Every finding on record at Rims Health Care Inc

A partial extended survey for Medicare recertification for the home health provider was completed on 02/07/2024. The provider had six current patients. The Emergency Preparedness regulations were reviewed as part of the Medicare recertification survey completed on 02/07/2024. Two standard level deficiencies were identified.

Plan Based on All Hazards Risk Assessment CFR(s): 484.102(a)(1)-(2) §403.748(a)(1)-(2), §416.54(a)(1)-(2), §418.113(a)(1)-(2), §441.184(a)(1)-(2), §460.84(a)(1)-(2), §482.15(a)(1)-(2), §483.73(a)(1)-(2), §483.475(a)(1)-(2), §484.102(a)(1)-(2), §485.68(a)(1)-(2), §485.542(a)(1)-(2), §485.625(a)(1)-(2), §485.727(a)(1)-(2), §485.920(a)(1)-(2), §486.360(a)(1)-(2), §491.12(a)(1)-(2), §494.62(a)(1)-(2) [(a) Emergency Plan. The [facility] must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least every 2 years. The plan must do the following:] (1) Be based on and include a documented, facility-based and community-based risk assessment, utilizing an all-hazards approach.* (2) Include strategies for addressing emergency events identified by the risk assessment. * [For Hospices at §418.113(a):] Emergency Plan. The Hospice must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least every 2 years. The plan must do the following: (1) Be based on and include a documented, facility-based and community-based risk assessment, utilizing an all-hazards approach. (2) Include strategies for addressing emergency events identified by the risk assessment, including the management of the consequences of power failures, natural disasters, and other emergencies that would affect the hospice's ability to provide care. *[For LTC facilities at §483.73(a):] Emergency Plan. The LTC facility must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least annually. The plan must do the following: (1) Be based on and include a documented, facility-based and community-based risk assessment, utilizing an all-hazards approach, including missing residents. (2) Include strategies for addressing emergency events identified by the risk assessment. *[For ICF/IIDs at §483.475(a):] Emergency Plan. The ICF/IID must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least every 2 years. The plan must do the following: (1) Be based on and include a documented, facility-based and community-based risk assessment, utilizing an all-hazards approach, including missing clients. (2) Include strategies for addressing emergency events identified by the risk assessment. This STANDARD is not met as evidenced by: Based on policy review, record review, and interview the home health provider failed to ensure that an updated all hazards risk assessment was part of the emergency preparedness plan. This deficient practice has the potential to affect all patients served by the provider. Findings included: Review of the provider’s undated policy titled, “Emergency Preparedness Program,” showed in part that: - The plan is based on and includes documented facility based and community-based risk assessment utilizing an all-hazards approach and includes strategies for addressing every event identified by the risk assessment; and - The Hazard Vulnerability Analysis tool will be used to evaluate the level of risk and preparedness for a variety of hazard events. Review of the Emergency Preparedness Plan for the provider showed that the all-hazards risk assessment was last updated in 2019. During an interview on 02/06/2024 beginning at 2:00 PM, the administrator stated that the risk assessment was just carried forward year to year.

EP Training Program CFR(s): 484.102(d)(1) §403.748(d)(1), §416.54(d)(1), §418.113(d)(1), §441.184(d)(1), §460.84(d)(1), §482.15(d)(1), §483.73(d)(1), §483.475(d)(1), §484.102(d)(1), §485.68(d)(1), §485.542(d)(1), §485.625(d)(1), §485.727(d)(1), §485.920(d)(1), §486.360(d)(1), §491.12(d)(1). *[For RNCHIs at §403.748, ASCs at §416.54, Hospitals at §482.15, ICF/IIDs at §483.475, HHAs at §484.102, REHs at §485.542, "Organizations" under §485.727, OPOs at §486.360, RHC/FQHCs at §491.12:] (1) Training program. The [facility] must do all of the following: (i) Initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles. (ii) Provide emergency preparedness training at least every 2 years. (iii) Maintain documentation of all emergency preparedness training. (iv) Demonstrate staff knowledge of emergency procedures. (v) If the emergency preparedness policies and procedures are significantly updated, the [facility] must conduct training on the updated policies and procedures. *[For Hospices at §418.113(d):] (1) Training. The hospice must do all of the following: (i) Initial training in emergency preparedness policies and procedures to all new and existing hospice employees, and individuals providing services under arrangement, consistent with their expected roles. (ii) Demonstrate staff knowledge of emergency procedures. (iii) Provide emergency preparedness training at least every 2 years. (iv) Periodically review and rehearse its emergency preparedness plan with hospice employees (including nonemployee staff), with special emphasis placed on carrying out the procedures necessary to protect patients and others. (v) Maintain documentation of all emergency preparedness training. (vi) If the emergency preparedness policies and procedures are significantly updated, the hospice must conduct training on the updated policies and procedures. *[For PRTFs at §441.184(d):] (1) Training program. The PRTF must do all of the following: (i) Initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles. (ii) After initial training, provide emergency preparedness training every 2 years. (iii) Demonstrate staff knowledge of emergency procedures. (iv) Maintain documentation of all emergency preparedness training. (v) If the emergency preparedness policies and procedures are significantly updated, the PRTF must conduct training on the updated policies and procedures. *[For PACE at §460.84(d):] (1) The PACE organization must do all of the following: (i) Initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing on-site services under arrangement, contractors, participants, and volunteers, consistent with their expected roles. (ii) Provide emergency preparedness training at least every 2 years. (iii) Demonstrate staff knowledge of emergency procedures, including informing participants of what to do, where to go, and whom to contact in case of an emergency. (iv) Maintain documentation of all training. (v) If the emergency preparedness policies and procedures are significantly updated, the PACE must conduct training on the updated policies and procedures. *[For LTC Facilities at §483.73(d):] (1) Training Program. The LTC facility must do all of the following: (i) Initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected role. (ii) Provide emergency preparedness training at least annually. (iii) Maintain documentation of all emergency preparedness training. (iv) Demonstrate staff knowledge of emergency procedures. *[For CORFs at §485.68(d):](1) Training. The CORF must do all of the following: (i) Provide initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles. (ii) Provide emergency preparedness training at least every 2 years. (iii) Maintain documentation of the training. (iv) Demonstrate staff knowledge of emergency procedures. All new personnel must be oriented and assigned specific responsibilities regarding the CORF's emergency plan within 2 weeks of their first workday. The training program must include instruction in the location and use of alarm systems and signals and firefighting equipment. (v) If the emergency preparedness policies and procedures are significantly updated, the CORF must conduct training on the updated policies and procedures. *[For CAHs at §485.625(d):] (1) Training program. The CAH must do all of the following: (i) Initial training in emergency preparedness policies and procedures, including prompt reporting and extinguishing of fires, protection, and where necessary, evacuation of patients, personnel, and guests, fire prevention, and cooperation with firefighting and disaster authorities, to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles. (ii) Provide emergency preparedness training at least every 2 years. (iii) Maintain documentation of the training. (iv) Demonstrate staff knowledge of emergency procedures. (v) If the emergency preparedness policies and procedures are significantly updated, the CAH must conduct training on the updated policies and procedures. *[For CMHCs at §485.920(d):] (1) Training. The CMHC must provide initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles, and maintain documentation of the training. The CMHC must demonstrate staff knowledge of emergency procedures. Thereafter, the CMHC must provide emergency preparedness training at least every 2 years. This STANDARD is not met as evidenced by: Based on policy review, employee record review, and interview the home health provider failed to ensure that staff received Emergency Preparedness Training in one of one employee record reviewed (E-1). This deficient practice has the potential to affect all patients served by the provider. Findings included: Review of the provider’s undated policy titled, “Emergency Preparedness Program,” showed in part: - Each employee/contractual/PRN (pro re nata- as needed) staff along with Registered Nurse volunteer will be provided an initial in-service regarding agency emergency preparedness policy; and - In-service will be provided annually to evaluate and update Emergency Preparedness. E-1: Review of the employee file showed that emergency planning was completed on 11/07/2020 and that safety for staff was completed on 11/14/2020. The file failed to show any other emergency preparedness training. During an interview on 02/06/2024 beginning at 2:00 PM, the administrator stated that no emergency preparedness training had been completed since 2020 and that he/she would expect it to be completed every year.

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 policy review, review of the provider’s patient rights information, observation, and interview the home health provider failed to include the correct hours of operation for the state telephone hotline in two of two home visit observations (Records/Patients #1 and #2). This deficient practice has the potential to affect all patients served by the provider. Findings included: Review of the provider’s policy titled, “Patient Rights,” updated 07/13/2018, showed in part that a copy of the patient rights will be part of the provider information admission packet and left in the patient’s home. The patient rights will include the state toll free telephone hotline. Review of the patient admission packet that included the patient rights information provided by the administrator on 02/05/2024, failed to contain the correct hours of operation for the state telephone hotline. The provider’s information showed the hours of operation as 7:00 AM to midnight. (The current hours of operation for the hotline are 7:00 AM to 8:00 PM). RECORD/PATIENT #1: Observation on 02/06/2024, beginning at 10:45 AM, during the patient’s home visit, the patient’s admission packet was reviewed. The hours of operation for the state telephone hotline showed the incorrect hours of 7:00 AM to midnight. RECORD/PATIENT #3: Observation on 02/06/2024, beginning at 11:45 AM, during the patient’s home visit, the patient’s admission packet was reviewed. The hours of operation for the state telephone hotline showed the incorrect hours of 7:00 AM to midnight. During an interview on 02/06/2024, at 2:10 PM, the administrator stated that he/she was not aware the hotline hours had changed.

A review of all current medications CFR(s): 484.55(c)(5) A review of all medications the patient is currently using in order to identify any potential adverse effects and drug reactions, including ineffective drug therapy, significant side effects, significant drug interactions, duplicate drug therapy, and noncompliance with drug therapy. This ELEMENT is not met as evidenced by: Based on policy review, record review, observation, and interview the home health provider failed to maintain an accurate, updated medication profile in two of five full records reviewed (Records/Patients #1 and #3). This deficient practice has the potential to affect all patients served by the provider. Findings included: Review of the provider’s policy titled, “Medication Policy and Review,” revised 07/13/2018, showed in part that the registered nurse (RN) will review all medications that each patient is taking on the initial assessment. The skilled nurse (SN) will check with the patient/family each visit to determine if there were medication changes, reconcile medications as needed, document any changes, and update the medication list in the patient’s clinical chart. RECORD/PATIENT #1: Observation and interview showed on 02/06/2024, beginning at 10:45 AM, during the patient’s home visit, showed the following discrepancies with the provider’s current medication profile: -The medication profile showed an order for furosemide (helps rid the body of fluid) 40 milligrams (mg) daily as needed. The patient stated that he/she had not taken this since before Christmas; -The patient had a bottle dated 02/01/2024 of hydrocodone/APAP (a narcotic pain medication that contains Tylenol) 5-325 mg three times a day. The patient stated that he/she had been on this “forever”. The provider’s medication profile failed to include this medication; The patient had a bottle dated 12/12/2023, of bupropion XL (an anti-depressant also used for smoking cessation) 150 mg daily. The provider’s medication profile failed to include this medication; and -The patient stated that he/she used extra strength Tylenol probably on a weekly basis. The provider’s medication profile failed to include this medication. RECORD/PATIENT #3: Observation and interview showed on 02/06/2024, beginning at 11:45 AM, during the patient’s home visit, the patient’s medications were reviewed. The patient had a bottle dated 10/04/2023, of atorvastin (cholesterol lowering medication) 10 mg daily. The patient stated that he/she had been on this quite a while. The provider’s medication profile failed to include this medication. During an interview on 02/07/2024, beginning at 9:45 AM, the clinical manager stated that the medication profiles were updated as medication changes occurred.

Plan of care must include the following CFR(s): 484.60(a)(2)(i-xvi) The individualized plan of care must include the following: (i) All pertinent diagnoses; (ii) The patient's mental, psychosocial, and cognitive status; (iii) The types of services, supplies, and equipment required; (iv) The frequency and duration of visits to be made; (v) Prognosis; (vi) Rehabilitation potential; (vii) Functional limitations; (viii) Activities permitted; (ix) Nutritional requirements; (x) All medications and treatments; (xi) Safety measures to protect against injury; (xii) A description of the patient's risk for emergency department visits and hospital re-admission, and all necessary interventions to address the underlying risk factors. (xiii) Patient and caregiver education and training to facilitate timely discharge; (xiv) Patient-specific interventions and education; measurable outcomes and goals identified by the HHA and the patient; (xv) Information related to any advanced directives; and (xvi) Any additional items the HHA or physician or allowed practitioner may choose to include. This ELEMENT is not met as evidenced by: Based on policy review, record review and interview the home health provider failed to ensure staff developed an individualized, complete plan of care (POC) in two of five full records reviewed (Records/Patients #1 and #3). This deficient practice has the potential to affect all patients served by the provider. Findings included: Review of the provider’s policy titled, “Care Planning, Coordination, Quality,” revised 07/13/2018, showed in part that the provider will ensure that the patient receives an individualized POC that will include any revisions or additions. RECORD/PATIENT #1: Review of the record showed the patient was admitted to home health services on 06/10/2023. Diagnoses included respiratory failure, lung mass, and Type 2 diabetes mellitus (a group of diseases that results in too much sugar in the blood). Review of the recertification OASIS (outcome assessment and information set; a standardized data collection tool) dated 12/05/2023, showed diagnoses that included congestive heart failure (CHF, a decrease in the ability of the heart to pump blood). Review of the POC dated 12/07/2023, failed to include a diagnosis of CHF. Interventions included weekly weights but failed to include parameters for reporting weights to the physician. During an interview on 02/06/2024, beginning at 2:45 PM, the clinical manager stated that the CHF diagnosis should have been on the POC. He/she thought parameters for reporting weights to the physician would probably be a good idea. RECORD/PATIENT #3: Review of the record showed the patient was admitted to home health services on 12/19/2023. Diagnoses included uninhibited neurogenic bladder (a lack of bladder control due to neurological problems), spinal stenosis (narrowing of one or more spaces in the spinal canal) and muscle weakness. Review of the nursing clinical visit reports showed on 12/27/2023, the nurse set up the patient’s medications in a weekly medication planner. Review of the record failed to show updates to the POC to include filling of a weekly medication planner. During an interview on 02/07/2023, beginning at 9:45 AM, the clinical manager stated that he/she did not fill the patient’s medication planner at first. He/she included medication management on the POC which he/she thought was a “catch all” for whatever needed to be done.

Infection Prevention CFR(s): 484.70(a) Standard: Infection Prevention. The HHA must follow accepted standards of practice, including the use of standard precautions, to prevent the transmission of infections and communicable diseases. This STANDARD is not met as evidenced by: Based on policy review, observation and interview the home health provider failed to ensure staff used acceptable standards of practice for infection control in two of two home visit observations (Records/Patients #1 and #3). This deficient practice has the potential to affect all patients served by the provider. Findings included: Review of the provider’s policy titled, “Infection Control and Prevention,” dated 07/13/2018, showed in part that an alcohol based hand rub is a product that may be used instead of hand washing in certain situations. Clean reusable medical equipment with alcohol based spray or wipes between each patient and when soiled. RECORD/PATIENT #1: Observation showed on 02/06/2024, beginning at 10:45 AM, during the patient’s home visit, the patient used his/her supplies to check his/her blood pressure and oxygen level. The nurse used his/her stethoscope to assess the patient’s lung sounds. The nurse failed to clean his/her stethoscope before placing it back in his/her supply bag. RECORD/PATIENT #3: Observation showed on 02/06/2024, beginning at 11:45 AM, during the patient's home visit, showed the nurse checked the patient’s oxygen level with a pulse oximeter (measures the amount of oxygen in the blood) then placed it into a pouch without cleaning. The nurse then checked the patient’s temperature with a temporal (held close to the forehead) thermometer then placed it into the pouch with the pulse oximeter. The nurse checked the patient’s blood pressure and lung sounds. The nurse failed to clean the blood pressure cuff and stethoscope before placing it in his/her bag. The nurse applied gloves then touched the patient’s skin to assess his/her suprapubic catheter (a tube inserted into the abdomen to the bladder to drain urine) insertion site. The nurse removed his/her gloves, but failed to use hand sanitizer before applying new gloves. During an interview on 02/06/2024, at 12:35 PM, the nurse stated that he/she forgot to clean his/her equipment before placing it in his/her bag. He/she had wipes in his/her bag to use for cleaning equipment. During an interview on 02/07/2024, beginning at 9:45 AM, the nurse stated that he/she usually used hand sanitizer after removing gloves.

Infection control education CFR(s): 484.70(c) Standard: Education. The HHA must provide infection control education to staff, patients, and caregiver(s). This STANDARD is not met as evidenced by: Based on policy review, employee record review, and interview the home health provider failed to ensure that staff received infection control training in one of one employee record reviewed (E-1). This deficient practice has the potential to affect all patients served by the provider. Findings included: Review of the provider's policies showed the provider failed to have a policy regarding infection control training. E-1: Review of the employee file showed that infection control training was completed on 11/07/2020. The file failed to show any other infection control training. During an interview on 02/06/2024 beginning at 2:00 PM, the administrator stated that no infection control training had been completed since 2020 and that he/she would expect it to be completed every year.

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 policy review, record review, and interview the home health provider failed to ensure staff followed the physician ordered plan of care (POC) when staff failed to consistently document weekly weights in one of five full records reviewed (Record/Patient #1). This deficient practice has the potential to affect all patients served by the provider. Findings included: Review of the provider’s policy titled, “Conformance with Physician Orders,” updated 07/13/2018, showed in part that verbal orders are put in writing by the registered nurse (RN) or qualified therapist responsible for furnishing or supervising the ordered services. RECORD/PATIENT #1: Review of the record showed the patient was admitted to home health on 06/10/2023. Diagnoses included respiratory failure, lung mass, and Type 2 diabetes mellitus (a group of diseases that results in too much sugar in the blood). Review of the recertification POC dated 12/07/2023, included an order for weekly weights. Review of the clinical nursing visit reports showed the clinical manager failed to document the patient’s weight on 12/12/2023, 12/26/2023, 01/09/2024, 01/30/2024, and 02/01/2024. During an interview on 02/06/2024, beginning at 2:40 PM, the clinical manager stated that the weights should be documented. He/she probably forgot to document the weights.

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 nationally-recognized standards, policy review, employee record review, and interview the home health provider failed to ensure that staff received Alzheimer’s and Dementia training in one of one employee record reviewed (E-1). This deficient practice has the potential to affect all patients served by the provider. Findings included: Review of 19 CSR 30-26.010 (1) (B) required: "Licensed home health agencies shall provide dementia-specific training about Alzheimer's disease and related dementias to their employees and those persons working as independent contractors who provide direct care to or may have daily contact with residents, patients, clients or consumers with Alzheimer's disease or related dementias. 1. The training for persons providing direct care shall address the following areas, at a minimum: (A) An overview of Alzheimer's disease and related dementias; (B) Communicating with persons with dementia; (C) Behavior management; (D) Promoting independence in activities of daily living; and (E) Understanding and dealing with family issues. 2. Employees or independent contractors who do not provide direct care for, but may have daily contact with, persons with Alzheimer's disease or related dementias shall receive dementia-specific training that includes, at a minimum: (A) An overview of Alzheimer's disease and related dementias; and (B) Communicating with persons with dementia. 3. Dementia-specific training about Alzheimer's disease and related dementias shall be incorporated into orientation for new employees with direct patient contact and independent contractors with direct patient contact. The training shall be presented by an instructor who is qualified by education, experience, and knowledge in the current standards of practice regarding individuals with Alzheimer's disease and other related dementias. The training shall be provided annually and updated as needed. " Review of the provider’s policy titled, “Dementia/Alzheimer’s Disease Training Policy,” dated 05/09/2002, showed in part that the provider will incorporate training into new employee orientation and on-going in-service curricula for all employees involved in the care of persons with dementia. E-1: Review of the employee file showed that Alzheimer’s and Dementia training was completed on 11/14/2020. The file failed to show any other Alzheimer’s or Dementia training. During an interview on 02/06/2024 beginning at 2:00 PM, the administrator stated that no Alzheimer’s or Dementia training had been completed since 2020 and that he/she would expect it to be completed every year.

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 ensure that transfer summaries were completed in two of two transfer records reviewed (Records/Patients #4 and #5). This deficient practice has the potential to affect all patients served by the provider. Findings included: Review of the provider’s undated policy titled, “Implementation and Compliance with Oasis (Outcome and Assessment Information Set; a standardized data collection tool),” showed in part, an assessment to be completed if patient has been admitted to an inpatient facility for a 24-hour admission or longer stay within two days of acknowledgement. Review of the provider’s policy titled, “Discharge Planning, Discharge and Transfer of Patient from the Agency,” dated 11/29/2019, showed in part, the agency will send all necessary medical information pertaining to the patient’s current course of illness and treatment, post discharge goals of care, any treatment preferences, to the receiving facility or health care practitioner to ensure the safe and effective transition of care. RECORD/PATIENT #4: Review of the clinical record showed the patient was admitted to home health services on 10/19/2023 with a primary diagnosis of Hypertensive Kidney Disease (a medical condition that refers to the damage done to the kidneys due to chronic high blood pressure). Review of a Completion of Care, Oasis Data Sets, and Discharge/Transfer Summary showed the following: - The assessment was completed on 12/28/2023; - The patient was discharged to an inpatient facility and was not discharged from the provider; - The date of discharge to the inpatient facility was 12/27/2023; and - The section marked Discharge/Transfer Summary was blank. Review of a clinical visit report, dated 01/09/2024, and completed by the registered nurse (RN) showed in part, the patient was hospitalized from 12/27/2023 to 01/01/2024. The provider failed to complete a transfer summary and failed to forward information regarding the patient to the inpatient facility. RECORD/PATIENT #5: Review of the clinical record showed the patient was admitted to home health services on 12/13/2023 with a primary diagnosis of Alzheimer’s Disease (a disease marked by progressive loss of mental capacity). Review of a Completion of Care, Oasis Data Sets, and Discharge/Transfer Summary showed the following: - The assessment was completed on 01/31/2024; - The patient was discharged to an inpatient facility and was not discharged from the provider; - The date of discharge to the inpatient facility was 01/30/2024; and - The section marked Discharge/Transfer Summary was blank. As of the date of exit on 02/07/2024, the patient remained in the inpatient facility. The provider failed to complete a transfer summary and failed to forward information regarding the patient to the inpatient facility. During an interview on 02/07/2024 beginning at 10:00 AM, the clinical manager stated that a discharge summary was not completed because he/she misinterpreted how the assessment read and did not realize that the discharge/summary part of the assessment needed to be completed.

Authentication CFR(s): 484.110(b) Standard: Authentication. All entries must be legible, clear, complete, and appropriately authenticated, dated, and timed. Authentication must include a signature and a title (occupation), or a secured computer entry by a unique identifier, of a primary author who has reviewed and approved the entry. This STANDARD is not met as evidenced by: Based on policy review, record review, and interview the home health provider failed to ensure the clinical notes were entered into the patient’s record in a timely manner in one of five full records reviewed (Record/Patient #1). This deficient practice has the potential to affect all patients served by the provider. Findings included: Review of the provider’s policy titled, “Clinical Notes,” revised 06/21/00, showed in part that the clinical notes are to be in the patient’s chart within five to seven days of the visit. RECORD/PATIENT #1: Review of the clinical record on 02/05/2024, showed the clinical record failed to include the plan of care (POC) for the dates of 12/07/2023 to 02/05/2024, and failed to include clinical visit notes since 01/17/2024. During an interview on 02/05/2024, at 2:45 PM, the administrator stated that the clinical manager had the POC and notes and would bring them the following morning. During an interview on 02/05/2024, at 3:05 PM, the administrator stated that the notes were late. He/she thought he/she would expect the notes to be in the patient’s record within a week. During an interview on 02/06/2024, beginning at 2:40 PM, the clinical manager stated that he/she thought the documentation should be in within seven to ten days.

The Emergency Preparedness regulations were reviewed as part of the Medicare certification survey completed on 08/04/2021. During the survey it was determined RIMS Health Care is in compliance with the requirements of 42 CFR 484.102 Condition of Participation: Emergency Preparedness for Home Health Agencies.

A partial extended standard survey for Medicare certification for RIMS Health Care was completed on 08/04/2021. The agency had 7 current patients. Three home visits were completed and a total of six clinical records reviewed. A COVID 19 focused infection control survey was completed in conjunction with the survey and one deficiency was identified related to the focused infection control survey.

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, home visit observation, clinical record review, and interview, the agency failed to ensure an accurate medication review and/or update of the patient's medications was completed in two (Record/Patient #1 and #3) three home visit observations performed. This deficient practice has the potential to affect all patients served by the agency. Findings included: Review of the agency's policy revised 07/13/2018 titled "Medication Policy and Review" showed: - The registered nurse (RN) will review all medications that the patient is taking on the initial assessment to determine the patient's current medications to identify any potential side effects, significant drug interactions including ineffective drug therapy, and non-compliance with drug therapy; - The skilled nurse will check with the patient/family each visit to determine if there are medication changes, reconcile medications as needed, document any changes, inform and/or verify with referring physician and/or physician that added or changed the medication/s, leave a medication sheet in the patient's home, review and instruct patient/representative as needed, and document changes with signature/initials, update the medication list in the clinical record; - Medications will be reviewed by the RN or RN supervisor with all assessments to include resumption of care, recertification, discharge/transfer and/or significant change in condition assessments; - All assessments shall be signed and dated by the RN to verify review of the medications; - Upon satisfactory review, the patient's medication sheet will also be signed and dated by the RN documenting any changes in medications and its effects have been communicated to all disciplines involved in the patient's care; - In the event of new medications found in the patient's home or interim orders for new medications by the RN, this information will be documented on the appropriate clinical form for that date; and - The RN and/or RN supervisor will update the medication sheet by documenting new medication/s, sign and date. RECORD/PATIENT #1: Review of the referral medication list dated for 07/21/2021 showed the following: - Prednisone (corticosteroid) 5 mg one or two tablets every day; - Ventolin HFA (used to prevent and treat wheezing and shortness of breath) 90 mcg (microgram) four puffs every four to six hours as needed; - Novolog U-100 (rapid acting insulin) inject 20 units subcutaneously (injection) three times every day "before breakfast and dinner"; and - Novolog 70/30 (premixed insulin that helps control blood sugar) inject 45 units subcutaneously every twelve hours per insulin protocol. During the patient's home visit observation on 08/02/2021 beginning at 4:30 PM, review of the medications showed the following discrepancies with the agency's current medication profile: -The medication profile showed an order for atorvastatin (lowers bad cholesterol and raises good cholesterol in the blood) 40 mg (milligrams) one tablet at hour of sleep and the patient's medication list showed atorvastatin 40 mg two tablets at hour of sleep; -The medication profile showed an order for torsemide (diuretic) 20 mg two tablets every day. The patient stated he/she took one tablet once a day; - The medication profile showed Ventolin HFA 90 mcg one to two puffs every four to six hours. The patient said he/she only used the Ventolin as a rescue inhaler (inhaler that dispenses medication to relieve or stop the symptoms of an asthma attack); - The medication profile showed prednisone 10 mg one tablet every day. The patient stated he/she took 5 mg every day; - The home medication list showed carvedilol (used to treat high blood pressure and heart failure) 3.125 mg twice a day. The medication profile did not list carvedilol; - The medication profile showed Novolog 10 units after meals subcutaneously (injection). The patient said he/she took the insulin before meals according to a sliding scale (the increasing administration of the pre-meal insulin dose based on the blood sugar level before the meal) and he/she never used more than 10 units; and - The medication profile showed Novolog 70/30, 30 units twice a day subcutaneously. The patient stated he/she took 20 units twice a day. During an interview with the director of nursing (DON) on 08/03/2021 at 9:34 AM, the DON stated the following: - The patient did not have a sliding scale for insulin and he/she did not know where the patient got this; the patient had a sliding scale a long time ago; - When he/she reconciles medications he/she takes the medication sheet from admission and circles discrepancies, notifies the physician and attaches to a telephone order with correct medications, and he/she did not have telephone orders for this patient; - If a patient says he/she is taking different medications that is different from the POC, he/she writes the medication down and notifies the physician; - He/she reconciles the patient's medications once a week or when there are changes; - The medication list is generated from what is in the home; - He/she did not reconcile medications from the patient's referral. No further information was provided. RECORD/PATIENT #3: Review of recertification plan of care (POC) dated 07/24/2021 through 09/22/2021 showed: - Lantus (a long acting insulin to control blood glucose (sugar) levels) insulin, 13 units od (daily) in the PM; and - Lacosamide (used to control partial onset seizures (seizures that involve only one part of the brain) in adults) 200 milligrams (mg) one tablet two times (BID) daily per gastrostomy tube (g-tube) and staff put a line through this medications with no explanation or signature. Review of the current medication profile sheet last dated 07/23/2021 showed: - Lantus insulin 16 units daily in the PM, with order date of 12/28/2020; - Morphine sulfate (a narcotic for pain) 0.025 milliliters (ml) 100 mg/5 ml every four hours as needed (PRN); and - Lacosamide 200 mg, one tablet BID per the g-tube. During a home visit observation and interview on 08/03/2021 at 10:30 AM, the care giver stated: - The Lantus insulin dose was 16 units every PM now and no date was given for the change in the dosage; - Morphine sulfate was discontinued after the patient was discharged from hospice and admitted to the care of the home health agency; and - Lacosamide 200 mg was given three times daily (TID) now and was changed two to three weeks ago to TID. During an interview on 08/03/2021 at 2:20 PM, the director of nursing said: - The morphine sulfate was discontinued after hospice was discharged and the patient was admitted to the agency; - There no order found for the change in dose of the Lantus insulin; and - She did not know the dose had changed for the Lacosamide.

Plan of care CFR(s): 484.60(a)(1) Each patient must receive the home health services that are written in an individualized plan of care that identifies patient-specific measurable outcomes and goals, and which is established, periodically reviewed, and signed by a doctor of medicine, osteopathy, or podiatry acting within the scope of his or her state license, certification, or registration. If a physician or allowed practitioner refers a patient under a plan of care that cannot be completed until after an evaluation visit, the physician or allowed practitioner is consulted to approve additions or modifications to the original plan. This STANDARD is not met as evidenced by: Based on policy review, clinical record review, and interview, the agency failed to provide each patient with a written individualized plan of care (POC) that was established by the physician in, but not limited to, three (Records/Patients #1, #2, and #3) of the seven current agency patients, when the agency skilled nurse (SN) failed to contact the physician for POC orders. This systemic deficient practice has the potential to impact the safe delivery of care for all agency patients. Findings included: Review of the agency's undated policy titled, "Nursing Care Plan Form," showed in part, nursing care plans are to be written on every patient at the beginning of the case and updated with each assessment utilizing the nursing assessment and the physician's plan of treatment. Review of the agency's policy titled, "Conformance with Physician's Orders" dated 07/13/2018, showed in part, the agency will comply with physician orders and documentation will be included in the patient's clinical record. RECORD/PATIENT #1: Review of the referral dated 07/21/2021 showed skilled nursing (SN) to evaluate and treat. Review of the clinical record showed a start of care assessment dated 07/23/2021. The clinical record failed to include documentation that the SN communicated with the patient's physician for assessment findings and approved orders, discipline and frequency. Review of the POC dated 07/23/2021 through 09/21/2021 showed, in part, the following: - Diagnoses included diabetic ulcers to left and right feet, type 2 diabetes mellitus (a disease that occurs when your blood sugar is too high) with neurological (problems affecting the nervous system) complications, end stage renal disease, and heart failure; - SN three times a week for eight weeks for skilled observation and assessment of ulcers; - Clean ulcers with warm water and mild soap, gently pat dry, apply gentamicin (antibiotic) 1% cream to ulcers, cover with dry sterile dressing and kling wrap (elastic wrap), and secure with skin friendly tape; - Assess renal status for proper placement of intravenous access for dialysis (a substitute for the normal function of the kidney) to right upper chest and tubing to "left abdominal area" for peritoneal access (a flexible, hollow tube surgically placed in the lower abdomen); and - On 08/02/2021 the administrator provided a physician signed POC dated 08/02/2021 (10 days after the start of care). During an interview on 08/03/2021 at 2:21 PM, the director of nursing (DON) said he/she called the physician for wound care orders but did not document the orders. The physician did not have time to give orders and would mail the information. There are no physician orders until the plan of care is signed by the physician and returned to the agency. RECORD/PATIENT#2: Review of the referral dated 07/07/2021 showed skilled nursing (SN) and physical therapy (PT) to evaluate and treat. Review of the clinical record showed a start of care assessment dated 07/07/2021. The clinical record failed to include documentation that the SN or PT communicated with the patient's physician for assessment findings and approved orders, discipline and frequency. Review of the POC dated 07/07/2021 - 09/05/2021 showed, in part, the following: - Diagnosis included osteoarthritis (a type of arthritis that occurs when flexible tissue at the ends of bones wears down), hypertensive kidney disease (high blood pressure caused by the narrowing of the arteries that carry blood to the kidneys), hypertension (high blood pressure) and gait disturbance (deviation from normal walking); - SN one time a week for four weeks for skilled observation and assessment of CVCP (heart and lung) status, renal status for blood pressures, chest pain, dizziness, shortness of breath, breathing pattern, oxygen levels, fatigue, tolerance and endurance for ADL's (activities of daily living), change in urination, color changes, skin integrity, compliance with low salt diet, level of pain and pain management; - Provide education regarding disease management, pain management, infection control, safety measures and emergency planning; - Report warranted changes to doctor; - PT one time a week for one week, one to two times a week for five weeks for Evaluation; - Therapeutic procedures; - Neuromuscular reeducation (a technique used by physical therapists to restore normal body movement patterns), gait training (a type of physical therapy to help improve your ability to stand and walk); and - Therapeutic activities. On 08/04/2021 the DON (director of nursing) was unable to provide a signed copy of the POC dated 07/07/2021-09/05/2021 (28 days after the start of care). RECORD/PATIENT #3: Review of the referral dated 09/25/2020 showed: - Skilled nursing (SN) and physical therapy (PT) evaluate and treat; and - Diagnoses: HTN (high blood pressure), DM (diabetes mellitus. abnormal blood glucose/sugar levels), COPD (chronic obstructive pulmonary disease, asthma, emphysema) and bed bound. Review of the clinical record showed a start of care (SOC) assessment dated 09/27/2020. The clinical record failed to include documentation that the SN communicated with the patient's physician with assessment findings in order to obtain approved orders, disciplines to treat, and frequency of visits for a complete and individualized POC. Review of the POC dated 09/27/2020 through 11/25/2020 showed, in part, the following: - Diagnoses included but not limited to: Infected sacral (tailbone) wound, respiratory failure, quadriplegia (paralysis of all four extremities), anoxic (lack of oxygen) brain injury, and atrial fibrillation (irregular, rapid heartbeat); - SN three times a week for eight weeks for skilled observation and assessment of cardiac/respiratory status for breathing integrity of tracheostomy (an opening created at the front of the neck so a tube can be inserted into the windpipe (trachea) to help you breathe. If necessary, the tube can be connected to an oxygen supply and a breathing machine called a ventilator), evidence of cardiac dysfunction, signs and symptoms (s/s) of seizure activity, proper function and use of equipment, level of pain, skin integrity, s/s of hypoglycemia (low blood glucose levels)/hyperglycemia (elevated blood glucose levels), complications of diabetes, medication management, and safety measures. Assess wound/ulcer for s/s of infection, amount/quality of drainage, color and temperature changes and proper function of NPWT (negative pressure wound therapy, also called vacuum-assisted wound closure, and refers to wound dressing systems that continuously or intermittently apply sub atmospheric pressure to the system, which provides a positive pressure to the surface of a wound for wound healing). Clean wound/ulcer with wound cleaner, pat dry, use whit crystal foam to wound tunneling, black foam to wound ulcer, cover with clear plastic covering, check for secure seal, connect to suctions tubing, check pressure at 12 milligrams (mg)/ hg (mercury) (a unit of measurement) on vacuum pump and change canister each visit. Provide instruction for infection control, safety measures, skin integrity, wound care and use of NPWT, s/s of seizures, s/s of respiratory distress, s/s of cardiac dysfunction, emergency planning, and s/s of wound infections. Report warranted changes to doctor. - PT one time per week for eight weeks for evaluation, therapeutic exercises, establish home program, stretching/flexibility, safety training, patient/caregiver education, patient/caregiver involved in development of goals and in agreement with the POC. The administrator provided a physician signed POC dated 10/27/2020, 30 days after the start of care. During an interview on 08/03/2021 at 2:21 PM, the DON stated he/she called the podiatrist on 07/21/2021 prior to the assessment for wound care orders and there was no telephone order written. During an interview on 08/04/2021 at 10:15 AM, the DON stated that: - No orders received prior to development of the POC for any patient; - Physicians are notified with the POC which is developed after assessment of patients.

Plan of care must include the following CFR(s): 484.60(a)(2)(i-xvi) The individualized plan of care must include the following: (i) All pertinent diagnoses; (ii) The patient's mental, psychosocial, and cognitive status; (iii) The types of services, supplies, and equipment required; (iv) The frequency and duration of visits to be made; (v) Prognosis; (vi) Rehabilitation potential; (vii) Functional limitations; (viii) Activities permitted; (ix) Nutritional requirements; (x) All medications and treatments; (xi) Safety measures to protect against injury; (xii) A description of the patient's risk for emergency department visits and hospital re-admission, and all necessary interventions to address the underlying risk factors. (xiii) Patient and caregiver education and training to facilitate timely discharge; (xiv) Patient-specific interventions and education; measurable outcomes and goals identified by the HHA and the patient; (xv) Information related to any advanced directives; and (xvi) Any additional items the HHA or physician or allowed practitioner may choose to include. This ELEMENT is not met as evidenced by: Based on policy review, clinical record review, observation, and interview, the agency failed to ensure that each patient's written individualized plan of care (POC) included all required elements in three (Record/Patient #1, #3, and #4) of five full records reviewed. This deficient practice has the potential to affect all patients served by the agency. Findings included: Review of the agency's policy dated 07/13/2018 titled "Care Planning, Coordination, and Quality" showed: - The agency will at the start of care (SOC), have the agency staff complete all items of the OASIS (mandated assessment tool) to determine that the patient received an individualize written plan of care that will include revisions or additions; - The OASIS will be used as a tool to determine the patient specific needs including identification of the responsible discipline and measurable outcomes; and - Coordination of services/care will be documented in writing of any changes shared with the home health team/medical team/family/caregivers and others that may be involved. Review of the agency's undated policy titled "Nursing Care Plan Form" showed: - Policy: Nursing care plans are to be written on every patient at the beginning of the case and updated with each assessment or as indicated; - The POC is use to provide effective, goal directed intervention; - Recognized problems should be stated in order of importance; - Actions to resolve the problem which are predicated upon nursing knowledge, physician's plan of treatment, and input of related health disciplines are then listed; and - POC to be updated as necessary. RECORD/PATIENT #1: Review of the POC dated 07/23/2021 through 09/21/2021 showed, in part, the following: - Diagnosis included diabetic ulcers to left and fight feet, type 2 diabetes mellitus (a disease that occurs when your blood sugar is too high) with neurological (problems affecting the nervous system) complications, end stage renal disease, and heart failure; - Treatments included but not limited to: Clean ulcers with warm water and mild soap, gently pat dry, apply gentamicin (antibiotic) 1% cream to ulcers, cover with dry sterile dressing using "2 X 4s", kling wrap (elastic wrap); - Assess signs and symptoms of hyperglycemia (high blood glucose levels) and hypoglycemia (low blood glucose levels); and - The POC did not include the type and location of the ulcers and parameters for blood glucose levels. RECORD/PATIENT #3: Review of the POC dated 07/24/2021 through 09/22/2021 showed: - Diagnoses include but not limited to: Brain injury, respiratory failure, seizure disorder and hypertension (high blood pressure); - The POC did not include diabetes mellitus (abnormally high blood glucose/sugar levels); - The POC showed Lantus insulin (a long acting insulin) 13 units every day in the PM; - The POC showed the patient takes three or more medications including insulin; - Treatments included but not limited to: Assessment of the cardiovascular (related to the heart and blood vessels) and cardiopulmonary (related to the heart and lungs) status, and signs and symptoms of hyperglycemia and hypoglycemia - The POC did not include parameters for blood glucose levels, vital signs to include blood pressure, pulse, respirations, O2 saturation levels (the amount of oxygen in the blood stream) and when to notify the physician of abnormal results; and - The POC did not include how to administer medications via the PEG tube which included crushing of medications, amount of water to mix with medications, when to flush the PEG tube and how much water to flush the PEG tube before and after medication administration and nutrition administration, did not include the amount of nutrition to be administered via the PEG tube, or rate of flow for administration. Review of the POC dated 09/27/2020 through 11/25/2020 showed: - Diagnoses included but not limited to: Respiratory failure, quadriplegia (paralysis of all extremities), anoxic brain injury (lack of oxygen to the brain causing diminished brain function. If the oxygen deprivation continues, anoxic brain injuries may even become fatal), and atrial fibrillation (rapid, irregular heart rate); - Diagnoses did not include diabetes mellitus (abnormally high blood glucose/sugar levels); - The POC showed Lantus insulin 10 units everyday; - Durable medical equipment included but not limited to: Tracheostomy (an opening created at the front of the neck so a tube can be inserted into the windpipe (trachea) to help a patient to breathe), tracheostomy tube, and PEG (percutaneous endoscopic gastrostomy, a tube surgically placed into the stomach through which nourishment is administered when a patient cannot take food/fluids by mouth); - Treatments included but not limited to: Assessment of cardiac and respiratory status for breathing integrity with the tracheostomy, evidence of cardiac dysfunction, signs and symptoms of hyperglycemia (high blood glucose levels) and hypoglycemia (low blood glucose levels); - The POC did not include parameters for blood glucose levels, vital signs to include blood pressure, pulse, respirations, O2 saturation levels (the amount of oxygen in the blood stream) and when to notify the physician of abnormal results; and - Did not include how to administer medications via the PEG tube which included crushing of medications, amount of water to mix with medications, when to flush the PEG tube and how much water to flush the PEG tube before and after medication administration and nutrition administration, did not include the complete amount of nutrition to be administered via the PEG tube, or complete rate of flow for administration, and did not include suction equipment. RECORD/PATIENT #4: Review of the POC dated 06/25/2021 through 08/23/2021 showed: - Diagnoses included but not limited to: Heart failure and diabetes mellitus; - The POC did not include parameters for vital signs, O2 saturation levels or blood glucose levels and when to notify the physician of abnormal results; and - Treatments included but not limited to: assess cardiopulmonary status, signs and symptoms of hyperglycemia and hypoglycemia. On 08/04/2021 at 10:15 AM, the findings were reviewed with the agency director of nursing and no additional information was provided.

Only as ordered by a physician CFR(s): 484.60(b)(1) Drugs, services, and treatments are administered only as ordered by a physician or allowed practitioner. This ELEMENT is not met as evidenced by: Based on policy review, clinical record review, observation, and interview, the agency failed to provide drugs, services and treatments only as ordered by a physician in, but not limited to, two (Record/Patients #2 and #5) out of five full records reviewed. This deficient practice has the potential to adversely affect the care and services provided to all the agency's patients. Findings included: Review of the agency's policy titled, "Conformance with Physician Orders" dated 07/13/2018 showed in part: - Policy: The agency will comply with physician orders and documentation will be included in the patient's clinical record; and - Procedures: Drugs and treatments are administered by the professional staff only as ordered by the physician. Review of the agency's policy titled, "Admission Procedure" dated 06/21/00 showed in part, once a referral for home health care is received, the patient's admission to the agency is based on the need that exists for skilled nursing care or one of the therapies (speech, occupational, physical). RECORD/PATIENT #2: Review of the plan of care (POC) dated 07/07/2021 through 09/05/2021 showed, in part, the following: - Physical Therapy (PT) one time a week for one week, one to two times a week for five weeks for evaluation; - Therapeutic procedures; - Neuromuscular reeducation - Gait training (a type of physical therapy to help improve your ability to stand and walk); and - Therapeutic activities. Review of the Physical therapy notes failed to show an evaluation completed until 07/22/2021. During a home visit observation on 08/03/2021 starting at 10:15 AM, PT A was observed applying dry heat to the patient's knees. Review of the POC dated 07/07/2021 - 09/05/2021 failed to show orders for application of dry heat. During an interview with the administrator on 08/03/2021 at 1:30 PM he/she stated skilled nursing needed to perform an initial visit within 48 hours after receipt of the referral to home health services. If the initial visit was delayed, it would be documented on POC. No further information was provided. During an interview on 08/04/2021 at 10:10 AM with the DON, he/she stated that there should be an order from the physician for application of dry heat; it is a modality. RECORD/PATIENT #5: Review of the agency's Intake Form dated 02/04/2021 showed orders for skilled nursing and physical therapy to evaluate and treat. Review of the medical record failed to show a physical therapy evaluation. During an interview on 08/04/2021 at 9:34 AM and 10:05 AM the DON stated: - A physical therapy evaluation was not done and there was no communication with the physician; - The referral cannot be accepted as an order so they did not have to do a physical therapy evaluation; and - The referral is not an order and is not signed by a physician and there should not be a deficiency.

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 review of the agency's current patient rights information, home visit observation, clinical record review, and interview, the agency failed to ensure each patient received written information related to visit schedule/instructions, in three (Record #1, #2, and #3) of three applicable home visits. This deficient practice has the potential to affect all patients served by the agency. Findings included: Review of the agency's policy titled "Admission Policy" dated 06/21/00, did not show that a written visit schedule which included what discipline was visiting and the frequency of the visits would be left in the home for the patient. RECORD/PATIENT #1: Review of the plan of care (POC) dated 07/23/2021 through 09/12/2021 showed skilled nursing three times a week for eight weeks. The home visit observation on 08/02/2021 at 4:30 PM showed the admission packet and information provided to patients included a schedule for recording of discipline visits. The schedule was blank and failed to include any scheduled discipline visits. The skilled nurse verbally let the patient know the next skilled nursing visit was 08/06/2021. Per interview with the skilled nurse he/she stated if the patient had a set schedule he/she would fill out the calendar but the patient was very busy with other medical appointments. Surveyor: Neely, Terri RECORD/PATIENT #2: Review of the clinical record showed the patient was admitted to home health services on 07/07/2021 with osteoarthritis (degenerative joint disease). The agency was to provide physical therapy including therapeutic exercise, gait training (physical therapy training to improve your ability to walk) and neuromuscular reeducation (a physical therapy technique used to restore normal body movement patterns). Review of the POC dated 07/07/2021 through 09/05/2021, showed that the physician ordered physical therapy (PT) one time a week for one week, then one to two times a week for five weeks. During a home visit observation on 08/03/2021 starting at 10:15 AM, the home folder was reviewed and the agency failed to provide a written schedule of visits for the physical therapist. During an interview with PT A on 08/03/2021 during the home visit that started at 10:15 AM, he/she stated that the patient knew the schedule. PT A did not leave a schedule because Tuesdays and Thursdays were the days he/she made visits to the patient; so he/she did not leave a schedule. RECORD/PATIENT #3: Review of the patient's admission folder during a home visit on 08/03/2021 at 10:30 AM showed: - The agency notice of patient rights and other information given to the patient/caregiver during the initial visit contained the right to be informed of the types of disciplines which will be provided and the frequency of the visits that are proposed; and - A blank copy of the calendar to be used to record discipline visits for the patient/caregiver. Review of the clinical record showed skilled nurse 2 - 3 visits per week for 8 weeks and 1 - 2 PRN (as needed) visits. During the home visit on 08/03/2021 at 10:30 AM, the caregiver stated that he/she knew when the nurse was to come; it was always Monday, Wednesday, and Friday. During an interview on 08/03/2021 at 10:30 AM, the director of nursing stated that he/she communicated with the caregiver by text or phone call for times of a visit but the caregiver knew he/she always came on Monday, Wednesday, and Friday.

Patient medication schedule/instructions CFR(s): 484.60(e)(2) Patient medication schedule/instructions, including: medication name, dosage and frequency and which medications will be administered by HHA personnel and personnel acting on behalf of the HHA. This ELEMENT is not met as evidenced by: Based on home visit observation and interview, the agency failed to provide the patient/caregiver with an updated/current copy of written instructions outlining the patient's medication schedule, including medication name, dosage, and frequency in two (Record/Patient #1 and #3) of three home visit observations. This deficient practice has the potential to affect all patients served by the agency. Findings included: RECORD/PATIENT #1 During a home visit observation on 08/02/2021 at 4:30 PM with the director of nursing, the surveyor observed the patient's home folder. The agency failed to provide updated/current instructions outlining the patient's medication schedule/instruction, including the medication's name, dosage, and frequency. RECORD/PATIENT #3: During a home visit observation on 08/03/2021 at 10:30 AM with the director of nursing, the surveyor observed the patient's home folder. The agency failed to provide updated/current instructions outlining the patient's medication schedule/instruction, including the medication's name, dosage, and frequency. On 08/04/2021 at 10:15 AM, the above findings were reviewed with the director of nursing who acknowledged the above findings. No additional documentation could be provided.

Treatments and therapy services CFR(s): 484.60(e)(3) Any treatments to be administered by HHA personnel and personnel acting on behalf of the HHA, including therapy services. This ELEMENT is not met as evidenced by: Based on policy review, 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 in, but not limited to, two (Record/Patient #1 and #2) of three home visit observations. This deficient practice has the potential to adversely affect the patient's knowledge of self-care and agency expectations in all patients served by the agency. Findings included: Review of the policy "Patient Rights" dated 07/13/2018 showed in part: The patient rights will include treatment or care. RECORD/PATIENT #1 Review of the plan of care (POC) dated 07/23/2021 through 09/21/2021 showed, in part, the following: - SN three times a week for eight weeks for skilled observation and assessment of ulcers; - Clean ulcers with warm water and mild soap, gently pat dry, apply gentamicin (antibiotic) 1% cream to ulcers, cover with dry sterile dressing and kling wrap (elastic wrap), and secure with skin friendly tape; and - Educate and train patient regarding ulcer care, signs/symptoms to report, potential complications, disease process, diet, healing process, and safety measures. During a home observation visit on 08/02/2021 starting at 4:30 PM with the director of nursing, the surveyor observed the patient's home admission packet. The agency failed to provide written therapy instructions to the patient in the home. RECORD/PATIENT #2 Review of the plan of care (POC) dated 07/07/2021 through 09/05/2021 showed, in part, the following: - Physical therapy (PT) one time a week for one week, one to two times a week for five weeks for evaluation; - Therapeutic procedures; - Neuromuscular reeducation (a technique used by physical therapists to restore normal body movement patterns); - Gait training (a type of PT to help improve your ability to stand and walk); and - Therapeutic activities. During a home observation visit on 08/03/2021 starting at 10:15 AM with PT A, the surveyor observed the patient's home admission packet. The agency failed to provide written therapy instructions to the patient in the home. Per interview with PT A, he/she stated that written instructions were not included in the folder because the program had not changed. It had remained much the same; and at discharge he/she reviewed it verbally with the patient.

Infection Prevention CFR(s): 484.70(a) Standard: Infection Prevention. The HHA must follow accepted standards of practice, including the use of standard precautions, to prevent the transmission of infections and communicable diseases. This STANDARD is not met as evidenced by: Based on policy review, record review, observation, and interview, the agency failed to ensure staff followed infection control standards of practice in one (Record/Patient #1) of three home visit observations. This deficient practice has the potential to affect the health and safety of all patients served by the agency. Findings included: Review of the agency's policy titled, "Infection Control and Prevention" dated 07/13/18 showed, in part, hand washing is the most important method of preventing the spread of infection. For hand washing to be effective in the spread of infection, it must be performed thoroughly, properly, and consistently. An alcohol-based hand rub is a product that may be used instead of hand washing to clean hands in certain situations. RECORD/PATIENT #1: Review of the plan of care dated 07/23/2021 through 09/21/2021 showed the following: - Diagnoses included left and right diabetic ulcers- feet and type 2 diabetes mellitus (a disease that occurs when your blood sugar is too high) with neurological (problems affecting the nervous system) complications; - Treatments included but not limited to: Clean ulcers with warm water and mild soap, gently pat dry, apply gentamicin (antibiotic) 1% cream to ulcers, cover with dry sterile dressing using "2 X 4's", kling wrap (elastic wrap); and - Provide education regarding infection control. A home visit observation on 08/02/2021 beginning at 4:30 PM, showed the following: - With gloved hands the director of nursing removed the old dressing from the patient's left great toe ulcer; - Removed the gloves and did not wash or use an alcohol-based hand rub and donned a new pair of gloves; - He/she reached into the patient's supply bag and opened a gauze dressing and cleansed the patient's left great toe ulcer; - With the same gloved hands he/she applied gentamicin to the left great toe ulcer and skin prep to the area around the left great toe ulcer; - Removed the gloves and donned a new glove to his/her right hand without washing hands or using an alcohol-based hand rub; - Moved his/her face mask with ungloved left hand and without washing left hand donned a new glove to left hand; and - Touched face mask with same gloved hands and placed a folded 4 x 4 gauze dressing to the patient's left great toe ulcer. During an interview with the director of nursing on 08/03/2021 at 9:40 AM, the director of nursing said he/she should have gelled his/her hands in between glove changes, especially with Covid and the patient's co-morbidities.

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 agency policy, observation and interview, the agency failed to maintain a coordinated agency-wide program for surveillance, identification, prevention, control, and investigation of infectious and communicable diseases that is a part of the agency's quality assessment and performance improvement (QAPI) program (a data driven and proactive approach to quality improvement). This deficient practice has the potential to affect the health and safety of all the agency's patients. Findings included: Review of the agency's policy dated 07/13/2018 titled "Infection Control and Prevention" showed in part: Control Procedure: - Surveillance: Determining an infection requires review of the patient's chart and see if the patient had signs and symptoms of an infection. Surveillance definition covers bloodstream, urinary tract, respiratory/pneumonia, and surgical sites; - Identification: Identify signs and symptoms-fever and chills, very low body temperature, urinating less than normal, rapid pulse, rapid breathing, nausea and vomiting and diarrhea, wound infection, feelings of malaise (a feeling of weakness, overall discomfort, illness, or simply not feeling well), fever, fluid drainage, continual or increased pain, redness and swelling, hot incision site, odor and color changes of drainage. - Control: Surveillance and identification; and - Investigation of infectious and communicable diseases is an integral part of the QAPI program: Investigation of infectious and communicable diseases as practical in the home care setting based on signs and symptoms of infectious and communicable diseases. Review of the minutes of the governing body dated 7/13/2018 showed in part: - Once infections are identified for patients and/or staff, the agency must be able to identify infection type, establish prevention, and monitor effectiveness; - Establish separate logs for patients and staff; - Logs will be maintained monthly; - Include names of patients, infection type and prevention; - All identified infections will be logged and tracked from SOC (start of care) to D/C (discharge) for patients and staff; and - Attach copy of logs to minutes for Governing Body approval. Review of the Infection Control Log was blank and showed no documentation from October 2019 to present. Prior to October, 2019, zeros were marked in each month from August 2018 to September 2019. During an interview on 08/03/2021 at 12:05 PM, the administrator stated that: - He/she did not think there were any infections in the months that were marked with zeros; - No information was recorded related to the lack of documentation from October 2019 to present; and - The agency reviewed the OASIS (a mandated assessment tool to be completed by agency staff) infection control information to monitor infections.

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 policy review, clinical record review, and interview, the agency failed to provide services as ordered by the physician on the plan of care (POC , but not limited to. two (Record/Patient #3 and #4) of five full records reviewed. This deficient practice has the potential to affect all patients served by the agency. Findings included: Review of the agency's policy dated 07/13/2018 titled "Conformance with Physician Orders" showed: - Policy: The agency will comply with physician orders and documentation will be included in the patient's clinical record; - Drugs and treatments are administered by the professional staff only as ordered by the physician. RECORD/PATIENT #3: Review of the POC dated 05/25/2021 through 07/23/2021 showed: - Skilled nurse (SN) 2 - 3 w8 (2 - 3 times per week for 8 weeks). Clinical record review showed: - One missed SN visit week of 05/31/2021 and no documentation as to why staff missed the visit; - One missed SN visit week of 06/14/2021 and no documentation as to why staff missed the visit; and - One missed SN visit week of 07/05/2021 and no documentation as to why staff missed the visit. Review of the POC dated 07/24/2021 through 09/22/2021 showed: - Skilled nurse (SN) 2 - 3 w8 (2 - 3 times per week for 8 weeks) and 1 - 2 PRN (as needed) visits. Clinical record review showed: - One missed SN visit week of 07/26/2021 and no documentation as to why staff missed the visit. During an interview on 08/04/2021 at 10:15 AM, the director of nursing (DON) stated that: - A wound nurse practitioner made monthly visits to assess the patient's wound and on those visit days he/she did not make a SN visit; - He/she could not locate documentation as to why SN visits were missed on the dates listed above. RECORD/PATIENT #4: Review of the POC dated 06/25/2021 through 08/23/2021 showed: - Physical therapy (PT) 1 - 2 w 6 (one to two times per week for six weeks). Clinical record review showed: - One missed PT visit for week of 7/05/2021. During an interview on 08/04/2021 at 10:15 AM, the DON stated that he/she did not know why the visit for week of 07/05/2021 was not made, it was the week following a holiday, and he/she found no documentation as to why the visit was missed.

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, clinical record review, and interview, the agency failed to ensure a completed transfer summary was sent within two business days of a planned transfer to a respite facility and an unplanned transfer to a hospital which affected three (Record/Patient #3 and #4) of five full records reviewed for transfer summaries and failed to send a discharge summary within five business days to the physician in one (Record/Patient #6) discharge record reviewed. This deficient practice has the potential to affect all patients served by the agency. Findings included: Review of the agency's policy dated 07/13/2018 titled "Transfer and Discharge" showed: - The agency will transfer or discharge when outcomes/goals have been achieved and/or an alternate method of health care is necessary; - The referring physician will be notified of the transfer and/or discharge and cause/reason verbally and in writing; - Notification to the referring physician within five business days. RECORD/PATIENT #3: Review of the plan of care (POC) dated 05/25/2021 through 07/23/2021 showed: - Diagnoses included but not limited to: Aspiration pneumonia, sacral (lower end of spine near the tailbone) ulcer (open sore), brain injury, diabetes mellitus (abnormal blood glucose/sugar levels) and respiratory failure. Review of the clinical record showed: - An unsigned addendum physician order dated 06/02/2021 at 1:00 PM showed the patient admitted to respite care (temporary institutional care of a sick, elderly, or disabled person, providing relief for their usual caregiver) 06/03/2021 through 06/08/2021; resume skilled nurse (SN) visits on 06/09/2021; - A SN clinical visit report date 06/02/2021 at 1:00 PM showed no indication/documentation of admission to respite service on 06/03/2021 through 06/08/2021; - No completed transfer summary found in the clinical record that was sent to the physician or the receiving facility within two days of the unplanned transfer for respite care. During an interview on 08/03/2021 at 9:22 AM, the administrator stated that the check mark at the top of the order indicated the order had been sent to the physician. During an interview on 08/04/2021 at 10:15 AM, the director of nursing (DON) stated that: - No completed transfer summary information was sent to the receiving facility or the physician; and - He/she provided the unsigned addendum physician order showing the patient admitted to respite care on 06/03/2021, but had no documentation of when the order was sent to the physician. RECORD/PATIENT #4: Review of the POC dated 04/26/2021 through 06/24/2021 showed: - Start of care: 04/26/2021; - Diagnoses included but not limited to: Parkinson's (a progressive nervous system disorder that affects movement) disease, heart failure, muscle weakness, diabetes mellitus, and arthritis; - Physical therapy (PT) evaluation and treatment. Review of a transfer summary dated 04/27/2021 showed: - Transfer to an inpatient facility; and - Family member contacted agency to inform that patient had been admitted to the hospital; During an interview on 08/04/2021 at 10:15 AM, the DON stated that he/she did not send a transfer summary to the physician, but contacted the physician by phone and did not send the transfer summary to the hospital. RECORD/PATIENT #6: Review of the clinical record showed the patient was admitted to the agency on 05/11/2021 with diagnoses of osteoarthritis (a type of arthritis that occurs when flexible tissue at the ends of bones wears down), multiple joint pain, Type II DM (adult onset diabetes mellitus, hypertension (high blood pressure) and anemia (a condition in which the blood does not have enough healthy red blood cells). Review of the discharge summary dated 06/17/2021 failed to show it was mailed or faxed to referring physician. During an interview on 08/03/2021 at 9:22 AM the administrator stated that the checkmark in the top right corner means it was sent to the physician.