriers on the couch, and put her bag and equipment on the barriers. A cat was visible walking around the room. While RN #2 was checking the patient's vital signs, the surveyor observed the cat walk across the nurse's clean barrier. After being informed of the cat by the surveyor, the nurse asked a family member to take the cat away, cleaned the area, and placed new barriers down. RN #2 then performed picc (peripherally inserted central catheter)(an extended use IV) line care. When cleaning the insertion site of the picc line, RN #2 swabbed in an up and down motion, then back and forth over the site. Observation of the skilled nurse visit in its entirety failed to evidence a head to toe assessment of the patient. RN #2 failed to assess the patient's post-surgical site (left hip) for infection. Clinical record review evidenced the patient had a diagnosis of Lymphoma (a cancer of the lymphatic system, which is part of the body's germ-fighting network) and was at high risk for infection. During an interview on 3/6/2023 at 3:19 PM, the Clinical Manager indicated the nurse should ask the patient or family to remove pets from the room where a picc line dressing is being performed and the nurse should cleanse the picc line site in a circular motion away from the point of insertion. The Clinical Manager indicated the nurse should have assessed the patient head-to-toe for any signs of infection. 1. Record review of an agency policy titled “Standard Precautions” revised March 2018, stated “Policy … Blood and body fluid precautions will be followed for all patients … Purpose … To Prevent transmission of communicable diseases … Procedure … 1. The concept of body substance isolation encompasses all the principles of Standard Precautions/ blood and body fluid precaution, and extends to all moist body parts/tissues/surfaces, including fluids, solids, tissue and moist areas, e.g., mucous membranes … 2. … All health care workers will routinely use appropriate barrier precautions to prevent skin and mucous membrane exposure when contact with blood or other body fluids of any patient is anticipated ….” 2. Record review of an agency policy titled “Guidelines for COVID-19 Virus” dated July 2020, stated “Policy The Agency will implement current CDC [Center for Disease Prevention and Control] guidelines for patients and staff who are diagnosed or suspected of having the COVID-19 virus … Procedure … Home Visits … 4. Staff must utilize appropriate PPE per current CDC guidelines ….” 3. Review of the Center for Disease Prevention and Control website evidenced an article titled “Interim Infection Prevention and Control Recommendations for Healthcare Personnel During the Coronavirus Disease 2019 (COVID-19) Pandemic” updated September 27, 2022, stated “…1. Recommended routine infection prevention and control (IPC) practices during the COVID-19 pandemic … Implement Source Control Measures … Source control refers to use of respirators or well-fitting facemasks or cloth masks to cover a person’s mouth and nose to prevent spread of respiratory secretions when they are breathing, talking, sneezing, or coughing … People, particularly those at high risk for severe illness, should wear the most protective form of source control they can that fits well and that they will wear consistently … HCP [healthcare providers] and healthcare facilities might also consider using or recommending source control when caring for patients who are moderately to severely immunocompromised ….” 4. Review of an agency policy titled, "PERIPHERALLY INSERTED CENTRAL CATHETER (PICC) MAINTENANCY AND MANAGEMENT OF POTENTIAL COMPLICATIONS" dated March 2005 indicated the site should be cleaned in a circular fashion moving from the exit site of the catheter out at least 3-4 inches in diameter, then allowed to air dry. 5. An observation of a home visit was conducted on 2/24/2023, for patient #2, start of care 12/14/2022, from 11:02 AM to 11:58 AM, with home health aide (HHA) #1. During the observation at 11:04 AM, HHA #1 pulled down their mask and indicated the patient understood better with it that way. HHA #1 assisted the patient to undress and onto the shower chair. At 11:09 AM, HHA #1 wet a clean washcloth with warm water and handed to the patient to wash their face, ears and neck. HHA #1 rinsed and applied soap to the same washcloth and washed patient #2’s upper back, shoulders and under arms. At 11:11 AM, patient #2 requested to wash their face again and was allowed to use the washcloth that had been used on soiled body parts. Observation evidenced HHA #1 failed to follow current CDC recommendations per agency policy to wear a mask for source control to prevent the spread of the Covid-19 virus. Observation evidenced patient #1 washed their face with a clean washcloth, then used a soiled washcloth on their face. Observation failed to evidence standard precautions were implemented to prevent the spread contaminated materials to mucous membranes, such as the eyes, nose and mouth. Observation failed to evidence Standard Precaution and Covid-19 policy and procedures were followed to prevent the transmission of communicable disease and infection. During an interview on 3/6/2023, at 9:58 AM, clinical manager #2 indicated clinicians should wear a mask in patient homes. During an interview on 3/6/2023, at 9:59 AM, clinical manager #2 indicated HHA #1 should have gotten a clean washcloth to use on the patient's face.

Infection control CFR(s): 484.70(b)(1)(2) Standard: Control. The HHA must maintain a coordinated agency-wide program for the surveillance, identification, prevention, control, and investigation of infectious and communicable diseases that is an integral part of the HHA's quality assessment and performance improvement (QAPI) program. The infection control program must include: (1) A method for identifying infectious and communicable disease problems; and (2) A plan for the appropriate actions that are expected to result in improvement and disease prevention. This STANDARD is not met as evidenced by: Based on observation, record review and interview, the agency failed to maintain a program for the surveillance, identification, prevention, control and investigation of infectious and communicable diseases in 4 of 4 records reviewed with known or obtained infection (Patient #4, 5, 6, 7). The findings include: 6. Clinical record review on 3/6/2023, for patient #6, start of care 2/1/2023, evidenced a faxed document from entity #1, titled “Physician Orders Details” signed by the wound care physician on 2/13/2023. This document had an area subtitled “Wound Orders” which stated “… Keflex [antibiotic medication used to treat a wide variety of bacterial infections] to be taken as ordered until GONE ….” Record review failed to evidence the agency staff reported/documented the patient was prescribed an antibiotic or had an infection. Record review failed to evidence patient #6 listed on the agency’s infection log. During an interview on 3/6/2023, at 10:57 AM, clinical manager #2 indicated they did not know why the patient was taking the antibiotic medication, Keflex. 1. Review of an agency policy titled "Infection Control Surveillance System: Prioritized Risks Defined", revised March 2018, indicated the agency will perform infection control surveillance for patient infections reported at time of admission, patient infections reported while on service, and employee communicable infections. 2. Clinical record review evidenced Patient #4 was admitted to home health on 1/30/2023 for IV antibiotic therapy due to Bacteremia (infection in the blood). Review of the agency's infection log on 2/23/2023 from 11/29/2022 to present failed to evidence any entries for Patient #4. 3. Clinical record review evidenced Patient #5 was admitted to home health on 1/28/2023 for IV antibiotic therapy due to an infected abscess of the back. Review of the agency's infection log on 2/23/2023 from 11/29/2022 to present failed to evidence any entries for Patient #5. 4. Observation of a home visit for Patient #7 on 2/28/2023 at 11:36 AM evidenced a conversation between the patient and LPN (licensed practical nurse) #1. The patient indicated they had a urinalysis at their doctor's office about 3 weeks ago, and were started on an antibiotic, which they took for 8 days. LPN #1 indicated she was aware and that she would have to re-check the patient's urine in one month. Review of the agency's infection log on 2/23/2023 from 11/29/2022 to present failed to evidence any entries for Patient #7. 5. During an interview on 3/6/2023 at 2:50 PM, the Clinical Manager indicated if a patient is diagnosed with an infection or is being treated with antibiotics, they should be entered in the Infection Control Log.

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 record review and interview, the agency failed to ensure the involvement of all skilled professional staff in the patient's plan of care in 1 of 2 active patient records receiving IV [intravenous] antibiotics (Patient #5). The findings include: Review of an agency policy titled "Care Planning Process" dated March 2018 indicated the agency will utilize information gathered during patient assessments to create the patient's care plan. Review of the plan of care for 1/27/2023 to 3/27/2023 for Patient #5 indicated nurse shall assess the patient's need for therapy services. Review of the start of care assessment dated 1/28/2023, signed by RN (registered nurse) #1 indicated the patient required maximum assistance to safely leave the home, had poor balance, unsteady gait, activity intolerance, and muscle weakness. The assessment indicated the patient was previously independent with activities of daily living without any assistance, but now requires human assistance and a cane. Clinical record review failed to evidence the nurse requested a physical therapy evaluation. During an interview on 3/6/2023 at 3:45 PM, when informed of the findings, the Clinical Manager indicated based on the admission assessment, the nurse should have entered a physical therapy evaluation. 410 IAC 17-12-2(g)

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 observation, record review and interview, the agency failed to provide services as ordered in the plan of care in 3 of 7 active patient records reviewed (Patient #4, 5, 7). The findings include: *. Clinical record review on 3/6/2023, for patient #2, start of care 12/14/2022, diagnoses included but not limited to high blood pressure, diabetes, and dementia, evidenced an agency document titled “Home Health Certification and Plan of Care” for certification period 12/14/2022 – 2/11/2023. This document had an area subtitled “Orders for Discipline and Treatment” which stated “Nursing … SN [skilled nurse] to provide skilled assessment, teaching/training and reinforcement of teaching, to properly assess, manage and mitigate pain … SN to assess cardiovascular status, identify any signs and symptoms of impaired cardiovascular function … SN to assess patient with Senile dementia disease, identify any signs and symptoms requiring intervention … SN to assess and instruct patient/caregiver on the importance of proper diabetic foot care and precautions ….” Record review evidenced an agency document titled “Missed Visit” signed by Clinical Manager #2 on 1/14/2023, which stated “Family – Caregiver able to assist Patient” as the reason for the missed visit. Record review failed to evidence patient #2’s caregiver could provide skilled assessments for pain, impaired cardiovascular function, dementia, or diabetic foot care. Record review failed to evidence the skilled professionals followed the Plan of Care. During an interview on 3/6/2023, Clinical Manager #2 indicated the caregiver would monitor the patients vitals and medication but could not provide skilled assessments. Clinical Manager #2 indicated the visit should have been made up. 1. Review of an agency policy titled "Plan of Care - CMS #485 and Physician Orders", revised March 2019, indicated each patient must receive the home health services that are written in an individualized plan of care that has been established and periodically reviewed by the physician. 2. Review of the plan of care for Patient #4, certification period 1/30/2023 to 3/30/2023, evidenced the following skilled nursing orders: perform complete physical assessment with each visit with emphasis on lymphoma (cancer of the lymphatic system, which is part of the body's germ-fighting network) with recent bacteremia (an infection in the blood) and left hip replacement; assess integumentary (skin) status, identify any signs and symptoms of impaired skin integrity. During a home visit on 2/27/2023 at 2:00 PM, RN (registered nurse) #2 was observed checking Patient #4's vital signs, drawing blood from the picc (peripherally inserted central catheter)(an extended use IV) line, and changing the dressing on the picc line. The patient's body (except for the arms) remained covered with a blanket throughout the visit. RN #2 failed to use a stethoscope and to visualize the patient's skin at any time during the visit. Observation of the visit, viewed in its entirety, failed to evidence a complete physical assessment. During an interview on 3/6/2023 at 3:13 PM, the Clinical Manager indicated the nurse should perform a head-to-toe assessment at each visit including listening to the patient's chest, back and abdomen with a stethoscope. The Clinical Manager indicated the patient's skin should be assessed by visualizing the skin, especially the heels, elbows, hips and sacral area. When informed of the findings, the Clinical Manager shook their head and was silent. 3. Review of the plan of care for Patient #5, certification period 1/27/2022 to 3/27/2023, indicated the nurse was to draw labs weekly and send the results to Physician #4. Clinical record review failed to evidence lab results drawn on 2/2/2023, 2/9/2023, and 2/20/2023 were sent to Physician #4 During an interview on 3/6/2023 at 3:49 PM, the Clinical Manager indicated the lab results should be sent to the physician, and this should be documented in the patient's electronic medical record (Axxess). When informed of the findings, the Clinical Manager reviewed the patient's record and indicated it failed to evidence lab results were sent to Physician #4. 4. Review of the plan of care for Patient #7, certification period 1/26/2023 to 3/26/2023, evidenced the following skilled nursing orders: perform complete physical assessment with each visit with emphasis on wound care; assess integumentary (skin) status, identify any signs and symptoms of impaired skin integrity. During observation of a home visit on 2/28/2023 at 11:00 AM, LPN (licensed practical nurse) #1 performed wound care for Patient #7 (a wheelchair bound paraplegic). The patient was observed to be wearing a long sleeved sweater and socks. Observation of the visit failed to evidence LPN visualizing the patients elbows and heels. During an interview on 3/6/2023 at 3:13 PM, the Clinical Manager indicated the nurse should perform a head-to-toe assessment at each visit. The Clinical Manager indicated the patient's skin should be assessed by visualizing the skin, especially the heels, elbows, hips and sacral area. When informed of the findings on 3/7/2023 at 10:13 AM, the Clinical Manager indicated LPN #1 should have moved or removed the patient's clothing in order to perform a skin assessment.

Preparing clinical notes CFR(s): 484.75(b)(6) Preparing clinical notes; This ELEMENT is not met as evidenced by: Based on observation, record review and interview, the nurse failed to prepare current, complete, and accurate clinical notes in 7 of 10 patient records reviewed (Patient #2, #4, #5, #6, #7, #8, #10). The findings include: 7. Clinical record review on 3/6/2023, for patient #2, start of care 12/14/2022, diagnoses included but not limited to diabetes and dementia, evidenced agency documents titled “SN [skilled nurse] Discharge Summary” electronically signed by Registered Nurse (RN) #2 on 2/3/2023. An area subtitled “Patient Condition and Outcomes” indicated the patient was stable but failed to indicate the status goals were met or not. An area subtitled “Service(s) Provided” indicated skilled nursing and physical therapy but failed to indicate home health aide services provided. Review of this document failed to evidence discharge instructions were given to the patient/caregiver. Record review failed to evidence the skilled nurse prepared complete and accurate documentation on the discharge summary. Record review of agency documents titled “SN Teaching/Training Visit” from 1/20/2023 and 1/27/2023, which were electronically signed by RN #2. These documents had an area subtitled “Neurological [pertaining to the brain, central nervous system, and peripheral nerves]” which indicated the patient was oriented to person, place, and was forgetful. Another area subtitled “Visit Narrative” which indicated the patient was alert and oriented to self only. An area subtitled “Endocrine [pertaining to hormones secreted in the blood]/Hematologic [pertaining to the blood]” indicated there were no problems identified during the assessment. Record review failed to evidence blood sugar information related to the patient’s pertinent diagnosis of diabetes was accurately assessed and documented. Record review evidenced contradictory documentation of the patient neurological status. Record review failed to evidence complete documentation of the patient’s endocrine assessment. Record review failed to evidence the skilled nurse prepared complete and accurate documentation on the skilled nurse visit notes. During an interview on 3/6/2023, at 10:18 AM, Clinical Manager #2 indicated the patients diabetes was managed by diet and all blood sugar information should be documented under the Endocrine/Hematologic section. 8. Clinical record review on 3/1/2023, for patient #6, start of care 2/1/2023, primary diagnosis to Type 2 diabetes with foot ulcer, of the agency’s Electronic Health Record (Axxess) evidenced Skilled Nurse (SN) visits were not started for 2/15/2023 (14 days late), and 2/17/2023 (12 days late). On 3/1/2023, at 3:51 PM, agency documents were retrieved titled “SN Wound Care Visit” for 2/15/2023, and 2/17/2023, which were completed and signed by Licensed Practical Nurse (LPN) #1. During an interview on 3/6/2023, at 10:47 AM, when queried why the visits were not completed when requested, but completed when received, Clinical Manager #2 indicated they sent a message on their communication application (WhatsApp) to all clinicians to complete outstanding documentation. Clinical Manager #2 indicated it took LPN #1 12 – 14 days to complete documentation for visits 2/15/2023, and 2/17/2023. 9. Clinical record review on 3/7/2023, for patient #10, start of care 11/15/2022, primary diagnosis of bladder cancer, evidenced an agency document titled “SN Teaching/Training Visit” electronically signed by RN #2, on 11/21/2022, had a section subtitled "Labs" which indicated a blood test was obtained venipuncture from the right upper arm PICC with a 24 gauge needle. Record review evidenced an agency document titled "OASIS-D1 Resumption of Care" electronically signed by RN #2 on 12/6/2023, which had an area subtitled "Labs and Infection Control" which indicated a blood test was obtained venipuncture from the right upper arm PICC with a 25 gauge needle. During an interview on 3/7/2023, at 11:22 AM, Clinical Manager #2 indicated the agency nurse should not draw blood venipuncture from a PICC. 1. Review of an agency policy titled "Skilled Professional Services", revised March 2018, indicated skilled professionals will provide appropriate assessments, reassessments, care planning, and provide care per physician orders. The policy indicated skilled professionals must assume responsibility for preparing clinical note Review of an agency policy titled "Medical Record Entries and Authentication, revised March 2018, indicated all entries in patient records will be legible, clear, complete, appropriately authenticated, dated and timed. Review of an agency policy titled "Timely Submission of Patient Documentation", revised October 2017, indicated the agency will ensure the timely and proper submission of patient documentation. The policy indicated physicians' orders must be submitted to the agency within 3 days of receipt, all visit notes must be submitted within 3 days from the date of visit, and the patient discharge summary must be submitted within 5 business days. 2. Review of the electronic medical record (Axxess) for patient #1 evidenced a start of care visit was completed on 2/13/2023 and regular skilled nurse visits on 2/14/2023, 2/17/2023, and 2/20/2023. Clinical record review on 2/27/2023 at 10:13 AM failed to evidence any completed visit notes for any regular skilled nurse visits. During an interview on 2/23/2023 at 9:41 AM, when queried what timeframe was allowed for clinicians to turn in documentation following a visit, the Clinical Manager stated "Five days. I'll have to check. I need to look that up." 3. Clinical record review for Patient #4, start of care 1/20/2023, evidenced skilled nursing visit notes dated 2/6/2023, 2/13/2023, and 2/20/2023. Each of these notes had a section titled "Labs" which indicated the nurse drew blood from the patient's picc (peripherally inserted central catheter)(an extended-use IV access), and blood test was obtained via venipuncture (inserting a needle into a vein) using a 25 gauge needle. During an interview on 3/6/2023 at 3:02 PM, the Clinical Manager indicated a lab draw was either drawn via the picc line or venipuncture, but not both. The Clinical Manager indicated the labs should have been drawn via the picc line, but the nurse's documentation was not clear. 4. Clinical record review for Patient #5 evidenced a start of care assessment dated 1/28/2023. In a subsection titled, "Nutritional Approaches", this assessment indicated the patient was receiving IV feedings. Review of the plan of care for certification period 1/27/2023 to 3/27/2023 indicated the patient was on a low cholesterol, heart healthy, low fat, no added salt diet. Review of the plan of care failed to evidence IV feedings. During an interview on 3/6/2023 at 3:46 PM, the Clinical Manager indicated Patient #5 did not receive IV feedings, and the nurse documented the IV feedings in error. 5. Observation of a home visit for Patient #7 was conducted on 2/28/2023 at 11:00 AM. When performing wound care to the patient's 3 wounds, LPN (licensed practical nurse) #1 indicated they normally use alginate (a specialized wound care product) in the wound, then cover it with gauze, but because the patient was going to be getting bathed later that day, she covered the wounds with plain gauze in order to not waste the alginate. Observation of the home visit failed to evidence the nurse measuring the patient's wounds. Review of LPN #1's visit note for 2/28/2023 indicated they used alginate on 2 of the 3 wounds. Review of the visit note failed to evidence wound care observed at the home visit. Review of the visit note evidenced measurements for all 3 wounds. During an interview on 3/7/2023 at 10:10 AM, the Clinical Manager indicated the nurse should document the care as it was provided at the visit. 6. Clinical record review for Patient #8 evidenced a document identified by the Clinical Manager as the 60-day summary, dated 11/8/2022, signed by RN (registered nurse )#3 and a document identified by the Clinical Manager as the discharge summary, dated 1/11/2023, signed by the Clinical Manager. Both of these documents had a subsection titled, "Emergency Preparedness" which indicated the patient went to Entity #3 for dialysis every Monday, Wednesday, and Friday. Review of the patient's clinical record in Axxess failed to evidence the patient was on dialysis. During an interview on 3/7/2023 at 10:58 AM, the Clinical Manager indicated the patient had never been on dialysis while on their service. The Clinical Manager indicated she did not know why dialysis information was included on both documents.

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 observation, record review and interview, the skilled professionals failed to communicate pertinent information regarding the patient’s plan of care to the physician for 3 of 7 active clinical records reviewed (Patient #2, #3, #6). The findings include: 4. Review of the plan of care for Patient #5, certification period 1/27/2023 to 3/27/2023, evidenced Physician #5 (primary care) and Physician #4 (infectious disease specialist) were both following the patient. The plan of care indicated the patient was receiving IV antibiotics for an abscess to their back. Clinical record review evidenced a Communication Note dated 2/17/2023, signed by RN (registered nurse) #2, which indicated the patient cancelled the skilled nurse visit because they had flu-like symptoms. Clinical record review failed to evidence Physician #4 was notified of the patient's flu-like symptoms. During an interview on 3/6/2023 at 3:54 PM, when informed of the findings, the Clinical Manager indicated the nurse should have notified both Physician #4 and Physician #5 of the patient's new symptoms. 1. Record review of an agency policy titled “Plan of Care – CMS #485 and Physician Orders” revised March 2019, stated “Procedure … 4. … Discharge planning begins early in the provision of care and must be revised as the patient's condition or life circumstances change. There must be evidence in the medical record that the Agency discussed any such changes with the patient, his or her representative (if any) and the responsible physician. Other physicians who contributed orders to the patient's plan of care must also be notified of changes to the patient's discharge plan … The patient's physician orders for treatments and services are the foundation of the plan of care. If the Agency misses a visit or a treatment or services as required by the plan of care, which results in any potential for clinical impact upon the patient, then the Agency must notify the responsible physician of such missed treatment or service. The physician decides whether the treatment or service may be skipped or whether additional intervention is required by the Agency due to the clinical impact on the patient ….” 2. An observation of a home visit was conducted on 2/27/2023, from 12:35 PM to 1:30 PM, with patient #3 and Physical Therapist (PT) #2. At 12:50 PM, patient #3 stated, “I want to get back to work.” At 12:59 PM, patient #3 stated, “I’m going back to work next week.” PT #2 replied “One more visit. I’ll make sure you’re safe.” Observation evidenced PT #2 and patient #3 discussed a plan for discharge after one more PT visit. Clinical record review on 3/6/2023, for patient #3, start of care 2/2/2023, failed to evidence a plan for discharge was communicated to the patient’s physician. During an interview on 3/2/2023, at 2:43 PM, when queried how changes in the patient’s services were communicated to the patient, Clinical Manager #2 indicated when patient goals are met, the clinician should notify the Clinical Manager, who would notify the physician to verify and create a physician order or communication note. During an interview on 3/6/2023, at 10:35 AM, Clinical Manager #2 indicated they were unaware of an upcoming PT discharge for patient #2. 3. Clinical record review on 3/6/2023, for patient #2, start of care 12/14/2022, diagnoses included but not limited to high blood pressure and dementia, evidenced agency documents titled “Missed Visit” from 1/7/2023 and 1/14/2023, which were electronically signed by Clinical Manager #2. These documents stated, “Physician Office Notified: No ….” Record review failed to evidence the physician was notified of missed visits. During an interview on 3/2/2023, at 2:45 PM, when queried how missed visits were communicated with the physician, Clinical Manager #2 indicated if multiple visits were missed, they would communicate with the physician and patient’s family/caregiver. Clinical Manager #2 stated “If it’s one visit, no. But more than one, then we would let the doctor know.” 4. Clinical record review on 3/6/2023, for patient #6, start of care 2/1/2023, primary diagnosis to Type 2 diabetes with foot ulcer, evidenced a document from Entity #1, titled “Visit Discharge Instructions Details” dated 1/23/2023 and signed by Person #6. This document described the orders for treatment to be provided by the home health agency was to apply silver alginate (for use in the treatment of high risk or infected chronic wounds) to the wound bed, cover with dry gauze, wrap with rolled gauze and secure with tape, 3 times per week. Record review of a document from Entity #1, titled “Physician Orders Details” electronically signed by Person #6 on 2/13/2023, which indicated the patient was prescribed an antibiotic. This document also indicated an updated wound care treatment to apply medical grade Honey (used to speed the healing of wounds through its anti-inflammatory effects) to the wound bed, cover with dry dressing, and change every other day. Review of this document evidenced a new medication and an updated wound care treatment was ordered by Person #6. Record review of a document from Entity #1, titled “Physician Orders Details” electronically signed by Person #6 on 2/27/2023, which indicated an updated wound care treatment to apply Iodosorb (topical medicated gel for wounds) to the wound bed, cover with dry dressing, and change every other day. Review of this document evidenced an updated wound care treatment was orderd by Person #6. Record review failed to evidence the updated orders on 2/13/2023 and 2/27/2023, from Person #6 were communicated to the patient’s primary physician listed on the plan of care. During an interview on 3/6/2023, at 10:57 AM, Clinical Manager #2 indicated they were unsure why the patient was prescribed an antibiotic. During an interview on 3/6/2023, at 11:00 AM, Clinical Manager #2 indicated when the agency received documents from Entity #1, they were printed and scanned into the Electronic Health Record (Axxess). Clinical Manager #2 indicated they should receive a copy of the orders to review and write new orders for the patient’s primary physician as needed.

HH aide supervision elements CFR(s): 484.80(h)(4)(i-vi) Home health aide supervision must ensure that aides furnish care in a safe and effective manner, including, but not limited to, the following elements: (i) Following the patient's plan of care for completion of tasks assigned to a home health aide by the registered nurse or other appropriate skilled professional; (ii) Maintaining an open communication process with the patient, representative (if any), caregivers, and family; (iii) Demonstrating competency with assigned tasks; (iv) Complying with infection prevention and control policies and procedures; (v) Reporting changes in the patient's condition; and (vi) Honoring patient rights. This ELEMENT is not met as evidenced by: Based on record review and interview, the skilled professional failed to provide oversight to ensure all assistants followed written instructions for 1 of 1 HHA supervised by a Physical Therapist (PT #1). The findings include: Record review of an agency policy titled “Home Health Aide Supervision” revised March 2018, stated “Procedure … 4. Home Health Aide supervision must ensure that aides furnish care in a safe and effective manner, including, but not limited to, the following elements: … Following the patient's plan of care for completion of tasks assigned to a Home Health Aide by the registered nurse or other appropriate skilled professional … Demonstrating competency with assigned tasks … Reporting changes in the patient's condition ….” Clinical record review on 3/6/2023, for patient #2, start of care 12/14/2022, evidenced an agency document titled “HHAide [home health aide] Care Plan” for episode 12/14/2022 – 2/11/2023, electronically signed by Registered Nurse (RN) #1. This document listed tasks for the HHA to complete during every visit which included but were not limited to shampoo/comb hair, and assistance with ambulation, elimination, and incontinent care. Record review evidenced agency documents titled “HHA Visit” electronically signed by HHA #1, failed to evidence the HHA Care Plan was implemented as instructed. Record review evidenced skin and pericare (cleaning of patients private parts including the genitals and buttocks) every HHA Visit but was not listed on the HHA Care Plan. Record review failed to evidence HHA #1 offered shampoo and combed the patient’s hair on 12/20/2022, 1/11/2023, and 1/23/2023. Record review failed to evidence HHA #1 offered shampoo and incontinence care on 1/4/2023, and 1/6/2023. Record review failed to evidence HHA #1 offered shampoo/comb hair and assistance with elimination on 1/13/2023. Record review failed to evidence HHA #1 offered shampoo/comb hair, or assistance with elimination and ambulation on 1/19/2023. Record review evidenced an agency document titled “HHA Supervisory Visit” for patient #2 and HHA #1, electronically signed by PT #1 on 1/23/2023, which indicated HHA #1 followed the plan of care as assigned. Record review failed to evidence the skilled professional supervised the assistant to include review of the HHA visit notes to ensure the written care plan was being followed as instructed. During an interview on 3/2/2023, at 2:35 PM, Clinical Manager #2 indicated the SN or PT would report to the HHA the patient’s needs and a care plan would be created. Clinical Manager #2 indicated the HHA could not perform tasks that were not listed on the care plan because additional tasks added would need to be verified by the physician.

In accordance with current clinical practice CFR(s): 484.105(f)(2) All HHA services must be provided in accordance with current clinical practice guidelines and accepted professional standards of practice. This ELEMENT is not met as evidenced by: Based on observation, record review and interview, the agency failed to ensure skilled professional services practiced according to the agency's policies and procedures in 5 of 5 active patient records with a wound or IV [intravenous] antibiotics (Patient #4, #5, #6, #7, #10). The findings include: 1. Review of an agency policy titled "Professional Standards of Practice", revised October 2017, indicated all agency and staff will comply with accepted standards of practice and plans of care. 2. Review of an agency policy titled, "PERIPHERALLY INSERTED CENTRAL CATHETER (PICC) MAINTENANCY AND MANAGEMENT OF POTENTIAL COMPLICATIONS" dated March 2005, indicated the site should be cleaned in a circular fashion moving from the exit site of the catheter out at least 3-4 inches in diameter, then allowed to air dry. The policy also indicated the external catheter length should be measured to verify it corresponds to initial placement measurement. 3. Observation of a skilled nurse visit for Patient #4 was conducted on 2/27/2023 at 2:00 PM. RN (registered nurse) #2 entered the patient's room, set up barriers on the couch, and put her bag and equipment on the barriers. At 2:05 PM, RN #2 took the patient's blood pressure on their right wrist. The patient was observed to have a picc (peripherally inserted central catheter) line in their right arm. When cleaning the insertion site of the picc line, RN #2 swabbed in an up and down motion, then back and forth over the site. Observation of the home visit failed to evidence the nurse measured the external catheter length. Clinical record review of all nurse's assessments for certification period 1/30/2023 to 3/30/2023, failed to evidence picc line measurements. Review of all nurse's assessments for certification period 1/30/2023 to 3/30/2023, indicated the nurse took the blood pressure on the same arm as the picc line (right side). During an interview on 3/6/2023 at 3:19 PM, the Clinical Manager indicated the nurse should measure the picc line as written in the agency policy. The Clinical Manager indicated if a patient has a picc line, the blood pressure should never be taken on the same arm, above or below the picc line. 4. Review of the plan of care for certification period 1/27/2023 to 3/27/2023, indicated Patient #5 had a right upper arm picc line. Review on 3/2/2023,of all nurse's assessments for certification period 1/27/2023 to 3/27/2023, failed to evidence picc line measurements. During an interview on 3/6/2023 at 3:19 PM, the Clinical Manager indicated the nurse should measure the picc line as written in the agency policy. 5. Observation of a wound care home visit for Patient #7 was conducted on 2/28/2023 at 11:00 AM. Observation of the home visit failed to evidence LPN (licensed practical nurse) #1 measured the patient's wounds. Observation during the home visit at 11:36 AM, evidenced a conversation between the patient and LPN #1. The patient indicated they had a urinalysis at their doctor's office about 3 weeks ago, and were started on an antibiotic, which they took for 8 days. LPN #1 indicated she was aware and that she would have to re-check the patient's urine in one month. Clinical record review evidenced the patient received one skilled nurse visit per week. During an interview on 2/28/2023 at 11:45 AM, LPN #1 indicated it was the agency's policy to measure patient wounds once per week. During an interview on 3/7/2023 at 10:18 AM, the Clinical Manager indicated it was the agency's policy to measure patient wounds once per week, and LPN #1 should have measured the patient's wounds at the home visit, as it was the only nurse visit that week. Clinical record review of all orders and current visit notes back to 12/31/2022, failed to evidence an antibiotic or urinalysis. During an interview on 3/7/2023 at 10:14 AM, when informed of the findings, the Clinical Manager indicated the nurse should have written an order for the antibiotic and urinalysis after talking to the patient's physician. When queried, the Clinical Manager indicated the patient's clinical record failed to evidence communication with or orders from the physician for an antibiotic or urinalysis. Clinical record review on 3/2/2023, indicated the nurse was providing wound care for 3 different wounds: sacrum, right hip, and right buttocks. Clinical record review evidenced the current wound care was ordered on 9/23/2022. Review of the skilled nurse visit notes indicated no change in the sacral wound size from 9/28/2023 to 2/24/2023. Review of the skilled nurse visit notes indicated no change in the right hip wound from 9/28/2022 to 11/18/2022, then only .5cm change in size from 11/30/2022 to 2/24/2023. Review of the skilled nurse visit notes indicated no change in the right buttocks wound from 10/7/2022 to 2/24/2023. Clinical record review failed to evidence a change in wound care despite no improvement of the wounds. Clinical record review failed to evidence communication with the physician about the unchanged wound sizes and current treatment. During an interview on 3/7/2023 at 10:20 AM, the Clinical Manager indicated if a wound was not improving within 2 weeks of starting treatment, it was the agency's policy that the nurse contact the physician to determine if a change in treatment was needed. 6. Clinical record review on 3/6/2023, for patient #6, start of care 2/1/2023, primary diagnosis of type 2 diabetes with foot ulcers, evidenced agency documents titled “LPN/LVN [licensed practical nurse/licensed vocational nurse] Visit” signed by LPN #1, which indicated the patient had 3 ulcers to the patient’s left foot: Wound 1 located on the mid foot measured (length by width by depth in centimeters) 10 cm x 8 cm x 0.1 cm; Wound 2 located on the great toe measured 2 cm x 2 cm x 0.1 cm; Wound 3 located on the fifth toe measured 1 cm x 1 cm x 0.1 cm. These measurements were documented for the following LPN Visit dates: 2/3/2023, 2/9/2023, 2/15/2023, 2/17/2023, 2/22/2023, and 2/24/2023. Review failed to evidence a change in the size in the patients wound. Record review evidenced documents titled “Physician Orders Details” electronically signed by Person #6 on 2/13/2023 and 2/27/2023, which indicated assessments provided by the nursing staff at Entity #1. Record review of these documents evidenced a decrease in size of the 3 diabetic ulcers on the patient’s left foot. On 2/27/2023, wound 1 measured 3 cm x 4 cm x 0.1 cm, wound 2 measured 0.6 cm x 1 cm x 0.1 cm, wound 3 measured 0.7 cm x 1.1 cm x 0.1 cm. Record review failed to evidence the skilled nurse documented wound care according to agency policy and procedure, to include weekly measurements. During an interview on 3/1/2023, at 10:23 AM, Clinical Manager #2 indicated wounds should be measured by the skilled nurse weekly, using a paper ruler to measure the length and width, and Q-tip to measure depth. 7. Clinical record review on 3/7/2023, for patient #10, start of care 11/15/2022, primary diagnosis of bladder cancer, all nurse's assessments for certification period 11/15/2022 to 12/6/2022, failed to evidence picc line measurements. Record review failed to evidence the skilled nurse performed picc line assessments per agency policy and procedure.